Como escolher o tratamento certo para o doente certo no MM R/R?
How to choose the right treatment for the right patient in R/R MM?
EstaapresentaçãoconstituiumserviçoprestadoàTakeda,tendosidosujeitaahonoráriosPT/IXZ/1019/0052
Oconteúdodestaapresentaçãoédaautoriadopalestrante,refletindoasuaperspetivaclínicae/outrabalhosseusnãopublicados
Mª Victoria Mateos, MD, PhD
Conflict of Interest
• Honoraria from lectures and participation in advisory boards: Janssen, Celgene, Amgen, Takeda, GSK, EDO, Pharmamar, Adaptive
Oconteúdodestaapresentaçãoédaautoriadopalestrante,refletindoasuaperspetivaclínicae/outrabalhosseusnãopublicadosThecontentofthispresentationisauthor`sown,reflectinghisclinicalperspectiveandorhisunpublishedworks.
EstaapresentaçãoconstituiumserviçoprestadoàTakeda,tendosidosujeitaahonorários.ThispresentationconstitutesaserviceprovidedtoTakedaandhasbeensubjecttohonoraria.
MGUS, monoclonal gammopathy of unknown significance; MM, multiple myeloma. 1. Durie BGM. Concise review of the disease and treatment options. Multiple myeloma, cancer of the bone marrow. International Myeloma Foundation, 2016. Available at: www.myeloma.org/sites/default/files/images/publications/UnderstandingPDF/concisereview.pdf (accessed January 2018); 2. Manier S et al. Nat Rev Clin Oncol 2017;14:100–113.
Tumour cell diversity and clonal evolution drive MM relapse
Relapsed refractory
Relapse
RemissionMGUS or smouldering
myeloma
Active myeloma
Relapse
Time
M p
rote
in
SYMPTOMATICASYMPTOMATIC 1
2
RCT, randomised clinical trials. Yong K et al. Br J Haematol 2016;175:252–264.
Treatment intentions derived from evidence from RCTs may not reflect what is possible in real-life practice
• Clinical trials suggest that patients benefit from treatment at later stages, however, in reality, few patients reach fourth and fifth lines of treatment
• Understanding the reasons for discontinuation of treatment can provide an insight into patient outcomes and treatment decisions
RRMM: relapsed/refractory multiple myeloma.
Main objectives for the treatment of RRMM patients
Induces deep, long-
lasting responses
Well-tolerated
Minimal impact on
patient lifestyle and healthcare resources
Factors influencing the decision in order to make the right choice for RRMM patients
Type of relapse
Further options
Efficacy and toxicity
of the previous therapies
RRMM: relapsed/refractory multiple myeloma.
First relapse after Bortezomib-based induction
Triplets based on Rd DaraRd or KRd or IxaRd or EloRd
Rd
Pomalidomide-Dex (as a backbone)
+ Cyclo or Ixa or Bort or Dara or Elo
Daratumumab (single agent or combination)
Clinical trial
At second or subsequent relapse
First relapse after IMiD-based induction
Doublets Kd / Vd
Triplets based on Bortezomib DaraVD or PanoVD or
EloVD or VCD
Main challenges • The selection of the rescue therapy is mainly influenced by the first line of therapy • The first line of therapy is rapidly evolving towards new standards of care • Treatment recommendations vary internationally
Moreau P et al.Annals of Oncology 2017
IMiD: Immunomodulatory drug; Kd: Carfilzomib and dexamethasone; Vd: Bortezomib and dexamethasone; DaraVD: Daratumumab, bortezomib and dexamethasone; PanoVd:Panobinostat, bortezomib and dexamethasone; EloVD: Elotuzumab, bortezomib and dexamethasone; Rd: Lenalidomide and dexamethasone; DaraRd: Daratumumab, lenalidomide and dexamethasone; KRd: Carfilzomib, lenalidomide and dexamethasone; IxaRd: Ixazomib, lenalidomide and dexamethasone; EloRd: Elotuzumab, lenalidomide and dexamethasone
Relapse/Refractory MM patients ESMO guidelines 2017
Moreau P, et al. Ann Oncol 2017;00:1–11, 2017.
First relapse after Bortezomib-based induction
Triplets based on Rd DaraRd or KRd or IxaRd or EloRd
Doublets RdX
EfficacyPOLLUX
DaraRd vs Rd1-3ASPIRE
KRd vs Rd4,5ELOQUENT-2 ERd vs Rd6
TOURMALINE-MM1 IRd vs Rd7
PFS HR (95% CI) 0.44 (0.35–0.55) 44.5 m vs 17.5 m
0.670 (0.558–0.803) 26.3 m vs 17.6 m
0.71 (0.59–0.86) 19.4 m vs 14.9 m
0.74 (0.59–0.94) 20.6 m vs. 14.7 m
ORR, % 93 87 79 78≥ CR, % 57 (MRDneg 30%) 32 5 14DOR, months NE 28.6 21.2 20.5
OS HR (95% CI) 0.63 (0.42–0.95) 0.79 (0.63–0.99) 48 m vs. 40 m
0.78 (0.63–0.96) 43.7 m vs 39.6 m NE
1st line • Bortezomib-based combinations • Exposed or not to lenalidomide but no progressing under lenalidomide therapy
Rd: Lenalidomide and dexamethasone; DaraRd: Daratumumab, lenalidomide and dexamethasone; KRd: Carfilzomib, lenalidomide and dexamethasone; IxaRd: Ixazomib, lenalidomide and dexamethasone; EloRd: Elotuzumab, lenalidomide and dexamethasone PFS: Progression free survival; HR: Hazard ratio; ORR: Overall response rate; CR: Complete response; DOR: Duration of treatment; OS: Overall Survival ; CI: Confidence interval ; MRDneg: Minimal residual disease; NE: Non-estimated; Cross-trial comparisons are potentially confounded by differences in trial design and study population
Which patients do they fit today in the ESMO guidelines 2017
KRd (n=396)
244 (61.6%) 26.1
Rd (n=396)
272 (68.7) 16.6
0.66 (0.55–0.78) 1-sided P<0.0001
1.0
0.8
0.6
0.4
0.2
0
Prop
ortio
n Su
rviv
ing
W
ithou
t Pro
gres
sion
0
Months Since Randomization
KRd Rd
6 24 42 54 7812 18 30 36 48 60 66 72
396 396
337 291
282 211
227 154
178 118
136 99
109 81
94 61
65 45
45 30
32 21
17 13
2 4
0 0
KRd Rd
Number of patients at risk:
HR (95% CI) at 18 months = 0.55 (0.44–0.69)
Siegel D et al. JCO 2017
KRd vs Rd: ORR 87% vs 66.7%; ≥CR 32% vs 9%
PFS OS
Stewart K et al. NEJM2015
KRD in first relapse resulted in median PFS of 29 monthsRd:Lenalidomideanddexamethasone;KRd:Carfilzomib,lenalidomideanddexamethasone;CR:Completeresponse;OS:OverallSurvival;HR:HazarRatio;CI:ConfidenceintervalPFS:Progressionfreesurvival
Carfilzomib + lenalidomide and dexamethasone vs lenalidomide and dexamethasone in RRMM: ASPIRE
Daratumumab + lenalidomide and dexamethasone vs lenalidomide and dexamethasone in RRMM: POLLUX 3-year follow-up
Bahlisetal.,ASH2018;abstract1996
Updated PFSa
● Median follow-up: 44.3 months ● D-Rd significantly prolonged PFS vs Rd in
the ITT population (median: 44.5 months vs 17.5 months; HR, 0.44; 95% CI, 0.35-0.55; P<0.0001)
56% reduction in the risk of progression or death in patients receiving D-Rd
aThe upper bound 95% CI is currently not estimable; median PFS may change with additional follow-up once the upper bound 95% CI estimate is reached.
