Ninlaro

IXAZOMIB (NINLARO) 3 mg capsule: Each capsule contains 3 mg of ixazomib (as 4.3 mg of ixazomib citrate).
IXAZOMIB (NINLARO) 4 mg capsule: Each capsule contains 4 mg of ixazomib (as 5.7 mg of ixazomib citrate).
Excipients/Inactive Ingredients: IXAZOMIB (NINLARO) 3 mg hard capsules: Capsule contents: Microcrystalline cellulose, Magnesium stearate, Talc.
Capsule shell: Gelatin, Titanium dioxide (E171), Black iron oxide (E172).
Printing ink: Shellac, Propylene glycol, Potassium hydroxide, Black iron oxide (E172).
IXAZOMIB (NINLARO) 4 mg hard capsules: Capsule contents: Microcrystalline cellulose, Magnesium stearate, Talc.
Capsule shell: Gelatin, Titanium dioxide (E171), Yellow iron oxide (E172), Red iron oxide (E172).
Printing ink: Shellac, Propylene glycol, Potassium hydroxide, Black iron oxide (E172).

Pharmacotherapeutic group: Antineoplastic agents, other antineoplastic agents. ATC code: L01XX50.
Pharmacology: Pharmacodynamics: Mechanism of action: Ixazomib citrate, a prodrug, is a substance that rapidly hydrolyses under physiological conditions to its biologically active form, ixazomib. Ixazomib is an oral, highly selective and reversible proteasome inhibitor. Ixazomib preferentially binds and inhibits the chymotrypsin-like activity of the beta 5 subunit of the 20S proteasome.
Ixazomib induced apoptosis of several tumour cell types in vitro. Ixazomib demonstrated in vitro cytotoxicity against myeloma cells from patients who had relapsed after multiple prior therapies, including bortezomib, lenalidomide, and dexamethasone. The combination of ixazomib and lenalidomide demonstrated synergistic cytotoxic effects in multiple myeloma cell lines. In vivo, ixazomib demonstrated antitumour activity in various tumour xenograft models, including models of multiple myeloma. In vitro, ixazomib affected cell types found in the bone marrow microenvironment including vascular endothelial cells, osteoclasts and osteoblasts.
Cardiac electrophysiology: Ixazomib did not prolong the QTc interval at clinically relevant exposures based on the results of a pharmacokinetic-pharmacodynamic analysis of data from 245 patients. At the 4 mg dose, mean change from baseline in QTcF was estimated to be 0.07 msec (90% CI; -0.22, 0.36) from the model based analysis. There was no discernible relationship between ixazomib concentration and the RR interval suggesting no clinically meaningful effect of ixazomib on heart rate.
Clinical efficacy and safety: The efficacy and safety of IXAZOMIB (NINLARO) in combination with lenalidomide and dexamethasone was evaluated in an international randomized, double blind, placebo controlled, multicenter Phase 3 superiority study (C16010) in patients with relapsed and/or refractory multiple myeloma who had received at least one prior therapy. A total of 722 patients (intent-to-treat [ITT] population) were randomized in a 1:1 ratio to receive either the combination of IXAZOMIB (NINLARO), lenalidomide, and dexamethasone (N=360; IXAZOMIB (NINLARO) regimen) or placebo, lenalidomide and dexamethasone (N=362; placebo regimen) until disease progression or unacceptable toxicity. Patients enrolled in the trial had multiple myeloma that was refractory, including primary refractory, had relapsed after prior therapy, or had relapsed and was refractory to any prior therapy. Patients that changed therapies prior to disease progression were eligible for enrolment, as well as those with controlled cardiovascular conditions. The Phase 3 study excluded patients who were refractory to lenalidomide or proteasome inhibitors and patients who received more than three prior therapies. For the purposes of this study, refractory disease was defined as disease progression on treatment or progression within 60 days after the last dose of lenalidomide or a proteasome inhibitor. As data are limited in these patients, a careful risk benefit assessment is recommended before initiating the IXAZOMIB (NINLARO) regimen. Thromboprophylaxis was recommended for all patients in both treatment groups according to the lenalidomide SmPC. Concomitant medications, such as antiemetic, antiviral, and antihistamine medications were given to patients at the physician's discretion as prophylaxis and/or management of symptoms.
Patients received IXAZOMIB (NINLARO) 4 mg or placebo on Days 1, 8, and 15 plus lenalidomide (25 mg) on Days 1 through 21 and dexamethasone (40 mg) on Days 1, 8, 15, and 22 of a 28-day cycle. Patients with renal impairment received a starting dose of lenalidomide according to its SmPC. Treatment continued until disease progression or unacceptable toxicities.
The baseline demographics and disease characteristics were balanced and comparable between the study regimens. The median age was 66 years, range 38-91 years; 58% of patients were older than 65 years. Fifty seven percent of patients were male. Eighty five percent of the population was White, 9% Asian and 2% Black. Ninety three percent of patients had an ECOG performance status of 0-1 and 12% had baseline ISS stage III disease (N=90).
Twenty five percent of patients had a creatinine clearance of < 60 mL/min. Twenty three percent of patients had light chain disease and 12% of patients had measurable disease by free light chain assay only. Nineteen percent had high-risk cytogenetic abnormalities (del[17], t[4;14], t[14;16]) (N=137), 10% had del(17) (N=69) and 34% had 1q amplification (1q21) (N=247). Patients received one to three prior therapies (median of 1) including prior treatment with bortezomib (69%), carfilzomib (<1%), thalidomide (45%), lenalidomide (12%), melphalan (81%). Fifty seven percent of patients had undergone prior stem cell transplantation. Seventy seven percent of patients relapsed after prior therapies and 11% were refractory to prior therapies. Primary refractory, defined as best response of stable disease or disease progression on all prior therapies, was documented in 6% of patients.
The primary endpoint was progression-free survival (PFS) according to the 2011 International Myeloma Working Group (IMWG) Consensus Uniform Response Criteria as assessed by a blinded independent review committee (IRC) based on central laboratory results. Response was assessed every 4 weeks until disease progression. At the primary analysis (median follow up of 14.7 months and a median of 13 cycles), PFS was statistically significantly different between the treatment arms. PFS results are summarized in Table 1 and Figure 1. The improvement in PFS in the IXAZOMIB (NINLARO) regimen was supported by improvements in overall response rate. (See Table 1 and Figure 1.)

