Auditory disturbances (high frequency hearing loss, decreased hearing), and ocular disturbances (lens opacities, cataracts, elevations in intraocular pressure, and retinal disorders) were reported at a frequency of less than 1% with deferasirox therapy in the clinical studies. The frequency of auditory adverse events irrespective of causality was increased among pediatric patients who received deferasirox doses greater than 25 mg/kg/day when serum ferritin was less than 1,000 mcg/L [see Warnings and Precautions ( 5.6)] .
Perform auditory and ophthalmic testing (including slit-lamp examinations and dilated fundoscopy) before starting deferasirox treatment and thereafter at regular intervals (every 12 months). If disturbances are noted, monitor more frequently. Consider dose reduction or interruption.
The following clinically significant adverse reactions are also discussed in other sections of the labeling:
- Acute Kidney Injury, Including Acute Renal Failure Requiring Dialysis, and Renal Tubular Toxicity Including Fanconi Syndrome [see Warnings and Precautions ( 5.1)]
- Hepatic Toxicity and Failure [see Warnings and Precautions ( 5.2)]
- Gastrointestinal (GI) Hemorrhage [see Warnings and Precautions ( 5.3)]
- Bone Marrow Suppression [see Warnings and Precautions ( 5.4)]
- Hypersensitivity [see Warnings and Precautions ( 5.7)]
- Severe Skin Reactions [see Warnings and Precautions ( 5.8)]
- Skin Rash [see Warnings and Precautions ( 5.9)]
- Auditory and Ocular Abnormalities [see Warnings and Precautions ( 5.10)]
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
Transfusional Iron Overload
A total of 700 adult and pediatric patients were treated with deferasirox for 48 weeks in premarketing studies. These included 469 patients with beta-thalassemia, 99 with rare anemias, and 132 with sickle cell disease. Of these patients, 45% were male, 70% were Caucasian and 292 patients were less than 16 years of age. In the sickle cell disease population, 89% of patients were black. Median treatment duration among the sickle cell patients was 51 weeks. Of the 700 patients treated, 469 (403 beta-thalassemia and 66 rare anemias) were entered into extensions of the original clinical protocols. In ongoing extension studies, median durations of treatment were 88 to 205 weeks.
Six hundred twenty-seven (627) patients with MDS were enrolled across 5 uncontrolled trials. These studies varied in duration from 1 to 5 years. The discontinuation rate across studies in the first year was 46% (AEs 20%, withdrawal of consent 10%, death 8%, other 4%, lab abnormalities 3%, and lack of efficacy 1%). Among 47 patients enrolled in the study of 5-year duration, 10 remained on deferasirox at the completion of the study.
Table 1 displays adverse reactions occurring in greater than 5% of deferasirox-treated beta-thalassemia patients (Study 1), sickle cell disease patients (Study 3), and patients with MDS (MDS pool). Abdominal pain, nausea, vomiting, diarrhea, skin rashes, and increases in serum creatinine were the most frequent adverse reactions reported with a suspected relationship to deferasirox. Gastrointestinal symptoms, increases in serum creatinine, and skin rash were dose related.
|*Adverse reaction frequencies are based on adverse events reported regardless of relationship to study drug.|
|**Includes ‘abdominal pain’, ‘abdominal pain lower’, and ‘abdominal pain upper’, which were reported as adverse events.|
|***Includes ‘blood creatinine increased’ and ‘blood creatinine abnormal’, which were reported as adverse events. See also Table 2.|
(Sickle Cell Disease)
|Adverse Reactions||Deferasirox N = 296 n (%)||Deferoxamine N = 290 n (%)||Deferasirox N = 132 n (%)||Deferoxamine N = 63 n (%)||Deferasirox N = 627 n (%)|
|Abdominal Pain**||63 (21)||41 (14)||37 (28)||9 (14)||145 (23)|
|Diarrhea||35 (12)||21 (7)||26 (20)||3 (5)||297 (47)|
|Creatinine Increased***||33 (11)||0 (0)||9 (7)||0||89 (14)|
|Nausea||31 (11)||14 (5)||30 (23)||7 (11)||161 (26)|
|Vomiting||30 (10)||28 (10)||28 (21)||10 (16)||83 (13)|
|Rash||25 (8)||9 (3)||14 (11)||3 (5)||83 (13)|
In Study 1, a total of 113 (38%) patients treated with deferasirox had increases in serum creatinine greater than 33% above baseline on 2 separate occasions (Table 2) and 25 (8%) patients required dose reductions. Increases in serum creatinine appeared to be dose related [see Warnings and Precautions ( 5.1)] . In this study, 17 (6%) patients treated with deferasirox developed elevations in SGPT/ALT levels greater than 5 times the ULN at 2 consecutive visits. Of these, 2 patients had liver biopsy proven drug-induced hepatitis and both discontinued deferasirox therapy [see Warnings and Precautions ( 5.2)] . An additional 2 patients, who did not have elevations in SGPT/ALT greater than 5 times the ULN, discontinued deferasirox because of increased SGPT/ALT. Increases in transaminases did not appear to be dose related. Adverse reactions that led to discontinuations included abnormal liver function tests (2 patients) and drug-induced hepatitis (2 patients), skin rash, glycosuria/proteinuria, Henoch Schönlein purpura, hyperactivity/insomnia, drug fever, and cataract (1 patient each).
