Adverse reactions : תופעות לוואי

8        ADVERSE REACTIONS
The following clinically significant adverse reactions are also discussed in other sections of the labeling:
•      Peripheral Neuropathy [see Warnings and Precautions (7.1)]
•      Hypotension [see Warnings and Precautions (7.2)]
•      Cardiac Toxicity [see Warnings and Precautions (7.3)]
•      Pulmonary Toxicity [see Warnings and Precautions (7.4)]
•      Posterior Reversible Encephalopathy Syndrome (PRES) [see Warnings and Precautions (7.5)]
•      Gastrointestinal Toxicity [see Warnings and Precautions (7.6)]
•      Thrombocytopenia/Neutropenia [see Warnings and Precautions (7.7)]
•      Hepatic impairment [see Warnings and Precautions (7.8)]
•      Tumor Lysis Syndrome [see Warnings and Precautions (7.9)]
•      Hepatic Toxicity [see Warnings and Precautions (7.10)]
•      Thrombotic Microangiopathy [see Warnings and Precautions (7.11)] 
8.1 Clinical Trials Experience
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 clinical practice.
Summary of Clinical Trial in Patients with Previously Untreated Multiple Myeloma Table 8 describes safety data from 340 patients with previously untreated multiple myeloma who received VELCADE (1.3 mg/m2) administered intravenously in combination with melphalan (9 mg/m2) and prednisone (60 mg/m2) in a prospective randomized study.
The safety profile of VELCADE in combination with melphalan/prednisone is consistent with the known safety profiles of both VELCADE and melphalan/prednisone.


Table 8: Most Commonly Reported Adverse Reactions (≥10% in the VELCADE, Melphalan and Prednisone Arm) with Grades 3 and ≥4 Intensity in the Previously Untreated Multiple Myeloma Study VELCADE, Melphalan and Prednisone            Melphalan and Prednisone (n=340)                               (n=337)
Body System                                   Total         Toxicity Grade, n (%)     Total      Toxicity Grade, n (%) Adverse Reaction                              n (%)            3             ≥4       n (%)         3             ≥4 Blood and Lymphatic System Disorders
Thrombocytopenia                          164 (48)        60 (18)        57 (17)   140 (42)    48 (14)       39 (12) Neutropenia                               160 (47)       101 (30)        33 (10)   143 (42)    77 (23)       42 (12) Anemia                                    109 (32)        41 (12)         4 (1)    156 (46)    61 (18)        18 (5) Leukopenia                                108 (32)        64 (19)         8 (2)    93 (28)     53 (16)        11 (3) Lymphopenia                                78 (23)        46 (14)        17 (5)    51 (15)      26 (8)         7 (2) Gastrointestinal Disorders
Nausea                                    134 (39)        10 (3)           0       70 (21)      1 (<1)          0 Diarrhea                                  119 (35)        19 (6)          2 (1)     20 (6)      1 (<1)          0 Vomiting                                   87 (26)        13 (4)           0       41 (12)      2 (1)           0 Constipation                               77 (23)         2 (1)           0        14 (4)        0             0 Abdominal pain upper                       34 (10)        1 (<1)           0        20 (6)        0             0 Nervous System Disorders
Peripheral neuropathy*                    156 (46)        42 (12)         2 (1)     4 (1)         0             0 Neuralgia                                 117 (34)        27 (8)          2 (1)     1 (<1)        0             0 Paresthesia                                42 (12)         6 (2)           0        4 (1)         0             0 General Disorders and Administration Site Conditions
Fatigue                                    85 (25)        19 (6)          2 (1)    48 (14)      4 (1)           0 Asthenia                                   54 (16)        18 (5)           0        23 (7)      3 (1)           0 Pyrexia                                    53 (16)         4 (1)           0        19 (6)      1 (<1)        1 (<1) Infections and Infestations
Herpes Zoster                              39 (11)        11 (3)           0        9 (3)       4 (1)           0 Metabolism and Nutrition Disorders
Anorexia                                   64 (19)         6 (2)           0        19 (6)        0             0 Skin and Subcutaneous Tissue Disorders
Rash                                       38 (11)         2 (1)           0        7 (2)         0             0 Psychiatric Disorders
Insomnia                                   35 (10)        1 (<1)           0        21 (6)        0             0 * Represents High Level Term Peripheral Neuropathies NEC