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A second, non-inferential, PFS analysis was conducted with a median follow up of 23 months. At this analysis, estimated median PFS was 20 months in the ixazomib regimen and 15.9 months in the placebo regimen (HR=0.82 [95% CI (0.67, 1.0)]) in the ITT population. For patients with one prior therapy, the median PFS was 18.7 months in the ixazomib regimen and 17.6 months in the placebo regimen (HR = 0.99). For patients with 2 or 3 prior therapies, PFS was 22.0 months in the ixazomib regimen and 13.0 months in the placebo regimen (HR = 0.62).
At the final analysis for OS at a median duration of follow up of approximately 85 months, median OS in the ITT population was 53.6 months for patients in the ixazomib regimen and 51.6 months for patients in the placebo regimen (HR = 0.94 [95% CI: 0.78, 1.13; p=0.495]). For patients with one prior therapy, the median OS was 54.3 months in the ixazomib regimen and 58.3 months in the placebo regimen (HR = 1.02 [95% CI: 0.80, 1.29]). For patients with 2 or 3 prior therapies, the median OS was 53.0 months in the ixazomib regimen and 43.0 months in the placebo regimen (HR = 0.85 [95% CI: 0.64, 1.11]).
A randomised, double-blind, placebo-controlled Phase 3 study was conducted in China (N=115) with a similar study design and eligibility criteria. Many of the patients enrolled in the study had advanced disease with Durie-Salmon Stage III (69%) at initial diagnosis and a treatment history of receiving at least 2 prior therapies (60%) and being thalidomide refractory (63%). At the primary analysis (median follow up of 8 months and a median of 6 cycles), the median PFS was 6.7 months in the ixazomib regimen compared to 4 months in the placebo regimen (p-value=0.035, HR=0.60). At the final analysis for OS at a median follow up of 19.8 months, OS was improved for patients treated in the ixazomib regimen compared with placebo [p-value=0.0014, HR=0.42, 95% CI: 0.242, 0.726 ]).
As multiple myeloma is a heterogeneous disease, benefit may vary across subgroups in the Phase 3 study (C16010) (see Figure 2).

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In the Phase 3 study (C16010), 10 patients (5 in each treatment regimen) had severe renal impairment at baseline. Of the 5 patients in the IXAZOMIB (NINLARO) regimen, one patient had a confirmed partial response and 3 confirmed stable disease (however 2 were unconfirmed partial response and 1 was an unconfirmed very good partial response). Of the 5 patients in the placebo regimen, 2 had a confirmed very good partial response.
Quality of life as assessed by global health scores (EORTC QLQ-C30 and MY-20) was maintained during treatment and was similar in both treatment regimens in the Phase 3 study (C16010).
Paediatric population: The European Medicines Agency has waived the obligation to submit the results of studies with IXAZOMIB (NINLARO) in all subsets of the paediatric population in multiple myeloma (see Dosage & Administration for information on paediatric use).
Maintenance therapy with multiple myeloma following autologous stem cell transplant: International Phase III study (double blind controlled comparative study): A total of 656 patients (including 22 Japanese patients) ^{Note 7)} with newly diagnosed multiple myeloma following autologous stem cell transplantation (ASCT) were randomized in a 3:2 fashion to ixazomib maintenance: placebo ^{Note 8)}.
The study criteria excluded patients who relapsed after induction therapy, or refractory to induction therapy (without objective response following ASCT).
The primary endpoint was progression-free survival (PFS) as assessed by a blinded independent review committee (IRC), and the ixazomib arm demonstrated significant improvement in PFS. (Data cutoff on 16 April, 2018).
^{Note 7)} Patients who had undergone induction therapy according to regional standard of care, followed by a conditioning regimen containing high-dose melphalan (200 mg/m²).
^{Note 8)} Dosing for ixazomib or matching placebo: 3 mg PO once daily on Days 1, 8, and 15 of a 28-day cycle for the first 4 cycles. If tolerated in the first 4 cycles, the dose was escalated to 4 mg beginning at Cycle 5 Day 1, and administered on the same schedule for the duration of therapy. Therapy continued to approximately 24 months, disease progression, or intolerable toxicity, whichever came first. (See Figure 3 and Table 2.)

