Rare Diseases

 

Talking to patients about some common drug-related adverse reactions

Adverse reactions may lead patients to stop taking therapy, to skip doses, or to attempt to self-manage adverse reactions in an attempt to minimize them.1,2

Reduce the severity of some common adverse reactions while maintaining the GLEEVEC dose whenever possible

The severity of some adverse reactions may be reduced with supportive care, while others may require dosage adjustment, dose interruption, or discontinuation.3,4

Below are some possible adverse reactions, how to communicate with your patients about them, and the supportive care measures you may suggest.

Possible side effect Supportive measures you may suggest

Edema

How it might manifest for the patient:
Swelling in the legs, feet, or around the eyes; quick weight gain
  • An over-the-counter steroid cream or prescription eye drops to reduce swelling around the eyes
  • A diuretic to help rid the body of extra fluid
  • A reduction in salt intake

Rash

How it might manifest for the patient:
Scaly skin; red, itchy bumps on skin
  • An over-the-counter or prescription antihistamine or steroid cream

Nausea

How it might manifest for the patient:
Feeling queasy, like you have to throw up or like you have indigestion
  • Taking GLEEVEC with a meal and a large glass of water at least 2 hours before bedtime
  • A prescription antiemetic (antinausea) medication

Muscle cramps

How it might manifest for the patient:
Pain or spasms usually in the legs, feet, or calves; a "charley horse"
  • Calcium or magnesium supplements
  • An increase in fluid intake

Musculoskeletal pain

How it might manifest for the patient:
Whole-body aches; twitching or burning muscles; feeling like you have the flu
  • An over-the-counter or prescription pain reliever

Diarrhea

How it might manifest for the patient:
Frequent bowel movements; loose stools
  • An over-the-counter medication

Fatigue

How it might manifest for the patient:
Weariness or exhaustion
  • Rest
  • Adequate diet and fluid intake

Please see Important Safety Information and full Prescribing Information.

1. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487-497.

2. Partridge AH, Avorn J, Wang PS, Winer EP. Adherence to therapy with oral antineoplastic agents. J Natl Cancer Inst. 2002;94:652-661.

3. GLEEVEC® (imatinib mesylate) tablets prescribing information. East Hanover, NJ: Novartis Pharmaceuticals Corporation; January 2012.

4. Deininger MW, O'Brien SG, Ford JM, Druker BJ. Practical management of patients with chronic myeloid leukemia receiving imatinib. J Clin Oncol. 2003;21:1637-1647.

 

Always consider benefits and risks when making a treatment decision

Serious adverse reactions to GLEEVEC® (imatinib mesylate)
 