Relapsed Multiple Myeloma Randomized Study of VELCADE vs Dexamethasone The safety data described below and in Table 10 reflect exposure to either VELCADE (n=331) or dexamethasone (n=332) in a study of patients with relapsed multiple myeloma. VELCADE was administered intravenously at doses of 1.3 mg/m2 twice weekly for two out of three weeks (21 day cycle). After eight, 21 day cycles patients continued therapy for three, 35 day cycles on a weekly schedule. Duration of treatment was up to 11 cycles (nine months) with a median duration of six cycles (4.1 months). For inclusion in the trial, patients must have had measurable disease and one to three prior therapies. There was no upper age limit for entry.
Creatinine clearance could be as low as 20 mL/min and bilirubin levels as high as 1.5 times the upper limit of normal. The overall frequency of adverse reactions was similar in men and women, and in patients <65 and ≥65 years of age. Most patients were Caucasian [see Clinical Studies (15.1)].
Among the 331 VELCADE-treated patients, the most commonly reported (>20%) adverse reactions overall were nausea (52%), diarrhea (52%), fatigue (39%), peripheral neuropathies (35%), thrombocytopenia (33%), constipation (30%), vomiting (29%), and anorexia (21%). The most commonly reported (>20%) adverse reaction reported among the 332 patients in the dexamethasone group was fatigue (25%). Eight percent (8%) of patients in the VELCADE-treated arm experienced a Grade 4 adverse reaction; the most common reactions were thrombocytopenia (4%) and neutropenia (2%). Nine percent (9%) of dexamethasone-treated patients experienced a Grade 4 adverse reaction. All individual dexamethasone-related Grade 4 adverse reactions were less than 1%.
Serious Adverse Reactions and Adverse Reactions Leading to Treatment Discontinuation in the Relapsed Multiple Myeloma Study of VELCADE vs Dexamethasone
Serious adverse reactions are defined as any reaction that results in death, is life-threatening, requires hospitalization or prolongs a current hospitalization, results in a significant disability, or is deemed to be an important medical event. A total of 80 (24%) patients from the VELCADE treatment arm experienced a serious adverse reaction during the study, as did 83 (25%) dexamethasone-treated patients. The most commonly reported serious adverse reactions in the VELCADE treatment arm were diarrhea (3%), dehydration, herpes zoster, pyrexia, nausea, vomiting, dyspnea, and thrombocytopenia (2% each). In the dexamethasone treatment group, the most commonly reported serious adverse reactions were pneumonia (4%), hyperglycemia (3%), pyrexia, and psychotic disorder (2% each).                                                                                                                              A total of 145 patients, including 84 (25%) of 331 patients in the VELCADE treatment group and 61 (18%) of 332 patients in the dexamethasone treatment group were discontinued from treatment due to adverse reactions. Among the 331 VELCADE-treated patients, the most commonly reported adverse reaction leading to discontinuation was peripheral neuropathy (8%). Among the 332 patients in the dexamethasone group, the most commonly reported adverse reactions leading to treatment discontinuation were psychotic disorder and hyperglycemia (2% each).
Four deaths were considered to be VELCADE-related in this relapsed multiple myeloma study: one case each of cardiogenic shock, respiratory insufficiency, congestive heart failure and cardiac arrest. Four deaths were considered dexamethasone-related: two cases of sepsis, one case of bacterial meningitis, and one case of sudden death at home.
Most Commonly Reported Adverse Reactions in the Relapsed Multiple Myeloma Study of VELCADE vs Dexamethasone The most common adverse reactions from the relapsed multiple myeloma study are shown in Table 9. All adverse reactions with incidence >10% in the VELCADE arm are included.
Table 9: Most Commonly Reported Adverse Reactions ( (≥10% in VELCADE Arm), with Grades 3 and 4 Intensity in the Relapsed Multiple Myeloma Study of VELCADE vs Dexamethasone (N=663)
VELCADE                                             Dexamethasone
(N=331)                                                (N=332)
Adverse
Reactions               All             Grade 3           Grade 4               All            Grade 3            Grade 4 Any Adverse
324 (98)          193 (58)            28 (8)           297 (89)          110 (33)            29 (9) Reactions
Nausea                172 (52)            8 (2)               0               31 (9)               0                 0 Diarrhea NOS          171 (52)           22 (7)               0              36 (11)            2 (<1)               0 Fatigue               130 (39)           15 (5)               0              82 (25)             8 (2)               0 Peripheral
115 (35)           23 (7)             2 (<1)            14 (4)               0               1 (<1) neuropathies*
Thrombocytope
109 (33)           80 (24)            12 (4)            11 (3)             5 (2)             1 (<1) nia
Constipation          99 (30)             6 (2)               0               27 (8)            1 (<1)               0 Vomiting NOS          96 (29)             8 (2)               0               10 (3)            1 (<1)               0 Anorexia              68 (21)             8 (2)               0                8 (2)            1 (<1)               0 Pyrexia               66 (20)            2 (<1)               0               21 (6)            3 (<1)             1 (<1) Paresthesia           64 (19)             5 (2)               0               24 (7)               0                 0 Anemia NOS            63 (19)            20 (6)             1 (<1)            21 (6)             8 (2)               0 Headache NOS          62 (19)            3 (<1)               0               23 (7)            1 (<1)               0 
Table 9: Most Commonly Reported Adverse Reactions ( (≥10% in VELCADE Arm), with Grades 3 and 4 Intensity in the Relapsed Multiple Myeloma Study of VELCADE vs Dexamethasone (N=663)
VELCADE                                     Dexamethasone
(N=331)                                        (N=332)
Adverse
Reactions                All            Grade 3            Grade 4          All         Grade 3           Grade 4 Neutropenia           58 (18)            37 (11)             8 (2)        1 (<1)          1 (<1)             0 Rash NOS              43 (13)            3 (<1)                0           7 (2)            0                0 Appetite
36 (11)               0                  0          12 (4)            0                0 decreased NOS
Dyspnea NOS           35 (11)            11 (3)              1 (<1)       37 (11)         7 (2)            1 (<1) Abdominal pain
35 (11)             5 (2)                0           7 (2)            0                0 NOS
Weakness              34 (10)            10 (3)                0          28 (8)          8 (2)              0 * Represents High Level Term Peripheral Neuropathies NEC

Safety Experience from the Phase 2 Open-Label Extension Study in Relapsed Multiple Myeloma In the Phase 2 extension study of 63 patients, no new cumulative or new long-term toxicities were observed with prolonged VELCADE treatment. These patients were treated for a total of 5.3 to 23months, including time on VELCADE in the prior VELCADE study [see Clinical Studies (15.1)].