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Adverse reactions were observed in 78% (307/394) of patients (including 13 Japanese patients) in the ixazomib arm. The common adverse reactions (≥ 10%) were nausea [31% (124 patients)], diarrhoea (22% [86 patients)], vomiting [22% (86 patients)], and fatigue [11% (45 patients)].
Maintenance therapy with multiple myeloma for which autologous stem cell transplant is not indicated: International Phase III study (double-blind controlled study): A total of 706 patients (including 32 Japanese patients) with newly diagnosed multiple myeloma, who were not indicated for ASCT and responded to initial therapy,^{Note 11)} were randomized in a 3:2 fashion to receive either ixazomib or control drug (placebo) orally ^{Note 12)}. The study criteria excluded patients who relapsed after initial therapy, or refractory to initial therapy.
The primary endpoint was PFS as assessed by an IRC based on central laboratory results, and the ixazomib arm demonstrated significant improvement in PFS. (Data cutoff on 12 August, 2019).
^{Note 11)} Patients who achieved at least a partial response to initial therapy were included.
^{Note 12)} Dosing for ixazomib: 3 mg PO once weekly on Days 1, 8, and 15 of a 28-day cycle for the first 4 cycles. If tolerated in the first 4 cycles, the dose was escalated to 4 mg beginning at Cycle 5 Day 1. Therapy with ixazomib or placebo continued to approximately 24 months, disease progression, or intolerable toxicity, whichever came first. (See Figure 4 and Table 3.)

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Adverse reactions were observed in 67% (284/426) of patients (including 17 Japanese patients) in the ixazomib arm. The common adverse reactions (≥ 10%) were nausea [22% (92 patients)], vomiting [19% (82 patients)], diarrhoea [18% (76 patients)], and peripheral sensory neuropathy [12% (50 patients)].
Pharmacokinetics: Absorption: After oral administration, peak plasma concentrations of ixazomib were achieved at approximately one hour after dosing. The mean absolute oral bioavailability is 58%. Ixazomib AUC increases in a dose proportional manner over a dose range of 0.2-10.6 mg.
Administration with a high-fat meal decreased ixazomib AUC by 28% compared with administration after an overnight fast (see Dosage & Administration).
Distribution: Ixazomib is 99% bound to plasma proteins and distributes into red blood cells with a blood-to-plasma AUC ratio of 10. The steady state volume of distribution is 543 L.
Biotransformation: After oral administration of a radiolabeled dose, 70% of total drug-related material in plasma was accounted for by ixazomib. Metabolism by multiple CYP enzymes and non-CYP proteins is expected to be the major clearance mechanism for ixazomib. At clinically relevant ixazomib concentrations, in vitro studies using human cDNA-expressed cytochrome P450 isozymes indicate that no specific CYP isozyme predominantly contributes to ixazomib metabolism and non-CYP proteins contribute to overall metabolism. At concentrations exceeding those observed clinically, ixazomib was metabolized by multiple CYP isoforms with estimated relative contributions of 3A4 (42.3%), 1A2 (26.1%), 2B6 (16.0%), 2C8 (6.0%), 2D6 (4.8%), 2C19 (4.8%) and 2C9 (< 1%).
Elimination: Ixazomib exhibits a multi-exponential disposition profile. Based on a population PK analysis, systemic clearance (CL) was approximately 1.86 L/hr with inter-individual variability of 44%.
The terminal half-life (t_1/2) of ixazomib was 9.5 days. Approximately 2-fold accumulation in AUC was observed with weekly oral dosing on Day 15.
Excretion: After administration of a single oral dose of 14C-ixazomib to 5 patients with advanced cancer, 62% of the administered radioactivity was excreted in urine and 22% in the faeces.
Unchanged ixazomib accounted for < 3.5% of the administered dose recovered in urine.
Special populations: Hepatic impairment: The PK of ixazomib is similar in patients with normal hepatic function and in patients with mild hepatic impairment (total bilirubin ≤ ULN and AST > ULN or total bilirubin > 1-1.5 x ULN and any AST) based on the results of a population PK analysis.
The PK of ixazomib was characterized in patients with normal hepatic function at 4 mg (N=12), moderate hepatic impairment at 2.3 mg (total bilirubin > 1.5-3 x ULN, N=13) or severe hepatic impairment at 1.5 mg (total bilirubin > 3 x ULN, N=18). Unbound dose-normalized AUC was 27% higher in patients with moderate or severe hepatic impairment as compared to patients with normal hepatic function (see Dosage & Administration).
Renal impairment: The PK of ixazomib is similar in patients with normal renal function and in patients with mild or moderate renal impairment (creatinine clearance ≥ 30 mL/min) based on the results of a population PK analysis.
The PK of ixazomib was characterized at a dose of 3 mg in patients with normal renal function (creatinine clearance ≥ 90 mL/min, N=18), severe renal impairment (creatinine clearance < 30 mL/min, N=14), or ESRD requiring dialysis (N=6). Unbound AUC was 38% higher in patients with severe renal impairment or ESRD requiring dialysis as compared to patients with normal renal function. Pre- and post-dialyzer concentrations of ixazomib measured during the haemodialysis session were similar, suggesting that ixazomib is not dialyzable (see Dosage & Administration).
Age, gender, race: There was no clinically meaningful effect of age (23-91 years), sex, body surface area (1.2-2.7 m²), or race on the clearance of ixazomib based on the results of a population PK analysis. The mean AUC was 35% higher in Asian patients; however, there was overlap in the AUC of ixazomib across White and Asian patients.
Toxicology: Preclinical safety data: Mutagenicity: Ixazomib was not mutagenic in a bacterial reverse mutation assay (Ames assay) or clastogenic in a bone marrow micronucleus assay in mice. Ixazomib was positive in an in vitro clastogenicity test in human peripheral blood lymphocytes. However, ixazomib was negative in an in vivo comet assay in mice, in which percent tail DNA was assessed in the stomach and liver.
Therefore, the weight of evidence indicates that NINLARO is not considered to present a genotoxic risk.
Reproductive and embryo foetal development: Ixazomib caused embryo-foetal toxicity in pregnant rats and rabbits only at maternally toxic doses and at exposures that were slightly higher than those observed in patients receiving the recommended dose. Studies of fertility and early embryonic development and pre- and post-natal toxicology were not conducted with ixazomib, but evaluation of reproductive tissues was conducted in the general toxicity studies. There were no effects due to ixazomib treatment on male or female reproductive organs in studies up to 6-months duration in rats and up to 9 months duration in dogs.
Animal toxicology and/or pharmacology: In multi-cycle repeated-dose toxicity studies conducted in rats and dogs, the principal target organs included the gastrointestinal tract, lymphoid tissues, and the nervous system. In the 9-month study (10 cycles) in dogs orally administered with a dosing schedule mimicking the clinical regimen (28 day cycle), microscopic neuronal effects were generally minimal in nature and only observed at 0.2 mg/kg (4 mg/m²). The majority of target organ findings demonstrated partial to full recovery following discontinuation of treatment, with the exception of neuronal findings in the lumbar dorsal root ganglion and dorsal column.
Following oral administration, a tissue distribution study in rats revealed that the brain and spinal cord were amongst the tissues with the lowest levels, suggesting that the penetration of ixazomib through the blood-brain barrier appears to be limited. However, the relevance to humans is unknown.
Non-clinical safety pharmacology studies both in vitro (on hERG channels) and in vivo (in telemetered dogs following single oral administration) demonstrated no effects of ixazomib on cardiovascular or respiratory functions at AUC more than 8-fold higher than the clinical value.