Fluid retention and edema Patients should be weighed and monitored regularly for signs and symptoms of edema or serious fluid retention. Severe fluid retention was reported in 9% to 13.1% of patients with KIT+ GIST. If severe fluid retention occurs, manage with diuretic therapy and withhold GLEEVEC until the event has resolved and then resume depending on the initial severity of the event.
Hematologic toxicity Cytopenias, including anemia, neutropenia, and thrombocytopenia, have been reported. Complete blood counts should be performed weekly for the first month, biweekly for the second month, and periodically thereafter as clinically indicated (eg, every 2-3 months). Dose reduction, treatment interruption, or in rare cases discontinuation of treatment may be required for severe neutropenia or thrombocytopenia.
Severe congestive heart failure and left ventricular dysfunction Severe congestive heart failure and left ventricular dysfunction have been reported in patients taking GLEEVEC. Patients with cardiac disease or renal failure, risk factors for cardiac failure, or history of renal failure should be monitored carefully. Patients with signs or symptoms should be evaluated and treated.
Hepatotoxicity Severe hepatotoxicity, including fatalities, may occur with both short-term and long-term use. Assess liver function before initiation of treatment and monitor monthly thereafter, or as clinically indicated. Dose adjustments or drug interruption may be required. A 25% decrease in the recommended dose should be used for patients with severe hepatic impairment.
Hemorrhage In the Phase 3 unresectable or metastatic GIST studies, 13% of patients reported NCI Grades 3/4 hemorrhage at any site. In the Phase 2 unresectable or metastatic GIST study, 5% of patients reported severe gastrointestinal (GI) and/or intratumoral bleeds. GI tumor sites may have been the source of GI bleeds; therefore, GI symptoms should be monitored at the start of therapy.
Gastrointestinal disorders GLEEVEC should be taken with food and a large glass of water to minimize possible GI irritation. There have been rare reports, including fatalities, of GI perforation.
Hypereosinophilic cardiac toxicity In patients with hypereosinophilic syndrome with occult infiltration of HES cells within the myocardium, cardiogenic shock and left ventricular dysfunction have been associated with HES cell degranulation upon initiation of GLEEVEC. The condition was reported to be reversible with the administration of systemic steroids, circulatory support measures, and temporarily withholding GLEEVEC.
Dermatologic toxicities Bullous dermatologic reactions, including erythema multiforme and Stevens-Johnson syndrome, have been reported.
Hypothyroidism Hypothyroidism has been reported in thyroidectomy patients undergoing levothyroxine replacement during treatment with GLEEVEC. TSH levels should be closely monitored.
Toxicities from long-term use Consider potential toxicities—specifically liver, kidney, and cardiac toxicity—and immunosuppression.
Fetal harm Fetal harm can occur when administered to a pregnant woman; therefore, women of reproductive potential should be advised to not become pregnant and use highly effective contraception while taking GLEEVEC. Breastfeeding should be avoided while taking GLEEVEC because of the potential for serious adverse reactions in nursing infants.
Growth retardation Growth retardation has been reported in children and preadolescents receiving GLEEVEC. The long-term effects of prolonged treatment with GLEEVEC on growth in children are unknown; therefore, monitoring of growth in children taking GLEEVEC is recommended.
Tumor lysis syndrome Cases of tumor lysis syndrome (TLS), including fatal cases, have been reported. Patients with tumors having a high proliferative rate or high tumor burden prior to treatment should be monitored closely for TLS. Correction of clinically significant dehydration and treatment of high uric acid levels are recommended prior to initiation of GLEEVEC.
Dizziness, blurred vision, and somnolence Motor vehicle accidents involving patients receiving GLEEVEC have been reported. Patients should be advised that they may experience undesirable effects such as dizziness, blurred vision, or somnolence during treatment with GLEEVEC. Caution should be recommended when driving a car or operating machinery.

GLEEVEC® (imatinib mesylate) tablets are indicated for:

