Special Warning : אזהרת שימוש

5 WARNINGS AND PRECAUTIONS
5.1 Tumor Lysis Syndrome
Tumor lysis syndrome (TLS), including fatal events and renal failure requiring dialysis, has occurred in patients treated with VENCLEXTA [see Adverse Reactions (6.1)].
VENCLEXTA can cause rapid reduction in tumor and thus poses a risk for TLS at initiation and during the ramp-up phase in all patients, and during reinitiation after dosage interruption in patients with CLL/SLL. Changes in blood chemistries consistent with TLS that require prompt management can occur as early as 6 to 8 hours following the first dose of VENCLEXTA and at each dose increase. TLS, including fatal cases, has been reported after a single 20 mg dose of VENCLEXTA.
In patients with CLL/SLL who followed the current (5-week) dose ramp-up and the TLS prophylaxis and monitoring measures, the rate of TLS was 2% in the VENCLEXTA CLL/SLL monotherapy trials. The rate of TLS remained consistent with VENCLEXTA in combination with obinutuzumab or rituximab. With a 2- to 3- week dose ramp-up and higher starting dose in patients with CLL/SLL, the TLS rate was 13% and included deaths and renal failure [see Adverse Reactions (6.1)].
In patients with AML who followed the current 3-day ramp-up dosing schedule and the TLS prophylaxis and monitoring measures, the rate of TLS was 1.1% in patients who received VENCLEXTA in combination with azacitidine (VIALE-A). In patients with AML who followed a 4-day ramp-up dosing schedule and the TLS prophylaxis and monitoring measures, the rate of TLS was 5.6% and included deaths and renal failure in patients who received VENCLEXTA in combination with low-dose cytarabine (VIALE-C) [see Adverse Reactions (6.1)].
The risk of TLS is a continuum based on multiple factors, particularly reduced renal function , tumor burden, and type of malignancy. Splenomegaly may also increase the risk of TLS in patients with CLL/SLL.
Assess all patients for risk and provide appropriate prophylaxis for TLS, including hydration 
and anti-hyperuricemics. Monitor blood chemistries and manage abnormalities promptly.
Employ more intensive measures (intravenous hydration, frequent monitoring, hospitalization) as overall risk increases Interrupt dosing if needed; when restarting VENCLEXTA, follow dose modification guidance [see Dosage and Administration (2.1, 2.2, 2.3,2.4) and Use in Specific Populations (8.6)].

Concomitant use of VENCLEXTA with P-gp inhibitors or strong or moderate CYP3A inhibitors increases venetoclax exposure, which may increase the risk of TLS at initiation and during the ramp-up phase of VENCLEXTA. For patients with CLL/SLL, coadministration of VENCLEXTA with strong CYP3A inhibitors at initiation and during the 5-week ramp-up phase is contraindicated [see Contraindications (4)]. For patients with AML, reduce the dose of VENCLEXTA when coadministered with strong CYP3A inhibitors at initiation and during the 3- or 4-day ramp-up phase. For patients with CLL/SLL or AML, reduce the dose of VENCLEXTA when coadministered with moderate CYP3A4 inhibitors or P-gp inhibitors [see Dosage and Administration (2.6) and Drug Interactions (7.1)].


5.2 Neutropenia
In patients with CLL, Grade 3 or 4 neutropenia developed in 63% to 64% of patients and Grade 4 neutropenia developed in 31% to 33% of patients when treated with VENCLEXTA in combination and monotherapy studies. Febrile neutropenia occurred in 4% to 6% of patients [see Adverse Reactions (6.1)].
In patients with AML, baseline neutrophil counts worsened in 95% to 100% of patients treated with VENCLEXTA in combination with azacitidine, decitabine, or low-dose cytarabine.
Neutropenia can recur with subsequent cycles.
Monitor complete blood counts throughout the treatment period. For interruption and dose resumption of VENCLEXTA for severe neutropenia, see Table 4 for CLL and Table 6 for AML [see Dosage and Administration (2.5)]. Consider supportive measures including antimicrobials and growth factors (e.g., G-CSF) .

5.3 Infections
Fatal and serious infections, such as pneumonia and sepsis, have occurred in patients treated with VENCLEXTA [see Adverse Reactions (6.1)].
Monitor patients for signs and symptoms of infection and treat promptly. Withhold VENCLEXTA for Grade 3 and 4 infection until resolution. For dose resumptions, see Table 4 for CLL and Table 6 for AML [see Dosage and Administration (2.5)].


5.4 Immunization
Do not administer live attenuated vaccines prior to, during, or after treatment with VENCLEXTA until B-cell recovery occurs. The safety and efficacy of immunization with live attenuated vaccines during or following VENCLEXTA therapy have not been studied. Advise patients that vaccinations may be less effective.

5.5 Embryo-Fetal Toxicity
Based on findings in animals and its mechanism of action, VENCLEXTA may cause embryo- fetal harm when administered to a pregnant woman. In an embryo-fetal study conducted in mice, administration of venetoclax to pregnant animals at exposures equivalent to that observed in patients at a dose of 400 mg daily resulted in post-implantation loss and decreased fetal weight.
Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment with VENCLEXTA and for 30 days after the last dose [see Use in Specific Populations (8.1, 8.3)].

5.6 Effects on ability to drive and use machines

Fatigue and dizziness have been reported in some patients taking VENCLEXTA and should be considered when assessing a patient’s ability to drive or operate machines.

