8 USE IN SPECIFIC POPULATIONS
Based on its mechanism of action [see Clinical Pharmacology (12.1)] and findings in animals, bortezomib for injection can cause fetal harm when administered to a pregnant woman. There are no studies with the use of bortezomib for injection in pregnant women to inform drug-associated risks. Bortezomib caused embryo-fetal lethality in rabbits at doses lower than the clinical dose (see Data). Advise pregnant women of the potential risk to the fetus.
Adverse outcomes in pregnancy occur regardless of the health of the mother or the use of medications. The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively.
Bortezomib was not teratogenic in nonclinical developmental toxicity studies in rats and rabbits at the highest dose tested (0.075 mg/kg; 0.5 mg/m2 in the rat and 0.05 mg/kg; 0.6 mg/m2 in the rabbit) when administered during organogenesis. These dosages are approximately 0.5 times the clinical dose of 1.3 mg/m2 based on body surface area.
Bortezomib caused embryo-fetal lethality in rabbits at doses lower than the clinical dose (approximately 0.5 times the clinical dose of 1.3 mg/m2 based on body surface area). Pregnant rabbits given bortezomib during organogenesis at a dose of 0.05 mg/kg (0.6 mg/m2) experienced significant postimplantation loss and decreased number of live fetuses. Live fetuses from these litters also showed significant decreases in fetal weight.
There are no data on the presence of bortezomib or its metabolites in human milk, the effects of the drug on the breastfed child, or the effects of the drug on milk production. Because many drugs are excreted in human milk and because the potential for serious adverse reactions in a breastfed child from bortezomib for injection is unknown, advise nursing women not to breastfeed during treatment with bortezomib for injection and for two months after treatment.
8.3 Females and Males of Reproductive Potential
Based on its mechanism of action and findings in animals, bortezomib for injection can cause fetal harm when administered to a pregnant woman [see Use in Specific Populations (8.1)].
Conduct pregnancy testing in females of reproductive potential prior to initiating bortezomib for injection treatment.
Advise females of reproductive potential to use effective contraception during treatment with bortezomib for injection and for seven months after the last dose.
Based on the mechanism of action and findings in animals, bortezomib for injection may have an effect on either male or female fertility [see Nonclinical Toxicology (13.1)].
8.4 Pediatric Use
Safety and effectiveness have not been established in pediatric patients.
The activity and safety of bortezomib for injection in combination with intensive reinduction chemotherapy was evaluated in pediatric and young adult patients with lymphoid malignancies (pre-B cell ALL 77%, 16% with T-cell ALL, and 7% T-cell lymphoblastic lymphoma (LL)), all of whom relapsed within 36 months of initial diagnosis in a single-arm multicenter, nonrandomized cooperative group trial. An effective reinduction multiagent chemotherapy regimen was administered in three blocks. Block 1 included vincristine, prednisone, doxorubicin and pegaspargase; Block 2 included cyclophosphamide, etoposide and methotrexate; Block 3 included high-dose cytosine arabinoside and asparaginase. Bortezomib for injection was administered at a dose of 1.3 mg/m2 as a bolus intravenous injection on Days 1, 4, 8, and 11 of Block 1 and Days 1, 4, and 8 of Block 2. There were 140 patients with ALL or LL enrolled and evaluated for safety. The median age was ten years (range: 1 to 26), 57% were male, 70% were white, 14% were black, 4% were Asian, 2% were American Indian/ Alaska Native, 1% were Pacific Islander.
The activity was evaluated in a prespecified subset of the first 60 evaluable patients enrolled on the study with pre-B ALL ≤21 years and relapsed <36 months from diagnosis. The complete remission (CR) rate at day 36 was compared to that in a historical control set of patients who had received the identical backbone therapy without bortezomib for injection. There was no evidence that the addition of bortezomib for injection had any impact on the CR rate.
No new safety concerns were observed when bortezomib for injection was added to a chemotherapy backbone regimen as compared with a historical control group in which the backbone regimen was given without bortezomib for injection.
The BSA-normalized clearance of bortezomib in pediatric patients was similar to that observed in adults.
8.5 Geriatric Use
Of the 669 patients enrolled in the relapsed multiple myeloma study, 245 (37%) were 65 years of age or older: 125 (38%) on the bortezomib for injection arm and 120 (36%) on the dexamethasone arm. Median time to progression and median duration of response for patients ≥65 were longer on bortezomib for injection compared to dexamethasone [5.5 mo vs 4.3 mo, and 8.0 mo vs 4.9 mo, respectively]. On the bortezomib for injection arm, 40% (n=46) of evaluable patients aged ≥65 experienced response (CR + PR) vs 18% (n=21) on the dexamethasone arm. The incidence of Grade 3 and 4 events was 64%, 78% and 75% for bortezomib for injection patients ≤50, 51 to 64 and ≥65 years old, respectively [see Adverse Reactions (6.1), Clinical Studies (14.1)].
No overall differences in safety or effectiveness were observed between patients ≥age 65 and younger patients receiving bortezomib for injection; but greater sensitivity of some older individuals cannot be ruled out.
8.6 Renal Impairment
No starting dosage adjustment of bortezomib for injection is recommended for patients with renal impairment. In patients requiring dialysis, bortezomib for injection should be administered after the dialysis procedure [see Clinical Pharmacology (12.3)].
8.7 Hepatic Impairment
No starting dosage adjustment of bortezomib for injection is recommended for patients with mild hepatic impairment (total bilirubin ≤1× ULN and AST >ULN, or total bilirubin >1 to 1.5× ULN and any AST). The exposure of bortezomib is increased in patients with moderate (total bilirubin ≥1.5 to 3× ULN and any AST) and severe (total bilirubin >3× ULN and any AST) hepatic impairment. Reduce the starting dose in patients with moderate or severe hepatic impairment [see Dosage and Administration (2.8), Clinical Pharmacology (12.3)].
8.8 Patients with Diabetes
During clinical trials, hypoglycemia and hyperglycemia were reported in diabetic patients receiving oral hypoglycemics. Patients on oral antidiabetic agents receiving bortezomib for injection treatment may require close monitoring of their blood glucose levels and adjustment of the dose of their antidiabetic medication.