Safety Experience from the Phase 3 Open-Label Study of VELCADE Subcutaneous vs Intravenous in Relapsed Multiple Myeloma The safety and efficacy of VELCADE administered subcutaneously were evaluated in one Phase 3 study at the recommended dose of 1.3 mg/m2. This was a randomized, comparative study of VELCADE subcutaneous vs intravenous in 222 patients with relapsed multiple myeloma. The safety data described below and in Table 10 reflect exposure to either VELCADE subcutaneous (N=147) or VELCADE intravenous (N=74) [see Clinical Studies (15.1)].



Table 10: Most Commonly Reported Adverse Reactions (≥10%), with Grade 3 and ≥4 Intensity in the Relapsed Multiple Myeloma Study (N=221) of VELCADE Subcutaneous vs Intravenous
Subcutaneous                              Intravenous
(N=147)                                   (N=74)
Body System                                        Total         Toxicity Grade, n (%)       Total        Toxicity Grade, n (%) Adverse Reaction                                   n (%)           3              ≥4         n (%)          3              ≥4 Blood and Lymphatic System Disorders
Anemia                                          28 (19)         8 (5)           0         17 (23)        3 (4)           0 Leukopenia                                      26 (18)         8 (5)           0         15 (20)        4 (5)         1 (1) Neutropenia                                     34 (23)        15 (10)        4 (3)       20 (27)      10 (14)         3 (4) Thrombocytopenia                                44 (30)         7 (5)         5 (3)       25 (34)        7 (9)         5 (7) Gastrointestinal Disorders
Diarrhea                                        28 (19)         1 (1)           0         21 (28)        3 (4)           0 Nausea                                          24 (16)              0          0         10 (14)         0              0 Vomiting                                         13 (9)         3 (2)           0          8 (11)         0              0 General Disorders and Administration Site Conditions
Asthenia                                         10 (7)         1 (1)           0         12 (16)        4 (5)           0 Fatigue                                          11 (7)         3 (2)           0         11 (15)        3 (4)           0 Pyrexia                                         18 (12)              0          0          6 (8)          0              0 Nervous System Disorders
Neuralgia                                       34 (23)         5 (3)           0         17 (23)        7 (9)           0 Peripheral neuropathies*                        55 (37)         8 (5)         1 (1)       37 (50)      10 (14)         1 (1) Note: Safety population: 147 patients in the subcutaneous treatment group and 74 patients in the intravenous treatment group who received at least one dose of study medication
* Represents High Level Term Peripheral Neuropathies NEC

In general, safety data were similar for the subcutaneous and intravenous treatment groups. Differences were observed in the rates of some Grade ≥3 adverse reactions. Differences of ≥5% were reported in neuralgia (3% subcutaneous vs 9% intravenous), peripheral neuropathies (6% subcutaneous vs 15% intravenous), neutropenia (13% subcutaneous vs 18% intravenous), and thrombocytopenia (8% subcutaneous vs 16% intravenous).
A local reaction was reported in 6% of patients in the subcutaneous group, mostly redness. Only two (1%) patients were reported as having severe reactions, one case of pruritus and one case of redness. Local reactions led to reduction in injection concentration in one patient and drug discontinuation in one patient. Local reactions resolved in a median of six days.
Dose reductions occurred due to adverse reactions in 31% of patients in the subcutaneous treatment group compared with 43% of the intravenously-treated patients. The most common adverse reactions leading to a dose reduction included peripheral sensory neuropathy (17% in the subcutaneous treatment group compared with 31% in the intravenous treatment group); and neuralgia (11% in the subcutaneous treatment group compared with 19% in the intravenous treatment group).
Serious Adverse Reactions and Adverse Reactions Leading to Treatment Discontinuation in the Relapsed Multiple Myeloma Study of VELCADE Subcutaneous vs Intravenous.
The incidence of serious adverse reactions was similar for the subcutaneous treatment group (20%) and the intravenous treatment group (19%). The most commonly reported serious adverse reactions in the subcutaneous treatment arm were pneumonia and pyrexia (2% each). In the intravenous treatment group, the most commonly reported serious adverse reactions were pneumonia, diarrhea, and peripheral sensory neuropathy (3% each).
In the subcutaneous treatment group, 27 patients (18%) discontinued study treatment due to an adverse reaction compared with 17 patients (23%) in the intravenous treatment group. Among the 147 subcutaneously-treated patients, the most commonly reported adverse reactions leading to discontinuation were peripheral sensory neuropathy (5%) and neuralgia (5%). Among the 74 patients in the intravenous treatment group, the most commonly reported adverse reactions leading to treatment discontinuation were peripheral sensory neuropathy (9%) and neuralgia (9%).
Two patients (1%) in the subcutaneous treatment group and one (1%) patient in the intravenous treatment group died due to an adverse reaction during treatment. In the subcutaneous group the causes of death were one case of pneumonia and one case of sudden death. In the intravenous group the cause of death was coronary artery insufficiency.
Safety Experience from the Clinical Trial in Patients with Previously Untreated Mantle Cell Lymphoma Table 11 describes safety data from 240 patients with previously untreated mantle cell lymphoma who received VELCADE (1.3 mg/m2) administered intravenously in combination with rituximab (375 mg/m2), cyclophosphamide (750 mg/m2), doxorubicin (50 mg/m2), and prednisone (100 mg/m2) (VcR-CAP) in a prospective randomized study.
Infections were reported for 31% of patients in the VcR-CAP arm and 23% of the patients in the comparator (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone [R-CHOP]) arm, including the predominant preferred term of pneumonia (VcR-CAP 8% vs R-CHOP 5%).