Important Safety Information

  • GLEEVEC is often associated with edema and, occasionally, serious fluid retention. Severe fluid retention was reported in 9%-13.1% and 2.5%-11% of patients taking GLEEVEC for KIT+ GIST and CML, respectively. Patients should be weighed and monitored regularly for signs and symptoms of fluid retention, which can be serious or life threatening, and be advised to report any rapid, unexpected weight gain. The probability of edema tended to be increased among older patients (>65 years) or those taking higher doses of GLEEVEC. Severe edema and superficial edema was observed in 182 (11.1%) GIST patients and 1.5%-6% in CML patients, respectively. If severe fluid retention occurs, manage with diuretic therapy and withhold GLEEVEC until the event has resolved, and then resume depending on the initial severity of the event
  • Cytopenias have been reported. Complete blood counts should be performed weekly for the first month, biweekly for the second month, and periodically thereafter as clinically indicated (eg, every 2-3 months). Dose reduction, treatment interruption, or in rare cases discontinuation of treatment may be required for severe neutropenia or thrombocytopenia (see full Prescribing Information for dose adjustment recommendations)
  • Severe congestive heart failure and left ventricular dysfunction have been reported. Most of the patients with reported cardiac events have had other comorbidities and risk factors, including advanced age and previous medical history of cardiac disease. Patients with cardiac disease or risk factors for cardiac disease or history of renal failure should be monitored carefully, and any patient with signs or symptoms consistent with cardiac or renal failure should be evaluated and treated
  • Hepatotoxicity, occasionally severe, may occur. Cases of fatal liver failure and severe liver injury requiring liver transplants have been reported with both short-term and long-term use of GLEEVEC. Assess liver function before initiation of treatment and monthly thereafter, or as clinically indicated. A 25% decrease in the recommended dose should be used for patients with severe hepatic impairment. If severe hepatotoxicity occurs, GLEEVEC should be withheld until the event has resolved and then resumed depending on the initial severity of the event
  • When GLEEVEC is combined with chemotherapy, liver toxicity in the form of transaminase elevation and hyperbilirubinemia has been observed. Additionally, there have been reports of acute liver failure. Monitoring of hepatic function is recommended
  • In the newly diagnosed CML trial, 1.8% of patients had hemorrhage (NCI Grades 3/4).
  • In the Phase 3 unresectable or metastatic GIST studies, 13% of patients reported hemorrhage (NCI Grades 3/4) at any site. In the Phase 2 unresectable or metastatic GIST study, 5% of patients were reported to have severe gastrointestinal (GI) bleeds and/or intratumoral bleeds. GI tumor sites may have been the source of GI bleeds; therefore, GI symptoms should be monitored at the start of therapy
  • In patients with hypereosinophilic syndrome with occult infiltration of HES cells within the myocardium, cardiogenic shock and left ventricular dysfunction have been associated with HES cell degranulation upon initiation of GLEEVEC. The condition was reported to be reversible with the administration of systemic steroids, circulatory support measures, and temporarily withholding GLEEVEC. MDS/MPD disease and systemic mastocytosis may be associated with high eosinophil levels. Performance of an echocardiogram and determination of serum troponin should, therefore, be considered in patients with HES/CEL and in patients with MDS/MPD or ASM associated with high eosinophil levels. If either is abnormal, the prophylactic use of systemic steroids (1-2 mg/kg) for 1-2 weeks concomitantly with GLEEVEC should be considered at the initiation of therapy
  • Bullous dermatologic reactions (eg, erythema multiforme and Stevens-Johnson syndrome) have also been reported. In some cases, the reaction recurred upon rechallenge. Several postmarketing reports describe patients able to tolerate the reintroduction of GLEEVEC at a lower dose, with or without concomitant corticosteroids or antihistamines following resolution or improvement of the bullous reaction
  • Clinical cases of hypothyroidism have been reported in thyroidectomy patients undergoing levothyroxine replacement during treatment with GLEEVEC. TSH levels should be closely monitored in such patients
  • Consider potential toxicities—specifically liver, kidney, and cardiac toxicity—and immunosuppression from long-term use
  • Fetal harm can occur when administered to a pregnant woman. Therefore, women of reproductive potential should be advised not to become pregnant while taking GLEEVEC tablets and to avoid breastfeeding while taking GLEEVEC because of the potential for serious adverse reactions in nursing infants. Sexually active female patients taking GLEEVEC should use highly effective contraception. If the patient does become pregnant while taking GLEEVEC, the patient should be advised of the potential hazard to the fetus