6 ADVERSE REACTIONS
The following clinically significant adverse reactions are described elsewhere in the labeling:
•        Tumor Lysis Syndrome [see Warnings and Precautions (5.1)]
•        Neutropenia [see Warnings and Precautions (5.2)]
•        Infections [see Warnings and Precautions (5.3)] 

6.1 Clinical Trials Experience
Because clinical trials are conducted under widely variable conditions, adverse event rates observed in clinical trials of a drug cannot be directly compared with rates of clinical trials of another drug and may not reflect the rates observed in practice.
In CLL/SLL, the safety population reflects exposure to VENCLEXTA as monotherapy in patients in M13-982, M14-032, and M12-175 and in combination with obinutuzumab or rituximab in patients in CLL14 and MURANO. In this CLL/SLL safety population, the most common adverse reactions (≥20%) for VENCLEXTA were neutropenia, thrombocytopenia, anemia, diarrhea, nausea, upper respiratory tract infection, cough, musculoskeletal pain, fatigue, and edema.
In AML, the safety population reflects exposure to VENCLEXTA in combination with decitabine, azacitidine, or low-dose cytarabine in patients in M14-358, VIALE-A, and VIALE- C. In this safety population, the most common adverse reactions (≥30% in any trial) were nausea, diarrhea, thrombocytopenia, constipation, neutropenia, febrile neutropenia, fatigue, vomiting, edema, pyrexia, pneumonia, dyspnea, hemorrhage, anemia, rash, abdominal pain, sepsis, musculoskeletal pain, dizziness, cough, oropharyngeal pain, and hypotension.
Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma
VENCLEXTA in Combination with Obinutuzumab

The safety of VENCLEXTA in combination with obinutuzumab (VEN+G) (N=212) versus obinutuzumab in combination with chlorambucil (GClb) (N=214) was evaluated in CLL14, a randomized, open-label, actively controlled trial in patients with previously untreated CLL [see Clinical Studies (14.1)]. Patients randomized to the VEN+G arm were treated with VENCLEXTA and obinutuzumab in combination for six cycles, then with VENCLEXTA as monotherapy for an additional six cycles. Patients initiated the first dose of the 5-week ramp-up for VENCLEXTA on Day 22 of Cycle 1 and once completed, continued VENCLEXTA 400 mg orally once daily for a total of 12 cycles. The trial required a total Cumulative Illness Rating Scale (CIRS) >6 or CLcr <70 mL/min, hepatic transaminases and total bilirubin ≤2 times upper limit of normal and excluded patients with any individual organ/system impairment score of 4 by CIRS except eye, ear, nose, and throat organ system. The median duration of exposure to VENCLEXTA was 10.5 months (range: 0 to 13.5 months) and the median number of cycles of obinutuzumab was 6 in the VEN+G arm.
Serious adverse reactions were reported in 49% of patients in the VEN+G arm, most often due to febrile neutropenia and pneumonia (5% each). Fatal adverse reactions that occurred in the absence of disease progression and with onset within 28 days of the last study treatment were reported in 2% (4/212) of patients, most often from infection.
In the VEN+G arm, adverse reactions led to treatment discontinuation in 16% of patients, dose reduction in 21%, and dose interruption in 74%. Neutropenia led to discontinuation of VENCLEXTA in 2% of patients, dose reduction in 13%, and dose interruption in 41%.
Table 9 presents adverse reactions identified in CLL14.
Table 9. Adverse Reactions (≥10%) in Patients Treated with VEN+G in CLL14 VENCLEXTA + Obinutuzumab Obinutuzumab + Chlorambucil
(N = 212)                   (N = 214)
Adverse Reaction
All Grades        Grade ≥ 3   All Grades      Grade ≥ 3
(%)             (%)           (%)           (%)
Blood and lymphatic system disorders
Neutropeniaa                60              56            62            52 a
Anemia                      17               8            20             7 Gastrointestinal disorders
Diarrhea                    28               4            15             1 Nausea                      19               0            22             1 Constipation                13               0             9             0 Vomiting                    10               1             8             1 General disorders and administration site conditions
Fatiguea                    21               2            23             1 Infections and infestations
Upper respiratory
17              1             17            1 tract infectiona a
Includes multiple adverse reaction terms.

Other clinically important adverse reactions (All Grades) reported in <10% of patients treated with VEN+G are presented below:
Blood and lymphatic system disorders: febrile neutropenia (6%)
Infection and infestations (all include multiple adverse reaction terms): pneumonia (9%), urinary tract infection (6%), sepsis (4%)
Metabolism and nutrition disorder: tumor lysis syndrome (1%)
During treatment with VENCLEXTA monotherapy after completion of VEN+G, the adverse reaction that occurred in ≥10% of patients was neutropenia (26%). The grade ≥3 adverse reactions that occurred in ≥2% of patients were neutropenia (23%) and anemia (2%).
Table 10 presents laboratory abnormalities CLL14.
Table 10. New or Worsening Clinically Important Laboratory Abnormalities (≥10%) in Patients Treated with VEN+G in CLL14
VENCLEXTA +                  Obinutuzumab +
Obinutuzumab                  Chlorambucil
(N = 212)                    (N = 214)
Laboratory Abnormalitya
All Grades Grade 3 or 4 All Grades Grade 3 or 4
(%)            (%)           (%)            (%)
Hematology
Leukopenia                             90             46            89             41 Lymphopenia                            87             57            87             51 Neutropenia                            83             63            79             56 Thrombocytopenia                       68             28            71             26 Anemia                                 53             15            46             11 Chemistry
Blood creatinine increased             80              6            74              2 Hypocalcemia                           67              9            58              4 Hyperkalemia                           41              4            35              3 Hyperuricemia                          38             38            38             38 a
Includes laboratory abnormalities that were new or worsening, or with worsening from baseline unknown.
Grade 4 laboratory abnormalities that developed in ≥2% of patients treated with VEN+G included neutropenia (32%), leukopenia and lymphopenia (10%), thrombocytopenia (8%), hypocalcemia (8%), hyperuricemia (7%), blood creatinine increased (3%), hypercalcemia (3%), and hypokalemia (2%).