Table 11: Most Commonly Reported Adverse Reactions (≥5%) with Grades 3 and ≥4 Intensity in the Previously Untreated Mantle Cell Lymphoma Study
VcR-CAP                                           R-CHOP
(n=240)                                           (n=242)
Toxicity         Toxicity                           Toxicity        Toxicity Body System                All          Grade 3          Grade ≥4            All            Grade 3         Grade ≥4 Adverse Reactions         n (%)          n (%)             n (%)            n (%)            n (%)            n (%) Blood and Lymphatic System Disorders
Neutropenia         209 (87)           32 (13)          168 (70)         172 (71)         31 (13)         125 (52) Leukopenia          116 (48)           34 (14)           69 (29)          87 (36)         39 (16)          27 (11) Anemia              106 (44)           27 (11)            4 (2)           71 (29)         23 (10)           4 (2) Thrombocytopeni a                 172 (72)           59 (25)          76 (32)          42 (17)           9 (4)            3 (1) Febrile neutropenia        41 (17)           24 (10)           12 (5)          33 (14)           17 (7)          15 (6) Lymphopenia          68 (28)           25 (10)          36 (15)          28 (12)           15 (6)           2 (1) Nervous System Disorders
Peripheral neuropathy*      71 (30)            17 (7)            1 (<1)          65 (27)           10 (4)            0 Hypoesthesia         14 (6)             3 (1)               0             13 (5)             0               0 Paresthesia          14 (6)             2 (1)               0             11 (5)             0               0 Neuralgia           25 (10)             9 (4)               0             1 (<1)             0               0 General Disorders and Administration Site Conditions
Fatigue              43 (18)          11 (5)             1 (<1)          38 (16)           5 (2)             0 Pyrexia              48 (20)           7 (3)                0            23 (10)           5 (2)             0 Asthenia             29 (12)           4 (2)             1 (<1)           18 (7)           1 (<1)            0 Edema peripheral      16 (7)          1 (<1)                0             13 (5)              0              0 Gastrointestinal Disorders
Nausea                 54 (23)         1 (<1)              0             28 (12)             0                0 Constipation           42 (18)         1 (<1)              0              22 (9)           2 (1)              0 Stomatitis              20 (8)          2 (1)              0              19 (8)             0             1 (<1) Diarrhea               59 (25)         11 (5)              0              11 (5)           3 (1)           1 (<1) Vomiting               24 (10)         1 (<1)              0               8 (3)             0                0 Abdominal distension           13 (5)           0                 0              4 (2)              0               0 Infections and Infestations
Pneumonia              20 (8)          8 (3)             5 (2)           11 (5)           5 (2)            3 (1) Skin and Subcutaneous Tissue Disorders
Alopecia             31 (13)         1 (<1)               1 (<1)           33 (14)            4 (2)              0 Metabolism and Nutrition Disorders
Hyperglycemia          10 (4)            1 (<1)              0               17 (7)           10 (4)              0 Decreased appetite           36 (15)             2 (1)              0               15 (6)           1 (<1)              0 Vascular Disorders
Hypertension            15 (6)          1 (<1)              0               3 (1)               0                0 Psychiatric Disorders
Insomnia                16 (7)          1 (<1)              0               8 (3)               0                0 
Key: R-CHOP = rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone; VcR-CAP = VELCADE, rituximab, cyclophosphamide, doxorubicin, and prednisone.
* Represents High Level Term Peripheral Neuropathies NEC

The incidence of herpes zoster reactivation was 4.6% in the VcR-CAP arm and 0.8% in the R-CHOP arm. Antiviral prophylaxis was mandated by protocol amendment.
The incidences of Grade ≥3 bleeding events were similar between the two arms (four patients in the VcR-CAP arm and three patients in the R-CHOP arm). All of the Grade ≥3 bleeding events resolved without sequelae in the VcR-CAP arm.
Adverse reactions leading to discontinuation occurred in 8% of patients in VcR-CAP group and 6% of patients in R-CHOP group. In the VcR-CAP group, the most commonly reported adverse reaction leading to discontinuation was peripheral sensory neuropathy (1%; three patients). The most commonly reported adverse reaction leading to discontinuation in the R-CHOP group was febrile neutropenia (<1%; two patients).

Mantle Cell Lymphoma (MCL)
The safety profile of VELCADE in 240 MCL patients treated with VELCADE at 1.3 mg/m2 in combination with rituximab, cyclophosphamide, doxorubicin, and prednisone (VcR-CAP) versus 242 patients treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone [R-CHOP] was relatively consistent to that observed in patients with multiple myeloma with main differences described below. Additional adverse drug reactions identified associated with the use of the combination therapy (VcR-CAP) were hepatitis B infection (< 1%) and myocardial ischaemia (1.3%). The similar incidences of these events in both treatment arms, indicated that these adverse drug reactions are not attributable to VELCADE alone. Notable differences in the MCL patient population as compared to patients in the multiple myeloma studies were a ≥ 5% higher incidence of the haematological adverse reactions (neutropenia, thrombocytopenia, leukopenia, anemia, lymphopenia), peripheral sensory neuropathy, hypertension, pyrexia, pneumonia, stomatitis, and hair disorders.
Adverse drug reactions identified as those with a ≥ 1% incidence, similar or higher incidence in the VcR-CAP arm and with at least a possible or probable causal relationship to the components of the VcR-CAP arm, are listed in Table 8 below. Also included are adverse drug reactions identified in the VcR-CAP arm that were considered by investigators to have at least a possible or probable causal relationship to VELCADE based on historical data in the multiple myeloma studies.
Adverse reactions are listed below by system organ class and frequency grouping. Frequencies are defined as: Very common (≥ 1/10); common (≥ 1/100 to < 1/10); uncommon (≥ 1/1,000 to < 1/100); rare (≥ 1/10,000 to < 1/1,000); very rare (< 1/10,000), not known (cannot be estimated from the available data). Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness. Table 12 has been generated using Version 16 of the MedDRA.