In Study 3, a total of 48 (36%) patients treated with deferasirox had increases in serum creatinine greater than 33% above baseline on 2 separate occasions (Table 2) [see Warnings and Precautions ( 5.1)] . Of the patients who experienced creatinine increases in Study 3, 8 deferasirox-treated patients required dose reductions. In this study, 5 patients in the deferasirox group developed elevations in SGPT/ALT levels greater than 5 times the ULN at 2 consecutive visits and 1 patient subsequently had deferasirox permanently discontinued. Four additional patients discontinued deferasirox due to adverse reactions with a suspected relationship to study drug, including diarrhea, pancreatitis associated with gallstones, atypical tuberculosis, and skin rash.
In the MDS pool, in the first year, a total of 229 (37%) patients treated with deferasirox had increases in serum creatinine greater than 33% above baseline on 2 consecutive occasions (Table 2) and 8 (3.5%) patients permanently discontinued [see Warnings and Precautions ( 5.1)] . A total of 5 (0.8%) patients developed SGPT/ALT levels greater than 5 times the ULN at 2 consecutive visits. The most frequent adverse reactions that led to discontinuation included increases in serum creatinine, diarrhea, nausea, rash, and vomiting. Death was reported in the first year in 52 (8%) of patients [see Clinical Studies ( 14)] .
(Sickle Cell Disease)
|Laboratory Parameter||Deferasirox N = 296 n (%)||Deferoxamine N = 290 n (%)||Deferasirox N = 132 n (%)||Deferoxamine N = 63 n (%)||Deferasirox N = 627 n (%)|
|Creatinine increase > 33% at 2 consecutive post-baseline visits||113 (38)||41 (14)||48 (36)||14 (22)||229 (37)|
|Creatinine increase > 33% and > ULN at 2 consecutive post-baseline visits||7 (2)||1 (0)||3 (2)||2 (3)||126 (20)|
|SGPT/ALT > 5 x ULN at 2 post-baseline visits||25 (8)||7 (2)||2 (2)||0||9 (1)|
|SGPT/ALT > 5 x ULN at 2 consecutive post-baseline visits||17 (6)||5 (2)||5 (4)||0||5 (1)|
In clinical studies, urine protein was measured monthly. Intermittent proteinuria (urine protein/creatinine ratio greater than 0.6 mg/mg) occurred in 18.6% of deferasirox-treated patients compared to 7.2% of deferoxamine-treated patients in Study 1 [see Warnings and Precautions ( 5.1)].
Other Adverse Reactions
In the population of more than 5,000 patients with transfusional iron overload who have been treated with deferasirox during clinical trials, adverse reactions occurring in 0.1% to 1% of patients included gastritis, edema, sleep disorder, pigmentation disorder, dizziness, anxiety, maculopathy, cholelithiasis, pyrexia, fatigue, laryngeal pain, cataract, hearing loss, gastrointestinal hemorrhage, gastric ulcer (including multiple ulcers), duodenal ulcer, renal tubular disorder (Fanconi Syndrome), and acute pancreatitis (with and without underlying biliary conditions). Adverse reactions occurring in 0.01% to 0.1% of patients included optic neuritis, esophagitis, erythema multiforme, and drug reaction with eosinophilia and systemic symptoms (DRESS). Adverse reactions, which most frequently led to dose interruption or dose adjustment during clinical trials were rash, gastrointestinal disorders, infections, increased serum creatinine, and increased serum transaminases.
Pooled Analysis of Pediatric Clinical Trial Data
A nested case control analysis was conducted within a deferasirox pediatric pooled clinical trial dataset to evaluate the effects of dose and serum ferritin level, separately and combined, on kidney function. Among 1,213 children (aged 2 to 15 years) with transfusion-dependent thalassemia, 162 cases of acute kidney injury (eGFR ≤ 90 mL/min/1.73 m 2) and 621 matched-controls with normal kidney function (eGFR ≥ 120 mL/min/1.73 m 2) were identified. The primary findings were:
- A 26% increased risk of acute kidney injury was observed with each 5 mg/kg increase in daily deferasirox dosage starting at 20 mg/kg/day (95% CI: 1.08-1.48).
- A 25% increased risk for acute kidney injury was observed with each 250 mcg/L decrease in serum ferritin starting at 1,250 mcg/L (95% CI: 1.01-1.56).
- Among pediatric patients with a serum ferritin < 1,000 mcg/L, those who received deferasirox dosage > 30 mg/kg/day, compared to those who received lower dosages, had a higher risk for acute kidney injury (OR = 4.47, 95% CI: 1.25-15.95), consistent with overchelation.
In addition, a cohort based analysis of adverse events was conducted in the deferasirox pediatric pooled clinical trial data. Pediatric patients who received deferasirox dose > 25 mg/kg/day when their serum ferritin was < 1,000 mcg/L (n = 158) had a 6-fold greater rate of renal adverse events (IRR = 6.00, 95% CI: 1.75-21.36) and a 2-fold greater rate of dose interruptions (IRR = 2.06, 95% CI: 1.33-3.17) compared to the time-period prior to meeting these simultaneous criteria. Adverse events of special interest (cytopenia, renal, hearing, and gastrointestinal disorders) occurred 1.9‑fold more frequently when these simultaneous criteria were met, compared to preceding time‑periods (IRR = 1.91, 95% CI: 1.05-3.48) [see Warnings and Precautions ( 5.6)].
Additional pediatric use information is approved for Novartis Pharmaceuticals Corporation’s EXJADE ® (deferasirox) tablets for oral suspension. However, due to Novartis Pharmaceuticals Corporation’s marketing exclusivity rights, this drug product is not labeled with that pediatric information.
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