Iclusig · 4.6 Fertility, pregnancy and lactation · 2

HOS-096592 · has-adverse-reaction-information · PDF-Seite 57

Summary of the safety profile Patients with previously treated CML or Ph+ ALL or who have the T315I mutation (PACE Study) In the PACE phase 2 trial (see section 5.1) the most common serious adverse reactions (treatment-emergent frequencies) were pneumonia (7.3%), pancreatitis (5.8%), abdominal pain (4.7%), atrial fibrillation (4.5%), pyrexia (4.5%), myocardial infarction (4.0%), peripheral arterial occlusive disease (3.8%), anaemia (3.8%), angina pectoris (3.3%), platelet count decreased (3.1%), febrile neutropenia (2.9%), hypertension (2.9%), coronary artery disease (2.7%), cardiac failure congestive (2.4%), cerebrovascular accident (2.4%), sepsis (2.4%), cellulitis (2.2%), acute kidney injury (2.0%), urinary tract infection (2.0%) and lipase increased (2.0%). Serious arterial cardiovascular, cerebrovascular, and peripheral vascular occlusive adverse reactions (treatment-emergent frequencies) occurred in 10%, 7%, and 9% of Iclusig-treated patients, respectively. Serious venous occlusive reactions (treatment-emergent frequencies) occurred in 5% of patients. Arterial cardiovascular, cerebrovascular, and peripheral vascular occlusive adverse reactions (treatment-emergent frequencies) occurred in 13%, 9%, and 11% of Iclusig-treated patients, respectively. Overall arterial occlusive adverse reactions have occurred in 25% of Iclusig-treated patients from the PACE phase 2 trial with a minimum 64 months follow-up, with serious adverse reactions occurring in 20% of patients. Some patients experienced more than one type of event. Venous thromboembolic reactions (treatment-emergent frequencies) occurred in 6% of patients. The incidence of thromboembolic events is higher in patients with Ph+ ALL or BP-CML than those with AP-CML or CP-CML. No venous occlusive events were fatal. After a minimum follow-up of 64 months, the rates of adverse reactions resulting in discontinuation were 20% in CP-CML, 11% in AP-CML, 15% in BP-CML and 9% in Ph+ ALL. Previously treated CP-CML (OPTIC Study) In the OPTIC phase 2 trial (see section 5.1) overall arterial occlusive adverse reactions have occurred in 13.8% of Iclusig-treated patients (45 mg cohort) including 2 of which were fatal, and serious adverse reactions occurred in 8.5% of patients (45 mg cohort). Arterial cardiovascular, cerebrovascular, and peripheral vascular occlusive adverse reactions (treatment-emergent frequencies) occurred in 5.3%, 4.3%, and 4.3% of Iclusig-treated patients (45 mg cohort), respectively. Of the 9

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HOS-096586 · has-adverse-reaction-information · PDF-Seite 16

Summary of the safety profile Patients with previously treated CML or Ph+ ALL or who have the T315I mutation (PACE Study) In the PACE phase 2 trial (see section 5.1) the most common serious adverse reactions (treatment-emergent frequencies) were pneumonia (7.3%), pancreatitis (5.8%), abdominal pain (4.7%), atrial fibrillation (4.5%), pyrexia (4.5%), myocardial infarction (4.0%), peripheral arterial 16 occlusive disease (3.8%), anaemia (3.8%), angina pectoris (3.3%), platelet count decreased (3.1%), febrile neutropenia (2.9%), hypertension (2.9%), coronary artery disease (2.7%), cardiac failure congestive (2.4%), cerebrovascular accident (2.4%), sepsis (2.4%), cellulitis (2.2%), acute kidney injury (2.0%), urinary tract infection (2.0%) and lipase increased (2.0%). Serious arterial cardiovascular, cerebrovascular, and peripheral vascular occlusive adverse reactions (treatment-emergent frequencies) occurred in 10%, 7%, and 9% of Iclusig-treated patients, respectively. Serious venous occlusive reactions (treatment-emergent frequencies) occurred in 5% of patients. Arterial cardiovascular, cerebrovascular, and peripheral vascular occlusive adverse reactions (treatment-emergent frequencies) occurred in 13%, 9%, and 11% of Iclusig-treated patients, respectively. Overall arterial occlusive adverse reactions have occurred in 25% of Iclusig-treated patients from the PACE phase 2 trial with a minimum 64 months follow-up, with serious adverse reactions occurring in 20% of patients. Some patients experienced more than one type of event. Venous thromboembolic reactions (treatment-emergent frequencies) occurred in 6% of patients. The incidence of thromboembolic events is higher in patients with Ph+ ALL or BP-CML than those with AP-CML or CP-CML. No venous occlusive events were fatal. After a minimum follow-up of 64 months, the rates of adverse reactions resulting in discontinuation were 20% in CP-CML, 11% in AP-CML, 15% in BP-CML and 9% in Ph+ ALL. Previously treated CP-CML (OPTIC Study) In the OPTIC phase 2 trial (see section 5.1) overall arterial occlusive adverse reactions have occurred in 13.8% of Iclusig-treated patients (45 mg cohort) including 2 of which were fatal, and serious adverse reactions occurred in 8.5% of patients (45 mg cohort). Arterial cardiovascular, cerebrovascular, and peripheral vascular occlusive adverse reactions (treatment-emergent frequencies) occurred in 5.3%, 4.3%, and 4.3% of Iclusi