Table 12: Adverse reactions in patients with Mantle Cell Lymphoma treated with VcR-CAP in a clinical trial System Organ Class          Incidence        Adverse reaction
Infections and infestations Very Common Pneumonia*
Common           Sepsis (inc septic shock)*, Herpes zoster (inc disseminated & ophthalmic), Herpes virus infection*, Bacterial infections*,
Upper/lower respiratory tract infection*, Fungal infection*, Herpes simplex*

                              Uncommon      Hepatitis B, Infection*, Bronchopneumonia
Blood and lymphatic           Very Common   Thrombocytopenia*, Febrile neutropenia, Neutropenia*, system disorders                            Leukopenia*, Anaemia*, Lymphopenia* Uncommon      Pancytopenia*
Immune system disorders       Common        Hypersensitivity*
Uncommon      Anaphylactic reaction
Metabolism and nutrition      Very Common   Decreased appetite disorders                     Common        Hypokalaemia*, Blood glucose abnormal*, Hyponatraemia*, Diabetes mellitus*, Fluid retention
Uncommon      Tumour lysis syndrome
Psychiatric disorders         Common        Sleep disorders and disturbances* Nervous system disorders      Very Common   Peripheral sensory neuropathy, Dysaesthesia*, Neuralgia* Common        Neuropathies*, Motor neuropathy*, Loss of consciousness (inc syncope), Encephalopathy*, Peripheral sensorimotor neuropathy,
Dizziness*, Dysgeusia*, Autonomic neuropathy
Uncommon        Autonomic nervous system imbalance
Eye disorders               Common          Vision abnormal*
Ear and labyrinth disorders Common          Dysacusis (inc tinnitus)* Uncommon        Vertigo*, Hearing impaired (up to and inc deafness)
Cardiac disorders           Common          Cardiac fibrillation (inc atrial), Arrhythmia*, Cardiac failure (inc left and right ventricular)*, Myocardial ischaemia, Ventricular dysfunction*
Uncommon      Cardiovascular disorder (inc cardiogenic shock)
Vascular disorders            Common        Hypertension*, Hypotension*, Orthostatic hypotension Respiratory, thoracic and     Common        Dyspnoea*, Cough*, Hiccups mediastinal disorders         Uncommon      Acute respiratory distress syndrome, Pulmonary embolism, Pneumonitis, Pulmonary hypertension, Pulmonary oedema (inc acute)
Gastrointestinal disorders    Very Common   Nausea and vomiting symptoms*, Diarrhoea*, Stomatitis*, Constipation
Common        Gastrointestinal haemorrhage (inc mucosal)*, Abdominal distension, Dyspepsia, Oropharyngeal pain*, Gastritis*, Oral ulceration*,
Abdominal discomfort, Dysphagia, Gastrointestinal inflammation*,
Abdominal pain (inc gastrointestinal and splenic pain)*, Oral disorder*
Uncommon      Colitis (inc clostridium difficile)*
Hepatobiliary disorders       Common        Hepatotoxicity (inc liver disorder) Uncommon      Hepatic failure
Skin and subcutaneous         Very Common   Hair disorder* tissue disorders              Common        Pruritus*, Dermatitis*, Rash* Musculoskeletal and           Common        Muscle spasms*, Musculoskeletal pain*, Pain in extremity connective tissue disorders
Renal and urinary disorders   Common        Urinary tract infection*
General disorders and         Very Common   Pyrexia*, Fatigue, Asthenia administration site           Common        Oedema (inc peripheral), Chills, Injection site reaction*, Malaise* conditions
Investigations                Common        Hyperbilirubinaemia*, Protein analyses abnormal*, Weight decreased, Weight increased
 * Grouping of more than one MedDRA preferred term.
Integrated Summary of Safety (Relapsed Multiple Myeloma and Relapsed Mantle Cell Lymphoma) Safety data from Phase 2 and 3 studies of single agent VELCADE 1.3 mg/m2/dose twice weekly for two weeks followed by a ten day rest period in 1163 patients with previously-treated multiple myeloma (N=1008) and previously-treated mantle cell lymphoma (N=155) were integrated and tabulated. This analysis does not include data from the Phase 3 open-label study of VELCADE subcutaneous vs intravenous in relapsed multiple myeloma. In the integrated studies, the safety profile of VELCADE was similar in patients with multiple myeloma and mantle cell lymphoma. [see Clinical Studies (15)].
In the integrated analysis, the most commonly reported (>20%) adverse reactions were nausea (49%), diarrhea (46%), asthenic conditions including fatigue (41%) and weakness (11%), peripheral neuropathies (38%), thrombocytopenia (32%), vomiting (28%), constipation (25%), and pyrexia (21%). Eleven percent (11%) of patients experienced at least one episode of ≥Grade 4 toxicity, most commonly thrombocytopenia (4%) and neutropenia (2%).
In the Phase 2 relapsed multiple myeloma clinical trials of VELCADE administered intravenously, local skin irritation was reported in 5% of patients, but extravasation of VELCADE was not associated with tissue damage.
Serious Adverse Reactions and Adverse Reactions Leading to Treatment Discontinuation in the Integrated Summary of Safety A total of 26% of patients experienced a serious adverse reaction during the studies. The most commonly reported serious adverse reactions included diarrhea, vomiting and pyrexia (3% each), nausea, dehydration, and thrombocytopenia (2% each) and pneumonia, dyspnea, peripheral neuropathies, and herpes zoster (1% each).
Adverse reactions leading to discontinuation occurred in 22% of patients. The reasons for discontinuation included peripheral neuropathy (8%), and fatigue, thrombocytopenia, and diarrhea (2% each).
In total, 2% of the patients died and the cause of death was considered by the investigator to be possibly related to study drug: including reports of cardiac arrest, congestive heart failure, respiratory failure, renal failure, pneumonia and sepsis.
Most Commonly Reported Adverse Reactions in the Integrated Summary of Safety The most common adverse reactions are shown in Table 13. All adverse reactions occurring at ≥10% are included. In the absence of a randomized comparator arm, it is often not possible to distinguish between adverse events that are drug-caused and those that reflect the patient’s underlying disease. Please see the discussion of specific adverse reactions that follows.


