1. Name Of The Medicinal Product
SPRYCEL®
SPRYCEL®
SPRYCEL®
SPRYCEL®
SPRYCEL®
SPRYCEL®
2. Qualitative And Quantitative Composition
Each film-coated tablet contains 20 mg, 50 mg, 70 mg, 80 mg, 100 mg or 140 mg dasatinib (as monohydrate).
Excipients
Each 20 mg tablet contains 27 mg of lactose monohydrate.
Each 50 mg tablet contains 67.5 mg of lactose monohydrate.
Each 70 mg tablet contains 94.5 mg of lactose monohydrate.
Each 80 mg tablet contains 108 mg of lactose monohydrate.
Each 100 mg tablet contains 135.0 mg of lactose monohydrate.
Each 140 mg tablet contains 189 mg of lactose monohydrate.
For a full list of excipients, see section 6.1.
3. Pharmaceutical Form
Film-coated tablet (tablet).
20 mg: White to off-white, biconvex, round tablet with “BMS” debossed on one side and “527” on the other side.
50 mg: White to off-white, biconvex, oval tablet with “BMS” debossed on one side and “528” on the other side.
70 mg: White to off-white, biconvex, round tablet with “BMS” debossed on one side and “524” on the other side.
80 mg: White to off-white, biconvex, triangular tablet with "BMS 80" debossed on one side and "855" on the other side.
100 mg: White to off-white, biconvex, oval tablet with “BMS 100” debossed on one side and “852” on the other side.
140 mg: White to off-white, biconvex, round tablet with "BMS 140" debossed on one side and "857" on the other side.
4. Clinical Particulars
4.1 Therapeutic Indications
SPRYCEL is indicated for the treatment of adult patients with:
• newly diagnosed Philadelphia chromosome positive (Ph+) chronic myelogenous leukaemia (CML) in the chronic phase.
• chronic, accelerated or blast phase CML with resistance or intolerance to prior therapy including imatinib mesilate.
• Ph+ acute lymphoblastic leukaemia (ALL) and lymphoid blast CML with resistance or intolerance to prior therapy.
4.2 Posology And Method Of Administration
Therapy should be initiated by a physician experienced in the diagnosis and treatment of patients with leukaemia.
Posology
The recommended starting dose for chronic phase CML is 100 mg dasatinib once daily, administered orally.
The recommended starting dose for accelerated, myeloid or lymphoid blast phase (advanced phase) CML or Ph+ ALL is 140 mg once daily, administered orally (see section 4.4).
Treatment duration
In clinical studies, treatment with SPRYCEL was continued until disease progression or until no longer tolerated by the patient. The effect of stopping treatment after the achievement of a complete cytogenetic response (CCyR) has not been investigated.
To achieve the recommended dose, SPRYCEL is available as 20 mg, 50 mg, 70 mg, 80 mg, 100 mg and 140 mg film-coated tablets. Dose increase or reduction is recommended based on patient response and tolerability.
Dose escalation
In clinical studies in adult CML and Ph+ ALL patients, dose escalation to 140 mg once daily (chronic phase CML) or 180 mg once daily (advanced phase CML or Ph+ ALL) was allowed in patients who did not achieve a haematologic or cytogenetic response at the recommended starting dose.
Dose adjustment for adverse reactions
Myelosuppression
In clinical studies, myelosuppression was managed by dose interruption, dose reduction, or discontinuation of study therapy. Platelet transfusion and red cell transfusion were used as appropriate. Haematopoietic growth factor has been used in patients with resistant myelosuppression.
Guidelines for dose modifications are summarized in Table 1.
Table 1: Dose adjustments for neutropenia and thrombocytopenia
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|
|
Chronic Phase CML
(starting dose 100 mg once daily)
|
ANC < 0.5 x 109/l
and/or
Platelets < 50 x 109/l
|
1 Stop treatment until ANC 9/l and platelets 9/l.
2 Resume treatment at the original starting dose.
3 If platelets < 25 x 109/l and/or recurrence of ANC < 0.5 x 109/l for > 7 days, repeat step 1 and resume treatment at a reduced dose of 80 mg once daily for second episode. For third episode, further reduce dose to 50 mg once daily (for newly diagnosed patients) or discontinue (for patients resistant or intolerant to prior therapy including imatinib).
|
Accelerated and Blast Phase CML and Ph+ ALL
(starting dose 140 mg once daily)
|
ANC < 0.5 x 109/l
and/or
Platelets < 10 x 109/l
|
1 Check if cytopenia is related to leukaemia (marrow aspirate or biopsy).
2 If cytopenia is unrelated to leukaemia, stop treatment until ANC 9/l and platelets 9/l and resume at the original starting dose.