DRd vs Rd: ORR 93% vs 76%; ≥CR 57% vs 23%. MRD neg rate: 30% vs 5%
Median PFS has not been reached with DRd in first relapse
DRd:Daratumumab,lenalidomideanddexamethasone;Rd:Lenalidomideanddexamethasone;HR:HazardratioORR:Overallresponserate;CR:Completeresponse;MRD;Minimalresidualdisease;NE:Not-estimeated;CI:ConfidenceInterval;PFS:Progressionfreesurvival;ITT:Intentiontotreat
A29%reductionintheriskofprogressionordeath(sustainedovertime)50%inthePFSrateat4years(21%vs14%)infavorofELoRd
ELOQUENT-2: EloRd vs Rd 4-year follow-up: Progression-free survivala
DimopoulosMA,etal.PresentedatEHA2017(AbstractS456),oralpresentation.
ELd n=321
Ld n=325
HR=0.71 (95% CI: 0.59–0.86); p=0.0004
Median PFS (95% CI)
19.4 mo (16.6–22.3)
14.9 mo (12.1–17.3)0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62
1-yearPFS 2-yearPFS 3-yearPFS 4-yearPFS
Prob
abilityofP
FS
Time(months)
Patientsatrisk
ELd
Ld
69%
41%
27%21%
57%
28%
19%14%
ELd
Ld
321 304 280 260 233 216 196 180 160 147 132 125 111 103 94 91 79 70 63 60 55 52 49 46 36 31 24 17 13 6 2 0
325 295 249 216 192 173 158 141 124 108 91 76 68 64 61 54 47 41 39 37 33 31 30 27 22 13 9 6 3 1 1 0
aAllrandomizedpatientsDatacut-offOct18,2016
● Minimumfollow-up:48months
EloRd/Eld:Elotuzumab,lenalidomideanddexamethasone;Rd/Ld:Lenalidomideanddexamethasone;HR:Hazardratio;CI:ConfidenceInterval;PFS:Progressionfreesurvival;
Ixazomib-Rd vs Rd in RRMM patients: Tourmaline-MM1: PFS with IRd vs placebo-Rd
Number of pts at risk:IRdPlacebo-Rd
360 345 332 315 298 283 270 248 233 224 206 182 145 119 111 95 72 58 44 34 26 14 9 1 0
362 340 325 308 288 274 254 237 218 208 188 157 130 101 85 71 58 46 31 22 15 5 3 0 0
Time from randomization (months)
Median follow-up: 14.8 months in the IRd group and 14.6 months in the placebo-Rd group
1.0
0.8
0.6
0.4
0.2
0.0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Prob
abili
ty o
f pro
gres
sion
-free
sur
viva
l
Log-rank test p=0.01 Hazard ratio (95% CI): 0.74 (0.59, 0.94)
Number of events: IRd 129; placebo-Rd 157
Median PFS: IRd: 20.6 months
Placebo-Rd: 14.7 months
MoreauPetal.NEJM2016;374(17):1621-34
IRd: Ixazomib, lenalidomide and dexamethasone; Rd: Lenalidomide and dexamethasone
Frailty Disease morbidity Risk assessment Treatment
history Lifestyle
ISS, International Staging System. Clegg A et al. Lancet 2013;381:752–762; Handforth C et al. Ann Oncol 2015;26:1091–1101; Chen X et al. Clin Interv Aging 2014;9:433–441; Palumbo A et al. Blood 2015;125:2068–2074; Jhaveri D et al. Haematologica 2016;101:1–881 (Abstract E1312); Sonneveld P et al. Leukemia 2013;27:1959–1969; Faiman BM et al. Clin J Oncol Nurs 2011;15(Suppl):66–76; Miceli TS et al. Clin J Oncol Nurs 2011;15:9–23; Greipp PR et al. J Clin Oncol 2005;23:3412–3420; Binder M et al. Haematologica 2016;101:P665; Merz M et al. Haematologica 2016;101:P650; Chng WJ et al. Leukemia 2016;30:1071–1078; Chung TH et al. PLoS One 2013;20:e66361; Sonneveld P et al. Leukemia 2013;27:1959–1969; Ramsenthaler C et al. BMC Cancer 2016;16:427; Williams LA et al. J Clin Oncol 2016;34:e18127; Ramasamy K et al. Haematologica 2017;102:E1457.
Patient-based factors are highly influential in treatment decision-making
Quality of life
Age
Performance status
Disability
Co-morbidities
Refractory disease
Renal impairment
Bone disease
ISS
Cyto-genetics
Previous therapies
Patient preference
Travel / infusion time
• Type of relapse: Indolent/biochemical relapse vs aggressive relapse
All combinations are feasible in both situations
• Age of the patients: All combinations are effective and well tolerated by elderly patients
• Number and type of prior lines: All studies were conducted in lenalidomide-naïve or sensitive patients and we are seeing now more patients lenalidomide-refractory
Treatment sequencing
Aspire: PFS by prior lines of therapy
HR, hazard ratio; KRd, carfilzomib with lenalidomide and dexamethasone; PFS, progression-free survival; Rd, lenalidomide and dexamethasone.Dimopoulos MA, et al. Blood Cancer Journal 2017; 7:e554; doi:10.1038/bcj.2017.31.
