`
`
`
`
`
`
`
` HIGHLIGHTS OF PRESCRIBING INFORMATION
`
`These highlights do not include all the information needed to use
`IMBRUVICA safely and effectively. See full prescribing information for
`IMBRUVICA.
`
`IMBRUVICA® (ibrutinib) capsules, for oral use
`
`Initial U.S. Approval: 2013
`
`
`----------------------------RECENT MAJOR CHANGES-------------------------
`
`
`08/2017
`Indications and Usage (1.5, 1.6)
`
`
`
`
`Dosage and Administration (2.2, 2.3, 2.4, 2.5)
`12/2017
`
`
`
` 12/2017
`Warnings and Precautions (5)
`
`
`----------------------------INDICATIONS AND USAGE--------------------------
`IMBRUVICA is a kinase inhibitor indicated for the treatment of adult patients
`with:
`
` Mantle cell lymphoma (MCL) who have received at least one prior
`
`therapy (1.1).
`Accelerated approval was granted for this indication based on overall
`
`response rate. Continued approval for this indication may be contingent
`
`upon verification and description of clinical benefit in a confirmatory
`
`trial.
`
`
` Chronic lymphocytic leukemia (CLL)/Small lymphocytic lymphoma
`
`(SLL) (1.2).
`
`
` Chronic lymphocytic leukemia (CLL)/Small lymphocytic lymphoma
`
`(SLL) with 17p deletion (1.3).
`
`
` Waldenström’s macroglobulinemia (WM) (1.4).
`
`
` Marginal zone lymphoma (MZL) who require systemic therapy and have
`received at least one prior anti-CD20-based therapy (1.5).
`Accelerated approval was granted for this indication based on overall
`
`response rate. Continued approval for this indication may be contingent
`
`upon verification and description of clinical benefit in a confirmatory
`
`trial.
`
`
` Chronic graft versus host disease (cGVHD) after failure of one or more
`
`lines of systemic therapy (1.6).
`
`
`-----------------------DOSAGE AND ADMINISTRATION----------------------
`
`
`
` MCL and MZL: 560 mg taken orally once daily (four 140 mg capsules
`
`once daily) (2.2).
`
`
`
` CLL/SLL, WM, and cGVHD: 420 mg taken orally once daily (three
`
`140 mg capsules once daily) (2.2).
`
`
`Capsules should be taken orally with a glass of water. Do not open, break, or
`
`chew the capsules (2.1).
`
`----------------------DOSAGE FORMS AND STRENGTHS--------------------
`Capsule: 70 mg and 140 mg (3)
`
`
`FULL PRESCRIBING INFORMATION: CONTENTS*
`
`
`1
`INDICATIONS AND USAGE
`
`
`1.1 Mantle Cell Lymphoma
`
`Chronic Lymphocytic Leukemia/Small Lymphocytic
`1.2
`
`Lymphoma
`
`1.3
`Chronic Lymphocytic Leukemia/Small Lymphocytic
`
`Lymphoma with 17p deletion
`
`
`1.4 Waldenström’s Macroglobulinemia
`
`1.5 Marginal Zone Lymphoma
`
`
`1.6
`Chronic Graft versus Host Disease
`
`
`2 DOSAGE AND ADMINISTRATION
`
`
`
`2.1 Dosing Guidelines
`
`
`2.2
`Recommended Dosage
`
`
`2.3 Dose Modifications for Adverse Reactions
`
`
`2.4 Dose Modifications for Use with CYP3A Inhibitors
`
`
`2.5 Dose Modifications for Use in Hepatic Impairment
`
`
`2.6 Missed Dose
`
`
`3 DOSAGE FORMS AND STRENGTHS
`
`
`
`4 CONTRAINDICATIONS
`
`
`
`5 WARNINGS AND PRECAUTIONS
`
`
`
`5.1 Hemorrhage
`
`
`5.2
`Infections
`
`
`5.3
`Cytopenias
`5.4
`Cardiac Arrhythmias
`
`
`5.5 Hypertension
`
`
`5.6
`Second Primary Malignancies
`
`
`5.7
`Tumor Lysis Syndrome
`
`
`5.8
`Embryo-Fetal Toxicity
`
`
`6 ADVERSE REACTIONS
`
`
`6.1
`Clinical Trials Experience
`Reference ID: 4198358
`
`------------------------------CONTRAINDICATIONS-----------------------------
`None (4)
`
`------------------------WARNINGS AND PRECAUTIONS----------------------
`
` Hemorrhage: Monitor for bleeding and manage (5.1).
`
`
`
` Infections: Monitor patients for fever and infections, evaluate promptly,
`
`
`
`and treat (5.2).
`
` Cytopenias: Check complete blood counts monthly (5.3).
`
`
`
` Cardiac arrhythmias: Monitor for symptoms of arrhythmias and manage
`(5.4).
`
` Hypertension: Monitor blood pressure and treat (5.5).
`
`
` Second Primary Malignancies: Other malignancies have occurred in
`
`patients, including skin cancers, and other carcinomas (5.6).
`
`
` Tumor Lysis Syndrome (TLS): Assess baseline risk and take precautions.
`
`Monitor and treat for TLS (5.7).