3 If recurrence of cytopenia, repeat step 1 and resume treatment at a reduced dose of 100 mg once daily (second episode) or 80 mg once daily (third episode).
4 If cytopenia is related to leukaemia, consider dose escalation to 180 mg once daily.
|
ANC: absolute neutrophil count
Non-haematological adverse reactions
If a moderate, grade 2, non-haematological adverse reaction develops with dasatinib, interrupt treatment until the event has resolved or returned to baseline. Resume at the same dose if this is the first occurrence and at a reduced dose if this is a recurrent event. If a severe grade 3 or 4, non-haematological adverse reaction develops with dasatinib, treatment must be withheld until the event has resolved. Thereafter, treatment can be resumed as appropriate at a reduced dose depending on the initial severity of the event. For patients with chronic phase CML who received 100 mg once daily, dose reduction to 80 mg once daily with further reduction from 80 mg once daily to 50 mg once daily, if needed, is recommended. For patients with advanced phase CML or Ph+ ALL who received 140 mg once daily, dose reduction to 100 mg once daily with further reduction from 100 mg once daily to 50 mg once daily, if needed, is recommended.
Pleural effusion: if a pleural effusion is diagnosed, interrupt dasatinib until patient is asymptomatic or has returned to baseline. If the episode does not improve within approximately one week, consider a course of diuretics or corticosteroids or both concurrently (see sections 4.4 and 4.8). Following resolution of the first episode, consider reintroduction of dasatinib at the same dose level. Following resolution of a subsequent episode, reintroduce dasatinib at one dose level reduction. Following resolution of a severe (grade 3 or 4) episode, treatment can be resumed as appropriate at a reduced dose depending on the initial severity of the event.
Paediatric population
The safety and efficacy of SPRYCEL in children and adolescents below 18 years of age have not yet been established. No data are available (see section 5.1).
Elderly population
No clinically relevant age-related pharmacokinetic differences have been observed in these patients. No specific dose recommendation is necessary in the elderly.
Hepatic impairment
Patients with mild, moderate or severe hepatic impairment may receive the recommended starting dose. However, SPRYCEL should be used with caution in patients with hepatic impairment (see sections 4.4 and 5.2).
Renal impairment
No clinical studies were conducted with SPRYCEL in patients with decreased renal function (the study in patients with newly diagnosed chronic phase CML excluded patients with serum creatinine concentration > 3 times the upper limit of the normal range, and studies in patients with chronic phase CML with resistance or intolerance to prior imatinib therapy excluded patients with serum creatinine concentration > 1.5 times the upper limit of the normal range). Since the renal clearance of dasatinib and its metabolites is < 4%, a decrease in total body clearance is not expected in patients with renal insufficiency.
Method of administration
SPRYCEL must be administered orally.
Tablets must not be crushed or cut in order to minimize the risk of dermal exposure, they must be swallowed whole. They can be taken with or without a meal and should be taken consistently either in the morning or in the evening.
4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients.
4.4 Special Warnings And Precautions For Use
Clinically relevant interactions
Dasatinib is a substrate and an inhibitor of cytochrome P450 (CYP) 3A4. Therefore, there is a potential for interaction with other concomitantly administered medicinal products that are metabolized primarily by or modulate the activity of CYP3A4 (see section 4.5).
Concomitant use of dasatinib and medicinal products that potently inhibit CYP3A4 (e.g. ketoconazole, itraconazole, erythromycin, clarithromycin, ritonavir, telithromycin) may increase exposure to dasatinib. Therefore, in patients receiving dasatinib, coadministration of a potent CYP3A4 inhibitor is not recommended (see section 4.5).