KRd (n=184) Rd (n=157)
Progression/Death, n (%) 91 (49.5) 88 (56.1)
Median PFS, mo 29.6 (95% CI, 23.2-33.5)
17.6 (95% CI, 15.0-22.2)
Hazard ratio (KRd/Rd) (95% CI) 0.713 (0.532-0.957)
P value (1-sided) 0.0118
KRd (n=212) Rd (n=239)
Progression/Death, n (%) 116 (54.7) 136 (56.9)
Median PFS, mo 25.8 (95% CI, 22.2-31.0)
16.7 (95% CI, 13.9-22.0)
Hazard ratio (KRd/Rd) (95% CI) 0.720 (0.561-0.923)
P value (1-sided) 0.0046
1 previous line of therapy ⩾2 previous lines of therapy
Phase 3 POLLUX study: DRd vs Rd in RRMM Subgroup analyses
DRd improved PFS versus Rd regardless of the number of prior lines of therapy
HR, hazard ratio; CI, confidence interval. PFS: Progression free survival DRd: Daratumumab,, lenalidomide and dexamethasone Rd: Lenalidomide and dexamethasone aKaplan-Meier estimate.
PFS Median follow-up: 32.9 months
Philippe Moreau, et al. Poster presentation at ASH 2017. Abstract 1883.
Eloquent-2: PFS in patients with ≥ median time from diagnosis (≥ 3.5 yrs) after 1PL or > 1PL
After 1PL After >1PL
DimopoulosMA,etal.PresentedatEHA2017(AbstractS456),oralpresentation.
Pl: previous line; Eld: Elotuzumab, lenalidomide and dexamethasone Ld:lenalidomide and dexamethasone
TOURMALINE-MM1: PFS according to the number of prior lines of therapy
After 1PL After 2-3PL
Pts with 2 or 3 PL or 1PL without trx seemed to have greater benefit than pts after 1PL and trxMateos MV et al. Haematologica. 2017 Oct;102(10):1767-1775.
Pl:Previousline;Trx:transplant;Pts:patients;HR:Hazardratio;CI:ConfidenceInterval
• Type of relapse: Indolent/biochemical relapse vs aggressive relapse All combinations are feasible in both situations • Age of the patients: All combinations are effective and well tolerated by elderly patients • Number and type of prior lines: All studies were conducted in lenalidomide-naïve or sensitive patients and we are seeing now more patients lenalidomide- refractory Would it be possible to use Rd-based combinations in patients already exposed to len but no len-refractory?
Rd: Lenalidomide and dexamethasone
Treatment sequencing
EfficacyPOLLUX
DaraRd vs Rd2-4ASPIRE
KRd vs Rd5-7ELOQUENT-2
ERd vs Rd8TOURMALINE-MM1
IRd vs Rd9,10
PFS HR (95% CI) 0.44 (0.35–0.55) 44.5 m vs 17.5 m
0.69 (0.57-0.83) 26.3 m vs 17.6 m
0.71 (0.59–0.86) 19.4 m vs 14.9 m
0.74 (0.59–0.94) 20.6 m vs. 14.7 m
ORR, % 93 87 79 78≥ CR, % 57 (MRDneg 30%) 32 5 14DOR, months NE 28.6 21.2 20.5
OS HR (95% CI) 0.63 (0.42–0.95) 0.79 (0.63–0.99) 48 m vs. 40 m
0.78 (0.63–0.96) 48.3 m vs 39.6 m NE
PFS HR (95% CI), median In len-exposed
0.38 (0.21–0.66) 38.8 m vs 18.6 m
0.796 (0.522–1.215) 19.4 m vs 13.9 m Only 5 pts 0.58
NR vs 17.5 m
1st line • Bortezomib-based combinations • Exposed or not to lenalidomide but not progressing under lenalidomide therapy
WhichpatientsfittheESMOguidelines2017?
1. Moreau P et al. Ann Oncol 2017;28(suppl_4):iv52-iv61; 2. Bahlis NJ, et al. ASH 2018, abstract 1996, poster presentation. 3. Usmani SZ, et al. ASH 2016, abstract 1151, oral presentation; 4. Usmani SZ, et al. ASH 2018, abstract 3288; 5. Stewart AK, et al. N Engl J Med. 2015;372:142-52; 6. Siegel DS, et al. J Clin Oncol 2018;36(8):728-734; 7. Dimopoulos MA, et al. Blood Cancer Journal
2017;7:e554; 8. Dimopoulos MA, et al., Cancer 2018;124(20):4032-4043; 9. Moreau P, et al. N Engl J Med. 2016;374:1621-34; 10. Mateos MV, et al. Haematalogica 2017;102(10):1767-1775.
First relapse after Bortezomib-based induction1
Triplets based on Rd DaraRd or KRd or IxaRd or EloRd
Doublets RdX
Rd: Lenalidomide and dexamethasone; DaraRd: Daratumumab, lenalidomide and dexamethasone; KRd: Carfilzomib, lenalidomide and dexamethasone; IxaRd: Ixazomib, lenalidomide and dexamethasone; EloRd: Elotuzumab, lenalidomide and dexamethasone PFS: Progression free survival; HR: Hazard ratio; ORR: Overall response rate; CR: Complete response; DOR: Duration of treatment; OS: Overall Survival ; CI: Confidence interval ; MRDneg: Minimal residual disease; NE: Non-estimated; Cross-trial comparisons are potentially confounded by differences in trial design and study population
• Type of relapse: Indolent/biochemical relapse vs aggressive relapse All combinations are feasible in both situations • Age of the patients: All combinations are effective and well tolerated by elderly patients • Number and type of prior lines: All studies were conducted in lenalidomide-naïve or sensitive patients and we are seeing now more patients lenalidomide-refractory • Cytogenetic abnormalities: Combination of PIs and IMiD’s is the optimal choice
PIs: Proteasome inhibitor; IMiDs: Immunomodulatory imide drugs
Treatment sequencing
Aspire study: KRd vs Rd: PFS by Cytogenetic Risk Status at Baseline
KRd(n = 48)
Rd(n = 52)
KRd(n = 147)
Rd(n = 170)
PFS, median months 23.1 13.9 PFS, median months 29.6 19.5
Hazard ratio (95% CI) 0.70 (0.43–1.16) Hazard ratio (95% CI) 0.66 (0.48–0.90)
CI, confidence interval; KRd, carfilzomib, lenalidomide, and dexamethasone; PFS, progression-free survival; Rd, lenalidomide and dexamethasone. Avet-Loiseau H, et al. Blood 2016;128(9):1174-1180.