`
` Embryo-Fetal Toxicity: Can cause fetal harm. Advise women of the
`potential risk to a fetus and to avoid pregnancy while taking the drug and
`for 1 month after cessation of therapy. Advise men to avoid fathering a
`
`child during the same time period (5.8, 8.3).
`
`
`
`------------------------------ADVERSE REACTIONS------------------------------
`The most common adverse reactions (≥20%) in patients with B-cell
`
`malignancies (MCL, CLL/SLL, WM and MZL) were neutropenia,
`
`
`
`thrombocytopenia, diarrhea, anemia, musculoskeletal pain, rash, nausea,
`
`bruising, fatigue, hemorrhage, and pyrexia (6).
`The most common adverse reactions (≥20%) in patients with cGVHD were
`fatigue, bruising, diarrhea, thrombocytopenia, muscle spasms, stomatitis,
`
`nausea, hemorrhage, anemia, and pneumonia (6).
`
`
`To report SUSPECTED ADVERSE REACTIONS, contact
`
`Pharmacyclics at 1-877-877-3536 or FDA at 1-800-FDA-1088 or
`
`www.fda.gov/medwatch.
`
`-------------------------------DRUG INTERACTIONS-----------------------------
`
` CYP3A Inhibitors: Dose adjustments may be recommended (2.4, 7.1).
`
`
` CYP3A Inducers: Avoid coadministration with strong CYP3A inducers
`
`(7.2).
`
`
`
`
`
`
`
`
`
`
`
`
`
`-----------------------USE IN SPECIFIC POPULATIONS-----------------------
`Hepatic Impairment (based on Child-Pugh criteria): Avoid use of
`IMBRUVICA in patients with severe baseline hepatic impairment. In patients
`with mild or moderate impairment, reduce IMBRUVICA dose (2.5, 8.6).
`
`
`See 17 for PATIENT COUNSELING INFORMATION and FDA
`
`approved patient labeling.
`
`
`Revised: 12/2017
`
`
`
`
`
`
`7
`
`
`
`Postmarketing Experience
`6.2
`
` DRUG INTERACTIONS
`
`
`Effect of CYP3A Inhibitors on Ibrutinib
`7.1
`
`
`Effect of CYP3A Inducers on Ibrutinib
`7.2
`
`
`8 USE IN SPECIFIC POPULATIONS
`
`
`8.1
`Pregnancy
`
`
`8.2
`Lactation
`
`
`8.3
`Females and Males of Reproductive Potential
`
`
`8.4
`Pediatric Use
`
`
`8.5 Geriatric Use
`
`
`8.6 Hepatic Impairment
`
`
`8.7
`Plasmapheresis
`
`
`10 OVERDOSAGE
`
`
`11 DESCRIPTION
`
`
`12 CLINICAL PHARMACOLOGY
`
`
`12.1 Mechanism of Action
`
`
`12.2 Pharmacodynamics
`
`
`12.3 Pharmacokinetics
`
`
`13 NONCLINICAL TOXICOLOGY
`
`
`13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
`
`
`14 CLINICAL STUDIES
`
`
`14.1 Mantle Cell Lymphoma
`
`14.2 Chronic Lymphocytic Leukemia/Small Lymphocytic
`
`Lymphoma
`
`
`14.3 Waldenström’s Macroglobulinemia
`
`14.4 Marginal Zone Lymphoma
`
`
`14.5 Chronic Graft versus Host Disease
`
`
`
`16 HOW SUPPLIED/STORAGE AND HANDLING
`
`
`17 PATIENT COUNSELING INFORMATION
`* Sections or subsections omitted from the full prescribing information are
`
`not listed.
`
`1
`
`
`
`
`
`FULL PRESCRIBING INFORMATION
`
`1
`INDICATIONS AND USAGE
`
`1.1 Mantle Cell Lymphoma
`IMBRUVICA is indicated for the treatment of adult patients with mantle cell lymphoma (MCL)
`who have received at least one prior therapy.
`Accelerated approval was granted for this indication based on overall response rate. Continued
`approval for this indication may be contingent upon verification and description of clinical
`benefit in a confirmatory trial [see Clinical Studies (14.1)].
`1.2
`Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma
`IMBRUVICA is indicated for the treatment of adult patients with chronic lymphocytic leukemia
`(CLL)/small lymphocytic lymphoma (SLL) [see Clinical Studies (14.2)].
`1.3
`Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma with 17p deletion
`
`IMBRUVICA is indicated for the treatment of adult patients with chronic lymphocytic leukemia
`(CLL)/small lymphocytic lymphoma (SLL) with 17p deletion [see Clinical Studies (14.2)].
`1.4 Waldenström’s Macroglobulinemia
`IMBRUVICA is indicated for the treatment of adult patients with Waldenström’s
`macroglobulinemia (WM) [see Clinical Studies (14.3)].
`
`1.5 Marginal Zone Lymphoma
`IMBRUVICA is indicated for the treatment of adult patients with marginal zone lymphoma
`
`
`(MZL) who require systemic therapy and have received at least one prior anti-CD20-based
`therapy.
`Accelerated approval was granted for this indication based on overall response rate [see Clinical
`
`
`Studies (14.4)]. Continued approval for this indication may be contingent upon verification and
`description of clinical benefit in a confirmatory trial.
