"The U.S. Food and Drug Administration today approved Imbruvica (ibrutinib) to treat patients with mantle cell lymphoma (MCL), a rare and aggressive type of blood cancer.
MCL is a rare form of non-Hodgkin lymphoma and represents about 6 "...
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared with rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.
The following adverse reactions are discussed in greater detail in other sections of the prescribing information:
- Thrombosis and Thromboembolism [see WARNINGS AND PRECAUTIONS]
- Hepatotoxicity [see WARNINGS AND PRECAUTIONS and DOSAGE AND ADMINISTRATION]
- Congestive Heart Failure [see WARNINGS AND PRECAUTIONS]
- Hypertension [see WARNINGS AND PRECAUTIONS]
- Pancreatitis [see DOSAGE AND ADMINISTRATION and WARNINGS AND PRECAUTIONS]
- Hemorrhage [see WARNINGS AND PRECAUTIONS]
- Fluid Retention [see WARNINGS AND PRECAUTIONS]
- Cardiac Arrhythmias [see WARNINGS AND PRECAUTIONS]
- Myelosuppression [see DOSAGE AND ADMINISTRATION and WARNINGS AND PRECAUTIONS]
The adverse reactions described in this section were identified in a single-arm, open-label, international, multicenter trial in 449 patients with CML or Ph+ ALL whose disease was considered to be resistant or intolerant to prior tyrosine kinase inhibitor (TKI) therapy including those with the BCR-ABL T315I mutation. All patients received a starting dose of 45 mg Iclusig once daily. At the time of analysis, the median duration of treatment with Iclusig was 337 days in patients with CPCML, 362 days in patients with AP-CML, 89 days in patients with BP-CML, and 81 days in patients with Ph+ ALL. The median dose intensity was 37 mg or, 83% of the expected 45 mg dose.
Adverse reactions reported in more than 10% of all patients treated with Iclusig in this trial are presented in Table 4. Overall, the most common non-hematologic adverse reactions ( ≥ 20%) were hypertension, rash, abdominal pain, fatigue, headache, dry skin, constipation, arthralgia, nausea, and pyrexia.
The rates of treatment-emergent adverse events resulting in discontinuation were 13% in CP-CML, 11% in AP-CML, 15% in BP-CML, and 9% in Ph+ ALL. The most common adverse events that led to treatment discontinuation were thrombocytopenia (4%) and infections (1%).
Dose modifications (dose delays or dose reduction) due to adverse reactions occurred in 74% of the patients. The most common adverse reactions ( ≥ 5%) that led to dose modifications include thrombocytopenia (30%), neutropenia (13%), lipase increased (12%), rash (11%), abdominal pain (11%), pancreatitis (6%), and ALT, AST, or GGT increased (6%).
Table 4: Adverse Reactions Occurring in > 10% of
Patients, Any Group
|System Organ Class||CP-CML
|Any Grade (%)||CTCAE Grade 3 / 4 (%)||Any Grade (%)||CTCAE Grade 3 / 4 (%)||Any Grade (%)||CTCAE Grade 3 / 4 (%)||Any Grade (%)||CTCAE Grade 3 / 4 (%)|
|Cardiac or Vascular disorders|
|Arterial ischemia (b)||13||7||12||6||8||5||3||0|
|Cardiac Failure (c)||6||4||6||2||15||11||6||6|
|Abdominal pain (d)||49||10||40||8||34||6||44||6|
|Oral mucositis (e)||10||1||15||1||23||0||9||3|
|GI hemorrhage (f)||2||< 1||8||1||11||5||9||6|
|Blood and lymphatic system disorders|
|Febrile neutropenia||1||< 1||4||4||11||11||25||25|
|Infections and infestations|
|Urinary tract infection||7||1||12||1||0||0||9||0|
|Upper respiratory tract infection||11||1||8||0||11||2||0||0|
|Nervous system disorders|
|Peripheral neuropathy (g)||13||2||8||0||8||0||6||0|
|Respiratory, thoracic, and mediastinal disorders|
|Skin and subcutaneous tissue disorders|
|Rash and related conditions||54||5||48||8||39||5||34||6|
|Musculoskeletal and connective tissue disorders|
|Pain in extremity||17||2||17||0||13||0||9||0|
|Bone pain||12||< 1||12||1||11||3||9||3|
|General disorders and administration site conditions|
|Fatigue or asthenia||39||3||36||6||35||5||31||3|
|Edema, peripheral||13||< 1||19||0||13||0||22||0|
|Metabolism and nutrition disorders|
|Decreased appetite||8||< 1||12||1||8||0||31||0|
|Weight decreased||6||< 1||7||0||5||0||13||0|
|Adverse drug reactions, reported using MedDRA and graded
using NCI-CTC-AE v 4.0 (NCI Common Terminology Criteria for Adverse Events) for
assessment of toxicity. Treatment-emergent, all causality events
a derived from blood pressure (BP) measurement recorded monthly while on trial
b includes cardiac, central nervous system, and peripheral arterial ischemia
c includes cardiac failure, cardiac failure congestive, cardiogenic shock, cardiopulmonary failure, ejection fraction decreased, pulmonary edema, right ventricular failure
d includes abdominal pain, abdominal pain upper, abdominal pain lower, abdominal discomfort
e includes aphthous stomatitis, lip blister, mouth ulceration, oral mucosal eruption, oral pain, oropharyngeal pain, pharyngeal ulceration, stomatitis, tongue ulceration
f includes gastric hemorrhage, gastric ulcer hemorrhage, hemorrhagic gastritis, gastrointestinal hemorrhage, hematemesis, hematochezia, hemorrhoidal hemorrhage, intra-abdominal hemorrhage, melena, rectal hemorrhage, and upper gastrointestinal hemorrhage
g includes burning sensation, hyperesthesia, hypoesthesia, neuralgia, neuropathy peripheral, paresthesia, peripheral sensorimotor neuropathy, polyneuropathy
Table 5: Serious Adverse Reactions (SAR)
|Arterial ischemic event||34 (8%)|
|Myocardial infarction or worsening coronary artery disease||21 (5%)|
|Stroke or TIA||8 (2%)|
|Peripheral arterial disease||7 (2%)|
|CNS hemorrhage||10 (2%)|
|Gastrointestinal hemorrhage||10 (2%)|
|Cardiac failure||20 (4%)|
|Atrial fibrillation||11 (2%)|
|Venous thromboembolism||10 (2%)|
|Abdominal pain||17 (4%)|
|Blood and lymphatic system disorders|
|Febrile neutropenia||13 (3%)|
|*includes pericardial effusion, pleural effusion, and ascites|
Myelosuppression was commonly reported in all patient populations. The frequency of grade 3 or 4 thrombocytopenia, neutropenia, and anemia was higher in patients with AP-CML, BP-CML, and Ph+ ALL than in patients with CP-CML (see Table 6).
