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Clinical Trials Experience

The following adverse reactions are also discussed in other sections of the labeling:

Renal Failure [see WARNINGS AND PRECAUTIONS]. Hepatic Failure [see WARNINGS AND PRECAUTIONS]. Fatal and non-fatal Gastrointestinal Bleedings [see WARNINGS AND PRECAUTIONS]. Cytopenias [see WARNINGS AND PRECAUTIONS].

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

A total of 700 adult and pediatric patients were treated with Exjade (deferasirox) for 48 weeks in premarketing studies. These included 469 patients with β-thalassemia, 99 with rare anemias, and 132 with sickle cell disease. Of these patients, 45% were male, 70% were Caucasian and 292 patients were < 16 years of age. In the sickle cell disease population, 89% of patients were Black. Median treatment duration among the sickle cell patients was 51 weeks. Of the 700 patients treated, 469 (403 ß-thalassemia and 66 rare anemias) were entered into extensions of the original clinical protocols. In ongoing extension studies, median durations of treatment were 88-205 weeks.

Table 1 displays adverse reactions occurring in > 5% of Exjade-treated β-thalassemia patients (Study 1) and sickle cell disease patients (Study 3) with a suspected relationship to study drug. Abdominal pain, nausea, vomiting, diarrhea, skin rashes, and increases in serum creatinine were the most frequent adverse reactions reported with a suspected relationship to Exjade. Gastrointestinal symptoms, increases in serum creatinine, and skin rash were dose related.

Table 1: Adverse Reactions Occurring in > 5% of Exjade-treated Patients in Study 1 and Study 3*

In Study 1, a total of 113 (38%) patients treated with Exjade had increases in serum creatinine > 33% above baseline on 2 separate occasions (Table 2) and 25 (8%) patients required dose reductions. Increases in serum creatinine appeared to be dose related [see WARNINGS AND PRECAUTIONS]. In this study, 17 (6%) patients treated with Exjade developed elevations in SGPT/ALT levels > 5 times the upper limit of normal at 2 consecutive visits. Of these, 2 patients had liver biopsy proven drug-induced hepatitis and both discontinued Exjade therapy [see WARNINGS AND PRECAUTIONS]. An additional 2 patients, who did not have elevations in SGPT/ALT > 5 times the upper limit of normal, discontinued Exjade because of increased SGPT/ALT. Increases in transaminases did not appear to be dose related. Adverse reactions that led to discontinuations included abnormal liver function tests (2 patients) and drug-induced hepatitis (2 patients), skin rash, glycosuria/proteinuria, Henoch Schönlein purpura, hyperactivity/insomnia, drug fever, and cataract (1 patient each).

In Study 3, a total of 48 (36%) patients treated with Exjade had increases in serum creatinine > 33% above baseline on 2 separate occasions (Table 2) [see WARNINGS AND PRECAUTIONS]. Of the patients who experienced creatinine increases in Study 3, 8 Exjade-treated patients required dose reductions. In this study, 5 patients in the Exjade group developed elevations in SGPT/ALT levels > 5 times the upper limit of normal at 2 consecutive visits and 1 patient subsequently had Exjade permanently discontinued. Four additional patients discontinued Exjade due to adverse reactions with a suspected relationship to study drug, including diarrhea, pancreatitis associated with gallstones, atypical tuberculosis, and skin rash.

Table 2: Number (%) of Patients with Increases in Serum Creatinine or SGPT/ALT in Study 1 and Study 3

Proteinuria

In clinical studies, urine protein was measured monthly. Intermittent proteinuria (urine protein/creatinine ratio > 0.6 mg/mg) occurred in 18.6% of Exjade-treated patients compared to 7.2% of deferoxamine-treated patients in Study 1. Although no patients were discontinued from Exjade in clinical studies up to 1 year due to proteinuria, monthly monitoring is recommended. The mechanism and clinical significance of the proteinuria are uncertain.

Other Adverse Reactions

In the population of more than 5,000 patients who have been treated with Exjade during clinical trials, adverse reactions occurring in 0.1% to 1% of patients included gastritis, edema, sleep disorder, pigmentation disorder, dizziness, anxiety, maculopathy, cholelithiasis, pyrexia, fatigue, pharyngolaryngeal pain, early cataract, hearing loss, gastrointestinal hemorrhage, gastric ulcer (including multiple ulcers), duodenal ulcer, and renal tubulopathy (Fanconi's syndrome). Adverse reactions occurring in 0.01% to 0.1% of patients included optic neuritis, esophagitis, and erythema multiforme. Adverse reactions which most frequently led to dose interruption or dose adjustment during clinical trials were rash, gastrointestinal disorders, infections, increased serum creatinine, and increased serum transaminases.