VENCLEXTA in Combination with Rituximab
The safety of VENCLEXTA in combination with rituximab (VEN+R) (N=194) versus bendamustine in combination with rituximab (B+R) (N=188) was evaluated in MURANO [see Clinical Studies (14.1)]. Patients randomized to VEN+R completed the scheduled ramp-up (5 weeks) and received VENCLEXTA 400 mg once daily, in combination with rituximab for 6 cycles followed by VENCLEXTA monotherapy, for a total of 24 months after ramp-up. At the time of analysis, the median duration of exposure to VENCLEXTA was 22 months and the median number of cycles of rituximab was 6 in the VEN+R arm.
Serious adverse reactions were reported in 46% of patients in the VEN+R arm, with most frequent (≥5%) being pneumonia (9%). Fatal adverse reactions that occurred in the absence of disease progression and within 30 days of the last VENCLEXTA treatment and/or 90 days of last rituximab were reported in 2% (4/194) of patients.
In the VEN+R arm, adverse reactions led to treatment discontinuation in 16% of patients, dose reduction in 15%, and dose interruption in 71%. Neutropenia and thrombocytopenia each led to discontinuation of VENCLEXTA in 3% of patients. Neutropenia led to dose interruption of VENCLEXTA in 46% of patients.


Table 11 presents adverse reactions identified in MURANO.
Table 11. Adverse Reactions (≥10%) in Patients Treated with VEN+R in MURANO VENCLEXTA + Rituximab         Bendamustine + Rituximab
(N = 194)                  (N = 188)
Adverse Reaction
All Grades        Grade ≥ 3   All Grades      Grade ≥ 3
(%)              (%)          (%)           (%)
Blood and lymphatic system disorders
Neutropeniaa                 65               62           50            44 a
Anemia                       16               11           23            14 Gastrointestinal disorders
Diarrhea                     40                3           17             1 Nausea                       21                1           34             1 Constipation                 14               <1           21             0 Infections and infestations
Upper respiratory
39               2            23             2 tract infectiona
Lower respiratory
18               2            10             2 tract infectiona
Pneumoniaa                   10                7           14            10 General disorders and administration site conditions
Fatiguea                     22                2           26            <1 a
Includes multiple adverse reaction terms.

Other clinically important adverse reactions (All Grades) reported in <10% of patients treated with VEN+R are presented below:
Blood and lymphatic system disorders: febrile neutropenia (4%)
Gastrointestinal disorders: vomiting (8%)
Infections and infestations: sepsis (<1%)
Metabolism and nutrition disorders: tumor lysis syndrome (3%)
During treatment with VENCLEXTA monotherapy after completion of VEN+R combination treatment, adverse reactions that occurred in ≥10% of patients were upper respiratory tract infection (21%), diarrhea (19%), neutropenia (16%), and lower respiratory tract infections (11%). The Grade 3 or 4 adverse reactions that occurred in ≥2% of patients were neutropenia (12%) and anemia (3%).
Table 12 presents laboratory abnormalities identified in MURANO.



Table 12. New or Worsening Clinically Important Laboratory Abnormalities (≥10%) in Patients Treated with VEN+R in MURANO
VENCLEXTA + Rituximab Bendamustine + Rituximab
(N = 194)                      (N = 188)
Laboratory Abnormality           All Grades  a   Grade 3 or 4 All Gradesa Grade 3 or 4 (%)            (%)             (%)            (%)
Hematology
Leukopenia                          89             46              81             35 Lymphopenia                         87             56              79             55 Neutropenia                         86             64              84             59 Anemia                              50             12              63             15 Thrombocytopenia                    49             15              60             20 Chemistry
Blood creatinine increased          77             <1              78              1 Hypocalcemia                        62              5              51              2 Hyperuricemia                       36             36              33             33 Hyperkalemia                        24              3              19              2 a
Includes laboratory abnormalities that were new or worsening, or with worsening from baseline unknown.
Grade 4 laboratory abnormalities that developed in ≥2% of patients treated with VEN+R included neutropenia (31%), lymphopenia (16%), leukopenia (6%), thrombocytopenia (6%), hyperuricemia (4%), hypocalcemia (2%), hypoglycemia (2%), and hypermagnesemia (2%).