Table 13: Most Commonly Reported (≥10% Overall) Adverse Reactions in Integrated Analyses of Relapsed Multiple Myeloma and Relapsed Mantle Cell Lymphoma Studies Using the 1.3 mg/m2 Dose (N=1163) All Patients                     Multiple Myeloma           Mantle Cell Lymphoma (N=1163)                            (N=1008)                      (N=155) Adverse                All              ≥Grade                All          ≥Grade          All            ≥Grade Reactions                                 3                                  3                              3 Nausea              567 (49)                36 (3)          511 (51)        32 (3)        56 (36)            4 (3) Diarrhea NOS        530 (46)                83 (7)          470 (47)        72 (7)        60 (39)           11 (7) Fatigue             477 (41)                86 (7)          396 (39)        71 (7)        81 (52)          15 (10) Peripheral          443 (38)            129 (11)            359 (36)       110 (11)       84 (54)          19 (12) neuropathies
*
Thrombocyto         369 (32)            295 (25)            344 (34)       283 (28)       25 (16)           12 (8) penia
Vomiting            321 (28)                44 (4)          286 (28)        40 (4)        35 (23)            4 (3) NOS
Constipation        296 (25)                17 (1)          244 (24)        14 (1)        52 (34)            3 (2) Pyrexia             249 (21)                16 (1)          233 (23)        15 (1)        16 (10)           1 (<1) Anorexia            227 (20)                19 (2)          205 (20)        16 (2)        22 (14)            3 (2) Anemia NOS          209 (18)                65 (6)          190 (19)        63 (6)        19 (12)            2 (1) Headache            175 (15)                8 (<1)          160 (16)         8 (<1)       15 (10)              0 NOS
Neutropenia         172 (15)            121 (10)            164 (16)       117 (12)         8 (5)            4 (3) Rash NOS            156 (13)                8 (<1)          120 (12)         4 (<1)       36 (23)            4 (3) Paresthesia         147 (13)                9 (<1)          136 (13)         8 (<1)       11 (7)            1 (<1) Dizziness           129 (11)                13 (1)          101 (10)         9 (<1)       28 (18)            4 (3) (excl vertigo)
Weakness            124 (11)                31 (3)          106 (11)        28 (3)        18 (12)            3 (2) * Represents High Level Term Peripheral Neuropathies NEC

Description of Selected Adverse Reactions from the Integrated Phase 2 and 3 Relapsed Multiple Myeloma and Phase 2 Relapsed Mantle Cell Lymphoma Studies
Gastrointestinal Toxicity
A total of 75% of patients experienced at least one gastrointestinal disorder. The most common gastrointestinal disorders included nausea, diarrhea, constipation, vomiting, and appetite decreased. Other gastrointestinal disorders included dyspepsia and dysgeusia. Grade 3 adverse reactions occurred in 14% of patients; ≥Grade 4 adverse reactions were ≤1%. Gastrointestinal adverse reactions were considered serious in 7% of patients. Four percent (4%) of patients discontinued due to a gastrointestinal adverse reaction. Nausea was reported more often in patients with multiple myeloma (51%) compared to patients with mantle cell lymphoma (36%).
Thrombocytopenia
Across the studies, VELCADE-associated thrombocytopenia was characterized by a decrease in platelet count during the dosing period (Days 1 to 11) and a return toward baseline during the ten day rest period during each treatment cycle. Overall, thrombocytopenia was reported in 32% of patients. Thrombocytopenia was Grade 3 in 22%, ≥Grade 4 in 4%, and serious in 2% of patients, and the reaction resulted in VELCADE discontinuation in 2% of patients [see Warnings and Precautions (7.7)].
Thrombocytopenia was reported more often in patients with multiple myeloma (34%) compared to patients with mantle cell lymphoma (16%). The incidence of ≥Grade 3 thrombocytopenia also was higher in patients with multiple myeloma (28%) compared to patients with mantle cell lymphoma (8%).