In combination with lenalidomide and dexamethasone is indicated for the treatment of adult patients with multiple myeloma who have received at least one prior therapy.
Maintenance therapy with multiple myeloma following autologous stem cell transplant.
Maintenance therapy with multiple myeloma for those who had not been treated with stem cell transplantation.

Treatment must be initiated and monitored under the supervision of a physician experienced in the management of multiple myeloma.
In combination with lenalidomide and dexamethasone is indicated for the treatment of adult patients with multiple myeloma who have received at least one prior therapy: The recommended starting dose of IXAZOMIB (NINLARO) is 4 mg administered orally once a week on Days 1, 8, and 15 of a 28-day treatment cycle.
The recommended starting dose of lenalidomide is 25 mg administered daily on Days 1 to 21 of a 28-day treatment cycle.
The recommended starting dose of dexamethasone is 40 mg administered on Days 1, 8, 15, and 22 of a 28-day treatment cycle. (See Table 4.)

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For additional information regarding lenalidomide and dexamethasone, refer to the Summary of Product Characteristics (SmPC) for these medicinal products.
Prior to initiating a new cycle of therapy: Absolute neutrophil count should be ≥ 1,000/mm³; Platelet count should be ≥ 75,000/mm³; Non haematologic toxicities should, at the physician's discretion, generally be recovered to patient's baseline condition or ≤ Grade 1 Treatment should be continued until disease progression or unacceptable toxicity. Treatment with IXAZOMIB (NINLARO) in combination with lenalidomide and dexamethasone for longer than 24 cycles should be based on an individual benefit risk assessment, as the data on the tolerability and toxicity beyond 24 cycles are limited (see Pharmacology: Pharmacodynamics under Actions).
Delayed or missed doses: In the event that a IXAZOMIB (NINLARO) dose is delayed or missed, the dose should be taken only if the next scheduled dose is ≥ 72 hours away. A missed dose should not be taken within 72 hours of the next scheduled dose. A double dose should not be taken to make up for a missed dose.
If a patient vomits after taking a dose, the patient should not repeat the dose but should resume dosing at the time of the next scheduled dose.
Dose modifications: The IXAZOMIB (NINLARO) dose reduction steps are presented in Table 5 and the dose modification guidelines are provided in Table 6. (See Table 5.)