`
`1.6
`Chronic Graft versus Host Disease
`IMBRUVICA is indicated for the treatment of adult patients with chronic graft-versus-host
`
`disease (cGVHD) after failure of one or more lines of systemic therapy [see Clinical Studies
`
`(14.5)].
`
`2
`DOSAGE AND ADMINISTRATION
`2.1
`Dosing Guidelines
`Administer IMBRUVICA orally once daily at approximately the same time each day. Swallow
`the capsules whole with water. Do not open, break, or chew the capsules.
`
`Reference ID: 4198358
`
`2
`
`
`
`
`Recommended Dosage
`2.2
`Mantle Cell Lymphoma and Marginal Zone Lymphoma
`The recommended dose of IMBRUVICA for MCL and MZL is 560 mg (four 140 mg capsules)
`orally once daily until disease progression or unacceptable toxicity.
`
`Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma and Waldenström’s
`Macroglobulinemia
`
`The recommended dose of IMBRUVICA for CLL/SLL and WM is 420 mg (three 140 mg
`
`capsules) orally once daily until disease progression or unacceptable toxicity.
`The recommended dose of IMBRUVICA for CLL/SLL when used in combination with
`bendamustine and rituximab (administered every 28 days for up to 6 cycles) is 420 mg
`
`(three 140 mg capsules) orally once daily until disease progression or unacceptable toxicity.
`
`Chronic Graft versus Host Disease
`The recommended dose of IMBRUVICA for cGVHD is 420 mg (three 140 mg capsules) orally
`once daily until cGVHD progression, recurrence of an underlying malignancy, or unacceptable
`toxicity. When a patient no longer requires therapy for the treatment of cGVHD, IMBRUVICA
`should be discontinued considering the medical assessment of the individual patient.
`2.3
`Dose Modifications for Adverse Reactions
`Interrupt IMBRUVICA therapy for any Grade 3 or greater non-hematological toxicities, Grade 3
`or greater neutropenia with infection or fever, or Grade 4 hematological toxicities. Once the
`symptoms of the toxicity have resolved to Grade 1 or baseline (recovery), IMBRUVICA therapy
`may be reinitiated at the starting dose. If the toxicity reoccurs, reduce dose by one capsule
`(140 mg per day). A second reduction of dose by 140 mg may be considered as needed. If these
`toxicities persist or recur following two dose reductions, discontinue IMBRUVICA.
`Recommended dose modifications are described below:
`
`
`
` Toxicity Occurrence
`First
`Second
`Third
`
`Fourth
`
`Dose Modification for MCL and
`
` MZL After Recovery
`Starting Dose = 560 mg
`
`Restart at 560 mg daily
`Restart at 420 mg daily
`Restart at 280 mg daily
`Discontinue IMBRUVICA
`
`Dose Modification for CLL/SLL,
` WM, and cGVHD After Recovery
`
`Starting Dose = 420 mg
`
`Restart at 420 mg daily
`Restart at 280 mg daily
`Restart at 140 mg daily
`Discontinue IMBRUVICA
`
`Reference ID: 4198358
`
`3
`
`
`
`
`Dose Modifications for Use with CYP3A Inhibitors
`2.4
`Recommended dose modifications are described below [see Drug Interactions (7.1)]:
`
`
`
` Patient Population Coadministered Drug
`B-Cell Malignancies Moderate CYP3A inhibitor
`
`
`
` Voriconazole 200 mg twice daily
`
`
` Posaconazole suspension 100 mg
`once daily, 100 mg twice daily, or
`200 mg twice daily
`
`
`
` Posaconazole suspension 200 mg
`
`three times daily or 400 mg twice
`daily
`
`
` Posaconazole IV injection 300 mg
`once daily
`
` Posaconazole delayed-release tablets
`300 mg once daily
`
`
` Other strong CYP3A inhibitors
`
`Chronic Graft versus
`
`Host Disease
`
`
`
` Moderate CYP3A inhibitor
`
`
`
` Recommended IMBRUVICA Dose
`
`140 mg once daily
`Interrupt dose as recommended [see
`Dosage and Administration (2.3)].
`
`
`
`70 mg once daily
`Interrupt dose as recommended [see
`Dosage and Administration (2.3)].
`
`
`Avoid concomitant use.
`If these inhibitors will be used short-
`term (such as anti-infectives for seven
`
`days or less), interrupt IMBRUVICA.
`
`
`420 mg once daily
`Modify dose as recommended [see
`
`
`Dosage and Administration (2.3)].
`
`
` Voriconazole 200 mg twice daily
`
`
` Posaconazole suspension 100 mg
`once daily, 100 mg twice daily, or
`200 mg twice daily
`
`280 mg once daily
`Modify dose as recommended [see
`
`Dosage and Administration (2.3)].
`
`
`140 mg once daily
`Interrupt dose as recommended [see
`Dosage and Administration (2.3)].
`
`
`
`
` Posaconazole suspension 200 mg
`
`three times daily or 400 mg twice
`daily
`
`
` Posaconazole IV injection 300 mg
`once daily
`
` Posaconazole delayed-release tablets
`300 mg once daily
`
` Other strong CYP3A inhibitors
`
`Avoid concomitant use.