Peripheral Neuropathy
Overall, peripheral neuropathies occurred in 38% of patients. Peripheral neuropathy was Grade 3 for 11% of patients and ≥Grade 4 for <1% of patients. Eight percent (8%) of patients discontinued VELCADE due to peripheral neuropathy. The incidence of peripheral neuropathy was higher among patients with mantle cell lymphoma (54%) compared to patients with multiple myeloma (36%).
In the VELCADE vs dexamethasone Phase 3 relapsed multiple myeloma study, among the 62 VELCADE-treated patients who experienced ≥Grade 2 peripheral neuropathy and had dose adjustments, 48% had improved or resolved with a median of 3.8 months from first onset.
In the Phase 2 relapsed multiple myeloma studies, among the 30 patients who experienced Grade 2 peripheral neuropathy resulting in discontinuation or who experienced ≥Grade 3 peripheral neuropathy, 73% reported improvement or resolution with a median time of 47 days to improvement of one grade or more from the last dose of VELCADE.
Hypotension
The incidence of hypotension (postural, orthostatic and hypotension NOS) was 8% in patients treated with VELCADE. Hypotension was Grade 1 or 2 in the majority of patients and Grade 3 in 2% and≥Grade 4 in <1%. Two percent (2%) of patients had hypotension reported as a serious adverse reaction, and 1% discontinued due to hypotension. The incidence of hypotension was similar in patients with multiple myeloma (8%) and those with mantle cell lymphoma (9%). In addition, <1% of patients experienced hypotension associated with a syncopal reaction.
Neutropenia
Neutrophil counts decreased during the VELCADE dosing period (Days 1 to 11) and returned toward baseline during the ten day rest period during each treatment cycle. Overall, neutropenia occurred in 15% of patients and was Grade 3 in 8% of patients and ≥Grade 4 in 2%. Neutropenia was reported as a serious adverse reaction in <1% of patients and <1% of patients discontinued due to neutropenia. The incidence of neutropenia was higher in patients with multiple myeloma (16%) compared to patients with mantle cell lymphoma (5%). The incidence of ≥Grade 3 neutropenia also was higher in patients with multiple myeloma (12%) compared to patients with mantle cell lymphoma (3%).
Asthenic Conditions (Fatigue, Malaise, Weakness, Asthenia)
Asthenic conditions were reported in 54% of patients. Fatigue was reported as Grade 3 in 7% and ≥Grade 4 in <1% of patients.
Asthenia was reported as Grade 3 in 2% and ≥Grade 4 in <1% of patients. Two percent (2%) of patients discontinued treatment due to fatigue and <1% due to weakness and asthenia. Asthenic conditions were reported in 53% of patients with multiple myeloma and 59% of patients with mantle cell lymphoma.
Pyrexia
Pyrexia (>38ºC) was reported as an adverse reaction for 21% of patients. The reaction was Grade 3 in 1% and ≥Grade 4 in <1%.
Pyrexia was reported as a serious adverse reaction in 3% of patients and led to VELCADE discontinuation in <1% of patients. The incidence of pyrexia was higher among patients with multiple myeloma (23%) compared to patients with mantle cell lymphoma (10%). The incidence of ≥Grade 3 pyrexia was 1% in patients with multiple myeloma and <1% in patients with mantle cell lymphoma.
Herpes Virus Infection
Consider using antiviral prophylaxis in subjects being treated with VELCADE. In the randomized studies in previously untreated and relapsed multiple myeloma, herpes zoster reactivation was more common in subjects treated with VELCADE (ranging between 6 to 11%) than in the control groups (3 to 4%). Herpes simplex was seen in 1 to 3% in subjects treated with VELCADE and 1 to 3% in the control groups. In the previously untreated multiple myeloma study, herpes zoster virus reactivation in the VELCADE, melphalan and prednisone arm was less common in subjects receiving prophylactic antiviral therapy (3%) than in subjects who did not receive prophylactic antiviral therapy (17%).
Retreatment in Relapsed Multiple Myeloma
A single-arm trial was conducted in 130 patients with relapsed multiple myeloma to determine the efficacy and safety of retreatment with intravenous VELCADE. The safety profile of patients in this trial is consistent with the known safety profile of VELCADE-treated patients with relapsed multiple myeloma as demonstrated in Tables 10, 11, and 13; no cumulative toxicities were observed upon retreatment. The most common adverse drug reaction was thrombocytopenia which occurred in 52% of the patients. The incidence of ≥Grade 3 thrombocytopenia was 24%. Peripheral neuropathy occurred in 28% of patients, with the incidence of ≥Grade 3 peripheral neuropathy reported at 6%. The incidence of serious adverse reactions was 12.3%. The most commonly reported serious adverse reactions were thrombocytopenia (3.8%), diarrhea (2.3%), and herpes zoster and pneumonia (1.5% each).
Adverse reactions leading to discontinuation occurred in 13% of patients. The reasons for discontinuation included peripheral neuropathy (5%) and diarrhea (3%).

Two deaths considered to be VELCADE-related occurred within 30 days of the last VELCADE dose; one in a patient with cerebrovascular accident and one in a patient with sepsis.
Additional Adverse Reactions from Clinical Studies
The following clinically important serious adverse reactions that are not described above have been reported in clinical trials in patients treated with VELCADE administered as monotherapy or in combination with other chemotherapeutics. These studies were conducted in patients with hematological malignancies and in solid tumors.
Blood and Lymphatic System Disorders: Anemia, disseminated intravascular coagulation, febrile neutropenia, lymphopenia, leukopenia
Cardiac Disorders: Angina pectoris, atrial fibrillation aggravated, atrial flutter, bradycardia, sinus arrest, cardiac amyloidosis, complete atrioventricular block, myocardial ischemia, myocardial infarction, pericarditis, pericardial effusion, Torsades de pointes, ventricular tachycardia
Ear and Labyrinth Disorders: Hearing impaired, vertigo
Eye Disorders: Diplopia and blurred vision, conjunctival infection, irritation Gastrointestinal Disorders: Abdominal pain, ascites, dysphagia, fecal impaction, gastroenteritis, gastritis hemorrhagic, hematemesis, hemorrhagic duodenitis, ileus paralytic, large intestinal obstruction, paralytic intestinal obstruction, peritonitis, small intestinal obstruction, large intestinal perforation, stomatitis, melena, pancreatitis acute, oral mucosal petechiae, gastroesophageal reflux
General Disorders and Administration Site Conditions: Chills, edema, edema peripheral, injection site erythema, neuralgia, injection site pain, irritation, malaise, phlebitis
Hepatobiliary Disorders: Cholestasis, hepatic hemorrhage, hyperbilirubinemia, portal vein thrombosis, hepatitis, liver failure Immune System Disorders: Anaphylactic reaction, drug hypersensitivity, immune complex mediated hypersensitivity, angioedema, laryngeal edema
Infections and Infestations: Aspergillosis, bacteremia, bronchitis, urinary tract infection, herpes viral infection, listeriosis, nasopharyngitis, pneumonia, respiratory tract infection, septic shock, toxoplasmosis, oral candidiasis, sinusitis, catheter-related infection
Injury, Poisoning and Procedural Complications: Catheter-related complication, skeletal fracture, subdural hematoma Investigations: Weight decreased
Metabolism and Nutrition Disorders: Dehydration, hypocalcemia, hyperuricemia, hypokalemia, hyperkalemia, hyponatremia, hypernatremia
Musculoskeletal and Connective Tissue Disorders: Arthralgia, back pain, bone pain, myalgia, pain in extremity Nervous System Disorders: Ataxia, coma, dizziness, dysarthria, dysesthesia, dysautonomia, encephalopathy, cranial palsy, grand mal convulsion, headache, hemorrhagic stroke, motor dysfunction, neuralgia, spinal cord compression, paralysis, postherpetic neuralgia, transient ischemic attack