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HOS-096588 · has-contraindication-information · PDF-Seite 52

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

HOS-096582 · has-contraindication-information · PDF-Seite 12

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

HOS-096581 · has-indication-information · PDF-Seite 2

Iclusig is indicated as monotherapy in adult patients with • chronic phase, accelerated phase, or blast phase chronic myeloid leukaemia (CML) who are resistant to dasatinib or nilotinib; who are intolerant to dasatinib or nilotinib and for whom subsequent treatment with imatinib is not clinically appropriate; or who have the T315I mutation 2  • Philadelphia chromosome positive acute lymphoblastic leukaemia (Ph+ ALL) who are resistant to dasatinib; who are intolerant to dasatinib and for whom subsequent treatment with imatinib is not clinically appropriate; or who have the T315I mutation. Iclusig is indicated in combination with reduced-intensity chemotherapy in adult patients with newly diagnosed Ph+ ALL (see section 5.1). Iclusig is indicated as monotherapy in paediatric patients 6 years of age or older with • chronic phase chronic myeloid leukaemia (CP-CML) who are resistant to dasatinib or nilotinib; who are intolerant to dasatinib or nilotinib and for whom subsequent treatment with imatinib is not clinically appropriate; or who have the T315I mutation. See sections 4.2 for the assessment of cardiovascular status prior to start of therapy and 4.4 for situations where an alternative treatment may be considered.

HOS-096587 · has-indication-information · PDF-Seite 45

Iclusig is indicated as monotherapy in paediatric patients 6 years of age or older with • chronic phase chronic myeloid leukaemia (CP-CML) who are resistant to dasatinib or nilotinib; who are intolerant to dasatinib or nilotinib and for whom subsequent treatment with imatinib is not clinically appropriate; or who have the T315I mutation. See sections 4.2 for the assessment of cardiovascular status prior to start of therapy and 4.4 for situations where an alternative treatment may be considered.

HOS-096590 · has-interaction-information · PDF-Seite 55

Substances that may increase ponatinib serum concentrations CYP3A inhibitors Ponatinib is metabolized by CYP3A4. Co-administration of a single 15 mg oral dose of Iclusig in the presence of ketoconazole (400 mg daily), a strong CYP3A inhibitor, resulted in modest increases in ponatinib systemic exposure, with 55 ponatinib AUC0-∞ and Cmax values that were 78% and 47% higher, respectively, than those seen when ponatinib was administered alone. Caution should be exercised and a reduction of the starting dose of Iclusig in adults to 30 mg should be considered with concurrent use of strong CYP3A inhibitors such as clarithromycin, indinavir, itraconazole, ketoconazole, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, troleandomycin, voriconazole, and grapefruit juice. For paediatric patients a reduction of the starting dose should be considered as described in section 4.2. Substances that may decrease ponatinib serum concentrations CYP3A inducers Co-administration of a single 45 mg dose of Iclusig in the presence of rifampin (600 mg daily), a strong CYP3A inducer, to 19 healthy volunteers, decreased the AUC0-∞ and Cmax of ponatinib by 62% and 42%, respectively, when compared to administration of ponatinib alone. Co-administration of strong CYP3A4 inducers such as carbamazepine, phenobarbital, phenytoin, rifabutin, rifampicin, and St. John’s Wort with ponatinib should be avoided, and alternatives to the CYP3A4 inducer should be sought, unless the benefit outweighs the possible risk of ponatinib underexposure. Substances that may have their serum concentrations altered by ponatinib Transporter substrates In vitro, ponatinib is an inhibitor of P-gp and BCRP. Therefore, ponatinib may have the potential to increase plasma concentrations of co-administered substrates of P-gp (e.g., digoxin, dabigatran, colchicine, pravastatin) or BCRP (e.g., methotrexate, rosuvastatin, sulfasalazine) and may increase their therapeutic effect and adverse reactions. Close clinical surveillance is recommended when ponatinib is administered with these medicinal products. Paediatric population Interaction studies have only been performed in adults.