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An alternating dose modification approach is recommended for IXAZOMIB (NINLARO) and lenalidomide for overlapping toxicities of thrombocytopenia, neutropenia and rash. For these toxicities, the first dose modification step is to withhold/reduce lenalidomide. Refer to the lenalidomide SmPC, under Dosage & Administration for the dose reduction steps for these toxicities. (See Table 6.)

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Maintenance therapy with multiple myeloma following autologous stem cell transplant and for those who had not been treated with stem cell transplantation: This drug is administered orally to adult patients usually in a fasted state, once a week for three weeks (Days 1, 8, and 15), followed by 13 days rest period (Days 16 - 28). This four-week treatment cycle is repeated. For cycle 1 - 4, the dose is 3 mg. For cycle 5 or later, the dose is 4 mg. The dosage may be reduced depending on the condition of the individual patient.
The efficacy and safety of this drug given in combination with other antineoplastic drugs other than lenalidomide and dexamethasone have not been established.
The efficacy and safety of this drug as dosing more than 24 months have not been established.
When an adverse reaction occurs with this drug, administration of this drug should be withheld, reduced, or discontinued referring to the following criteria.
Dose Reduction Steps for this Drug: (see Table 7).

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Criteria for Withholding, Dose Reduction, or Discontinuation: (see Table 8).

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Concomitant medicinal products: Antiviral prophylaxis should be considered in patients being treated with IXAZOMIB (NINLARO) to decrease the risk of herpes zoster reactivation. Patients included in studies with IXAZOMIB (NINLARO) who received antiviral prophylaxis had a lower incidence of herpes zoster infection compared to patients who did not receive prophylaxis.
Thromboprophylaxis is recommended in patients being treated with IXAZOMIB (NINLARO) in combination with lenalidomide and dexamethasone and should be based on an assessment of the patient's underlying risks and clinical status.
For other concomitant medicinal products that may be required, refer to the current lenalidomide and dexamethasone SmPC.
Special patient populations: Elderly: No dose adjustment of IXAZOMIB (NINLARO) is required for patients over 65 years of age. Discontinuations in patients > 75 years of age were reported in 13 patients (28%) in the IXAZOMIB (NINLARO) regimen and 10 patients (16%) in the placebo regimen. Cardiac arrhythmias in patients > 75 years of age were observed in 10 patients (21%) in the IXAZOMIB (NINLARO) regimen and 9 patients (15%) in the placebo regimen.
Hepatic impairment: No dose adjustment of IXAZOMIB (NINLARO) is required for patients with mild hepatic impairment (total bilirubin ≤ upper limit of normal (ULN) and aspartate aminotransferase (AST) > ULN or total bilirubin > 1-1.5 x ULN and any AST). The reduced dose of 3 mg is recommended in patients with moderate (total bilirubin > 1.5-3 x ULN) or severe (total bilirubin > 3 x ULN) hepatic impairment (see Pharmacology: Pharmacokinetics under Actions).
Renal impairment: No dose adjustment of IXAZOMIB (NINLARO) is required for patients with mild or moderate renal impairment (creatinine clearance ≥ 30 mL/min). The reduced dose of 3 mg is recommended in patients with severe renal impairment (creatinine clearance < 30 mL/min) or end-stage renal disease (ESRD) requiring dialysis. IXAZOMIB (NINLARO) is not dialyzable and, therefore, can be administered without regard to the timing of dialysis (see Pharmacology: Pharmacokinetics under Actions). Refer to the lenalidomide SmPC for dosing recommendations in patients with renal impairment.
Paediatric population: The safety and efficacy of IXAZOMIB (NINLARO) in children below 18 years of age have not been established. No data are available.
Method of administration: IXAZOMIB (NINLARO) is for oral use.
IXAZOMIB (NINLARO) should be taken at approximately the same time on days 1, 8, and 15 of each treatment cycle at least 1 hour before or at least 2 hours after food (see Pharmacology: Pharmacokinetics under Actions).
The capsule should be swallowed whole with water. It should not be crushed, chewed, or opened (see Special precautions for disposal and other handling under Cautions for Usage).

Overdose has been reported in patients taking IXAZOMIB (NINLARO). Symptoms of overdose are generally consistent with the known risks of IXAZOMIB (NINLARO) (see Adverse Reactions). Overdose of 12 mg (taken at one time) has resulted in serious adverse events, such as severe nausea, aspiration pneumonia, multiple organ failure and death.
There is no known specific antidote for IXAZOMIB (NINLARO) overdose. In the event of an overdose, monitor the patient closely for adverse reactions (Adverse Reactions) and provide appropriate supportive care. Ixazomib is not dialyzable (see Pharmacology: Pharmacokinetics under Actions).
Overdoses were most common in patients starting treatment with IXAZOMIB (NINLARO). The importance of carefully following all dosage instructions should be discussed with patients starting treatment. Instruct patients to take the recommended dosage as directed because overdose has led to deaths.