Psychiatric Disorders: Agitation, anxiety, confusion, insomnia, mental status change, psychotic disorder, suicidal ideation Renal and Urinary Disorders: Calculus renal, bilateral hydronephrosis, bladder spasm, hematuria, hemorrhagic cystitis, urinary incontinence, urinary retention, renal failure (acute and chronic), glomerular nephritis proliferative Respiratory, Thoracic and Mediastinal Disorders: Acute respiratory distress syndrome, aspiration pneumonia, atelectasis, chronic obstructive airways disease exacerbated, cough, dysphagia, dyspnea, dyspnea exertional, epistaxis, hemoptysis, hypoxia, lung infiltration, pleural effusion, pneumonitis, respiratory distress, pulmonary hypertension Skin and Subcutaneous Tissue Disorders: Urticaria, face edema, rash (which may be pruritic), leukocytoclastic vasculitis, pruritus Vascular Disorders: Cerebrovascular accident, cerebral hemorrhage, deep venous thrombosis, hypertension, peripheral embolism, pulmonary embolism, pulmonary hypertension
Mantle cell lymphoma
Antiviral prophylaxis was administered to 137 of 240 patients (57%) in the VcR-CAP arm. The incidence of herpes zoster among 
patients in the VcR-CAP arm was 10.7% for patients not administered antiviral prophylaxis compared to 3.6% for patients administered antiviral prophylaxis (see section 7.13).

Hepatitis B Virus (HBV) reactivation and infection

Mantle cell lymphoma
HBV infection with fatal outcomes occurred in 0.8% (n=2) of patients in the non-VELCADE treatment group (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone; R-CHOP ) and 0.4% (n=1) of patients receiving VELCADE in combination with rituximab, cyclophosphamide, doxorubicin, and prednisone (VcR-CAP). The overall incidence of hepatitis B infections was similar in patients treated with VcR-CAP or with R-CHOP (0.8% vs 1.2% respectively).

Mantle cell lymphoma

In study LYM-3002 in which VELCADE was administered with rituximab, cyclophosphamide, doxorubicin, and prednisone (R-CAP), the incidence of peripheral neuropathy in the combination regimens is presented in the table below: 
Table 14: Incidence of peripheral neuropathy in study LYM-3002 by toxicity and treatment discontinuation due to peripheral neuropathy

VcR-CAP                         R-CHOP

(N=240)                         (N=242)
Incidence of PN (%)

All GradePN                                    30                              29 
≥ Grade 2 PN                                   18                              9 
≥ Grade 3 PN                                   8                               4 
Discontinuation due to PN (%)                   2                               <1 
VcR-CAP=VELCADE, rituximab, cyclophosphamide, doxorubicin, and prednisone; R-CHOP= rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone; PN=peripheral neuropathy 
Peripheral neuropathy included the preferred terms: peripheral sensory neuropathy, neuropathy peripheral, peripheral motor neuropathy, and peripheral sensorimotor neuropathy 
Elderly MCL patients

42.9% and 10.4% of patients in the VcR-CAP arm were in the range 65-74 years and ≥ 75 years of age, respectively. Although in patients aged ≥ 75 years, both VcR-CAP and R-CHOP were less tolerated, the serious adverse event rate in the VcR-CAP groups was 68%, compared to 42% in the R-CHOP group.

8.2      Postmarketing Experience
The following adverse reactions have been identified from the worldwide postmarketing experience with VELCADE. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure:

Cardiac Disorders: Cardiac tamponade
Ear and Labyrinth Disorders: Deafness bilateral
Eye Disorders: Optic neuropathy, blindness, chalazion/blepharitis
Gastrointestinal Disorders: Ischemic colitis
Infections and Infestations: Progressive multifocal leukoencephalopathy (PML), ophthalmic herpes, herpes meningoencephalitis 

Nervous System Disorders: Posterior reversible encephalopathy syndrome (PRES, formerly RPLS), Guillain-Barré syndrome, demyelinating polyneuropathy
Respiratory, Thoracic and Mediastinal Disorders: Acute diffuse infiltrative pulmonary disease Skin and Subcutaneous Tissue Disorders: Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), acute febrile neutrophilic dermatosis (Sweet’s syndrome)

Reportingof suspected adverse reactions                                                                                    Reporting suspected adverse reactions after authorization of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Any suspected adverse events should be reported to the Ministry of Health according to the National Regulation by using an online form http://sideeffects.health.gov.il