`If these inhibitors will be used short-
`term (such as anti-infectives for seven
`
`days or less), interrupt IMBRUVICA.
`After discontinuation of a CYP3A inhibitor, resume previous dose of IMBRUVICA [see Dosage
`
` and Administration (2.2) and Drug Interactions (7.1)].
`
`Reference ID: 4198358
`
`4
`
`
`
`
`Dose Modifications for Use in Hepatic Impairment
`2.5
`The recommended dose is 140 mg daily for patients with mild hepatic impairment (Child-Pugh
`
` class A).
`The recommended dose is 70 mg daily for patients with moderate hepatic impairment (Child-
`Pugh class B).
`Avoid the use of IMBRUVICA in patients with severe hepatic impairment (Child-Pugh class C)
`[see Use in Specific Populations (8.6) and Clinical Pharmacology (12.3)].
`
`2.6 Missed Dose
`If a dose of IMBRUVICA is not taken at the scheduled time, it can be taken as soon as possible
`on the same day with a return to the normal schedule the following day. Extra capsules of
`IMBRUVICA should not be taken to make up for the missed dose.
`
`3
`DOSAGE FORMS AND STRENGTHS
`Capsule: 70 mg and 140 mg
`
`4
`CONTRAINDICATIONS
`
`None
`
`WARNINGS AND PRECAUTIONS
`5
`
`5.1 Hemorrhage
`Fatal bleeding events have occurred in patients treated with IMBRUVICA. Grade 3 or higher
`bleeding events (intracranial hemorrhage [including subdural hematoma], gastrointestinal
`bleeding, hematuria, and post procedural hemorrhage) have occurred in up to 6% of patients.
`Bleeding events of any grade, including bruising and petechiae, occurred in approximately half
`of patients treated with IMBRUVICA.
`The mechanism for the bleeding events is not well understood.
`IMBRUVICA may increase the risk of hemorrhage in patients receiving antiplatelet or
`
`anticoagulant therapies and patients should be monitored for signs of bleeding.
`Consider the benefit-risk of withholding IMBRUVICA for at least 3 to 7 days pre and post-
`surgery depending upon the type of surgery and the risk of bleeding [see Clinical Studies (14)].
`
`
`5.2
`Infections
`Fatal and non-fatal infections (including bacterial, viral, or fungal) have occurred with
`IMBRUVICA therapy. Grade 3 or greater infections occurred in 14% to 29% of patients [see
`
`Adverse Reactions (6.1, 6.2)]. Cases of progressive multifocal leukoencephalopathy (PML) and
`Pneumocystis jirovecii pneumonia (PJP) have occurred in patients treated with IMBRUVICA.
`Consider prophylaxis according to standard of care in patients who are at increased risk for
`opportunistic infections. Monitor and evaluate patients for fever and infections and treat
`appropriately.
`
`5
`
`Reference ID: 4198358
`
`
`
`
`Cytopenias
`5.3
`Treatment-emergent Grade 3 or 4 cytopenias including neutropenia (range, 13 to 29%),
`thrombocytopenia (range, 5 to 17%), and anemia (range, 0 to 13%) based on laboratory
`measurements occurred in patients with B-cell malignancies treated with single agent
`IMBRUVICA.
`Monitor complete blood counts monthly.
`5.4
`Cardiac Arrhythmias
`Fatal and serious cardiac arrhythmias have occurred with IMBRUVICA therapy. Grade 3 or
`greater ventricular tachyarrhythmias occurred in 0 to 1% of patients, and Grade 3 or greater atrial
`fibrillation and atrial flutter occurred in 0 to 6% of patients. These events have occurred
`particularly in patients with cardiac risk factors, hypertension, acute infections, and a previous
`history of cardiac arrhythmias.
`Periodically monitor patients clinically for cardiac arrhythmias. Obtain an ECG for patients who
`develop arrhythmic symptoms (e.g., palpitations, lightheadedness, syncope, chest pain) or new
`onset dyspnea. Manage cardiac arrhythmias appropriately, and if it persists, consider the risks
`and benefits of IMBRUVICA treatment and follow dose modification guidelines [see Dosage
`and Administration (2.3)].
`5.5 Hypertension
`Hypertension (range, 6 to 17%) has occurred in patients treated with IMBRUVICA with a
`median time to onset of 4.6 months (range, 0.03 to 22 months). Monitor patients for new onset
`hypertension or hypertension that is not adequately controlled after starting IMBRUVICA.
`Adjust existing anti-hypertensive medications and/or initiate anti-hypertensive treatment as
`appropriate.
`5.6
`Second Primary Malignancies
`Other malignancies (range, 3 to 16%) including non-skin carcinomas (range, 1 to 4%) have
`occurred in patients treated with IMBRUVICA. The most frequent second primary malignancy
`was non-melanoma skin cancer (range, 2 to 13%).
`5.7
`Tumor Lysis Syndrome
`Tumor lysis syndrome has been infrequently reported with IMBRUVICA therapy. Assess the
`baseline risk (e.g., high tumor burden) and take appropriate precautions. Monitor patients closely
`and treat as appropriate.