VENCLEXTA as Monotherapy
The safety of VENCLEXTA was evaluated in pooled data from three single-arm trials (M13- 982, M14-032, and M12-175). Patients received VENCLEXTA 400 mg orally once daily after completing the ramp-up phase (N= 352). The median duration of treatment with VENCLEXTA at the time of data analysis was 14.5 months (range: 0 to 50 months). Fifty-two percent of patients received VENCLEXTA for more than 60 weeks.
In the pooled dataset, the median age was 66 years (range: 28 to 85 years), 93% were White, and 68% were male. The median number of prior therapies was 3 (range: 0 to 15).
Serious adverse reactions were reported in 52% of patients, with the most frequent (≥5%) being pneumonia (9%), febrile neutropenia (5%), and sepsis (5%). Fatal adverse reactions that occurred in the absence of disease progression and within 30 days of venetoclax treatment were reported in 2% of patients in the VENCLEXTA monotherapy studies, most often (2 patients) from septic shock.
Adverse reactions led to treatment discontinuation in 9% of patients, dose reduction in 13%, and dose interruption in 36%. The most frequent adverse reactions leading to drug discontinuation were thrombocytopenia and autoimmune hemolytic anemia. The most frequent adverse reaction (≥5%) leading to dose reductions or interruptions was neutropenia (8%).
Table 13 presents adverse reactions identified in these trials.
Table 13. Adverse Reactions Reported in ≥10% (All Grades) or ≥5% (Grade ≥3) of Patients with Previously Treated CLL/SLL Who Received VENCLEXTA Monotherapy VENCLEXTA
(N = 352)
Adverse Reaction
All Grades               Grade ≥3
(%)                    (%)
Blood and lymphatic system disorders
Neutropeniaa                                   50                     45 a
Anemia                                         33                     18 a
Thrombocytopenia                               29                     20 a
Lymphopenia                                    11                      7 Febrile neutropenia                             6                      6 Gastrointestinal disorders
Diarrhea                                       43                      3 Nausea                                         42                      1 a
Abdominal pain                                 18                      3 Vomiting                                       16                      1 Constipation                                   16                     <1 a
Mucositis                                      13                     <1 Infections and infestations
Upper respiratory tract infectiona             36                      1 a
Pneumonia                                      14                      8 
VENCLEXTA
(N = 352)
Adverse Reaction
All Grades                Grade ≥3
(%)                     (%) a
Lower respiratory tract infection                11                       2 General disorders and administration site conditions
Fatiguea                                         32                       4 a
Edema                                            22                       2 Pyrexia                                          18                      <1 Musculoskeletal and connective tissue disorders
Musculoskeletal paina                            29                       2 Arthralgia                                       12                      <1 Respiratory, thoracic, and mediastinal disorders
Cougha                                           22                       0 a
Dyspnea                                          13                       1 Nervous system disorders
Headache                                         18                      <1 a
Dizziness                                        14                       0 Skin and subcutaneous tissue disorders
Rasha                                            18                      <1 Adverse reactions graded using NCI Common Terminology Criteria for Adverse Events version 4.0.
a
Includes multiple adverse reaction terms.
Table 14 presents laboratory abnormalities reported throughout treatment that were new or worsening from baseline. The most common (>5%) Grade 4 laboratory abnormalities observed with VENCLEXTA monotherapy were hematologic laboratory abnormalities, including neutropenia (33%), leukopenia (11%), thrombocytopenia (15%), and lymphopenia (9%).
Table 14. New or Worsening Laboratory Abnormalities in ≥40% (All Grades) or ≥10% (Grade 3 or 4) of Patients with Previously Treated CLL/SLL Who Received VENCLEXTA Monotherapy
VENCLEXTA
(N = 352)
Laboratory Abnormality                           a
All Grades                Grade 3 or 4
(%)                       (%)
Hematology
Leukopenia                               89                        42 Neutropenia                              87                        63 Lymphopenia                              74                        40 Anemia                                   71                        26 Thrombocytopenia                         64                        31 Chemistry

VENCLEXTA
(N = 352)
Laboratory Abnormality
All Gradesa                    Grade 3 or 4
(%)                            (%)
Hypocalcemia                               87                             12 Hyperglycemia                              67                              7 Hyperkalemia                               59                              5 AST increased                              53                              3 Hypoalbuminemia                            49                              2 Hypophosphatemia                           45                             11 Hyponatremia                               40                              9 a
Includes laboratory abnormalities that were new or worsening, or worsening from baseline unknown.
Important Adverse Reactions in CLL/SLL
Tumor Lysis Syndrome
Tumor lysis syndrome is an important identified risk when initiating VENCLEXTA.
CLL14
The incidence of TLS was 1% (3/212) in patients treated with VEN+G [see Warnings and Precautions (5.1)]. All three events of TLS resolved and did not lead to withdrawal from the trial. Obinutuzumab administration was delayed in two cases in response to the TLS events.
MURANO
The incidence of TLS was 3% (6/194) in patients treated with VEN+R. After 77/389 patients were enrolled in the trial, the protocol was amended to incorporate the current TLS prophylaxis and monitoring measures described in sections 2.2 and 2.4 [see Dosage and Administration (2.2, 2.4)]. All events of TLS occurred during the VENCLEXTA ramp-up period and were resolved within two days. All six patients completed the ramp-up and reached the recommended daily dose of 400 mg of VENCLEXTA. No clinical TLS was observed in patients who followed the current 5-week ramp-up schedule and TLS prophylaxis and monitoring measures [see Dosage and Administration (2.2, 2.4)]. Rates of laboratory abnormalities relevant to TLS for patients treated with VEN+R are presented in Table 12.