Hypersensitivity to the active substance or to any of the excipients listed in Description.
As IXAZOMIB (NINLARO) is administered in combination with lenalidomide and dexamethasone, refer to the SmPC for these medicinal products for additional contraindications.

As IXAZOMIB (NINLARO) is administered in combination with lenalidomide and dexamethasone, refer to the SmPC for these medicinal products for additional special warnings and precautions for use.
Thrombocytopenia: Thrombocytopenia has been reported with IXAZOMIB (NINLARO) (see Adverse Reactions) with platelet nadirs typically occurring between Days 14-21 of each 28-day cycle and recovery to baseline by the start of the next cycle (see Adverse Reactions).
Platelet counts should be monitored at least monthly during IXAZOMIB (NINLARO) treatment.
More frequent monitoring should be considered during the first three cycles as per the lenalidomide SmPC. Thrombocytopenia can be managed with dose modifications (see Dosage & Administration) and platelet transfusions as per standard medical guidelines.
Gastrointestinal toxicities: Diarrhoea, constipation, nausea and vomiting have been reported with IXAZOMIB (NINLARO), occasionally requiring use of antiemetic and antidiarrhoeal medicinal products and supportive care (see Adverse Reactions). The dose should be adjusted for severe (Grade 3-4) symptoms (see Dosage & Administration). In case of severe gastrointestinal events, monitoring of serum potassium level is recommended.
Peripheral neuropathy: Peripheral neuropathy has been reported with IXAZOMIB (NINLARO) (see Adverse Reactions). The patient should be monitored for symptoms of peripheral neuropathy. Patients experiencing new or worsening peripheral neuropathy may require dose modification (see Dosage & Administration).
Peripheral oedema: Peripheral oedema has been reported with IXAZOMIB (NINLARO) (see Adverse Reactions). The patient should be evaluated for underlying causes and provide supportive care, as necessary. The dose of dexamethasone should be adjusted per its prescribing information or IXAZOMIB (NINLARO) for Grade 3 or 4 symptoms (see Dosage & Administration).
Cutaneous reactions: Rash has been reported with IXAZOMIB (NINLARO) (see Adverse Reactions). Rash should be managed with supportive care or with dose modification if Grade 2 or higher (see Dosage & Administration). Stevens-Johnson syndrome has also been reported with ixazomib (see Adverse Reactions). If Stevens-Johnson syndrome occurs, discontinue ixazomib.
Thrombotic microangiopathy: Cases of thrombotic microangiopathy (TMA), including thrombotic thrombocytopenic purpura (TTP), have been reported in patients who received ixazomib. Some of these events have been fatal. Signs and symptoms of TMA should be monitored for. If the diagnosis is suspected, stop ixazomib and evaluate patients for possible TMA. If the diagnosis of TMA is excluded, ixazomib can be restarted. The safety of reinitiating ixazomib therapy in patients previously experiencing TMA is not known.
Hepatotoxicity: Drug-induced liver injury, hepatocellular injury, hepatic steatosis, hepatitis cholestatic and hepatotoxicity have been uncommonly reported with IXAZOMIB (NINLARO) (see Adverse Reactions).
Hepatic enzymes should be monitored regularly and the dose should be adjusted for Grade 3 or 4 symptoms (see Dosage & Administration).
Posterior reversible encephalopathy syndrome: Posterior reversible encephalopathy syndrome (PRES) has occurred in patients receiving IXAZOMIB (NINLARO). PRES is a rare, reversible, neurological disorder which can present with seizure, hypertension, headache, altered consciousness, and visual disturbances. Brain imaging, preferably Magnetic Resonance Imaging, is used to confirm the diagnosis. In patients developing PRES, discontinue IXAZOMIB (NINLARO).
Strong CYP3A inducers: Strong inducers may reduce the efficacy of IXAZOMIB (NINLARO), therefore the concomitant use of strong CYP3A inducers such as carbamazepine, phenytoin, rifampicin and St. John's Wort (Hypericum perforatum), should be avoided (see Interactions and Pharmacology: Pharmacokinetics under Actions). Closely monitor patients for disease control if co-administration with a strong CYP3A inducer cannot be avoided.
Effects on ability to drive and use machines: IXAZOMIB (NINLARO) has minor influence on the ability to drive or use machines. Fatigue and dizziness have been observed in clinical trials. Patients should be advised not to drive or operate machines if they experience any of these symptoms.
Use in Pregnancy: Women should avoid becoming pregnant while being treated with IXAZOMIB (NINLARO). If IXAZOMIB (NINLARO) is used during pregnancy or if the patient becomes pregnant while taking IXAZOMIB (NINLARO), the patient should be apprised of the potential hazard to the foetus. Women of childbearing potential must use highly effective contraception while taking IXAZOMIB (NINLARO) and for 90 days after stopping treatment (see Interactions and Use in Pregnancy & Lactation).
Women using hormonal contraceptives should additionally use a barrier method of contraception.

