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ZIRABEV Adverse Reactions (bevacizumab-bvzr)

6 ADVERSE REACTIONS

The following clinically significant adverse reactions are described elsewhere in the labeling:

6.1 Clinical Trials Experience

Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice.

The safety data in Warnings and Precautions and described below reflect exposure to bevacizumab in 4463 patients including those with mCRC (AVF2107g, E3200), non-squamous NSCLC (E4599), GBM (EORTC 26101), mRCC (BO17705), cervical cancer (GOG-0240), epithelial ovarian, fallopian tube, or primary peritoneal cancer (MO22224, AVF4095, GOG-0213, and GOG-0218) or another cancer at the recommended dose and schedule for a median of 6 to 23 doses. The most common adverse reactions observed in patients receiving bevacizumab as a single agent or in combination with other anti-cancer therapies at a rate >10% were epistaxis, headache, hypertension, rhinitis, proteinuria, taste alteration, dry skin, hemorrhage, lacrimation disorder, back pain, and exfoliative dermatitis.

Across clinical studies, bevacizumab was discontinued in 8% to 22% of patients because of adverse reactions [see Clinical Studies (14)].

Metastatic Colorectal Cancer

In Combination with bolus IFL

The safety of bevacizumab was evaluated in 392 patients who received at least one dose of bevacizumab in a double-blind, active-controlled study (AVF2107g), which compared bevacizumab (5 mg/kg every 2 weeks) with bolus-IFL to placebo with bolus IFL in patients with mCRC [see Clinical Studies (14.1)]. Patients were randomized (1:1:1) to placebo with bolus IFL, bevacizumab with bolus IFL, or bevacizumab with fluorouracil and leucovorin. The demographics of the safety population were similar to the demographics of the efficacy population. All Grades 3–4 adverse reactions and selected Grades 1–2 adverse reactions (i.e., hypertension, proteinuria, thromboembolic events) were collected in the entire study population. Adverse reactions are presented in Table 2.

Table 2: Grades 3–4 Adverse Reactions Occurring at Higher Incidence (≥2%) in Patients Receiving Bevacizumab vs. Placebo in Study AVF2107g
Adverse Reaction*Bevacizumab with IFL
(N=392)
Placebo with IFL
(N=396)
*
NCI-CTC version 3
Hematology
  Leukopenia37%31%
  Neutropenia21%14%
Gastrointestinal
  Diarrhea34%25%
  Abdominal pain8%5%
  Constipation4%2%
Vascular
  Hypertension12%2%
  Deep vein thrombosis9%5%
  Intra-abdominal thrombosis3%1%
  Syncope3%1%
General
  Asthenia10%7%
  Pain8%5%

In Combination with FOLFOX4

The safety of bevacizumab was evaluated in 521 patients in an open-label, active-controlled study (E3200) in patients who were previously treated with irinotecan and fluorouracil for initial therapy for mCRC. Patients were randomized (1:1:1) to FOLFOX4, bevacizumab (10 mg/kg every 2 weeks prior to FOLFOX4 on Day 1) with FOLFOX4, or bevacizumab alone (10 mg/kg every 2 weeks). Bevacizumab was continued until disease progression or unacceptable toxicity. The demographics of the safety population were similar to the demographics of the efficacy population.

Selected Grades 3–5 non-hematologic and Grades 4–5 hematologic occurring at a higher incidence (≥2%) in patients receiving bevacizumab with FOLFOX4 compared to FOLFOX4 alone were fatigue (19% vs. 13%), diarrhea (18% vs. 13%), sensory neuropathy (17% vs. 9%), nausea (12% vs. 5%), vomiting (11% vs. 4%), dehydration (10% vs. 5%), hypertension (9% vs. 2%), abdominal pain (8% vs. 5%), hemorrhage (5% vs. 1%), other neurological (5% vs. 3%), ileus (4% vs. 1%) and headache (3% vs. 0%). These data are likely to under-estimate the true adverse reaction rates due to the reporting mechanisms.

First-Line Non-Squamous Non-Small Cell Lung Cancer

The safety of bevacizumab was evaluated as first-line treatment in 422 patients with unresectable NSCLC who received at least one dose of bevacizumab in an active-controlled, open-label, multicenter trial (E4599) [see Clinical Studies (14.3)]. Chemotherapy-naïve patients with locally advanced, metastatic or recurrent non–squamous NSCLC were randomized (1:1) to receive six 21-day cycles of paclitaxel and carboplatin with or without bevacizumab (15 mg/kg every 3 weeks). After completion or upon discontinuation of chemotherapy, patients randomized to receive bevacizumab continued to receive bevacizumab alone until disease progression or until unacceptable toxicity. The trial excluded patients with predominant squamous histology (mixed cell type tumors only), CNS metastasis, gross hemoptysis (1/2 teaspoon or more of red blood), unstable angina, or receiving therapeutic anticoagulation. The demographics of the safety population were similar to the demographics of the efficacy population.