Monotherapy Studies (M13-982 and M14-032)
In 168 patients with CLL treated according to recommendations described in sections 2.1 and 2.2, the rate of TLS was 2% [see Dosage and Administration (2.2, 2.4)]. All events either met laboratory TLS criteria (laboratory abnormalities that met ≥2 of the following within 24 hours of each other: potassium >6 mmol/L, uric acid >476 µmol/L, calcium <1.75 mmol/L, or phosphorus >1.5 mmol/L), or were reported as TLS events. The events occurred in patients who had a lymph node(s) ≥5 cm and/or absolute lymphocyte count (ALC) ≥25 x 109/L. All events resolved within 5 days. No TLS with clinical consequences such as acute renal failure, cardiac arrhythmias, or sudden death and/or seizures was observed in these patients. All patients had CLcr ≥50 mL/min. Laboratory abnormalities relevant to TLS were hyperkalemia (17% all Grades, 1% Grade ≥3), hyperphosphatemia (14% all Grades, 2% Grade ≥3), hypocalcemia (16% all Grades, 2% Grade ≥3), and hyperuricemia (10% all Grades, <1% Grade ≥3).
In the initial Phase 1 dose-finding trials, which had shorter (2-3 week) ramp-up phase and higher starting doses, the incidence of TLS was 13% (10/77; 5 laboratory TLS, 5 clinical TLS), including 2 fatal events and 3 events of acute renal failure, 1 requiring dialysis. After this experience, TLS risk assessment, dosing regimen, TLS prophylaxis and monitoring measures were revised [see Dosage and Administration (2.2, 2.4)].
Acute Myeloid Leukemia
VENCLEXTA in Combination with Azacitidine
The safety of VENCLEXTA in combination with azacitidine (VEN+AZA) (N=283) versus placebo in combination with azacitidine (PBO+AZA) (N=144) was evaluated in VIALE-A, a double-blind, randomized trial, in patients with newly diagnosed AML [see Clinical Studies (14.2)]. At baseline, patients were ≥75 years of age or had comorbidities that precluded the use of intensive induction chemotherapy based on at least one of the following criteria: baseline ECOG performance status of 2-3, severe cardiac or pulmonary comorbidity, moderate hepatic impairment, CLcr < 45 mL/min, or other comorbidity. Patients were randomized to receive VENCLEXTA 400 mg orally once daily after completion of the ramp-up phase in combination with azacitidine (75 mg/m2 either intravenously or subcutaneously on Days 1-7 of each 28-day cycle) or placebo in combination with azacitidine. Among patients who received VEN+AZA, the median duration of exposure to VENCLEXTA was 7.6 months (range: <0.1 to 30.7 months).

Serious adverse reactions were reported in 83% of patients who received VEN+AZA, with the most frequent (≥5%) being febrile neutropenia (30%), pneumonia (22%), sepsis (excluding fungal; 19%), and hemorrhage (6%). Fatal adverse reactions occurred in 23% of patients who received VEN+AZA, with the most frequent (≥2%) being pneumonia (4%), sepsis (excluding fungal; 3%), and hemorrhage (2%).
Adverse reactions led to permanent discontinuation of VENCLEXTA in 24% of patients, dose reductions in 2%, and dose interruptions in 72%. Adverse reactions which led to discontinuation of VENCLEXTA in ≥2% of patients were sepsis (excluding fungal; 3%) and pneumonia (2%). The most frequent adverse reaction leading to dose reduction was pneumonia (0.7%). Adverse reactions which required a dose interruption in ≥5% of patients included 
febrile neutropenia (20%), neutropenia (20%), pneumonia (14%), sepsis (excluding fungal; 11%), and thrombocytopenia (10%). Among patients who achieved bone marrow clearance of leukemia, 53% underwent dose interruptions for absolute neutrophil count (ANC) <500/microliter.
Table 15 presents adverse reactions identified in VIALE-A.
Table 15. Adverse Reactions (≥10%) in Patients with AML Who Received VEN+AZA with a Difference Between Arms of ≥5% for All Grades or ≥2% for Grade 3 or 4 Reactions Compared with PBO+AZA in VIALE-A
VENCLEXTA + Azacitidine    Placebo + Azacitidine
(N = 283)               (N = 144)
Adverse Reaction
All Grades Grade 3 or 4 All Grades Grade 3 or 4
(%)           (%)       (%)           (%)
Gastrointestinal disorders
Nausea                              44             2        35            <1 a
Diarrhea                            43             5        33             3 b
Vomiting                            30             2        23            <1 c
Stomatitis                          18             1        13             0 d
Abdominal pain                      18            <1        13             0 Blood and lymphatic system disorders
Febrile neutropenia                 42            42        19            19 Musculoskeletal and connective tissue disorders
Musculoskeletal paine               36             2        28             1 General disorders and administration site conditions
Fatiguef                            31             6        23             2 g
Edema                               27            <1        19             0 Vascular disorders
Hemorrhageh                         27             7        24             3 i
Hypotension                         12             5         8             3 Metabolism and nutrition disorders
Decreased appetitej                 25             4        17            <1 Skin and subcutaneous tissue disorders
Rashk                               25             1        15             0 Infections and infestations
Sepsisl (excluding fungal)          22            22        16            14 m
Urinary tract infection             16             6         9             6 Respiratory, thoracic and mediastinal disorders
Dyspnean                            18             4        10             2 Nervous system disorders
Dizzinesso                          17            <1         8            <1 a
Includes diarrhea and colitis.