  • Growth retardation has been reported in children and preadolescents receiving GLEEVEC. The long-term effects of prolonged treatment with GLEEVEC on growth in children are unknown; therefore, monitoring of growth in children taking GLEEVEC is recommended
  • Cases of tumor lysis syndrome (TLS), including fatal cases, have been reported. The patients at risk of TLS are those with tumors having a high proliferative rate or high tumor burden prior to treatment. These patients should be monitored closely and appropriate precautions taken. Correction of clinically significant dehydration and treatment of high uric acid levels are recommended prior to initiation of GLEEVEC
  • Motor vehicle accidents involving patients receiving GLEEVEC have been reported. Patients should be advised that they may experience undesirable effects such as dizziness, blurred vision, or somnolence during treatment with GLEEVEC. Caution should be recommended when driving a car or operating machinery
  • In Ph+ CML trials,* severe (NCI Grades 3/4) lab abnormalities—including neutropenia (3.6%-48%), anemia (1%-42%), thrombocytopenia (<1%-33%), and hepatotoxicity (~5%)—and severe (NCI Grades 3/4) adverse experiences, including hemorrhage (1.8%-19%), fluid retention (eg, pleural effusion, pulmonary edema, and ascites) (2.5%-11%) and superficial edema (1.5%-6%), and musculoskeletal pain (2%-9%) were reported among patients receiving GLEEVEC. Severe fluid retention appears to be dose related, was more common in the advanced phase studies (where the dosage was 600 mg/day), and is more common in the elderly
  • In HES/CEL patients, instances of Grade 3 leukopenia, neutropenia, lymphopenia, and anemia were reported
  • For DFSP, severe (NCI Grades 3/4) lab abnormalities included anemia (17%), thrombocytopenia (17%), neutropenia (8%), and increased creatinine (8%)
  • In the Phase 2 unresectable or metastatic GIST trial (400 mg/d; 600 mg/d), severe (NCI Grades 3/4) lab abnormalities—including anemia (3%; 9%) and neutropenia (10%; 11%)—were reported among patients receiving GLEEVEC. In Phase 3 unresectable or metastatic GIST trials (400 mg/day; 800 mg/day), the most frequently reported adverse reactions included abdominal pain (14%; 12%), edema (9%; 13%), fatigue (12%; 12%), nausea (9%; 8%), vomiting (9%; 8%), diarrhea (8%; 9%), rash (8%; 9%), myalgia (6%; 4%), anemia (5%; 6%), and anorexia (7%; 5%). The percentages listed represent NCI Grades 3 and above
  • In the adjuvant GIST study comparing 12 months of GLEEVEC vs placebo treatment (GLEEVEC; placebo), severe (NCI Grades 3 and above) lab abnormalities included increase in liver enzymes (ALT) (3%; 0%), (AST) (2%; 0%), decreased neutrophil count (3%; 1%), and decrease in hemoglobin (1%; 0%); severe (NCI Grades 3 and above reported at rates >1%) adverse reactions included abdominal pain (3%; 1%), diarrhea (3%; 1%), rash (3%; 0%), fatigue (2%; 1%), nausea (2%; 1%), vomiting (2%; 1%), decreased white blood cell count (1%; 0%), and periorbital edema (1%; 0%). The frequencies of these reported lab abnormalities and severe adverse reactions were similar in a study comparing 12 vs 36 months of GLEEVEC treatment (12 mo; 36 mo), except for liver enzyme AST (2%; 3%), decreased neutrophil count (5%; 5%), decreased white blood cell count (2%; 3%), pain (1%; 3%), infection (2%; 3%), and blurred vision (1%; 1%), which were higher among patients receiving 36 months of adjuvant treatment with GLEEVEC*
  • There have also been reports, including fatalities, of cardiac tamponade, cerebral edema, acute respiratory failure, and GI perforation
  • GLEEVEC is metabolized by the CYP3A4 isoenzyme and is an inhibitor of CYP3A4, CYP2D6, and CYP2C9. Significant reductions in imatinib concentrations may occur when GLEEVEC is administered concomitantly with agents that are strong CYP3A4 inducers such as rifampin, St. John's wort, and enzyme-inducing anti-epileptic drugs, eg, phenytoin. The concomitant use of strong CYP3A4 inducers should be avoided. If patients must be administered a strong CYP3A4 inducer, the dosage of GLEEVEC should be increased by at least 50%, and clinical response should be carefully monitored. Caution is recommended when GLEEVEC is administered with CYP3A4 inhibitors such as ketoconazole, with CYP2D6 substrates that have a narrow therapeutic window, or with CYP3A4 substrates that have a narrow therapeutic window. Other examples of commonly used drugs that may significantly interact with GLEEVEC include acetaminophen, warfarin, erythromycin, and metoprolol. Grapefruit juice should also be avoided in patients taking GLEEVEC. (Please see full Prescribing Information for other potential drug interactions)
  • Patients with moderate renal impairment (CrCL = 20-39 mL/min) should receive a 50% decrease in the recommended starting dose; future doses can be increased as tolerated. Doses greater than 600 mg are not recommended in patients with mild renal impairment (CrCL = 40-59 mL/min). For patients with moderate renal impairment, doses greater than 400 mg are not recommended. GLEEVEC should be used with caution in patients with severe renal impairment