High Risk Standard RiskHigh Risk
Avet-loiseau. blood 2017
Tourmaline MM1: IRd vs Rd: PFS in patients according to the cytogenetic risk
DK/IXA/1606/00033
IRd: Ixazomib, lenalidomide and dexamethasone; Rd: Lenalidomide and dexamethasone; PFS: Progression free survival; HR: Hazard ratio
Tourmaline MM1: IRd vs Rd: PFS in patients according to the cytogenetic risk
In the Tourmaline – MM1 the median PFS benefit with IRd versus placebo-Rd was consistent using different positivity cut-offs of del (17p) and t(4;14)
Avet Loiseau Blood 2017
DK/IXA/1606/00033
IRd: Ixazomib, lenalidomide and dexamethasone; Rd: Lenalidomide and dexamethasone PFS: Progression free survival; HR: Hazard ratio
• Type of relapse: Indolent/biochemical relapse vs aggressive relapse All combinations are feasible in both situations • Age of the patients: All combinations are effective and well tolerated by elderly patients • Number and type of prior lines: All studies were conducted in lenalidomide-naïve or sensitive patients and we are seeing now more patients lenalidomide-refractory • Cytogenetic abnormalities: Combination of PIs and IMiD’s is the optimal choice • Toxicity profile/comorbidities: Renal impairment: K/I/Elo/Dara can be used in renal impairment and R should be adjusted. Cardiovascular toxicity/severe COPD/ skin sensitivity….... • Patients preferences/lifestyle/ visits to the hospital....
Treatment sequencing
Pis: Proteasome inhibitor; IMiDs: Immunomodulatory drugs; COPD: Chronic Obstructive Pulmonary Disease
• Minimum number of planned hospital visits required for administration/collection of MM treatments over 18 cycles1–5*
*Patients are treated until progression or unacceptable toxicity. Calculation excludes visits for monitoring. Standard carfilzomib (IV) regimen is 18 cycles; number of administrations of carfilzomib per cycle: cycle 1-12 = 6 doses (2 consecutive doses each week for 3 weeks), cycle 13-18 = 4 doses (2 consecutive doses during 1st and 3rd week). Treatment with carfilzomib + Rd for longer than 18 cycles should be based on an individual benefit-risk assessment, as the data on the tolerability and toxicity of carfilzomib beyond 18 cycles are limited;2–4 Daratumumab is administered (IV) in, weekly for the first 8 weeks, then once every two weeks throughout weeks 9–24, followed by every 4 weeks from week 25 until disease progression or unacceptable toxicity. Calculation: 18 x 4 =72 weeks in 18 cycles. (1 x 8) + (1 x 16/2) + (1 x 64/2) = 28 doses.5 IRd, ixazomib-lenalidomide-dexamethasone; MM, multiple myeloma; Rd, lenalidomide-dexamethasone. 1. NINLARO® Summary of Product Characteristics; 2. REVLIMID® 25 mg Summary of Product Characteristics. 3. Dexamethasone 2 mg Tablets Summary of Product Characteristics; 4. KYPROLIS® Summary of Product Characteristics; 5. DARZALEX® Summary of Product Characteristics.
Administration of combination treatments can have lifestyle implications for patients
Rd: Lenalidomide and dexamethasone
Burden to patient, caregiver, and healthcare system reduced
IRd KRd ERd DaraRdRoute of administration PO IV IV IV
Minimum clinic visits based on 18 cycles
18 96 44 28
Dosing schedule Days 1, 8, and 15 of 28-day cycle
Days 1, 2, 8, 9, 15, and 16 of 28-day cycle.
Additional IV hydration needed especially before each dose in Cycle 1, but
may be in other cycles also
Days 1, 8, 15, 22 of 28-day cycles 1 & 2 then Days 1
and 15 cycle 3+. Premedication required
45-90 minutes prior to Elo
Days 1,8,15, 22 of 28-day cycles 1&2 then Days 1 and 15 cycles 3-6 then Day 1 of each cycle.
Premedication required
Hospital/clinic visit Every 4 weeks Twice a week Weekly x 8 then twice weekly
Weekly x 8 then twice weekly cycles 3-6 then
monthly
Premedication N N Y Y
Prehydration N Y N N
Minimum administration time in clinic/ hospital per visit
0 hours Over 2 hours (130 minutes)
About 5 hours (290 minutes)
About 8 hours 1st infusion (3-4 hours the
subsequent-ones)
• IV treatments require regular clinic visits and involve infusion times which place a substantial burden on patients. • IV regimens are associated with substantially higher administration costs than oral regimens
DaraRd: Daratumumab, lenalidomide and dexamethasone; KRd: Carfilzomib, lenalidomide and dexamethasone; IRd: Ixazomib, lenalidomide and dexamethasone; ERd: Elotuzumab, lenalidomide and dexamethasone; iv: Intravenous administration ; PO: Oral administration
1- RCM Ixazomib, 2- RCM carfilzomib; 3 – RCM elotuzumab; 4- RCM Daratumumab
Personal experience
There are significant resource implications of combination treatments
Median time from check-in to
administration
120 minutes
Median travel time
120 minutes
Median travel distance
100 Kms
Patients requiring hospital transport
40%
University Hospital of Salamanca
PFS/TTNT of PI-based regimens in RRMM: Results of phase 2/3 studies vs RWE
1.MoreauP,etal.NEnglJMed2016;374:1621–34.2.RichardsonPG,etal.BloodCancerJ.2018;8(11):1093.RichardsonPG,etalBlood.2014123(10):1461-94.StewartAK,etal.NEnglJMed2015;372:142–52.5.DimopoulosMA,etal.LancetOncol.2016;17(1):27-38
PFS*/TTNT**(patientswith1-3previoustreatmentlines)
*RealworlddatapresentedasPFS/TTNTintervals.PFS,progressionfreesurvival;PI,proteassomeinhibitor;RRMM,relapsed/refractorymultiplemyeloma;RWE,realworldevidence;TTNT,timetonexttreatment;VRd,bortezomib,lenalidomideanddexamethasone;Rd,Lenalidomideanddexamethasone
DOTandTTNTofVRd,KRd,orIRdinpatientswithRRMM:ClinicalpracticeintheUSvsclinicaltrialexperience
