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REVLIMID® + Dexamethasone in Multiple Myeloma
Information for healthcare providers
REVLIMID® (lenalidomide) in combination with dexamethasone is indicated for the treatment of multiple myeloma patients who have received at least 1 prior therapy.
In order to prescribe REVLIMID®, you and your patients must be enrolled in RevAssist®.
Two multicenter, randomized, double-blind, placebo-controlled Phase III studies compared REVLIMID® + oral pulse dex to placebo + dex in patients who had received at least 1 prior treatment.
Due to the potential for hematologic toxicities, patients on therapy should have their complete blood counts monitored every 2 weeks for the first 12 weeks and then at least monthly thereafter. Patients may require dose interruption and/or dose reduction.
Dosing
REVLIMID® dosing for multiple myeloma: a starting dose of 25 mg orally with water, once a day, for the first 21 days of repeated 28-day cycles.
Dex dosing for multiple myeloma: 40 mg/day orally on days 1–4, 9–12, and 17–20 of each 28-day cycle for the first 4 cycles of therapy, and then 40 mg/day orally on days 1–4 every 28 days.
REVLIMID® is available in 4 dosage strengths
(Not Actual Size)
(Not Actual Size)
(Not Actual Size)
(Not Actual Size)
Pharmacodynamic properties of REVLIMID®
The mechanism of action is not fully understood, but REVLIMID®:
Possesses immunomodulatory, antiangiogenic and antineoplastic properties
Inhibits the secretion of proinflammatory cytokines and increases secretion of anti-inflammatory cytokines from peripheral blood mononuclear cells
Inhibits growth of multiple myeloma cells from patients and cells from the MM.1S human myeloma cell line and Namalwa cells
Inhibits the expression of cyclooxygenase-2 (COX-2) but not COX-1 in vitro
REVLIMID®
(lenalidomide) in combination with dexamethasone is indicated for the treatment
of multiple myeloma patients who have received at least one prior therapy.
REVLIMID®
(lenalidomide) is indicated for patients with transfusion-dependent anemia due to
low- or intermediate-1–risk myelodysplastic syndromes (MDS) associated with a deletion
5q cytogenetic abnormality with or without additional cytogenetic abnormalities.
WARNINGS:
1. POTENTIAL FOR HUMAN BIRTH DEFECTS.
Lenalidomide is an analogue of thalidomide. Thalidomide is a known human teratogen
that causes severe life-threatening human birth defects. If lenalidomide is taken
during pregnancy, it may cause birth defects or death to an unborn baby. Females
should be advised to avoid pregnancy while taking REVLIMID®
(lenalidomide).
Male Patients: It is not known whether lenalidomide is present in the semen of patients
receiving the drug. Therefore, males receiving REVLIMID®
(lenalidomide) must always use a latex condom during any sexual contact with females
of childbearing potential even if they have undergone a successful vasectomy.
Special Prescribing Requirements
Because of this potential toxicity and to avoid fetal
exposure to REVLIMID® (lenalidomide),
REVLIMID® (lenalidomide) is only
available under a special restricted distribution program. This program is called
“RevAssist®”. Under this program,
only prescribers and pharmacists registered with the program can prescribe and dispense
the product. In addition, REVLIMID®
(lenalidomide) must only be dispensed to patients who are registered and meet all
the conditions of the RevAssist®
program.
2. HEMATOLOGIC TOXICITY (NEUTROPENIA AND THROMBOCYTOPENIA).
This drug is associated with significant neutropenia and thrombocytopenia. Eighty
percent of patients with del 5q myelodysplastic syndromes had to have a dose delay/reduction
during the major study. Thirty-four percent of patients had to have a second dose
delay/reduction. Grade 3 or 4 hematologic toxicity was seen in 80% of patients enrolled
in the study. Patients on therapy for del 5q myelodysplastic syndromes should have
their complete blood counts monitored weekly for the first 8 weeks of therapy and
at least monthly thereafter. Patients may require dose interruption and/or reduction.
Patients may require use of blood product support and/or growth factors. (see DOSAGE
and ADMINISTRATION)
3. DEEP VENOUS THROMBOSIS AND PULMONARY EMBOLISM.
This drug has demonstrated a significantly increased risk of deep venous thrombosis
(DVT) and pulmonary embolism (PE) in patients with multiple myeloma who were treated
with REVLIMID® (lenalidomide)
combination therapy. Patients and physicians are advised to be observant for the
signs and symptoms of thromboembolism. Patients should be instructed to seek medical
care if they develop symptoms such as shortness of breath, chest pain, or arm or
leg swelling. It is not known whether prophylactic anticoagulation or antiplatelet
therapy prescribed in conjunction with REVLIMID®
(lenalidomide) may lessen the potential for venous thromboembolic events. The decision
to take prophylactic measures should be done carefully after an assessment of an
individual patient’s underlying risk factors.
You can get the information about REVLIMID®
(lenalidomide) and the RevAssist®
program on the Internet at www.REVLIMID.com
or by calling the manufacturer's toll-free number at
1-888-423-5436.