As IXAZOMIB (NINLARO) is administered in combination with lenalidomide and dexamethasone, refer to the SmPC for these medicinal products for additional information on fertility, pregnancy and lactation.
Women of childbearing potential/Contraception in males and females: Male and female patients who are able to have children must use effective contraceptive measures during and for 90 days following treatment. IXAZOMIB (NINLARO) is not recommended in women of childbearing potential not using contraception.
When IXAZOMIB (NINLARO) is administered together with dexamethasone, which is known to be a weak to moderate inducer of CYP3A4 as well as other enzymes and transporters, the risk for reduced efficacy of oral contraceptives needs to be considered. Therefore, women using oral hormonal contraceptives should additionally use a barrier method of contraception.
Pregnancy: IXAZOMIB (NINLARO) is not recommended during pregnancy as it can cause foetal harm when administered to a pregnant woman. Therefore, women should avoid becoming pregnant while being treated with IXAZOMIB (NINLARO).
There are no data for the use of IXAZOMIB (NINLARO) in pregnant women. Studies in animals have shown reproductive toxicity.
IXAZOMIB (NINLARO) is given in combination with lenalidomide, Lenalidomide is structurally related to thalidomide. Thalidomide is a known human teratogenic active substance that causes severe life-threatening birth defects. If lenalidomide is taken during pregnancy, a teratogenic effect in humans is expected. The conditions of the Pregnancy Prevention Programme for lenalidomide must be fulfilled for all patients unless there is reliable evidence that the patient does not have childbearing potential. Please refer to the current lenalidomide SmPC.
Breast feeding: It is unknown whether IXAZOMIB (NINLARO) or its metabolites are excreted in human milk. No animal data are available. A risk to newborns/infants cannot be excluded and therefore breast feeding should be discontinued.
IXAZOMIB (NINLARO) will be given in combination with lenalidomide and breast-feeding should be stopped because of the use of lenalidomide.
Fertility: Fertility studies have not been conducted with IXAZOMIB (NINLARO).

As IXAZOMIB (NINLARO) is administered in combination with lenalidomide and dexamethasone, refer to the SmPC for these medicinal products for additional undesirable effects.
Summary of the safety profile: The safety profile of NINLARO is based on available clinical trial data and post-marketing experience to date. Frequencies of adverse reactions described as follows and in Table 9 have been determined based on data generated from clinical studies.
Unless otherwise noted, the data presented as follows is the pooled safety data from the pivotal, Phase 3, global C16010 study (n=720) and the double-blind, placebo-controlled C16010 China Continuation Study (n=115). The most frequently reported adverse reactions (≥ 20%) across 418 patients treated within the ixazomib regimen and 417 patients within the placebo regimen were diarrhoea (47% vs. 38%), thrombocytopenia (41% vs. 24%), neutropenia (37% vs. 36%), constipation (31% vs. 24%), upper respiratory tract infection (28% vs. 24%), peripheral neuropathy (28% vs. 22%), nausea (28% vs. 20%), back pain (25% vs. 21%), rash (25% vs. 15%), peripheral oedema (24% vs. 19%), vomiting (23% vs. 12%) and bronchitis (20% vs. 15%). Serious adverse reactions reported in ≥ 2% of patients included diarrhoea (3%), thrombocytopenia (2%) and bronchitis (2%).
Tabulated list of adverse reactions: The following convention is used for the classification of the frequency of an adverse drug reaction (ADR): 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 system organ class, the adverse drug reactions are ranked by frequency, with the most frequent reactions first. Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness. (See Table 9.)