Retrospective cohort study design: Patients who initiated KRd, VRd, or IRd (index regimen) as treatment line 2, 3, or 4 between January 2008 and December 2016 in Humedica, a large US-based EMR database Endpoints: DOT, TTNT, discontinuation rates
• This study suggests that patients were able to stay on the PI component of an oral PI-Rd triplet for longer than patients receiving IV PI-Rd triplets; this may translate into improved TTNT
HigherDOTandTTNTvaluesinIRdvsKRdandVRdpatients
VRd KRd IRd
n 343 139 49
Medianage(years) 69 65 73
Medianfollow-up(months) 17.3 8.3 5.2
MedianDOT(months)
PIcomponentalone 5.4 6.1 NR
Entireregimen 8.7 6.3 NR
MedianTTNT(months) 12.9 8.7 NR
DiscontinuationratesforPIcomponent(%)
9months 63 71 40
12months 72 76 NR
18months 83 89 NR
DOT (PI component)
Month from start of regimen
100
80
60
40
20
00 6 12 21 24
Trea
tmen
t con
tinua
tion
prob
abili
ty (%
)
3 9 15 18
IRdKRdVRd
TTNT
Month from start of regimen
100
80
60
40
20
00 6 12 21 24
Eve
nt-fr
ee p
roba
bilit
y (%
)
3 9 15 18
IRdKRdVRd
VRd–Bortezomib,lenalidomidedexamethasone;KRd–Carfilzomib,lenalidomide,dexamethasone;IRd–Ixazomib,lenalidomide,dexamethasone;DOT–Durationoftreatment;TTNT–Timetonexttreatment;PI–ProteassomeInhibitor;Rd-Lenalidomideanddexamethasone 1.ChariP,etal.Blood2017;132(suppl):1818
ComparativeEffectivenessofTripletsContainingBortezomib(B),Carfilzomib(C),Daratumumab(D),orIxazomib(I)inRelapsed/RefractoryMultipleMyeloma(RRMM)inRoutineCareintheUS
Retrospective cohort study design: 1432 adults with RRMM with at least 1 prior line of therapy (LOT) and initiating a triplet regimen containing B, C, D, or I. Endpoints: DOT, TTNT
TTNTwaslongerforIxazomibbasedregimensvsbortezomib,carfilzomib,anddaratumumab-based
≥2Linesoftherapy 2or3Linesoftherapy
• InRRMMpatients,medianTTNTwaslongerforIxazomibbasedregimensvsB-,C-,andD-basedtriplets.• ThemedianTTNT(months)resultswere11.1forI-,and9.8forB-,6.7forC-,and7.2forD-basedtriplets.DOT–Durationoftreatment;TTNT–Timetonexttreatment
AdaptedfromDaviesFetal.EHAPoster#PS1419
Ixazomib-basedBortezomib-basedDaratumumab-basedCarfilzomib-based
Ixazomib-basedBortezomib-basedDaratumumab-basedCarfilzomib-based
Real-worlddataontheefficacyandsafetyofIRdinRRMM:DatafromtheCzechRMG1
Characteristic Allpatients(N=127)
Medianage(range),years 66(41–84)
Bortezomib-refractory,% 18.9
Lenalidomide-refractory,% 7.9
1stlinetreatment† Patients,%
Bortezomib 94.5
Thalidomide 40.9
Lenalidomide 18.9
Carfilzomib 5.5
IRduseperlineoftreatment Patients,%
Second 58.5
Third 23.7
Fourth 7.6
Fifthandbeyond 10.1
Efficacyoutcomes
ORR(≥PR),% 67.1
CR 11.4
VGPR 16.5
PR 39.2
MR 10.1
≤SD 22.8
PFSafter1line,months Notreached
After2lines 23.1
After3lines 8.7
After≥4lines 4.6Grade≥3toxicities Patients,%
Neutropenia 35.1
Thrombocytopenia 22.8
Anaemia 12.3
Infection 19.3
*Riskstatusundeterminablein34patients.†Byindividualdrugs.CR,completeresponse;IRd,ixazomib,lenalidomide,dexamethasone;MR,minimalresponse;ORR,overallresponserate;PFS,progression-freesurvival;PR,partialresponse;RMG,registryofmonoclonalgammopathies;RRMM,relapsed/refractorymultiplemyeloma;SD,stabledisease;VGPR,verygoodPR1.Minariketal,Blood2018;132(suppl):1959.
CASE REPORT
EstecasoclínicofoidesenvolvidoporumperitoemHematologiaparafinsformaçãomédicacontínuarefletindoasuaexperienciaclinicaepessoal.
Patient history*
Initial diagnosis
• Diagnosed with MM IgG-kappa (ISS-2; R-ISS-2) in April 2012
• Myeloma-defining event: anaemia (Hb: 10.9 g/dL)
• No high-risk cytogenetic abnormalities • No extramedullary disease
Patient name:Sex:
Age:
Alexander
Male
69 years old
Prior medical history
• Medication for hypertension and hypercholesterolaemia
Lifestyle
• Generally active; plays tennis and golf • Regularly looked after two grandsons
*Thispatientcaserepresentsanindividualpatientexperienceonlyanddoesnotrepresentallpatients.Hb,haemoglobin;IgG,immunoglobulinG;ISS,InternationalStagingSystem;MM,multiplemyeloma;R-ISS,RevisedInternationalStagingSystem.
First-line therapy
• Patient received VMP x 9 cycles, followed by Rd x 9 cycles (Spanish trial GEM-2010):
• He was able to continue playing tennis and golf • He achieved sCR after 18 cycles, but MRD remained positive • Good tolerability without significant AE/SAEs
May 2012
AE,adverseevent;MRD,minimalresidualdisease;Rd,lenalidomide-dexamethasone;SAE,seriousadverseevent;sCR,stringentcompleteresponse;VMP,bortezomib-melphalan-prednisone.
Biochemical relapse
• In a follow-up visit (1 year and 2 months after treatment end), while the patient was asymptomatic, IF results tested positive (confirmed twice)
January 2015
• Serum protein electrophoresis showed an M-spike of 0.6 g/dL • 2 months later, M-spike was still 0.5 g/dL
May 2015
IF,immunofixation.
Clinical relapse
• In a follow-up visit (1 year and 2 months after treatment end), while the patient was asymptomatic, IF results tested positive (confirmed twice)
January 2015
• Serum protein electrophoresis showed an M-spike of 0.6 g/dL • 2 months later, M-spike was still 0.5 g/dL
May 2015
December 2015
• Mild fatigue: • Hb level decreased to 11 g/dL • PET-CT positive uptake observed in right hip with no lytic lesions • No high-risk features
PET-CT,Positronemissiontomography–computedtomography.Hb:Hemoglobin
The first question Alexander asked us was about the duration of the treatment
1. Continuous therapy
2. Fixed-duration therapy (as per first-line therapy)
OS:Overallsurvival;RRMM,relapsed/refractorymultiplemyeloma;m,months;2L,secondline.
Prolonged duration of therapy is associated with improved OS in patients undergoing second-line therapy
Real-world US data in RRMM1,2
HariP,etal.ClinLymphomaMyelomaLeuk2018;18:152–160.