ADDITIONAL WARNINGS: HEMATOLOGIC
TOXICITY
Multiple Myeloma
In the pooled multiple myeloma studies, Grade 3 and 4 hematologic
toxicities were more frequent in patients treated with the combination of REVLIMID® (lenalidomide) and dexamethasone
than in patients treated with dexamethasone alone
Patients on therapy should have their complete blood counts monitored
every 2 weeks for the first 12 weeks and then monthly thereafter
Patients may require dose interruption and/or dose reduction
CONTRAINDICATIONS:
Pregnancy Category X:
Lenalidomide is contraindicated in pregnant women and women capable
of becoming pregnant. When there is no alternative, females of childbearing potential
may be treated with lenalidomide provided adequate precautions are taken to avoid
pregnancy
Hypersensitivity:
REVLIMID® (lenalidomide)
is contraindicated in any patients who have demonstrated hypersensitivity to the
drug or its components
PRECAUTIONS:
Angioedema, Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis:
Angioedema and serious dermatologic reactions including Stevens-Johnson
syndrome (SJS) and toxic epidermal necrolysis (TEN) have been reported. These events
can be fatal. Patients with a prior history of Grade 4 rash associated with thalidomide
treatment should not receive REVLIMID®
(lenalidomide). REVLIMID® (lenalidomide)
interruption or discontinuation should be considered for Grade 2-3 skin rash. REVLIMID® (lenalidomide) must be discontinued
for angioedema, Grade 4 rash, exfoliative or bullous rash, or if SJS or TEN is suspected,
and should not be resumed following discontinuation for these reactions
Tumor Lysis Syndrome:
Lenalidomide has antineoplastic activity and therefore the complications
of tumor lysis syndrome may occur. The patients at risk of tumor lysis syndrome
are those with high tumor burden prior to treatment. These patients should be monitored
closely and appropriate precautions taken
Renal impairment:
Since lenalidomide is primarily excreted unchanged by the kidney,
adjustments to the starting dose of REVLIMID®
(lenalidomide) are recommended to provide appropriate drug exposure in patients
with moderate or severe (CLcr < 60 mL/min) renal impairment and in patients
on dialysis
Because elderly patients are more likely to have decreased renal
function, care should be taken in dose selection, and it would be prudent to monitor
renal function
Nursing mothers: It is not known
whether REVLIMID® (lenalidomide)
is excreted in human milk.
Because of the potential for adverse reactions in nursing infants,
a decision should be made whether to discontinue nursing or the drug, taking into
account the importance of the drug to the mother
ADVERSE REACTIONS:
Multiple Myeloma
In the REVLIMID®
(lenalidomide)/dexamethasone treatment group, 151 patients (45%) underwent at least
one dose interruption with or without a dose reduction of REVLIMID® (lenalidomide) compared to 21% in the placebo/dexamethasone
treatment group
Of these patients who had one dose interruption with or without
a dose reduction, 50% in the REVLIMID®
(lenalidomide)/dexamethasone treatment group underwent at least one additional dose
interruption with or without a dose reduction compared to 21% in the placebo/dexamethasone
treatment group
Most adverse events and Grade 3/4 adverse events were more frequent
in MM patients who received the combination of REVLIMID®
(lenalidomide)/dexamethasone compared to placebo/dexamethasone
Other adverse events reported in multiple myeloma
patients (REVLIMID® (lenalidomide)/dexamethasone
vs dexamethasone/placebo): constipation (39% vs 19%), fatigue (38% vs 37%),
insomnia (32% vs 37%), muscle cramp (30% vs 21%), diarrhea (29% vs 25%), neutropenia
(28% vs 5%), anemia (24% vs 17%), asthenia (23% vs 25%), pyrexia (23% vs 19%), nausea
(22% vs 19%), headache (21% vs 21%), peripheral edema (21% vs 19%), dizziness (21%
vs 15%), dyspnea (20% vs 15%), tremor (20% vs 7%), decreased weight (18% vs 14%),
thrombocytopenia (17% vs 10%), rash (16% vs 8%), back pain (15% vs 14%), hyperglycemia
(15% vs 14%), and muscle weakness (15% vs 15%).
Myelodysplastic Syndromes
Thrombocytopenia (61.5%; 91/148) and neutropenia (58.8%; 87/148)
were the most frequently reported adverse events observed in the del 5q MDS population
Other adverse reactions reported in del 5q MDS patients
(REVLIMID® (lenalidomide)):
diarrhea (49%), pruritus (42%), rash (36%), fatigue (31%), constipation (24%), nausea
(24%), nasopharyngitis (23%), arthralgia (22%), pyrexia (21%), back pain (21%),
peripheral edema (20%), cough (20%), dizziness (20%), headache (20%), muscle cramp
(18%), dyspnea (17%), and pharyngitis (16%).
DOSAGE AND ADMINISTRATION:
Dosing is continued or modified based upon clinical and laboratory
findings. Dosing modifications are recommended to manage Grade 3 or 4 neutropenia
or thrombocytopenia or other Grade 3 or 4 toxicity judged to be related to REVLIMID® (lenalidomide)
For other Grade 3 or 4 toxicities judged to be related to REVLIMID® (lenalidomide), hold treatment and
restart at next lower dose level when toxicity has resolved to less than or equal
to Grade 2
Please see full Prescribing Information, including Boxed WARNINGS, CONTRAINDICATIONS, PRECAUTIONS,
and ADVERSE REACTIONS.