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Description of selected adverse reactions: Discontinuations: For each adverse reaction, one or more of the three medicinal products was discontinued in ≤ 1% of patients in the IXAZOMIB (NINLARO) regimen.
Thrombocytopenia: Two percent of patients in both the IXAZOMIB (NINLARO) regimen and the placebo regimen had a platelet count ≤ 10,000/mm³ during treatment. Less than 1% of patients in both regimens had a platelet count ≤ 5,000/mm³ during treatment. Thrombocytopenia resulted in discontinuation of one or more of the three medicinal products in < 2% of patients in the IXAZOMIB (NINLARO) regimen and 3% of patients in the placebo regimen. Thrombocytopenia did not result in an increase in haemorrhagic events or platelet transfusions.
Gastrointestinal toxicities: Diarrhoea resulted in discontinuation of one or more of the three medicinal products in 2% of patients in the IXAZOMIB (NINLARO) regimen and 1% of patients in the placebo regimen.
Rash: Rash occurred in 25% of patients in the IXAZOMIB (NINLARO) regimen compared to 15% of patients in the placebo regimen. The most common type of rash reported in both regimens was maculo-papular and macular rash. Grade 3 rash was reported in 3% of patients in the IXAZOMIB (NINLARO) regimen compared to 1% of patients in the placebo regimen. Rash resulted in discontinuation of one or more of the three medicinal products in 2% of patients in both regimens.
Peripheral neuropathy: Peripheral neuropathy occurred in 28% of patients in the IXAZOMIB (NINLARO) regimen compared to 22% of patients in the placebo regimen. Grade 3 adverse reactions of peripheral neuropathy were reported at 2% the Ixazomib regimen compared to 1% in the placebo regimen. The most commonly reported reaction was peripheral sensory neuropathy (21% and 15% in the IXAZOMIB (NINLARO) and placebo regimen, respectively). Peripheral motor neuropathy was not commonly reported in either regimen (< 1%). Peripheral neuropathy resulted in discontinuation of one or more of the three medicinal products in 3% of patients in both regimens.
Eye Disorders: Eye disorders were reported with many different preferred terms but in aggregate, the frequency was 34% in patients in the IXAZOMIB (NINLARO) regimen and 28% of patients in the placebo regimen. The most common adverse reactions were blurred vision (6% in the IXAZOMIB (NINLARO) regimen and 5% in the placebo regimen), dry eye (6% in the IXAZOMIB (NINLARO) regimen and 1% in the placebo regimen), and conjunctivitis (8% in the IXAZOMIB (NINLARO) regimen and 2% in the placebo regimen) and cataract (13% in the ixazomib regimen and 17% in the placebo regimen. Grade 3 adverse reactions were reported in 6% of patients in the IXAZOMIB (NINLARO) regimen and 8% of patients in the placebo regimen).
Other adverse reactions: Outside of the Phase 3 studies, the following serious adverse reactions were rarely reported: acute febrile neutrophilic dermatosis (Sweet's syndrome), Stevens-Johnson syndrome, transverse myelitis, posterior reversible encephalopathy syndrome, and tumour lysis syndrome.
In the pivotal Phase 3 trial, the following adverse reactions occurred with a similar rate between the IXAZOMIB (NINLARO) and placebo regimens: fatigue (28% vs. 26%), neutropenia (30% vs. 27%), decreased appetite (13% vs. 11%), hypotension (5% vs. 4%), heart failure (5% each), arrhythmia (17% vs 16%), and liver impairment including enzyme changes (11% to 9%).
The frequency of severe (Grade 3-4) events of hypokalaemia was higher in the IXAZOMIB (NINLARO) regimen (7%) than the placebo regimen (2%).
Fungal and viral pneumonia resulting in fatal outcome were rarely reported in patients given the IXAZOMIB (NINLARO), lenalidomide and dexamethasone combination.
Reporting of suspected adverse reactions: Reporting suspected adverse reactions after authorisation of the medicinal product is important.
It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions to the marketing authorization holder.
The patient must seek medical attention immediately at the first sign of any adverse drug reaction.

Pharmacokinetic interactions: CYP inhibitors: Co-administration of ixazomib with clarithromycin, a strong CYP3A inhibitor, did not result in a clinically meaningful change in the systemic exposure of ixazomib. Ixazomib C_max was decreased by 4% and AUC was increased by 11%. Therefore, no dose modification is required for ixazomib with co-administration of strong CYP3A inhibitors.
Co-administration of ixazomib with strong CYP1A2 inhibitors did not result in a clinically meaningful change in the systemic exposure of ixazomib based on the results of a population pharmacokinetic (PK) analysis. Therefore, no dose modification is required for ixazomib with co-administration of strong CYP1A2 inhibitors.
CYP inducers: Co-administration of ixazomib with rifampicin decreased ixazomib C_max by 54% and AUC by 74%. Therefore, co administration of strong CYP3A inducers with ixazomib is not recommended (see Precautions).
Effect of ixazomib on other medicinal products: Ixazomib is not a reversible or a time dependent inhibitor of CYPs 1A2, 2B6, 2C8, 2C9, 2C19, 2D6, or 3A4/5. Ixazomib did not induce CYP1A2, CYP2B6, and CYP3A4/5 activity or corresponding immunoreactive protein levels. Ixazomib is not expected to produce drug-drug interactions via CYP inhibition or induction.
Transporter based interactions: Ixazomib is a low affinity substrate of P-gp. Ixazomib is not a substrate of BCRP, MRP2 or hepatic OATPs. Ixazomib is not an inhibitor of P-gp, BCRP, MRP2, OATP1B1, OATP1B3, OCT2, OAT1, OAT3, MATE1, or MATE2-K. Ixazomib is not expected to cause transporter-mediated drug-drug interactions.
Oral contraceptives: When IXAZOMIB (NINLARO) is administered together with dexamethasone, which is known to be a weak to moderate inducer of CYP3A4 as well as other enzymes and transporters, the risk for reduced efficacy of oral contraceptives needs to be considered. Women using hormonal contraceptives should additionally use a barrier method of contraception.

Special precautions for disposal and other handling: IXAZOMIB (NINLARO) is cytotoxic. The capsule should not be removed until just prior to dosing.
The capsules should not be opened or crushed. Direct contact with the capsule contents should be avoided. In case of capsule breakage, avoid raising dust during clean up. If contact occurs, wash thoroughly with soap and water.
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
Incompatibilities: Not applicable.

Do not store above 30°C. Do not freeze.
Store in the original package in order to protect from moisture.
Shelf life: 3 years.

Targeted Cancer Therapy

L01XG03 - ixazomib ; Belongs to the class of proteasome inhibitors. Used in the treatment of cancer.

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