Dur
atio
n of
ther
apy
in 2
L (m
onth
s)
% Increase in 1-year OS relative to median duration of therapy in 2L
0,0% 3,5% 7,0% 10,5% 14,0%
6.9 months
7m to <8m8m to <9m9m to <10m10m to <11m11m to <12m≥12m
3.7%
6.7%
9.2%
11.1%
12.7%
14.0%
Treatment at first relapse: What is the best choice for Alexander?
• The patient agreed with the recommendation to receive continuous therapy:
• As he previously received VMP and Rd for 18 months with subsequent treatment-free interval, he could be a candidate for either PI- or IMiD-based combinations
• Alexander stated a preference for an IMiD-based regimen for convenience, and because he had a more positive experience with the last 9 cycles than with the first 9 cycles of his first-line therapy
• He also wanted to maintain an active lifestyle
IMiD,immunomodulatoryimidedrugs;PI,proteosomeinhibitor.VMP:Bortezomib,Melfalan,Prednisolone;Rd:Lenalidomideanddexamethasone
EfficacyPOLLUX
DaraRd vs Rd2-4ASPIRE
KRd vs Rd5-7ELOQUENT-2 ERd vs Rd8
TOURMALINE-MM1 IRd vs Rd9,10
PFS HR (95% CI) 0.44 (0.35–0.55) 44.5 m vs 17.5 m
0.670 (0.558–0.803) 26.3 m vs 17.6 m
0.71 (0.59–0.86) 19.4 m vs 14.9 m
0.74 (0.59–0.94) 20.6 m vs. 14.7 m
ORR, % 93 87 79 78≥ CR, % 57 (MRDneg 30%) 32 5 14DOR, months NE 28.6 21.2 20.5
OS HR (95% CI) 0.63 (0.42–0.95) 0.79 (0.63–0.99) 48 m vs. 40 m
0.78 (0.63–0.96) 48.3 m vs 39.6 m NE
PFS HR (95% CI), median In len-exposed
0.38 (0.21–0.66) 38.8 m vs 18.6 m
0.796 (0.522–1.215) 19.4 m vs 13.9 m Only 5 pts 0.58
NR vs 17.5 m
1st line • Bortezomib-based combinations • Exposed to lenalidomide but no progressing under lenalidomide therapy
How to make the right choice?
First relapse after Bortezomib-based induction1
Triplets based on Rd DaraRd or KRd or IxaRd or
EloRd
Doublets RdX
1. Moreau P et al. Ann Oncol 2017;28(suppl_4):iv52-iv61; 2. Bahlis NJ, et al. ASH 2018, abstract 1996, poster presentation. 3. Usmani SZ, et al. ASH 2016, abstract 1151, oral presentation; 4. Usmani SZ, et al. ASH 2018, abstract 3288; 5. Stewart AK, et al. N Engl J Med. 2015;372:142-52; 6. Siegel DS, et al. J Clin Oncol 2018;36(8):728-734; Dimopoulos MA, et al. Blood Cancer Journal 2017;7:e554; 8. Dimopoulos MA, et al., Cancer 2018;124(20):4032-4043; 9. Moreau P, et al. N Engl J Med. 2016;374:1621-34; 10. Mateos MV, et al. Haematalogica 2017;102(10):1767-1775.
Rd: Lenalidomide and dexamethasone; DaraRd: Daratumumab, lenalidomide and dexamethasone; KRd: Carfilzomib, lenalidomide and dexamethasone; IxaRd: Ixazomib, lenalidomide and dexamethasone; EloRd: Elotuzumab, lenalidomide and dexamethasone PFS: Progression free survival; HR: Hazard ratio; ORR: Overall response rate; CR: Complete response; DOR: Duration of treatment; OS: Overall Survival ; CI: Confidence interval ; MRDneg: Minimal residual disease; NE: Non-estimated;
1.CleggA,etal.Lancet2013;381:752–762;2.HandforthC,etal.AnnOncol2015;26:1091–1101;3.DimopoulosMA,etal.CancerTreatRev2015;41:827–835;4.FaimanBM,etal.ClinJOncolNurs2011;15suppl:66–76;5.MiceliTS,etal.ClinJOncolNurs2011;15:9–23;6.GreippPR,etal.JClinOncol2005;23:3412–3420;7.ChngWJ,etal.Leukemia2016;30:1071–1078;8.TarimanJD,etal.CancerTreatCommun2014;2:34–47;9.BarbeeMS,etal.AnnPharmacother2013;47:1136–1142;10.SonneveldP,etal.Leukemia2013;27:1959–69;11.RamsenthalerC,etal.BMCCancer2016;16:427.ISS:Internationalstagingsystem
Patient-based factors are highly influential in treatment decision making
Treatment history
Previous therapies3
Frailty
Age1,2
Performance status3
Disability1
Comorbidities1,2
Disease morbidity
Refractory disease3
Renal impairment4
Bone disease5
Risk assessment
ISS6
Cytogenetics6,7
Lifestyle
Quality of life10,11
Patient preference8
Travel/ infusion time9
1.CleggA,etal.Lancet2013;381:752–762;2.HandforthC,etal.AnnOncol2015;26:1091–1101;3.DimopoulosMA,etal.CancerTreatRev2015;41:827–835;4.FaimanBM,etal.ClinJOncolNurs2011;15suppl:66–76;5.MiceliTS,etal.ClinJOncolNurs2011;15:9–23;6.GreippPR,etal.JClinOncol2005;23:3412–3420;7.ChngWJ,etal.Leukemia2016;30:1071–1078;8.TarimanJD,etal.CancerTreatCommun2014;2:34–47;9.BarbeeMS,etal.AnnPharmacother2013;47:1136–1142;10.SonneveldP,etal.Leukemia2013;27:1959–69;11.RamsenthalerC,etal.BMCCancer2016;16:427.ISS:Internationalstagingsystem;VMP:Bortezomib,melphalanprednisolone;Rd:Lenalidomideanddexamethasone
Patient-based factors are highly influential in treatment decision making
Treatment history
Previous therapies3
Frailty
Age1,2
Performance status3
Disability1
Comorbidities1,2
Disease morbidity
Refractory disease3
Renal impairment4
Bone disease5
Risk assessment
ISS6
Cytogenetics6,7
Lifestyle
Quality of life10,11
Patient preference8
Travel/ infusion time9PS-0
No disabilities
Controlled co-morbidities
72 years old VMP, Rd
Sports, Family
Treatment at first relapse
• Patient received IRd: • VGPR achieved for over 2 years • ECOG PS 0 • Patient visits clinic on monthly basis • Active lifestyle maintained on treatment
January2016
ECOGPS,EasternCooperativeOncologyGroupPerformanceStatus;VGPR,verygoodpartialresponse.IRd:Ixazomib,lenalidomideanddexamethasone
Experience with treatment regimens can enhance practical guidance and management recommendations
• Experience in routine clinical practice can identify practical challenges that are not present in the trial setting, thereby helping to optimise treatment in real-world practice
• Practical learnings from experience with IRd include:
InformationisbasedonthepersonalexperienceofDrMateos.