Only Grades 3–5 non-hematologic and Grades 4–5 hematologic adverse reactions were collected. Grades 3–5 non-hematologic and Grades 4–5 hematologic adverse reactions occurring at a higher incidence (≥2%) in patients receiving bevacizumab with paclitaxel and carboplatin compared with patients receiving chemotherapy alone were neutropenia (27% vs. 17%), fatigue (16% vs. 13%), hypertension (8% vs. 0.7%), infection without neutropenia (7% vs. 3%), venous thromboembolism (5% vs. 3%), febrile neutropenia (5% vs. 2%), pneumonitis/pulmonary infiltrates (5% vs. 3%), infection with Grade 3 or 4 neutropenia (4% vs. 2%), hyponatremia (4% vs. 1%), headache (3% vs. 1%) and proteinuria (3% vs. 0%).

Recurrent Glioblastoma

The safety of bevacizumab was evaluated in a multicenter, randomized, open-label study (EORTC 26101) in patients with recurrent GBM following radiotherapy and temozolomide of whom 278 patients received at least one dose of bevacizumab and are considered safety evaluable [see Clinical Studies (14.4)]. Patients were randomized (2:1) to receive bevacizumab (10 mg/kg every 2 weeks) with lomustine or lomustine alone until disease progression or unacceptable toxicity. The demographics of the safety population were similar to the demographics of the efficacy population. In the bevacizumab with lomustine arm, 22% of patients discontinued treatment due to adverse reactions compared with 10% of patients in the lomustine arm. In patients receiving bevacizumab with lomustine, the adverse reaction profile was similar to that observed in other approved indications.

Metastatic Renal Cell Carcinoma

The safety of bevacizumab was evaluated in 337 patients who received at least one dose of bevacizumab in a multicenter, double-blind study (BO17705) in patients with mRCC. Patients who had undergone a nephrectomy were randomized (1:1) to receive either bevacizumab (10 mg/kg every 2 weeks) or placebo with interferon alfa [see Clinical Studies (14.5)]. Patients were treated until disease progression or unacceptable toxicity. The demographics of the safety population were similar to the demographics of the efficacy population.

Grades 3–5 adverse reactions occurring at a higher incidence (>2%) were fatigue (13% vs. 8%), asthenia (10% vs. 7%), proteinuria (7% vs. 0%), hypertension (6% vs. 1%; including hypertension and hypertensive crisis), and hemorrhage (3% vs. 0.3%; including epistaxis, small intestinal hemorrhage, aneurysm ruptured, gastric ulcer hemorrhage, gingival bleeding, hemoptysis, hemorrhage intracranial, large intestinal hemorrhage, respiratory tract hemorrhage, and traumatic hematoma). Adverse reactions are presented in Table 3.

Table 3: Grades 1–5 Adverse Reactions Occurring at Higher Incidence (≥5%) of Patients Receiving Bevacizumab vs. Placebo with Interferon Alfa in Study BO17705
Adverse Reaction*Bevacizumab with Interferon Alfa
(N=337)
Placebo with Interferon Alfa
(N=304)
*
NCI-CTC version 3
Metabolism and nutrition
  Decreased appetite36%31%
  Weight loss20%15%
General
  Fatigue33%27%
Vascular
  Hypertension28%9%
Respiratory, thoracic and mediastinal
  Epistaxis27%4%
  Dysphonia 5%0%
Nervous system
  Headache24%16%
Gastrointestinal
  Diarrhea21%16%
Renal and urinary
  Proteinuria20%3%
Musculoskeletal and connective tissue
  Myalgia19%14%
  Back pain12%6%

The following adverse reactions were reported at a 5-fold greater incidence in patients receiving bevacizumab with interferon-alfa compared to patients receiving placebo with interferon-alfa and not represented in Table 3: gingival bleeding (13 patients vs. 1 patient); rhinitis (9 vs. 0); blurred vision (8 vs. 0); gingivitis (8 vs. 1); gastroesophageal reflux disease (8 vs. 1); tinnitus (7 vs. 1); tooth abscess (7 vs. 0); mouth ulceration (6 vs. 0); acne (5 vs. 0); deafness (5 vs. 0); gastritis (5 vs. 0); gingival pain (5 vs. 0) and pulmonary embolism (5 vs. 1).

Persistent, Recurrent, or Metastatic Cervical Cancer

The safety of bevacizumab was evaluated in 218 patients who received at least one dose of bevacizumab in a multicenter study (GOG-0240) in patients with persistent, recurrent, or metastatic cervical cancer [see Clinical Studies (14.6)]. Patients were randomized (1:1:1:1) to receive paclitaxel and cisplatin with or without bevacizumab (15 mg/kg every 3 weeks), or paclitaxel and topotecan with or without bevacizumab (15 mg/kg every 3 weeks). The demographics of the safety population were similar to the demographics of the efficacy population.