Concomitant use of dasatinib and medicinal products that induce CYP3A4 (e.g. dexamethasone, phenytoin, carbamazepine, rifampicin, phenobarbital or herbal preparations containing Hypericum perforatum, also known as St. John's Wort) may substantially reduce exposure to dasatinib, potentially increasing the risk of therapeutic failure. Therefore, in patients receiving dasatinib, coadministration of alternative medicinal products with less potential for CYP3A4 induction should be selected (see section 4.5).
Concomitant use of dasatinib and a CYP3A4 substrate may increase exposure to the CYP3A4 substrate. Therefore, caution is warranted when dasatinib is coadministered with CYP3A4 substrates of narrow therapeutic index, such as astemizole, terfenadine, cisapride, pimozide, quinidine, bepridil or ergot alkaloids (ergotamine, dihydroergotamine) (see section 4.5).
The concomitant use of dasatinib and a histamine-2 (H2) antagonist (e.g. famotidine), proton pump inhibitor (e.g. omeprazole), or aluminium hydroxide/magnesium hydroxide may reduce the exposure to dasatinib. Thus, H2 antagonists and proton pump inhibitors are not recommended and aluminium hydroxide/magnesium hydroxide products should be administered up to 2 hours prior to, or 2 hours following the administration of dasatinib (see section 4.5).
Special populations
Based on the findings from a single-dose pharmacokinetic study, patients with mild, moderate or severe hepatic impairment may receive the recommended starting dose (see sections 4.2 and 5.2). Due to the limitations of this clinical study, caution is recommended when administering dasatinib to patients with hepatic impairment (see section 4.2).
Important adverse reactions
Myelosuppression
Treatment with dasatinib is associated with anaemia, neutropenia and thrombocytopenia. Their occurrence is more frequent in patients with advanced phase CML or Ph+ ALL than in chronic phase CML. Complete blood counts should be performed weekly for the first 2 months, and then monthly thereafter, or as clinically indicated. Myelosuppression was generally reversible and usually managed by withholding dasatinib temporarily or by dose reduction (see sections 4.2 and 4.8).
In a Phase III dose-optimisation study in patients with chronic phase CML with resistance or intolerance to prior imatinib therapy, grade 3 or 4 myelosuppression was reported more frequently in patients treated with 70 mg twice daily than in patients treated with 100 mg once daily.
Bleeding
In the Phase III study in patients with newly diagnosed chronic phase CML, 1 patient (< 1%) receiving dasatinib compared to 2 patients (1%) receiving imatinib had grade 3 or 4 haemorrhage. In clinical studies in patients with resistance or intolerance to prior imatinib therapy, severe central nervous system (CNS) haemorrhage occurred in < 1% of patients. Eight cases were fatal and 6 of them were associated with Common Toxicity Criteria (CTC) grade 4 thrombocytopenia. Grade 3 or 4 gastrointestinal haemorrhage occurred in 4% of patients with resistance or intolerance to prior imatinib therapy and generally required treatment interruptions and transfusions. Other grade 3 or 4 haemorrhage occurred in 2% of patients with resistance or intolerance to prior imatinib therapy. Most bleeding related events in these patients were typically associated with grade 3 or 4 thrombocytopenia (see section 4.8). Additionally, in vitro and in vivo platelet assays suggest that SPRYCEL treatment reversibly affects platelet activation.
Patients were excluded from participation in initial SPRYCEL clinical studies if they took medicinal products that inhibit platelet function or anticoagulants. In subsequent studies, the use of anticoagulants, acetylsalicylic acid, and non-steroidal anti-inflammatory drugs (NSAIDs) was allowed concurrently with SPRYCEL if the platelet count was > 50,000-75,000/mm3. Caution should be exercised if patients are required to take medicinal products that inhibit platelet function or anticoagulants.
Fluid retention
Dasatinib is associated with fluid retention. In the Phase III clinical study in patients with newly diagnosed chronic phase CML, grade 3 or 4 fluid retention was reported in 2 patients (1%) in each of the dasatinib and the imatinib-treatment groups (see section 4.8). In clinical studies in patients with resistance or intolerance to prior imatinib therapy, grade 3 or 4 fluid retention was reported in 10% of patients, including grade 3 or 4 pleural and pericardial effusion reported in 7% and 1% of patients, respectively. In these studies, grade 3 or 4 ascites and generalised oedema were each reported in < 1% of patients, and grade 3 or 4 pulmonary oedema was reported in 1% of patients.