`
`Reference ID: 4198358
`
`6
`
`
`
`
`Embryo-Fetal Toxicity
`5.8
`Based on findings in animals, IMBRUVICA can cause fetal harm when administered to a
`pregnant woman. Administration of ibrutinib to pregnant rats and rabbits during the period of
`organogenesis caused embryo-fetal toxicity including malformations at exposures that were
`2-20 times higher than those reported in patients with hematologic malignancies. Advise women
`to avoid becoming pregnant while taking IMBRUVICA and for 1 month after cessation of
`therapy. If this drug is used during pregnancy or if the patient becomes pregnant while taking
`this drug, the patient should be apprised of the potential hazard to a fetus [see Use in Specific
`Populations (8.1)].
`
`ADVERSE REACTIONS
`6
`
`The following adverse reactions are discussed in more detail in other sections of the labeling:
`
`
` Hemorrhage [see Warnings and Precautions (5.1)]
`
`
`
`Infections [see Warnings and Precautions (5.2)]
`
`
`
` Cytopenias [see Warnings and Precautions (5.3)]
`
`
` Cardiac Arrhythmias [see Warnings and Precautions (5.4)]
`
`
` Hypertension [see Warnings and Precautions (5.5)]
`
`
` Second Primary Malignancies [see Warnings and Precautions (5.6)]
`
`
` Tumor Lysis Syndrome [see Warnings and Precautions (5.7)]
`6.1
`Clinical Trials Experience
`Because clinical trials are conducted under widely variable conditions, adverse event rates
`observed in clinical trials of a drug cannot be directly compared with rates of clinical trials of
`another drug and may not reflect the rates observed in practice.
`Mantle Cell Lymphoma
`
`The data described below reflect exposure to IMBRUVICA in a clinical trial (Study 1104) that
`included 111 patients with previously treated MCL treated with 560 mg daily with a median
`treatment duration of 8.3 months.
`The most commonly occurring adverse reactions (≥ 20%) were thrombocytopenia, diarrhea,
`neutropenia, anemia, fatigue, musculoskeletal pain, peripheral edema, upper respiratory tract
`infection, nausea, bruising, dyspnea, constipation, rash, abdominal pain, vomiting and decreased
`appetite (see Tables 1 and 2).
`
`The most common Grade 3 or 4 non-hematological adverse reactions (≥ 5%) were pneumonia,
`abdominal pain, atrial fibrillation, diarrhea, fatigue, and skin infections.
`Fatal and serious cases of renal failure have occurred with IMBRUVICA therapy. Increases in
`creatinine 1.5 to 3 times the upper limit of normal occurred in 9% of patients.
`
`Reference ID: 4198358
`
`7
`
`
`
`
`Adverse reactions from the MCL trial (N=111) using single agent IMBRUVICA 560 mg daily
`occurring at a rate of ≥ 10% are presented in Table 1.
`
`Table 1: Non-Hematologic Adverse Reactions in ≥ 10% of Patients with MCL (N=111)
`
`Adverse Reaction
`Body System
`Gastrointestinal disorders Diarrhea
`Nausea
`Constipation
`Abdominal pain
`Vomiting
`Stomatitis
`Dyspepsia
`Infections and infestations Upper respiratory tract
`infection
`Urinary tract infection
`Pneumonia
`Skin infections
`Sinusitis
`Fatigue
`Peripheral edema
`Pyrexia
`Asthenia
`Bruising
`Rash
`Petechiae
`
`Musculoskeletal pain
`Muscle spasms
`
`Arthralgia
`Dyspnea
`Cough
`Epistaxis
`Metabolism and nutrition
`Decreased appetite
`disorders
`
`Dehydration
`
`Nervous system disorders Dizziness
`
`
`Headache
`
`
`General disorders and
`administration site
`conditions
`
`Skin and subcutaneous
`tissue disorders
`
`
`Musculoskeletal and
`connective tissue disorders
`
`
`Respiratory, thoracic and
`mediastinal disorders
`
`
`All Grades (%)
`51
`
`31
`
`25
`
`24
`
`23
`
`17
`
`11
`
`
`34
`
`14
`
`14
`
`14
`
`13
`
`41
`
`35
`
`18
`
`14
`30
`
`25
`
`11
`
`37
`
`14
`
`11
`27
`
`19
`
`11
`
`21
`
`12
`
`14
`
`13
`
`
`Grade 3 or 4 (%)
`5
`0
`0
`5
`0
`1
`0
`
`0
`3
`7
`5
`1
`5
`3
`1
`3
`0
`3
`0
`1
`0
`0
`4
`0
`0
`2
`4
`0
`0
`
`Table 2: Treatment-Emergent* Hematologic Laboratory Abnormalities
`in Patients with MCL (N=111)
`
`
`
`
`Platelets Decreased
`
`Neutrophils Decreased
`
`Hemoglobin Decreased
`* Based on laboratory measurements and adverse reactions
`
`
`Percent of Patients (N=111)
`
`
`Grade 3 or 4 (%)
`All Grades (%)
`
`
`57
`17
`
`
`47
`29
`
`
`41
`9
`
`Reference ID: 4198358
`
`8
`
`
`
`
`Ten patients (9%) discontinued treatment due to adverse reactions in the trial (N=111). The most
`frequent adverse reaction leading to treatment discontinuation was subdural hematoma (1.8%).