Postmarketing Experience

The following adverse reactions have been spontaneously reported during postapproval use of Exjade. Because these reactions are reported voluntarily from a population of uncertain size, in which patients may have received concomitant medication, it is not always possible to reliably estimate frequency or establish a causal relationship to drug exposure.

Skin and subcutaneous tissue disorders: leukocytoclastic vasculitis, urticaria, alopecia

Immune system disorders: hypersensitivity reactions (including anaphylaxis and angioedema).

The concomitant administration of Exjade and aluminum-containing antacid preparations has not been formally studied. Although deferasirox has a lower affinity for aluminum than for iron, do not administer Exjade with aluminum-containing antacid preparations.

Effect of Deferasirox on Drug Metabolizing Enzymes

Deferasirox inhibits human CYP3A4, CYP2C8, CYP1A2, CYP2A6, CYP2D6, and CYP2C19 in vitro . The clinical significance of deferasirox inhibition of CYP2A6, CYP2D6, and CYP2C19 is unknown.

Interaction with Midazolam and Other Agents Metabolized by CYP3A4

In healthy volunteers, the concomitant administration of Exjade and midazolam (a CYP3A4 probe substrate) resulted in a decrease of midazolam peak concentration by 23 % and exposure by 17%. In the clinical setting, this effect may be more pronounced. Therefore, due to a possible decrease in CYP3A4 substrate concentration and potential loss of effectiveness, use caution when deferasirox is administered with drugs metabolized by CYP3A4 (e.g., cyclosporine, simvastatin, hormonal contraceptive agents).

Interaction with Repaglinide and Other Agents Metabolized by CYP2C8

In a healthy volunteer study, the concomitant administration of Exjade (30 mg/kg/day for 4 days) and the CYP2C8 probe substrate repaglinide (single dose of 0.5 mg) resulted in an increase in repaglinide systemic exposure (AUC) to 2.3-fold of control and an increase in Cmax of 62%. If Exjade and repaglinide are used concomitantly, consider decreasing the dose of repaglinide and perform careful monitoring of blood glucose levels. Exercise caution when Exjade and other CYP2C8 substrates like paclitaxel are co-administered.

Interaction with Theophylline and Other Agents Metabolized by CYP1A2

In a healthy volunteer study, the concomitant administration of Exjade (repeated dose of 30 mg/kg/day) and the CYP1A2 substrate theophylline (single dose of 120 mg) resulted in an approximate doubling of the theophylline AUC and elimination half-life. The single dose Cmax was not affected, but an increase in theophylline Cmax is expected to occur with chronic dosing. This increase in plasma concentrations could lead to clinically significant theophylline induced CNS or other adverse reactions. Avoid the concomitant use of theophylline or other CYP1A2 substrates with a narrow therapeutic index with Exjade. If you must co-administer theophylline with Exjade, monitor theophylline concentrations and consider theophylline dose modification.

Use caution when Exjade is administered with other drugs metabolized by CYP1A2 such as cyclobenzaprine, imipramine, haloperidol, fluvoxamine, mexiletine, olanzapine, tizanidine, zileuton, and zolmitriptan.

Interaction with Agents Inducing UDP-glucuronosyltransferase (UGT) Metabolism

In a healthy volunteer study, the concomitant administration of Exjade (single dose of 30 mg/kg) and the potent UDP-glucuronosyltransferase (UGT) inducer rifampicin (600 mg/day for 9 days) resulted in a decrease of deferasirox systemic exposure (AUC) by 44%. Therefore, the concomitant use of Exjade with potent UGT inducers (e.g., rifampicin, phenytoin, phenobarbital, ritonavir) may result in a decrease in Exjade efficacy.

Avoid the concomitant use of potent UGT inducers with Exjade. If you must co-administer these agents together, consider increasing the initial dose of Exjade to 30 mg/kg and monitor serum ferritin levels and clinical responses for further dose modification [see DOSAGE AND ADMINISTRATION].

Interaction with Cholestyramine

The concomitant use of Exjade with cholestyramine may result in a decrease in Exjade efficacy. In healthy volunteers, the administration of cholesytramine after a single dose of deferasirox resulted in a 45% decrease in deferasirox exposure (AUC). Avoid the concomitant use of cholestyramine with Exjade. If you must coadminister these agents together, consider increasing the initial dose of Exjade to 30 mg/kg and monitor serum ferritin levels and clinical responses for further dose modification [see DOSAGE AND ADMINISTRATION].

Last reviewed on RxList: 8/19/2011
This monograph has been modified to include the generic and brand name in many instances.