Patients who develop symptoms suggestive of pleural effusion such as dyspnoea or dry cough should be evaluated by chest X-ray. Grade 3 or 4 pleural effusion may require thoracocentesis and oxygen therapy. Fluid retention events were typically managed by supportive care measures that include diuretics and short courses of steroids (see sections 4.2 and 4.8). While the safety profile of SPRYCEL in the elderly population was similar to that in the younger population, patients aged 65 years and older are more likely to experience fluid retention events and dyspnoea and should be monitored closely. Fluid retention was reported less frequently in patients treated with once daily schedule compared to twice daily in two Phase III dose-optimisation studies (see section 4.8).
Pulmonary arterial hypertension (PAH)
PAH (pre-capillary pulmonary arterial hypertension confirmed by right heart catheterization) has been reported in association with dasatinib treatment in post-marketing reports (see section 4.8). In these cases, PAH was reported after initiation of dasatinib therapy, including after more than one year of treatment.
Patients should be evaluated for signs and symptoms of underlying cardiopulmonary disease prior to initiating dasatinib therapy. An echocardiography should be performed at treatment initiation in every patient presenting symptoms of cardiac disease and considered in patients with risk factors for cardiac or pulmonary disease. Patients who develop dyspnoea and fatigue after initiation of therapy should be evaluated for common etiologies including pleural effusion, pulmonary oedema, anaemia, or lung infiltration. In accordance with recommendations for management of non-haematologic adverse reactions (see section 4.2) the dose of dasatinib should be reduced or therapy interrupted during this evaluation. If no explanation is found, or if there is no improvement with dose reduction or interruption, the diagnosis of PAH should be considered. The diagnostic approach should follow standard practice guidelines. If PAH is confirmed, dasatinib should be permanently discontinued. Follow up should be performed according to standard practice guidelines. Improvements in haemodynamic and clinical parameters have been observed in dasatinib-treated patients with PAH following cessation of dasatinib therapy.
QT Prolongation
In vitro data suggest that dasatinib has the potential to prolong cardiac ventricular repolarisation (QT Interval) (see section 5.3). In 258 dasatinib-treated patients and 258 imatinib-treated patients in the Phase III study in newly diagnosed chronic phase CML, 1 patient (< 1%) in each group had QTc prolongation reported as an adverse reaction. The median changes in QTcF from baseline were 3.0 msec in dasatinib-treated patients compared to 8.2 msec in imatinib-treated patients. One patient (< 1%) in each group experienced a QTcF > 500 msec. In 865 patients with leukaemia treated with dasatinib in Phase II clinical trials, the mean changes from baseline in QTc interval using Fridericia's method (QTcF) were 4 - 6 msec; the upper 95% confidence intervals for all mean changes from baseline were < 7 msec (see section 4.8).
Of the 2,182 patients with resistance or intolerance to prior imatinib therapy who received dasatinib in clinical studies, 14 (< 1%) had QTc prolongation reported as an adverse reaction. Twenty-one of these patients (1%) experienced a QTcF > 500 msec.
Dasatinib should be administered with caution to patients who have or may develop prolongation of QTc. These include patients with hypokalaemia or hypomagnesaemia, patients with congenital long QT syndrome, patients taking anti-arrhythmic medicinal products or other medicinal products which lead to QT prolongation, and cumulative high dose anthracycline therapy. Hypokalaemia or hypomagnesaemia should be corrected prior to dasatinib administration.
Cardiac adverse reactions
Dasatinib was studied in a randomised trial of 519 patients with newly diagnosed CML in chronic phase which included patients with prior cardiac disease. The cardiac adverse reactions of congestive heart failure/cardiac dysfunction and fatal myocardial infarction were reported in patients taking dasatinib. Adverse cardiac events were more frequent in patients with risk factors or a history of cardiac disease. Patients with risk factors (e.g. hypertension, hyperlipidemia, diabetes) or a history of cardiac disease (e.g. prior percutaneous coronary intervention, documented coronary artery disease) should be monitored carefully for clinical signs or symptoms consistent with cardiac dysfunction such as chest pain, shortness of breath, and diaphoresis.
If these clinical signs or symptoms develop, physicians are advised to interrupt dasatinib administration. After resolution, a functional assessment should be performed prior to resuming treatment with dasatinib. Dasatinib may be resumed at the original dose for mild/moderate events (
Patients with uncontrolled or significant cardiovascular disease were not included in the clinical studies.