HOS-096584 · has-interaction-information · PDF-Seite 15

Substances that may increase ponatinib serum concentrations CYP3A inhibitors Ponatinib is metabolized by CYP3A4. Co-administration of a single 15 mg oral dose of Iclusig in the presence of ketoconazole (400 mg daily), a strong CYP3A inhibitor, resulted in modest increases in ponatinib systemic exposure, with ponatinib AUC0-∞ and Cmax values that were 78% and 47% higher, respectively, than those seen when ponatinib was administered alone. Caution should be exercised and a reduction of the starting dose of Iclusig in adults to 30 mg should be considered with concurrent use of strong CYP3A inhibitors such as clarithromycin, indinavir, itraconazole, ketoconazole, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, troleandomycin, voriconazole, and grapefruit juice. For paediatric patients a reduction of the starting dose should be considered as described in section 4.2. Substances that may decrease ponatinib serum concentrations CYP3A inducers Co-administration of a single 45 mg dose of Iclusig in the presence of rifampin (600 mg daily), a strong CYP3A inducer, to 19 healthy volunteers, decreased the AUC0-∞ and Cmax of ponatinib by 62% and 42%, respectively, when compared to administration of ponatinib alone. 15 Co-administration of strong CYP3A4 inducers such as carbamazepine, phenobarbital, phenytoin, rifabutin, rifampicin, and St. John’s Wort with ponatinib should be avoided, and alternatives to the CYP3A4 inducer should be sought, unless the benefit outweighs the possible risk of ponatinib underexposure. Substances that may have their serum concentrations altered by ponatinib Transporter substrates In vitro, ponatinib is an inhibitor of P-gp and BCRP. Therefore, ponatinib may have the potential to increase plasma concentrations of co-administered substrates of P-gp (e.g., digoxin, dabigatran, colchicine, pravastatin) or BCRP (e.g., methotrexate, rosuvastatin, sulfasalazine) and may increase their therapeutic effect and adverse reactions. Close clinical surveillance is recommended when ponatinib is administered with these medicinal products. Paediatric population Interaction studies have only been performed in adults.

HOS-096585 · has-pregnancy-information · PDF-Seite 16

Women of childbearing potential/Contraception in males and females Women of childbearing age being treated with Iclusig should be advised not to become pregnant and men being treated with Iclusig should be advised not to father a child during treatment. An effective method of contraception should be used during treatment. It is unknown whether ponatinib affects the effectiveness of systemic hormonal contraceptives. An alternative or additional method of contraception should be used. Pregnancy Based on limited human data (less than 50 known pregnancy outcomes), cases of congenital megacolon (Hirschsprung’s disease) have been reported in children born to women exposed to ponatinib during the first trimester. Studies in animals have shown reproductive toxicity (see section 5.3). Iclusig should not be used during pregnancy unless the clinical condition of the woman requires treatment with ponatinib. If it is used during pregnancy, the patient must be informed of the potential risk to the foetus. Breast-feeding It is unknown whether Iclusig is excreted in human milk. Available pharmacodynamic and toxicological data cannot exclude potential excretion in human milk. Breast-feeding should be stopped during treatment with Iclusig. Fertility No human data on the effect of ponatinib on fertility are available. In rats, treatment with ponatinib has shown effects on female fertility and male fertility was not affected (see section 5.3). The clinical relevance of these findings to human fertility is unknown.

HOS-096591 · has-pregnancy-information · PDF-Seite 56

Women of childbearing potential/Contraception in males and females Women of childbearing age being treated with Iclusig should be advised not to become pregnant and men being treated with Iclusig should be advised not to father a child during treatment. An effective method of contraception should be used during treatment. It is unknown whether ponatinib affects the effectiveness of systemic hormonal contraceptives. An alternative or additional method of contraception should be used. Pregnancy Based on limited human data (less than 50 known pregnancy outcomes), cases of congenital megacolon (Hirschsprung’s disease) have been reported in children born to women exposed to ponatinib during the first trimester. Studies in animals have shown reproductive toxicity (see section 5.3). Iclusig should not be used during pregnancy unless the clinical condition of the woman requires treatment with ponatinib. If it is used during pregnancy, the patient must be informed of the potential risk to the foetus. Breast-feeding It is unknown whether Iclusig is excreted in human milk. Available pharmacodynamic and toxicological data cannot exclude potential excretion in human milk. Breast-feeding should be stopped during treatment with Iclusig. 56 Fertility No human data on the effect of ponatinib on fertility are available. In rats, treatment with ponatinib has shown effects on female fertility and male fertility was not affected (see section 5.3). The clinical relevance of these findings to human fertility is unknown.