`Adverse reactions leading to dose reduction occurred in 14% of patients.
`Patients with MCL who develop lymphocytosis greater than 400,000/mcL have developed
`intracranial hemorrhage, lethargy, gait instability, and headache. However, some of these cases
`were in the setting of disease progression.
`Forty percent of patients had elevated uric acid levels on study including 13% with values above
`10 mg/dL. Adverse reaction of hyperuricemia was reported for 15% of patients.
`Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma
`The data described below reflect exposure in one single-arm, open-label clinical trial
`(Study 1102) and three randomized controlled clinical trials (RESONATE, RESONATE-2, and
`HELIOS) in patients with CLL/SLL (n=1278 total and n=668 patients exposed to
`IMBRUVICA). Study 1102 included 51 patients with previously treated CLL/SLL, RESONATE
`included 391 randomized patients with previously treated CLL or SLL who received single agent
`IMBRUVICA or ofatumumab, RESONATE-2 included 269 randomized patients 65 years or
`older with treatment naïve-CLL or SLL who received single agent IMBRUVICA or
`chlorambucil, and HELIOS included 578 randomized patients with previously treated CLL or
`SLL who received IMBRUVICA in combination with bendamustine and rituximab or placebo in
`combination with bendamustine and rituximab.
`The most commonly occurring adverse reactions in Studies 1102, RESONATE, RESONATE-2,
`and HELIOS in patients with CLL/SLL receiving IMBRUVICA (≥ 20%) were neutropenia,
`thrombocytopenia, anemia, diarrhea, musculoskeletal pain, nausea, rash, bruising, fatigue,
`pyrexia and hemorrhage. Four to 10 percent of patients receiving IMBRUVICA in Studies 1102,
`
`RESONATE, RESONATE-2, and HELIOS discontinued treatment due to adverse reactions.
`These included pneumonia, hemorrhage, atrial fibrillation, rash and neutropenia (1% each).
`Adverse reactions leading to dose reduction occurred in approximately 6% of patients.
`Study 1102
`Adverse reactions and laboratory abnormalities from the CLL/SLL trial (N=51) using single
`agent IMBRUVICA 420 mg daily in patients with previously treated CLL/SLL occurring at a
`rate of ≥ 10% with a median duration of treatment of 15.6 months are presented in Tables 3
`
`and 4.
`
`Reference ID: 4198358
`
`9
`
`
`
`
`
`Table 3: Non-Hematologic Adverse Reactions in ≥ 10% of Patients with
`
`CLL/SLL (N=51) in Study 1102
`
`
`Body System
`Gastrointestinal disorders
`
`Infections and infestations
`
`General disorders and
`administration site
`conditions
`
`Skin and subcutaneous
`tissue disorders
`
`
`Respiratory, thoracic and
`mediastinal disorders
`
`
`Musculoskeletal and
`connective tissue disorders
`
`
`Nervous system disorders
`
`
`Metabolism and nutrition
`disorders
`
`Neoplasms benign,
`malignant, unspecified
`
`Vascular disorders
`Hypertension
`
`*One patient death due to histiocytic sarcoma.
`
`Adverse Reaction
`Diarrhea
`Constipation
`Nausea
`Stomatitis
`Vomiting
`Abdominal pain
`Dyspepsia
`Upper respiratory tract
`infection
`Sinusitis
`Skin infection
`Pneumonia
`Urinary tract infection
`Fatigue
`Pyrexia
`Peripheral edema
`Asthenia
`Chills
`Bruising
`Rash
`Petechiae
`
`Cough
`
`Oropharyngeal pain
`Dyspnea
`
`Musculoskeletal pain
`Arthralgia
`Muscle spasms
`
`Dizziness
`
`Headache
`
`Decreased appetite
`
`Second malignancies*
`
`All Grades (%)
`59
`
`22
`
`20
`
`20
`
`18
`
`14
`
`12
`
`
`47
`
`22
`
`16
`
`12
`
`12
`
`33
`
`24
`
`22
`
`14
`
`12
`
`51
`
`25
`
`16
`
`22
`
`14
`
`12
`
`25
`
`24
`
`18
`
`20
`
`18
`
`16
`
`Grade 3 or 4
`(%)
`4
`2
`2
`0
`2
`0
`0
`
`2
`6
`6
`10
`
`2
`6
`2
`0
`6
`0
`2
`0
`0
`0
`0
`0
`6
`0
`2
`0
`2
`2
`
`12*
`
`
`16
`
`
`0
`
`8
`
`Reference ID: 4198358
`
`10
`
`
`
`
`
`
`
`
` Table 4: Treatment-Emergent* Hematologic Laboratory Abnormalities
`in Patients with CLL/SLL (N=51) in Study 1102
`
`
`
`
`Percent of Patients (N=51)
`
`
`Grade 3 or 4 (%)
`All Grades (%)
`
`
`
`69
`12
`Platelets Decreased
`
`
`
`53
`26
`Neutrophils Decreased
`
`
`
`43
`Hemoglobin Decreased
`0
` * Based on laboratory measurements per IWCLL criteria and adverse reactions.