Lactose
This medicinal product contains 135 mg of lactose monohydrate in a 100 mg daily dose and 189 mg of lactose monohydrate in a 140 mg daily dose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicinal product.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
Active substances that may increase dasatinib plasma concentrations
In vitro studies indicate that dasatinib is a CYP3A4 substrate. Concomitant use of dasatinib and medicinal products which potently inhibit CYP3A4 (e.g. ketoconazole, itraconazole, erythromycin, clarithromycin, ritonavir, telithromycin) may increase exposure to dasatinib. Therefore, in patients receiving dasatinib, systemic administration of a potent CYP3A4 inhibitor is not recommended.
At clinically relevant concentrations, binding of dasatinib to plasma proteins is approximately 96% on the basis of in vitro experiments. No studies have been performed to evaluate dasatinib interaction with other protein-bound medicinal products. The potential for displacement and its clinical relevance are unknown.
Active substances that may decrease dasatinib plasma concentrations
When dasatinib was administered following 8 daily evening administrations of 600 mg rifampicin, a potent CYP3A4 inducer, the AUC of dasatinib was decreased by 82%. Other medicinal products that induce CYP3A4 activity (e.g. dexamethazone, phenytoin, carbamazepine, phenobarbital or herbal preparations containing Hypericum perforatum, also known as St. John´s Wort) may also increase metabolism and decrease dasatinib plasma concentrations. Therefore, concomitant use of potent CYP3A4 inducers with dasatinib is not recommended. In patients in whom rifampicin or other CYP3A4 inducers are indicated, alternative medicinal products with less enzyme induction potential should be used.
Histamine-2 antagonists and proton pump inhibitors
Long-term suppression of gastric acid secretion by H2 antagonists or proton pump inhibitors (e.g. famotidine and omeprazole) is likely to reduce dasatinib exposure. In a single-dose study in healthy subjects, the administration of famotidine 10 hours prior to a single dose of SPRYCEL reduced dasatinib exposure by 61%. In a study of 14 healthy subjects, administration of a single 100-mg dose of SPRYCEL 22 hours following a 4-day, 40-mg omeprazole dose at steady state reduced the AUC of dasatinib by 43% and the Cmax of dasatinib by 42%. The use of antacids should be considered in place of H2 antagonists or proton pump inhibitors in patients receiving SPRYCEL therapy (see section 4.4).
Antacids
Non-clinical data demonstrate that the solubility of dasatinib is pH-dependent. In healthy subjects, the concomitant use of aluminium hydroxide/magnesium hydroxide antacids with SPRYCEL reduced the AUC of a single dose of SPRYCEL by 55% and the Cmax by 58%. However, when antacids were administered 2 hours prior to a single dose of SPRYCEL, no relevant changes in dasatinib concentration or exposure were observed. Thus, antacids may be administered up to 2 hours prior to or 2 hours following SPRYCEL (see section 4.4).
Active substances that may have their plasma concentrations altered by dasatinib
Concomitant use of dasatinib and a CYP3A4 substrate may increase exposure to the CYP3A4 substrate. In a study in healthy subjects, a single 100 mg dose of dasatinib increased AUC and Cmax exposure to simvastatin, a known CYP3A4 substrate, by 20 and 37% respectively. It cannot be excluded that the effect is larger after multiple doses of dasatinib. Therefore, CYP3A4 substrates known to have a narrow therapeutic index (e.g. astemizole, terfenadine, cisapride, pimozide, quinidine, bepridil or ergot alkaloids [ergotamine, dihydroergotamine]) should be administered with caution in patients receiving dasatinib (see section 4.4).
In vitro data indicate a potential risk for interaction with CYP2C8 substrates, such as glitazones.
4.6 Pregnancy And Lactation
Pregnancy
There are no adequate data from the use of dasatinib in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3). The potential risk for humans is unknown.
SPRYCEL should not be used during pregnancy unless clearly necessary. If it is used during pregnancy, the patient must be informed of the potential risk to the foetus.
Breastfeeding
There is insufficient/limited information on the excretion of dasatinib in human or animal breast milk. Physico-chemical and available pharmacodynamic/toxicological data on dasatinib point to excretion in breast milk and a risk to the suckling child cannot be excluded.
