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 bortezomib (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 bortezomib in combination with melphalan/prednisone is consistent with the known safety profiles of both bortezomib and melphalan/prednisone.
Table 8: Most Commonly Reported Adverse Reactions (≥10% in the Bortezomib, Melphalan and Prednisone Arm) with Grades 3 and ≥4 Intensity in the Previously Untreated Multiple Myeloma Study 
Bortezomib, Melphalan and        Melphalan and Prednisone
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 bortezomib vs Dexamethasone The safety data described below and in Table 9 reflect exposure to either bortezomib (n=331) or dexamethasone (n=332) in a study of patients with relapsed multiple myeloma. Bortezomib 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 bortezomib-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 bortezomib-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 bortezomib 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 bortezomib 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 bortezomib 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 bortezomib treatment group and 61 (18%) of 332 patients in the dexamethasone treatment group were discontinued from treatment due to adverse reactions. Among the 331 bortezomib 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 bortezomib-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 bortezomib 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 bortezomib arm are included.


Table 9: Most Commonly Reported Adverse Reactions (≥10% in Bortezomib Arm), with Grades 3 and 4 Intensityin the Relapsed Multiple Myeloma Study of Bortezomib vs Dexamethasone (N=663) 
Bortezomib                           Dexamethasone
(N=331)                                 (N=332)
Adverse Reactions                 All        Grade 3       Grade 4         All       Grade 3        Grade 4 Any Adverse Reactions          324 (98)      193 (58)       28 (8)     297 (89)      110 (33)        29 (9) 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 neuropathies*       115 (35)       23 (7)        2 (<1)       14 (4)          0           1 (<1) 
Thrombocytopenia               109 (33)       80 (24)       12 (4)       11 (3)         5 (2)        1 (<1) 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 Neutropenia                     58 (18)       37 (11)        8 (2)      1 (<1)         1 (<1)           0 Rash NOS                        43 (13)        3 (<1)          0          7 (2)           0             0 Appetite decreased NOS          36 (11)           0            0         12 (4)           0             0 Dyspnea NOS                     35 (11)        11 (3)       1 (<1)      37 (11)         7 (2)        1 (<1) Abdominal pain NOS              35 (11)         5 (2)          0          7 (2)           0             0 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 bortezomib treatment. These patients were treated for a total of 5.3 to 23 months, including time on bortezomib in the prior bortezomib study [see Clinical Studies (15.1)].
Safety Experience from the Phase 3 Open-Label Study of bortezomib Subcutaneous vs Intravenous in Relapsed Multiple Myeloma
The safety and efficacy of Bortezomib 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 bortezomib subcutaneousvs intravenous in 222 patients with relapsed multiple myeloma. The safety data described below and in Table 10 reflect exposure to either bortezomib subcutaneous (N=147) or bortezomib 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 Bortezomib 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 Bortezomib 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 bortezomib (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    Grade
Body System                                   All          Grade 3        Grade ≥4           All         Grade 3      ≥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) Thrombocytopenia                         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=bortezomib, 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 bortezomib in 240 MCL patients treated with bortezomib 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 bortezomib 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 12 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 bortezomib 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    Very           Pneumonia*
Common
infestations       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        Very         Thrombocytopenia*, Febrile neutropenia, Neutropenia*, lymphatic system Common       Leukopenia*, Anaemia*, Lymphopenia* disorders        Uncommon     Pancytopenia*
Immune system Common          Hypersensitivity* disorders        Uncommon     Anaphylactic reaction

Metabolism and Very           Decreased appetite nutrition      Common disorders      Common         Hypokalaemia*, Blood glucose abnormal*, Hyponatraemia*, Diabetes mellitus*, Fluid retention
Uncommon   Tumour lysis syndrome
Psychiatric        Common     Sleep disorders and disturbances* disorders
Nervous system     Very       Peripheral sensory neuropathy, Dysaesthesia*, Neuralgia* disorders          Common
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 Common      Dysacusis (inc tinnitus)* disorders         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           Common     Hypertension*, Hypotension*, Orthostatic hypotension disorders
Respiratory,       Common     Dyspnoea*, Cough*, Hiccups thoracic and       Uncommon   Acute respiratory distress syndrome, Pulmonary mediastinal                   embolism, Pneumonitis, Pulmonary hypertension, disorders                     Pulmonary oedema (inc acute)
Gastrointestinal   Very       Nausea and vomiting symptoms*, Diarrhoea*, disorders          Common     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       Common          Hepatotoxicity (inc liver disorder) disorders           Uncommon        Hepatic failure
Skin and            Very            Hair disorder* subcutaneous        Common tissue disorders    Common          Pruritus*, Dermatitis*, Rash*
Musculoskeletal     Common          Muscle spasms*, Musculoskeletal pain*, Pain in extremity and connective tissue disorders
Renal and           Common          Urinary tract infection* urinary disorders
General             Very            Pyrexia*, Fatigue, Asthenia disorders and       Common administration      Common          Oedema (inc peripheral), Chills, Injection site reaction*, site conditions                     Malaise*
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 bortezomib 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 bortezomib subcutaneous vs intravenous in relapsed multiple myeloma. In the integrated studies, the safety profile of bortezomib 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 bortezomib administered intravenously, local skin irritation was reported in 5% of patients, but extravasation of bortezomib 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)
All        ≥Grade            All       ≥Grade           All         ≥Grade Adverse 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 neuropathies*         443 (38)      129 (11)       359 (36)     110 (11)       84 (54)        19 (12) 
Thrombocytopenia                 369 (32)      295 (25)       344 (34)      283 (28)        25 (16)        12 (8) Vomiting NOS                     321 (28)        44 (4)       286 (28)        40 (4)        35 (23)          4 (3) 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 NOS                     175 (15)        8 (<1)       160 (16)         8 (<1)       15 (10)            0 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 (excl vertigo)         129 (11)        13 (1)       101 (10)         9 (<1)       28 (18)          4 (3) 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, bortezomib-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 bortezomib 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 bortezomib 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 bortezomib vs dexamethasone Phase 3 relapsed multiple myeloma study, among the 62 bortezomib-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 bortezomib.
Hypotension
The incidence of hypotension (postural, orthostatic and hypotension NOS) was 8% in patients treated with bortezomib. 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 bortezomib 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 (> 38°C) 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 bortezomib 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 bortezomib. In the randomized studies in previously untreated and relapsed multiple myeloma, herpes zoster reactivation was more common in subjects treated with bortezomib (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 bortezomib and 1 to 3% in the control groups. In the previously untreated multiple myeloma study, herpes zoster virus reactivation in the bortezomib, 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 bortezomib. The safety profile of patients in this trial is consistent with the known safety profile of bortezomib-treated patients with relapsed multiple myeloma as demonstrated in Tables 9, 10, 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 bortezomib-related occurred within 30 days of the last bortezomib 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 bortezomib 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-bortezomib treatment group (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone; R-CHOP ) and 0.4% (n=1) of patients receiving bortezomib 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 bortezomib 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 Grade PN                            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 bortezomib. 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
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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)


Reporting of 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 https://sideeffects.health.gov.il