VENCLEXTA + Azacitidine                Placebo + Azacitidine
(N = 283)                          (N = 144)
Adverse Reaction
All Grades Grade 3 or 4 All Grades Grade 3 or 4
(%)              (%)              (%)                (%) b
Includes vomiting and hematemesis.
c
Includes stomatitis, mouth ulceration, mucosal inflammation, cheilitis, aphthous ulcer, glossitis, and tongue ulceration.
d
Includes abdominal pain, abdominal pain upper, abdominal discomfort, and abdominal pain lower.
e
Includes arthralgia, back pain, pain in extremity, musculoskeletal pain, bone pain, myalgia, neck pain, non-cardiac chest pain, arthritis, musculoskeletal chest pain, musculoskeletal stiffness, spinal pain, and musculoskeletal discomfort.
f
Includes fatigue and asthenia.
g
Includes edema peripheral, edema, generalized edema, eyelid edema, face edema, penile edema, periorbital edema, and swelling.
h
Includes epistaxis, hematuria, conjunctival hemorrhage, hemoptysis, hemorrhoidal hemorrhage, gingival bleeding, mouth hemorrhage, hemorrhage intracranial, vaginal hemorrhage, cerebral hemorrhage, gastrointestinal hemorrhage, muscle hemorrhage, skin hemorrhage, upper gastrointestinal hemorrhage, anal hemorrhage, eye hemorrhage, gastritis hemorrhagic, hemorrhage, hemorrhage urinary tract, hemorrhagic diathesis, hemorrhagic stroke, hemorrhagic vasculitis, lower gastrointestinal hemorrhage, mucosal hemorrhage, penile hemorrhage, post procedural hemorrhage, rectal hemorrhage, retinal hemorrhage, shock hemorrhagic, soft tissue hemorrhage, subdural hemorrhage, tongue hemorrhage, urethral hemorrhage, vessel puncture site hemorrhage, vitreous hemorrhage and wound hemorrhage.
i
Includes hypotension and orthostatic hypotension.
j
Includes decreased appetite and hypophagia.
k
Includes rash, rash maculo-papular, rash macular, drug eruption, rash papular, rash pustular, eczema, rash erythematous, rash pruritic, dermatitis acneiform, rash morbilliform, dermatitis, eczema asteatotic, exfoliative rash, and perivascular dermatitis.
l
Includes sepsis, escherichia bacteremia, escherichia sepsis, septic shock, bacteremia, staphylococcal bacteremia, klebsiella bacteremia, staphylococcal sepsis, streptococcal bacteremia, enterococcal bacteremia, klebsiella sepsis, pseudomonal bacteremia, pseudomonal sepsis, urosepsis, bacterial sepsis, clostridial sepsis, enterococcal sepsis, neutropenic sepsis, and streptococcal sepsis.
m
Includes urinary tract infection, escherichia urinary tract infection, cystitis, urinary tract infection enterococcal, urinary tract infection bacterial, pyelonephritis acute, and urinary tract infection pseudomonal.
n
Includes dyspnea, dyspnea exertional, and dyspnea at rest.
o
Includes dizziness and vertigo.
Other clinically important adverse reactions (All Grades) at ≥10% that did not meet criteria for Table 15 or <10% are presented below:
Hepatobiliary disorders: cholecystitis/cholelithiasisa (4%)
Infections and infestations: pneumoniab (33%)