Breast-feeding should be stopped during treatment with SPRYCEL.
Fertility
The effect of dasatinib on sperm is unknown, therefore both sexually active men and women should use effective methods of contraception during treatment.
4.7 Effects On Ability To Drive And Use Machines
No studies on the effects on the ability to drive and use machines have been performed. Patients should be advised that they may experience adverse reactions such as dizziness or blurred vision during treatment with dasatinib. Therefore, caution should be recommended when driving a car or operating machines.
4.8 Undesirable Effects
Summary of the safety profile
The data described below reflect exposure to SPRYCEL in 2,440 patients in clinical studies, including 258 patients with newly diagnosed chronic phase CML with a minimum of 12 months follow-up (starting dose 100 mg once daily) and 2,182 patients with imatinib resistant or intolerant CML or Ph+ ALL with a minimum of 24 months follow-up (starting dose 100 mg once daily, 140 mg once daily, 50 mg twice daily, or 70 mg twice daily). The median duration of therapy in this patient population was 15 months (range 0.03 - 36 months).
Of the 2,440 patients treated, 23% were
In the Phase III study in patients with newly diagnosed chronic phase CML the median duration of therapy was 14 months (range 0.03-24 months) for SPRYCEL and 14 months (range 0.3-26 months) for imatinib; the median average daily dose was 99 mg and 400 mg, respectively.
The majority of SPRYCEL-treated patients experienced adverse reactions at some time. Most reactions were of mild-to-moderate grade.
In the Phase III study in patients with newly diagnosed chronic phase CML, treatment was discontinued for adverse reactions in 5% of SPRYCEL-treated patients and 4% of imatinib-treated patients. Among patients with resistance or intolerance to prior imatinib therapy, the rates of discontinuation for adverse reactions were 15% in chronic phase CML, 16% in accelerated phase CML, 15% in myeloid blast phase CML, 8% in lymphoid blast phase CML and 8% in Ph+ ALL. In the Phase III dose-optimisation study in patients with chronic phase CML, the rate of discontinuation for adverse reactions was lower for patients treated with 100 mg once daily than for those treated with 70 mg twice daily (10% and 16%, respectively); the rates of dose interruption and reduction were also lower for patients treated with 100 mg once daily than for those treated with 70 mg twice daily. Less frequent dose reductions and interruptions were also reported for patients with advanced phase CML and Ph+ ALL treated with 140 mg once daily than for those treated with 70 mg twice daily.
The majority of imatinib-intolerant patients with chronic phase CML were able to tolerate treatment with SPRYCEL. In clinical studies in chronic phase CML, 10 of the 215 imatinib-intolerant patients had the same grade 3 or 4 non-hematologic toxicity with SPRYCEL as they did with prior imatinib; 8 of these 10 patients were managed with dose reduction and were able to continue SPRYCEL treatment.
The most frequently reported adverse reactions reported in SPRYCEL-treated patients with newly diagnosed chronic phase CML were fluid retention (including pleural effusion) (19%), diarrhoea (17%), headache (12%), rash (11%), musculoskeletal pain (11%), nausea (8%), fatigue (8%), myalgia (6%), vomiting (5%), and muscle inflammation (4%). The most frequently reported adverse reactions reported in SPRYCEL-treated patients with resistance or intolerance to prior imatinib therapy were fluid retention (including pleural effusion), diarrhoea, headache, nausea, skin rash, dyspnoea, haemorrhage, fatigue, musculoskeletal pain, infection, vomiting, cough, abdominal pain and pyrexia. Drug-related febrile neutropenia was reported in 5% of SPRYCEL-treated patients with resistance or intolerance to prior imatinib therapy.
In clinical studies with patients with resistance or intolerance to prior imatinib therapy, it was recommended that treatment with imatinib be discontinued at least 7 days before starting treatment with SPRYCEL.
Tabulated summary of adverse reactions
The following adverse reactions, excluding laboratory abnormalities, were reported in patients in SPRYCEL clinical studies and post-marketing experience (Table 2). These reactions are presented by system organ class and by frequency. Frequencies are defined as: very common (common (uncommon (rare (
Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.