`RESONATE
`Adverse reactions and laboratory abnormalities described below in Tables 5 and 6 reflect
`exposure to IMBRUVICA with a median duration of 8.6 months and exposure to ofatumumab
`with a median of 5.3 months in RESONATE in patients with previously treated CLL/SLL.
`
`
`
`
`
`Table 5: Adverse Reactions Reported in ≥ 10% of Patients and at Least 2% Greater in the
`
` IMBRUVICA Treated Arm in Patients with CLL/SLL in RESONATE
`
`
`Body System
`
`Adverse Reaction
`
`Gastrointestinal disorders
`
`Diarrhea
`
`Nausea
`
`Stomatitis*
`
`Constipation
`
`Vomiting
`General disorders and
`
`administration site conditions
`
`Pyrexia
`
`Infections and infestations
`Upper respiratory tract
`
`infection
`
`Pneumonia*
`
`Sinusitis*
`
`Urinary tract infection
`Skin and subcutaneous tissue
`
`disorders
`
`Rash*
`
`Petechiae
`
`Bruising*
`
`IMBRUVICA
`
`(N=195)
`Grade 3 or 4
`All Grades
`
`
`(%)
`(%)
`
`
`
`
`4
`48
`
`
`2
`26
`
`
`1
`17
`
`
`0
`15
`
`
`0
`14
`
`
`
`Ofatumumab
`
`(N=191)
`Grade 3 or 4
`All Grades
`
`
`(%)
`(%)
`
`
`
`
`2
`18
`
`
`0
`18
`
`
`1
`6
`
`
`0
`9
`
`
`1
`6
`
`
`
`
`24
`
`
`16
`
`
`15
`
`11
`
`10
`
`
`
`24
`
`14
`
`12
`
`
`2
`
`
`1
`
`
`10
`
`1
`
`4
`
`
`
`3
`
`0
`
`0
`
`
`15
`
`
`11
`
`
`13
`
`6
`
`5
`
`
`
`13
`
`1
`
`1
`
`
`1
`
`
`2
`
`
`9
`
`0
`
`1
`
`
`
`0
`
`0
`
`0
`
`11
`
`
`Reference ID: 4198358
`
`
`
`
`
`IMBRUVICA
`
`(N=195)
`Grade 3 or 4
`All Grades
`
`
`(%)
`(%)
`
`
`
`Ofatumumab
`
`(N=191)
`Grade 3 or 4
`All Grades
`
`
`(%)
`(%)
`
`
`
`
`Body System
`
`Adverse Reaction
`Musculoskeletal and
`
`connective tissue disorders
`
`Musculoskeletal Pain*
`
`Arthralgia
`
`Nervous system disorders
`
`Headache
`
`Dizziness
`Injury, poisoning and
`
`procedural complications
`
`
`
`0
`11
`Contusion
`
`
`
`Eye disorders
`
`
`
`0
`10
`Vision blurred
` Subjects with multiple events for a given ADR term are counted once only for each ADR term.
`
`
`
` The body system and individual ADR terms are sorted in descending frequency order in the IMBRUVICA arm.
`
`* Includes multiple ADR terms
`
`
`28
`
`17
`
`
`14
`
`11
`
`
`
`2
`
`1
`
`
`1
`
`0
`
`
`
`18
`
`7
`
`
`6
`
`5
`
`
`
`3
`
`
`3
`
`
`1
`
`0
`
`
`0
`
`0
`
`
`
`0
`
`
`0
`
`Table 6: Treatment-Emergent Hematologic Laboratory Abnormalities in Patients with
`CLL/SLL in RESONATE
`
`
`
`Neutrophils Decreased
`
`Platelets Decreased
`Hemoglobin Decreased
`
`IMBRUVICA
`(N=195)
`
`Grade 3 or 4
`All Grades
`(%)
`(%)
`
`
`
`23
`51
`52
`5
`
`36
`0
`
`Ofatumumab
`(N=191)
`
`Grade 3 or 4
`All Grades
`(%)
`(%)
`
`
`
`26
`57
`10
`45
`
`21
`0
`
`
`RESONATE-2
`Adverse reactions described below in Table 7 reflect exposure to IMBRUVICA with a median
`duration of 17.4 months. The median exposure to chlorambucil was 7.1 months in
`RESONATE-2.