Metabolism and nutrition disorders: tumor lysis syndrome (1%)
Nervous system disorders: headachec (11%)
Investigations: weight decreased (13%).
a
Includes cholecystitis acute, cholelithiasis, cholecystitis, and cholecystitis chronic.
b
Includes pneumonia, lung infection, pneumonia fungal, pneumonia klebsiella, atypical pneumonia, lower respiratory tract infection, pneumonia viral, lower respiratory tract infection fungal, pneumonia hemophilus, pneumonia pneumococcal, and pneumonia respiratory syncytial viral.
c
Includes headache and tension headache.
Table 16 presents laboratory abnormalities identified in VIALE-A.
Table 16. New or Worsening Laboratory Abnormalities (≥10%) in Patients with AML Who Received VEN+AZA with a Difference Between Arms of ≥5% for All Grades or ≥ 2% for Grade 3 or 4 Reactions Compared with PBO+AZA in VIALE-A
VENCLEXTA +                     Placebo +
Azacitidine                  Azacitidine
Laboratory Abnormality
All Grades Grade 3 or 4 All Grades Grade 3 or 4
(%)           (%)            (%)           (%)
Hematology
Neutrophils decreased                    98            98             88            81 Platelet decreased                       94            88             94            80 Lymphocytes decreased                    91            71             72            39 Hemoglobin decreased                     61            57             56            52 Chemistry
Bilirubin increased                      53             7             40             4 Calcium decreased                        51             6             39             9 Sodium decreased                         46            14             47             8 Alkaline phosphatase increased           42             1             29            <1 Blood bicarbonate decreased              31            <1             25             0 The denominator used to calculate the rate varied from 85 to 144 in the PBO+AZA arm and from 125 to 283 in the VEN+AZA arm based on the number of patients with at least one post- treatment value.
VENCLEXTA in Combination with Azacitidine or Decitabine
The safety of VENCLEXTA in combination with azacitidine (N=67) or decitabine (N=13) was evaluated in M14-358, a non-randomized trial of patients with newly diagnosed AML. At baseline, patients were ≥75 years of age, or had comorbidities that precluded the use of intensive induction chemotherapy based on at least one of the following criteria: baseline ECOG performance status of 2-3, severe cardiac or pulmonary comorbidity, moderate hepatic impairment, CLcr <45 mL/min, or other comorbidity [see Clinical Studies (14.2)]. Patients received VENCLEXTA 400 mg orally once daily after completion of the ramp-up phase in 
combination with azacitidine (75 mg/m2 either intravenously or subcutaneously on Days 1-7 of each 28-day cycle) or decitabine (20 mg/m2 intravenously on Days 1-5 of each 28-day cycle).
Azacitidine
The median duration of exposure to VENCLEXTA when administered in combination with azacitidine was 6.5 months (range: 0.1 to 38.1 months). The safety of VENCLEXTA in combination with azacitidine in this trial is consistent with that of VIALE-A.
Decitabine
The median duration of exposure to VENCLEXTA when administered in combination with decitabine was 8.4 months (range: 0.5 to 39 months).
Serious adverse reactions were reported in 85% of patients who received VENCLEXTA with decitabine, the most frequent (≥10%) being sepsis (excluding fungal; 46%), febrile neutropenia (38%), and pneumonia (31%). One (8%) fatal adverse reaction of bacteremia occurred within 30 days of starting treatment.
Permanent discontinuation of VENCLEXTA due to adverse reactions occurred in 38% of patients. The most frequent adverse reaction leading to permanent discontinuation (≥5%) was pneumonia (8%).
Dosage reductions of VENCLEXTA due to adverse reactions occurred in 15% of patients. The most frequent adverse reaction leading to dose reduction (≥5%) was neutropenia (15%).
Dosage interruptions of VENCLEXTA due to adverse reactions occurred in 69% of patients.
The most frequent adverse reactions leading to dose interruption (≥ 10%) were neutropenia (38%), febrile neutropenia (23%), leukopenia (15%), and pneumonia (15%).
The most common adverse reactions (≥30%) were febrile neutropenia (69%), fatigue (62%), constipation (62%), musculoskeletal pain (54%), dizziness (54%), nausea (54%), abdominal pain (46%), diarrhea (46%), pneumonia (46%), sepsis (excluding fungal; 46%), cough (38%), pyrexia (31%), hypotension (31%), oropharyngeal pain (31%), edema (31%), and vomiting (31%). The most common laboratory abnormalities (≥30%) were neutrophils decreased (100%), lymphocytes decreased (100%), white blood cells decreased (100%), platelets decreased (92%), calcium decreased (85%), hemoglobin decreased (69%), glucose increased (69%), magnesium decreased (54%), potassium decreased (46%), bilirubin increased (46%), albumin decreased (38%), alkaline phosphatase increased (38%), sodium decreased (38%), ALT increased (31%), creatinine increased (31%), and potassium increased (31%).
VENCLEXTA in Combination with Low-Dose Cytarabine
VIALE-C
The safety of VENCLEXTA in combination with low-dose cytarabine (VEN+LDAC) (N=142) versus placebo with low-dose cytarabine (PBO+LDAC) (N=68) was evaluated in VIALE-C, a double-blind randomized trial in patients with newly diagnosed AML. At baseline, patients were ≥75 years of age, or had comorbidities that precluded the use of intensive induction chemotherapy based on at least one of the following criteria: baseline ECOG performance status of 2-3, severe cardiac or pulmonary comorbidity, moderate hepatic impairment, CLcr <45 mL/min, or other comorbidity [see Clinical Studies (14.2)]. Patients were randomized to 
receive VENCLEXTA 600 mg orally once daily after completion of a 4-day ramp-up phase in combination with low-dose cytarabine (20 mg/m2 subcutaneously once daily on Days 1-10 of each 28-day cycle) or placebo in combination with low-dose cytarabine. Among patients who received VEN+LDAC, the median duration of exposure to VENCLEXTA was 3.9 months (range: <0.1 to 17.1 months).
Serious adverse reactions were reported in 65% of patients who received VEN+LDAC, with the most frequent (≥10%) being pneumonia (17%), febrile neutropenia (16%), and sepsis (excluding fungal; 12%). Fatal adverse reactions occurred in 23% of patients who received VEN+LDAC, with the most frequent (≥5%) being pneumonia (6%) and sepsis (excluding fungal; 7%).
Adverse reactions led to permanent discontinuation of VENCLEXTA in 25% of patients, dose reductions in 9%, and dose interruptions in 63%. The most frequent adverse reaction (>2%) which resulted in permanent discontinuation of VENCLEXTA was pneumonia (6%). Adverse reactions which required a dose reduction in ≥1% of patients were pneumonia (1%) and thrombocytopenia (1%), and the adverse reactions which required a dose interruption in ≥5% of patients included neutropenia (20%), thrombocytopenia (15%), pneumonia (8%), febrile neutropenia (6%), and sepsis (excluding fungal; 6%). Among patients who achieved bone marrow clearance of leukemia, 32% underwent dose interruptions for ANC <500/microliter.
Table 17 presents adverse reactions identified in VIALE-C.
Table 17. Adverse Reactions (≥10%) in Patients with AML Who Received VEN+LDAC with a Difference Between Arms of ≥5% for All Grades or ≥2% for Grade 3 or 4 Compared with PBO+LDAC in VIALE-C
VENCLEXTA + Low-Dose            Placebo + Low-Dose
Cytarabine                   Cytarabine
Adverse Reaction                     (N = 142)                    (N = 68) All Grades      Grade 3 or 4 All Grades Grade 3 or 4
(%)             (%)          (%)           (%)
Gastrointestinal disorders
Nausea                          42               1           31             0 Diarrhea                        28               3           16             0 Vomiting                        25              <1           13             0 a
Abdominal pain                  15              <1            9             3 b
Stomatitis                      15               1            6             0 Blood and lymphatic system disorders
Febrile neutropenia             32              32           29            29 Infections and infestations
Pneumoniac                      29              19           21            21 Vascular Disorders
Hemorrhaged                     27               8           16             1 e
Hypotension                     11               5            4             1 Musculoskeletal and connective tissue disorders