Table 2: Tabulated summary of adverse reactions
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Infections and infestations
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Very common
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infection (including bacterial, viral, fungal, non-specified)
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Common
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pneumonia (including bacterial, viral, and fungal), upper respiratory tract infection/inflammation, herpes virus infection, enterocolitis infection
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Uncommon
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sepsis (including fatal outcome)
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Neoplasms benign, malignant and unspecified (including cysts and polyps)
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Uncommon
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tumour lysis syndrome
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Blood and lymphatic system disorders
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Common
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febrile neutropenia, pancytopenia
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Rare
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aplasia pure red cell
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Immune system disorders
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Uncommon
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hypersensitivity (including erythema nodosum)
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Metabolism and nutrition disorders
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Common
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anorexia, appetite disturbances
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Uncommon
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hyperuricaemia, hypoalbuminemia
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Psychiatric disorders
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Common
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depression, insomnia
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Uncommon
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anxiety, confusional state, affect lability, libido decreased
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Nervous system disorders
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Very common
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headache
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Common
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neuropathy (including peripheral neuropathy), dizziness, dysgeusia, somnolence
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Uncommon
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CNS bleeding*a, syncope, tremor, amnesia
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Rare
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cerebrovascular accident, transient ischaemic attack, convulsion, optic neuritis
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Eye disorders
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Common
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visual disorder (including visual disturbance, vision blurred, and visual acuity reduced), dry eye
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Uncommon
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conjunctivitis
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Ear and labyrinth disorders
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Common
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tinnitus
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Uncommon
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vertigo
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Cardiac disorders
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Common
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congestive heart failure/cardiac dysfunction*b, pericardial effusion*, arrhythmia (including tachycardia), palpitations
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Uncommon
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myocardial infarction (including fatal outcome)*, electrocardiogram QT prolonged*, pericarditis, ventricular arrhythmia (including ventricular tachycardia), angina pectoris, cardiomegaly
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Rare
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cor pulmonale, myocarditis, acute coronary syndrome
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Not known
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atrial fibrillation/atrial flutter
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Vascular disorders
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Very common
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haemorrhage*c
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Common
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hypertension, flushing
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Uncommon
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hypotension, thrombophlebitis
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Rare
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livedo reticularis
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Not known
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thrombosis/embolism (including pulmonary embolism, deep vein thrombosis)
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Respiratory, thoracic and mediastinal disorders
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Very common
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pleural effusion*, dyspnoea
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Common
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cough, pulmonary oedema*, pulmonary hypertension*, lung infiltration, pneumonitis
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Uncommon
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bronchospasm, asthma
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Rare
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acute respiratory distress syndrome
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Not known
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interstitial lung disease, pulmonary arterial hypertension (pre-capillary pulmonary arterial hypertension)
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Gastrointestinal disorders
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Very common
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diarrhoea, vomiting, nausea, abdominal pain
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Common
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gastrointestinal bleeding*, colitis (including neutropenic colitis), gastritis, mucosal inflammation (including mucositis/stomatitis), dyspepsia, abdominal distension, constipation, oral soft tissue disorder
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Uncommon
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pancreatitis, upper gastrointestinal ulcer, oesophagitis, ascites*, anal fissure, dysphagia
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Rare
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protein-losing gastroenteropathy
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Not known
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fatal gastrointestinal haemorrhage*
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Hepatobiliary disorders
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Uncommon
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hepatitis, cholecystitis, cholestasis
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Skin and subcutaneous tissue disorders
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Very common
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skin rashd
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Common
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alopecia, dermatitis (including eczema), pruritus, acne, dry skin, urticaria, hyperhidrosis
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Uncommon
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acute febrile neutrophilic dermatosis, photosensitivity, pigmentation disorder, panniculitis, skin ulcer, bullous conditions, nail disorder, palmar-plantar erythrodysesthesia syndrome
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Musculoskeletal and connective tissue disorders
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Very common
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musculoskeletal pain
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Common
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arthralgia, myalgia, muscle inflammation, muscular weakness
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Uncommon
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musculoskeletal stiffness, rhabdomyolysis
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Rare
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tendonitis
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Renal and urinary disorders
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Uncommon
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renal failure, urinary frequency, proteinuria
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Reproductive system and breast disorders
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Uncommon
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gynecomastia, irregular menstruation
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General disorders and administration site conditions
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