Use following indolent or biochemical relapses
Use at first relapse in elderly after bortezomib-based combinations
Use at second and third relapses in patients who received ASCT in the first line
The extension of PFS irrespective of cytogenetic profile
Opportunities for patients who want to maintain their regular activity
Options for patients who do not want to or cannot come to the hospital every week
When patients are asked for their preference they
usually prefer the oral administration
Patient history*
Initial diagnosis • Diagnosed with MM IgG-kappa (ISS-2; R-ISS-2) in April 2012
• Myeloma-defining event: anaemia (Hb: 10.9 g/dL)
• No high-risk cytogenetic abnormalities • No extramedullary disease
Patient name:
Sex:
Age:
Alexander
Male
69 years old
Prior medical history • Medication for hypertension and hypercholesterolaemia
Lifestyle • Generally active; plays tennis and golf • Regularly looked after two grandsons
*Thispatientcaserepresentsanindividualpatientexperienceonlyanddoesnotrepresentallpatients.Hb,haemoglobin;IgG,immunoglobulinG;ISS,InternationalStagingSystem;MM,multiplemyeloma;R-ISS,RevisedInternationalStagingSystem.
IECRCM de NINLARO®
Estemedicamentoestásujeitoamonitorizaçãoadicional.NOMEDOMEDICAMENTO:NINLARO2,3mg,3mge4mg,cápsulasCOMPOSIÇÃOQUALITATIVAEQUANTITATIVA:NINLARO2,3mgcápsulas:Cadacápsulacontém2,3mgdeixazomib(3,3mgcomocitratodeixazomib).NINLARO3mgcápsulas:Cadacápsulacontém3mgdeixazomib(4,3mgcomocitratodeixazomib).NINLARO4mgcápsulas:Cadacápsulacontém4mgdeixazomib(5,7mgcomocitratodeixazomib).FORMAFARMACÊUTICA:Cápsulas.NINLARO2,3mgcápsulas:Cápsulasdegelatinaduracor-de-rosaclaras,tamanho4,gravadascom“Takeda”nacabeçae“2,3mg”nocorpocomtintapreta.NINLARO3mgcápsulas:Cápsulasdegelatinaduracinzentasclaras,tamanho4,gravadascom“Takeda”nacabeçae“3,0mg”nocorpocomtintapreta.NINLARO4mgcápsulas:Cápsulasdegelatinaduracor-de-laranjaclaras,tamanho3,gravadascom“Takeda”nacabeçae“4,0mg”nocorpocomtintapreta.INDICAÇÕESTERAPÊUTICAS:NINLARO,emcombinaçãocomlenalidomidaedexametasona,éindicadoparaotratamentodedoentesadultoscommielomamúltiplo,quetenhamrecebidopelomenosuma terapêuticaanterior.POSOLOGIAEMODODEADMINISTRAÇÃO:O tratamentodeve ser iniciadoemonitorizadosob supervisãodeummédicoexperienteno tratamentodemielomamúltiplo.Posologia:Adose inicial recomendadade ixazomibéde4mgadministradaporviaoralumavezporsemana,nosDias1,8e15deumciclodetratamentode28dias.Adoseinicialrecomendadadelenalidomidaéde25mgadministradadiariamentenosDias1a21deumciclodetratamentode28dias.Adoseinicialrecomendadadedexametasonaéde40mgadministradanosDias1,8,15e22deumciclodetratamentode28dias.Parainformaçãoadicionalrelacionadacomlenalidomidaedexametasona,consultaroRCMparaestesmedicamentos.Antesdeiniciarumnovociclodeterapêutica:•Acontagemabsolutadeneutrófilosdeveser≥1000/mm3;•Acontagemdeplaquetasdeveser≥75000/mm3;•Astoxicidadesnão-hematológicasdevem,noparecerdomédico,sergeralmenterecuperadasparaacondiçãoinicialdodoenteou≤Grau1.Otratamentodevesercontinuadoatéprogressãodadoençaoutoxicidadeinaceitável.Otratamentocomixazomibemcombinaçãocomlenalidomidaedexametasonapormaisde24ciclosdeverábasear-senumaavaliaçãodebenefício-riscoindividual,poisosdadossobreatolerabilidadeetoxicidadealémdos24ciclossãolimitados.Dosesatrasadasoufalhadas:Emcasodeatrasooufalhadeumadosedeixazomib,adoseapenasdeverásertomadaseapróximadoseprevistafora≥72horas.Umadosefalhadanãodevesertomadaduranteas72horasqueantecedemapróximadoseprevista.Nãodeverásertomadaumadoseadobrarparacompensarumadose falhada.Seumdoentevomitarapósa tomadeumadose,odoentenãodeverá repetiressa toma,massimretomara tomadapróximadosenaalturaprevista.Alteraçõesàdose:Passosde reduçãodedose ixazomib:Dose inicial recomendada:4mg (Érecomendadaumadosereduzidade3mgnapresençadecompromissohepáticomoderadoougrave,compromissorenalgraveoudoençarenalemfaseterminal(DRT)queexijadiálise).Primeirareduçãopara:3mg.Segundareduçãopara:2,3mg.Depoisdescontinuar.Érecomendadaumaabordagemalternativadealteraçãoàdoseparaixazomibelenalidomidaparatoxicidadessobrepostasdetrombocitopenia,neutropeniaeerupçãocutânea.Paraestastoxicidades,oprimeiropassodealteraçãoàdoseédesuspensão/reduçãodelenalidomida.ConsultaroRCMdalenalidomidaparainformaçãosobreospassosdereduçãodedoseparaestastoxicidades.Medicamentosconcomitantes:Aprofilaxiaantiviraldeveráserconsideradaemdoentesemtratamentocomixazomibparadiminuiroriscodereativaçãodoherpes-zóster.Osdoentesincluídosemestudos com ixazomib,que receberamprofilaxia antiviral, tiveramuma incidênciamenorde infeçãoporherpes-zóster, emcomparação comdoentesquenão receberamprofilaxia.A tromboprofilaxiaé recomendadaemdoentesem tratamento com ixazomib, emcombinação comlenalidomidaedexametasona,edevebasear-senumaavaliaçãodosriscossubjacenteseestadoclínicododoente.Paraoutrosmedicamentosconcomitantesquepossamsernecessários,consultarRCMdalenalidomidaedexametasona.Populaçõesdedoentesespeciais:Idosos:Nãoénecessárioajustededosedeixazomibparadoentescommaisde65anosdeidade.Foramnotificadasdescontinuaçõesemdoentescom>75anosem13doentes(28%)noregimedeixazomibeem10doentes(16%)noregimedeplacebo.Foramobservadasarritmias,emdoentescom>75anos, em 10 doentes (21%) no regime de ixazomib e em 9 doentes (15%) no regime de placebo. Compromisso hepático: Não é necessário ajuste de dose de ixazomib para doentes com compromisso hepático ligeiro [bilirrubina total ≤ limite superior normal (LSN) e aspartatoaminotransferase(AST)>LNSoubilirrubinatotal>11,5xLNSequalquerAST].