Table 6: Incidence of Clinically Relevant Grade 3/4*
|Thrombocytopenia (platelet count decreased)||36||47||57||47|
|Neutropenia (ANC decreased)||24||51||55||63|
|Leukopenia (WBC decreased)||14||35||53||63|
|Anemia (Hgb decreased)||9||26||55||34|
|ANC=absolute neutrophil count, Hgb=hemoglobin, WBC=white
blood cell count
*Reported using NCI-CTC-AE v 4.0
Table 7: Incidence of Clinically Relevant
Non-Hematologic Laboratory Abnormalities
|Laboratory Test||Safety Population N=449|
|Any Grade* (%)||G3-4 (%)|
|Liver function tests|
|Alkaline phosphatase increased||37||2|
|Amylase increased||3||< 1|
|Sodium increased||10||< 1|
|Bicarbonate decreased||11||< 1|
|Creatinine increased||7||< 1|
|Triglycerides increased||3||< 1|
|ALT=alanine aminotransferase, AST=aspartate
*Graded using NCI-CTC-AE v 4.0
Read the Iclusig (ponatinib tablets) Side Effects Center for a complete guide to possible side effects
Based on in vitro studies ponatinib is a substrate of CYP3A4/5 and to a lesser extent CYP2C8 and CYP2D6. Ponatinib also inhibits the P-glycoprotein (P-gp), ATP-binding cassette G2 (ABCG2) [also known as BCRP], and bile salt export pump (BSEP) transporter systems in vitro [see CLINICAL PHARMACOLOGY].
Drugs That Are Strong Inhibitors of CYP3A Enzymes
In a drug interaction study in healthy volunteers, co-administration of Iclusig with ketoconazole increased plasma ponatinib AUC0-inf and Cmax by 78% and 47%, respectively [see CLINICAL PHARMACOLOGY]. When administering Iclusig with strong CYP3A inhibitors (e.g., boceprevir, clarithromycin, conivaptan, grapefruit juice, indinavir, itraconazole, ketoconazole, lopinavir/ritonavir, nefazodone, nelfinavir, posaconazole, ritonavir, saquinavir, telaprevir, telithromycin, voriconazole), the recommended starting dose should be reduced to 30 mg once daily [see DOSAGE AND ADMINISTRATION]. Patients taking concomitant strong inhibitors may be at increased risk for adverse reactions [see CLINICAL PHARMACOLOGY].
Drugs That Are Strong Inducers of CYP3A Enzymes
Coadministration of Iclusig with strong CYP3A inducers was not evaluated in vitro or in a clinical trial; however, a reduction in ponatinib exposure is likely [see CLINICAL PHARMACOLOGY]. Coadministration of strong CYP3A inducers (e.g., carbamazepine, phenytoin, rifampin, and St. John's Wort) with Iclusig should be avoided unless the benefit outweighs the possible risk of ponatinib underexposure. Monitor patients for signs of reduced efficacy.
Drugs That Elevate Gastric pH
Coadministration of Iclusig with drugs that elevate the gastric pH was not evaluated in a clinical trial. Based on the chemical properties of ponatinib, elevated gastric pH may reduce bioavailability and exposure [see CLINICAL PHARMACOLOGY]. Coadministration of Iclusig with drugs that elevate the gastric pH (e.g., proton pump inhibitors, H2 blockers, or antacids) should be avoided unless the benefit outweighs the possible risk of ponatinib underexposure. Monitor patients for signs of reduced efficacy.
Drugs That Are Substrates of the P-gp or ABCG2 Transporter Systems
In vitro studies demonstrate that Iclusig inhibits the P-gp and ABCG2 [also known as BCRP] transporter systems. The effect of coadministration of Iclusig with sensitive substrates of the P-gp (e.g., aliskiren, ambrisentan, colchicine, dabigatran etexilate, digoxin, everolimus, fexofenadine, imatinib, lapatinib, maraviroc, nilotinib, posaconazole, ranolazine, saxagliptin, sirolimus, sitagliptin, tolvaptan, topotecan) and ABCG2 [also known as BCRP] (e.g., methotrexate, mitoxantrone, imatinib, irinotecan, lapatinib, rosuvastatin, sulfasalazine, topotecan) transporter systems on exposure of these substrates has not been evaluated in clinical studies.
Last reviewed on RxList: 7/30/2013
This monograph has been modified to include the generic and brand name in many instances.
Additional Iclusig Information
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