Common Side Effects of GLEEVEC Tablets

  • Almost all adult Ph+ CML patients who received GLEEVEC in clinical studies experienced adverse reactions at some time but most were mild to moderate in severity. The most frequently reported adverse reactions (all grades) and those with rates greater than 45% were superficial edema (60%-74%), nausea (50%-73%), diarrhea (43%-57%), hemorrhage (29%-57%), musculoskeletal pain (38%-49%), fatigue (39%-48%), rash and related terms (36%-47%), muscle cramps (28%-62%), and vomiting (23%-58%)†
  • The adverse reactions and safety profile for Ph+ ALL, MDS/MPD, ASM, and HES/CEL were generally similar to the safety profile for Ph+ CML
  • The adverse reactions were similar for Ph+ ALL as for Ph+ CML. The most frequently reported drug-related adverse reactions in the Ph+ ALL studies were mild nausea, vomiting, diarrhea, myalgia, muscle cramps, and rash. Superficial edemas were also a common finding in all studies and were described primarily as periorbital or lower-limb edemas. However, these edemas were rarely severe and may be managed (severity reduced) with diuretics, other supportive measures, or in some patients by reducing the dose of GLEEVEC
  • Frequently reported adverse reactions (all grades) in the 7 MDS/MPD patients assessed were nausea (57%); diarrhea and muscle cramps (43% each); anemia, fatigue, arthralgia, and periorbital edema (29% each)
  • All ASM patients experienced at least 1 adverse reaction at some time. The most frequently reported adverse reactions were diarrhea, nausea, ascites, muscle cramps, dyspnea, fatigue, peripheral edema, anemia, pruritus, rash, and lower respiratory tract infection
  • All HES/CEL patients experienced at least 1 adverse reaction, the most common being GI, cutaneous, and musculoskeletal disorders. Hematologic abnormalities were also frequent, with instances of Grade 3 leukopenia, neutropenia, lymphopenia, and anemia
  • Frequently reported adverse reactions (all grades) in the 12 DFSP patients assessed included nausea and fatigue (42% each); periorbital, peripheral, and eye edema (33% each); diarrhea, vomiting, rash, lacrimation increased, and anemia (25% each); face edema, pyrexia, exertional dyspnea, rhinitis, and anorexia (17% each)
  • Almost all patients who received GLEEVEC in the Phase 3 unresectable or metastatic GIST studies experienced adverse reactions at some time. Overall, the incidence of all grades of adverse reactions and the incidence of severe (CTC Grade 3 and above) adverse reactions were similar between the 2 treatment arms, except for edema and rash/related terms, which were reported more frequently in the 800-mg group. The most frequently reported adverse reactions (400 mg/day; 800 mg/day) (all grades) were edema (77%; 86%), fatigue (69%; 75%), nausea (58%; 65%), abdominal pain (57%; 55%), diarrhea (56%; 58%), rash and related terms (56%; 70%), vomiting (37%; 41%), myalgia (32%; 30%), anemia (32%; 35%), anorexia (31%; 36%), and arthralgia (14%; 12%). Therapy with GLEEVEC was discontinued for adverse reactions in 5% of patients studied*
  • In the adjuvant treatment of GIST studies, almost all the GLEEVEC- and placebo-treated patients experienced adverse reactions at some time. The most frequently reported adverse reactions were similar to those reported in other clinical studies in other patient populations. In Study 1, comparing 12 months of GLEEVEC treatment vs placebo (all grades), these included (GLEEVEC; placebo) diarrhea (59%; 29%), fatigue (57%; 41%), nausea (53%; 28%), periorbital edema (47%; 15%), decreased hemoglobin (47%; 27%), peripheral edema (27%; 15%), rash (26%; 13%), vomiting (26%; 14%), abdominal pain (21%; 22%), anorexia (17%; 9%), muscle spasms (16%; 3%), white blood cell count decreased (15%; 4%), arthralgia (15%; 15%), and myalgia (12%; 12%).* The frequencies of these reported adverse reactions were similar in Study 2, comparing 12 vs 36 months of GLEEVEC treatment (12 mo; 36 mo), except for decreased hemoglobin (72%; 80%), periorbital edema (59%; 74%), muscle spasms (31%; 49%), decreased white blood cell count (35%; 47%), pain (26%; 46%), peripheral edema (33%; 41%), rash (29%; 39%), arthralgia (9%; 17%), and myalgia (9%; 15%), which were higher among patients receiving 36 months of adjuvant treatment with GLEEVEC. Adverse reactions listed represent the most frequently reported for Study 1 with the addition of adverse reactions with higher rates in Study 2*
  • In the adjuvant GIST study comparing GLEEVEC vs placebo, drug was discontinued for adverse events in 17% of GLEEVEC- and 3% of placebo-treated patients. Edema, GI disturbances (nausea, vomiting, abdominal distension, and diarrhea), fatigue, low hemoglobin, and rash were the most frequently reported adverse reactions at the time of discontinuation. In the adjuvant study comparing 12 vs 36 months of GLEEVEC treatment, drug was discontinued for adverse events in 8% of patients treated for 12 months and 14% of patients treated for 36 months*
  • Supportive care may help reduce the severity of some mild to moderate adverse reactions. However, in some cases, either a dose reduction or interruption of treatment with GLEEVEC may be necessary
  • Doses of 400 mg or 600 mg should be administered once daily, whereas a dose of 800 mg should be administered at 400 mg twice a day. For daily dosing of 800 mg and above, dosing should be accomplished using the 400-mg tablet to reduce exposure to iron
  • GLEEVEC tablets should be taken with food and a large glass of water to minimize GI irritation
  • Patients should be instructed to take GLEEVEC exactly as prescribed and not to change their dose or stop taking GLEEVEC unless they are told to do so by their doctor. If patients miss a dose, they should be advised to take their dose as soon as possible unless it is almost time for their next dose, in which case the missed dose should not be taken. A double dose should not be taken to make up for any missed dose

*For more detailed study information, please see full Prescribing Information.

†Numbers indicate the range of percentages in 4 studies among adult patients, with newly diagnosed Ph+ CML, patients in blast crisis, accelerated phase, and in the chronic phase after failure of interferon-alpha therapy.