Érecomendadaadosereduzidade3mgemdoentescomcompromissohepáticomoderado(bilirrubinatotal>1,53xLNS)ougrave(bilirrubinatotal>3xLNS).Compromissorenal:Nãoénecessárioajustededosedeixazomibparadoentescomcompromissorenalligeirooumoderado(depuraçãodecreatinina≥30ml/min).Érecomendadaadosereduzidade3mgemdoentescomcompromissorenalgrave(depuraçãodecreatinina<30ml/min)oudoençarenalemfaseterminal(DRT)queexijadiálise.Ixazomibnãoédialisávele,porconseguinte,podeseradministradosemconsideraçãoàhoradediálise.ConsultaroRCMdalenalidomidapararecomendaçõesdeposologiaemdoentescomcompromissorenal.Populaçãopediátrica:Asegurançaeeficáciadeixazomibemcriançascomidadeinferiora18anosdeidadenãoforamestabelecidas.Nãoexistemdadosdisponíveis.Mododeadministração:ixazomibéadministradoporviaoral.Ixazomibdevesertomadoaproximadamenteàmesmahoranosdias1,8e15decadaciclodetratamento,pelomenos1horaantesoupelomenos2horasapósa ingestãodealimentos.A cápsuladeve serengolida inteira comágua.Nãodeve seresmagada,mastigadaouaberta.Contraindicações:Hipersensibilidadeà substância ativaouaqualquerumdosexcipientes.ConsultarRCMsda lenalidomidaedexametasonaparacontraindicaçõesadicionais.EFEITOSINDESEJÁVEIS:ConsultarRCMsdalenalidomidaedexametasonaparaefeitosindesejáveisadicionais.Resumodoperfildesegurança:OsdadosapresentadosabaixosãodadosdesegurançaagrupadosdoensaioclínicopilotodeFase3globalC16010(n=720)edoC16010-estudodecontinuaçãonaChina(n=115),emduplaocultação,controladoporplacebo(n=115).Asreaçõesadversasmaisfrequentementecomunicadas(≥20%)em417doentestratadosnoregimedeixazomibe418doentesnoregimedeplaceboforamdiarreia(39%vs.32%),trombocitopenia(33%vs.21%),neutropenia(33%vs.30%),obstipação(30%vs.22%),neuropatiaperiférica(25%vs.20%),náuseas(23%vs.18%),edemaperiférico(23%vs.17%),vómitos(20%vs.10%),einfeçãodotratorespiratóriosuperior(21%vs.16%).Asreaçõesadversasgravescomunicadasem≥2%dosdoentesincluíramtrombocitopenia(2%)ediarreia(2%).Reaçõesadversasemdoentestratadoscomixazomibemcombinaçãocomlenalidomidaedexametasona(todososgraus,Grau3eGrau4):Reaçõesadversas(todososgraus):Infeçõeseinfestações:Muitofrequentes:Infeçõesdotratorespiratóriosuperior;Frequentes:Herpes-zóster.Doençasdosangueesistemalinfático:Muitofrequentes:Trombocitopenia(representaumconjuntodetermospreferenciais),neutropenia.Doençasdosistemanervoso:Muitofrequentes:Neuropatiasperiféricas (representaumconjuntodetermospreferenciais).Doençasgastrointestinais:Muito frequentes:Diarreia,náuseas,vómitos,obstipação.Afeçõesdostecidoscutâneosesubcutâneos:Muito frequentes:Erupçãocutânea(representaumconjuntodetermospreferenciais).Afeçõesmúsculo-esqueléticasedostecidosconjuntivos:Muitofrequentes:Dorsalgia.Perturbaçõesgeraisealteraçõesnolocaldeadministração:Muitofrequentes:Edemaperiférico.ReaçõesadversasdeGrau3:Poucofrequentes:Infeçõesdotratorespiratóriosuperior; Frequentes: herpes-zóster. Doenças do sangue e sistema linfático:Muito frequentes: Trombocitopenia (representa um conjunto de termos preferenciais), neutropenia. Doenças do sistema nervoso: Frequentes: Neuropatias periféricas (representa um conjunto de termospreferenciais).Doençasgastrointestinais:Frequentes:Diarreia,náuseas;Poucofrequentes:Vómitos,obstipação.Afeçõesdostecidoscutâneosesubcutâneos:Frequentes:Erupçãocutânea(representaumconjuntodetermospreferenciais).Afeçõesmúsculo-esqueléticasedostecidosconjuntivos:Poucofrequentes:Dorsalgia.Perturbaçõesgeraisealteraçõesno localdeadministração:Frequentes:Edemaperiférico.ReaçõesadversasdeGrau4:Doençasdosangueesistema linfático:Frequentes:Trombocitopenia (representaumconjuntodetermospreferenciais),neutropenia.Dataderevisão:setembrode2018.EstádisponívelinformaçãopormenorizadasobreestemedicamentonosítiodainternetdaAgênciaEuropeiadeMedicamentos:http://www.ema.europa.eu.Medicamentosujeitoareceitamédicarestrita-Alíneaa)doArtigo118ºdoD.L.176/2006.MedicamentoaprovadoporavaliaçãopréviaaoabrigodoDL97/2015,de1dejunho.ParamaisinformaçõesdeverácontactarorepresentantelocaldotitulardaAutorizaçãodeIntroduçãonoMercado:Takeda-FarmacêuticosPortugal,Lda.,Av.daTorredeBelém,nº19–R/CEsq.–1400-342LisboaNIPC:502801204RegistadanaCRCdeCascaissobmesmonúmero;T+351211201457;F+351211201456.Paranotificaçãodereacçõesadversascontactar:[email protected]