`
`Reference ID: 4198358
`
`12
`
`
`
`
`
`Table 7: Adverse Reactions Reported in ≥ 10% of Patients and at Least 2% Greater in the
`
`IMBRUVICA Treated Arm in Patients with CLL/SLL in RESONATE-2
`
`
`
`
`IMBRUVICA
`Chlorambucil
`
`
`(N=135)
`(N=132)
`
`Body System
`Grade 3 or 4
`All Grades
`Grade 3 or 4
`All Grades
`
`
`
`
`
`Adverse Reaction
`(%)
`(%)
`(%)
`(%)
`
`
`
`
`
`Gastrointestinal disorders
`
`
`
`
`
` Diarrhea
`4
`42
`0
`17
`
`
`
`
`
` Stomatitis*
`1
`14
`1
`4
`Musculoskeletal and
`
`
`
`
`connective tissue disorders
`
`
`
`
`
`Musculoskeletal pain*
`4
`36
`0
`20
`
`
`
`
`
` Arthralgia
`1
`16
`1
`7
`
`
`
`
`
` Muscle spasms
`0
`11
`0
`5
`
`
`
`
`
`Eye Disorders
`
`
`
`
`
` Dry eye
`0
`17
`0
`5
`
`
`
`
`
` Lacrimation increased
`0
`13
`0
`6
`
`
`
`
`
` Vision blurred
`0
`13
`0
`8
`
`
`
`
` Visual acuity reduced
`0
`11
`0
`2
`Skin and subcutaneous tissue
`
`
`
`
`
`disorders
`
`
`
`
`
` Rash*
`4
`21
`2
`12
`
`
`
`
`
` Bruising*
`0
`19
`0
`7
`
`
`
`
`
`Infections and infestations
`
`
`
`
`
` Skin infection*
`2
`15
`1
`3
`
`
`
`
`
` Pneumonia*
`8
`14
`4
`7
`
`
`
`
`
` Urinary tract infections
`1
`10
`1
`8
`Respiratory, thoracic and
`
`
`
`
`
`mediastinal disorders
`
`
`
`
`
` Cough
`0
`22
`0
`15
`General disorders and
`
`
`
`
`
`administration site conditions
`
`
`
`
`
`1
`19
` Peripheral edema
`0
`9
`
`
`
`
`
`0
`17
` Pyrexia
`2
`14
`
`
`
`
`
`Vascular Disorders
`
`
`
`
`4
`14
` Hypertension*
`0
`1
`
`
`
`
`
`Nervous System Disorders
`
`
`
`
`
`1
`12
` Headache
`2
`10
` Subjects with multiple events for a given ADR term are counted once only for each ADR term.
`
`
`
`
` The body system and individual ADR terms are sorted in descending frequency order in the IMBRUVICA arm.
`
`* Includes multiple ADR terms
`
`
`
`
`
`Reference ID: 4198358
`
`13
`
`
`
`
`
`HELIOS
`Adverse reactions described below in Table 8 reflect exposure to IMBRUVICA + BR with a
`median duration of 14.7 months and exposure to placebo + BR with a median of 12.8 months in
`HELIOS in patients with previously treated CLL/SLL.
`
`Table 8: Adverse Reactions Reported in at Least 10% of Patients and at Least 2% Greater
`in the IMBRUVICA Arm in Patients with CLL/SLL in HELIOS
`
`
`Ibrutinib + BR
`
`(N=287)
`Grade 3 or 4
`All Grades
`
`
`(%)
`(%)
`
`
`
`
`Placebo + BR
`
`(N=287)
`Grade 3 or 4
`All Grades
`
`
`(%)
`(%)
`
`
`
`
`
`
`66
`
`34
`
`
`
`
`32
`
`20
`
`
`36
`
`12
`
`
`
`
`29
`
`12
`
`
`
`
`25
`
`
`19
`
`11
`
`
`13
`
`10
`
`
`
`
`55
`
`16
`
`
`
`1
`
`<1
`
`
`1
`
`<1
`
`
`
`0
`
`0
`
`
`
`
`2
`
`
`1
`
`2
`
`
`3
`
`2
`
`
`
`0
`
`
`Body System
`
`Adverse Reaction
`Blood and lymphatic
`
`system disorders
`
`
` Neutropenia*
`
` Thrombocytopenia*
`Skin and subcutaneous
`
`tissue disorders
`
` Rash *
`
` Bruising *
`
`Gastrointestinal disorders
`
` Diarrhea
`
` Abdominal Pain
`Musculoskeletal and
`connective tissue disorders
`
` Musculoskeletal pain*
`
` Muscle spasms
`General disorders and
`administration site
`
`conditions
`
` Pyrexia
`
`Vascular Disorders
`
`
`Hemorrhage*
`
`Hypertension *
`
`Infections and infestations
`
` Bronchitis
`
` Skin infection*
`Metabolism and nutrition
`
`disorders
`
`
`
`
`6
`2
`10
`Hyperuricemia
` The body system and individual ADR terms are sorted in descending frequency order in the IMBRUVICA arm.
`* Includes multiple ADR terms
`
`<1 used for frequency above 0 and below 0.5%
`
`
`
`
`
`61
`
`16
`
`
`
`4
`
`<1
`
`
`2
`
`1
`
`
`
`2
`
`<1
`
`
`
`
`4
`
`
`2
`
`5
`
`
`2
`
`3
`
`
`
`60
`
`26
`
`
`
`25
`
`8
`
`
`23
`
`8
`
`
`
`20
`
`5
`
`
`
`
`22
`
`
`9
`
`5
`
`
`10
`
`6
`
`
`
`
`Reference ID: 4198358
`
`14
`
`
`
`
`
`Atrial fibrillation of any grade occurred in 7% of patients treated with IMBRUVICA + BR and
`2% of patients treated with placebo + BR. The frequency of Grade 3 and 4 atrial fibrillation was
`3% in patients treated with IMBRUVICA + BR and 1% in patients treated with placebo +BR.
`Waldenström’s Macroglobulinemia and Marginal Zone Lymphoma
`
`The data described below reflect exposure to IMBRUVICA in open-label clinical trials that
`
`included 63 patients with previously treated WM (Study 1118) and 63 patients with previously
`treated MZL (Study 1121).
`The most commonly occurring adver