HOS-096583 · has-warning-information · PDF-Seite 12

Important adverse reactions Myelosuppression Iclusig is associated with severe (National Cancer Institute Common Terminology Criteria for Adverse Events grade 3 or 4) thrombocytopenia, neutropenia, and anaemia. Most of the patients with grade 3 or 4 platelet count decreased, anaemia or neutropenia, developed it within the first 3 months of treatment. The frequency of these events is greater in patients with accelerated phase CML (APCML) or blast phase CML (BPCML), or Ph+ ALL than in chronic phase CML (CPCML). A complete blood count should be performed every 2 weeks for the first 3 months and then monthly or as clinically indicated. Myelosuppression was generally reversible and usually managed by withholding Iclusig temporarily or reducing the dose (see section 4.2). Arterial occlusion Arterial occlusions, including fatal myocardial infarction, stroke, retinal arterial occlusions associated in some cases with permanent visual impairment or vision loss, stenosis of large arterial vessels of the brain, severe peripheral vascular disease, renal artery stenosis (associated with worsening, labile or treatment-resistant hypertension), and the need for urgent revascularization procedures have occurred in Iclusig-treated patients. Patients with and without cardiovascular risk factors, including patients age 50 years or younger, experienced these events. Arterial occlusion adverse events were more frequent with increasing age and in patients with history of ischaemia, hypertension, diabetes, or hyperlipidaemia. The risk of arterial occlusive events is likely to be dose-related (see sections 4.8 and 5.1). Arterial occlusive adverse reactions including serious reactions, have occurred in the clinical development (see section 4.8). Some patients experienced more than 1 type of event. Iclusig should not be used in patients with a history of myocardial infarction, prior revascularization or stroke, unless the potential benefit of treatment outweighs the potential risk (see sections 4.2 and 4.8). 12 In these patients, alternative treatment options should also be considered before starting treatment with ponatinib. Before starting treatment with ponatinib, the cardiovascular status of the patient should be assessed, including history and physical examination, and cardiovascular risk factors should be actively managed. Cardiovascular status should continue to be monitored and medical and supportive therapy for co

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HOS-096589 · has-warning-information · PDF-Seite 52

Important adverse reactions Myelosuppression Iclusig is associated with severe (National Cancer Institute Common Terminology Criteria for Adverse Events grade 3 or 4) thrombocytopenia, neutropenia, and anaemia. Most of the patients with grade 3 or 4 platelet count decreased, anaemia or neutropenia, developed it within the first 3 months of treatment. The frequency of these events is greater in patients with accelerated phase CML (APCML) or blast phase CML (BPCML), or Ph+ ALL than in chronic phase CML (CPCML). A complete blood count should be performed every 2 weeks for the first 3 months and then monthly or as clinically indicated. Myelosuppression was generally reversible and usually managed by withholding Iclusig temporarily or reducing the dose (see section 4.2). Arterial occlusion Arterial occlusions, including fatal myocardial infarction, stroke, retinal arterial occlusions associated in some cases with permanent visual impairment or vision loss, stenosis of large arterial vessels of the brain, severe peripheral vascular disease, renal artery stenosis (associated with worsening, labile or treatment-resistant hypertension), and the need for urgent revascularization procedures have occurred in Iclusig-treated patients. Patients with and without cardiovascular risk factors, including patients age 50 years or younger, experienced these events. Arterial occlusion adverse events were more frequent 52 with increasing age and in patients with history of ischaemia, hypertension, diabetes, or hyperlipidaemia. The risk of arterial occlusive events is likely to be dose-related (see sections 4.8 and 5.1). Arterial occlusive adverse reactions including serious reactions, have occurred in the clinical development (see section 4.8). Some patients experienced more than 1 type of event. Iclusig should not be used in patients with a history of myocardial infarction, prior revascularization or stroke, unless the potential benefit of treatment outweighs the potential risk (see sections 4.2 and 4.8). In these patients, alternative treatment options should also be considered before starting treatment with ponatinib. Before starting treatment with ponatinib, the cardiovascular status of the patient should be assessed, including history and physical examination, and cardiovascular risk factors should be actively managed. Cardiovascular status should continue to be monitored and medical and supportive therapy for con

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