VENCLEXTA + Low-Dose                   Placebo + Low-Dose
Cytarabine                         Cytarabine
Adverse Reaction                           (N = 142)                          (N = 68) All Grades        Grade 3 or 4       All Grades Grade 3 or 4
(%)               (%)                (%)           (%) f
Musculoskeletal pain              23                 3                 18             0 General Disorders and Administration Site Conditions
Fatigueg                          22                 2                 21             0 Nervous System Disorders
Headache                          11                 0                  6             0 a
Includes abdominal pain, abdominal pain upper, abdominal discomfort, and abdominal pain lower.
b
Includes stomatitis, mouth ulceration, aphthous ulcer, glossitis, mucosal inflammation, and tongue ulceration.
c
Includes pneumonia, lung infection, lower respiratory tract infection, pneumonia fungal, lower respiratory tract infection fungal, pneumocystis jirovecii pneumonia, pneumonia aspiration, pneumonia cytomegaloviral, and pneumonia pseudomonal.
d
Includes epistaxis, conjunctival hemorrhage, hemoptysis, gastrointestinal hemorrhage, gingival bleeding, mouth hemorrhage, upper gastrointestinal hemorrhage, hematuria, retinal hemorrhage, catheter site hemorrhage, cerebral hemorrhage, gastric hemorrhage, gastritis hemorrhagic, hemorrhage intracranial, hemorrhage subcutaneous, lip hemorrhage, mucosal hemorrhage, pharyngeal hemorrhage, post procedural hemorrhage, pulmonary alveolar hemorrhage, pulmonary hemorrhage, tooth pulp hemorrhage, uterine hemorrhage, and vascular access site hemorrhage.
e
Includes hypotension and orthostatic hypotension.
f
Includes back pain, arthralgia, pain in extremity, musculoskeletal pain, myalgia, neck pain, non-cardiac chest pain, arthritis, bone pain, musculoskeletal chest pain, and spinal pain.
g
Includes fatigue and asthenia.
Other clinically important adverse reactions (All Grades) at ≥10% that did not meet criteria for Table 17 or <10% are presented below:
Hepatobiliary disorders: cholecystitis/cholelithiasisa (1%)
Infections and infestations: sepsisb (excluding fungal; 15%), urinary tract infectionc (8%) Metabolism and nutrition disorders: decreased appetite (19%), tumor lysis syndrome (6%) Nervous system disorders: dizzinessd (9%)
Respiratory, thoracic, and mediastinal disorders: dyspneae (10%)
Investigations: weight decreased (9%).
a
Includes cholecystitis and cholecystitis acute b
Includes sepsis, bacteremia, septic shock, neutropenic sepsis, staphylococcal bacteremia, streptococcal bacteremia, bacterial sepsis, Escherichia bacteremia, pseudomonal bacteremia, and staphylococcal sepsis

c
Includes urinary tract infection and escherichia urinary tract infection d
Includes dizziness and vertigo e
Includes dyspnea and dyspnea exertional.
Table 18 describes laboratory abnormalities identified in VIALE-C.
Table 18. New or Worsening Laboratory Abnormalities (≥10%) in Patients with AML Who Received VEN+LDAC with Difference Between Arms of ≥5% for All Grades or ≥ 2% for Grade 3 or 4 Reactions Compared with PBO+LDAC in VIALE-C
VENCLEXTA + Low-Dose               Placebo + Low-Dose
Cytarabine                      Cytarabine
Laboratory Abnormality
All Grades Grade 3 or 4 All Grades Grade 3 or 4
(%)            (%)              (%)           (%)
Hematology
Platelets decreased                   97             95               92            90 Neutrophils decreased                 95             92               82            71 Lymphocytes decreased                 92             69               65            24 Hemoglobin decreased                  63             57               57            54 Chemistry
Bilirubin increased                   61              7               38             7 Albumin decreased                     61              6               43             4 Potassium decreased                   56             16               42            14 Calcium decreased                     53              8               45            13 Glucose increased                     52             13               59             9 AST increased                         36              6               37             1 Alkaline phosphatase increased        34              1               26             1 ALT increased                         30              4               26             1 Sodium increased                      11              3                6             1 The denominator used to calculate the rate varied from 38 to 68 in the PBO+LDAC arm and from 65 to 142 in the VEN+LDAC arm based on the number of patients with at least one post- treatment value.
M14-387
The safety of VENCLEXTA in combination with low-dose cytarabine (N=61) was evaluated in M14-387, a non-randomized, open- label trial of patients with newly diagnosed AML [see Clinical Studies (14.2)]. At baseline, patients were ≥75 years of age, or had comorbidities that precluded the use of intensive induction chemotherapy based on at least one of the following criteria: baseline ECOG performance status of 2-3, severe cardiac or pulmonary comorbidity, moderate hepatic impairment, CLcr <45 mL/min, or other comorbidity. Patients received VENCLEXTA 600 mg orally once daily after completion of the ramp-up phase in combination with low-dose cytarabine (20mg/m2 subcutaneously on Days 1-10 of each 28-day cycle). The safety of VENCLEXTA in combination with low-dose cytarabine is consistent with that of VIALE-C.

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

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