Grades 3–4 adverse reactions occurring at a higher incidence (≥2%) in 218 patients receiving bevacizumab with chemotherapy compared to 222 patients receiving chemotherapy alone were abdominal pain (12% vs. 10%), hypertension (11% vs. 0.5%), thrombosis (8% vs. 3%), diarrhea (6% vs. 3%), anal fistula (4% vs. 0%), proctalgia (3% vs. 0%), urinary tract infection (8% vs. 6%), cellulitis (3% vs. 0.5%), fatigue (14% vs. 10%), hypokalemia (7% vs. 4%), hyponatremia (4% vs. 1%), dehydration (4% vs. 0.5%), neutropenia (8% vs. 4%), lymphopenia (6% vs. 3%), back pain (6% vs. 3%), and pelvic pain (6% vs. 1%). Adverse reactions are presented in Table 4.

Table 4: Grades 1–4 Adverse Reactions Occurring at Higher Incidence (≥5%) in Patients Receiving Bevacizumab with Chemotherapy vs. Chemotherapy Alone in Study GOG-0240
Adverse Reaction*Bevacizumab with Chemotherapy
(N=218)
Chemotherapy
(N=222)
*
NCI-CTC version 3
General
  Fatigue80%75%
  Peripheral edema15%22%
Metabolism and nutrition
  Decreased appetite34%26%
  Hyperglycemia26%19%
  Hypomagnesemia24%15%
  Weight loss21%7%
  Hyponatremia19%10%
  Hypoalbuminemia16%11%
Vascular
  Hypertension29%6%
  Thrombosis10%3%
Infections
  Urinary tract infection22%14%
  Infection10%5%
Nervous system
  Headache22%13%
  Dysarthria8%1%
Psychiatric
  Anxiety17%10%
Respiratory, thoracic and mediastinal
  Epistaxis17%1%
Renal and urinary
  Increased blood creatinine16%10%
  Proteinuria10%3%
Gastrointestinal
  Stomatitis15%10%
  Proctalgia6%1%
  Anal fistula6%0%
Reproductive system and breast
  Pelvic pain14%8%
Hematology
  Neutropenia12%6%
  Lymphopenia12%5%

Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer

Stage III or IV Following Initial Surgical Resection

The safety of bevacizumab was evaluated in GOG-0218, a multicenter, randomized, double-blind, placebo-controlled, three arm study, which evaluated the addition of bevacizumab to carboplatin and paclitaxel for the treatment of patients with stage III or IV epithelial ovarian, fallopian tube, or primary peritoneal cancer following initial surgical resection [see Clinical Studies (14.7)]. Patients were randomized (1:1:1) to carboplatin and paclitaxel without bevacizumab (CPP), carboplatin and paclitaxel with bevacizumab for up to six cycles (CPB15), or carboplatin and paclitaxel with bevacizumab for six cycles followed by bevacizumab as a single agent for up to 16 additional doses (CPB15+). Bevacizumab was given at 15 mg/kg every three weeks. On this trial, 1215 patients received at least one dose of bevacizumab. The demographics of the safety population were similar to the demographics of the efficacy population.

Grades 3–4 adverse reactions occurring at a higher incidence (≥2%) in either of the bevacizumab arms versus the control arm were fatigue (CPB15+ - 9%, CPB15 - 6%, CPP - 6%), hypertension (CPB15+ - 10%, CPB15 - 6%, CPP - 2%), thrombocytopenia (CPB15+ - 21%, CPB15 - 20%, CPP - 15%) and leukopenia (CPB15+ - 51%, CPB15 - 53%, CPP - 50%). Adverse reactions are presented in Table 5.

Table 5: Grades 1–5 Adverse Reactions Occurring at Higher Incidence (≥5%) in Patients Receiving Bevacizumab with Chemotherapy vs. Chemotherapy Alone in Study GOG-0218
Adverse Reaction*Bevacizumab with Carboplatin and Paclitaxel followed by Bevacizumab Alone
(N=608)
Bevacizumab with Carboplatin and Paclitaxel
(N=607)
Carboplatin and Paclitaxel§
(N=602)
*
NCI-CTC version 3,
CPB15+,
CPB15,
§
CPP
General
  Fatigue80%72%73%
Gastrointestinal
  Nausea58%53%51%
  Diarrhea38%40%34%
  Stomatitis25%19%14%
Musculoskeletal and connective tissue
  Arthralgia41%33%35%
  Pain in extremity25%19%17%
  Muscular weakness15%13%9%
Nervous system
  Headache34%26%21%
  Dysarthria12%10%2%
Vascular
  Hypertension32%24%14%
Respiratory, thoracic and mediastinal
  Epistaxis31%30%9%
  Dyspnea26%28%20%
  Nasal mucosal disorder10%7%4%

Platinum-Resistant Recurrent Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer

The safety of bevacizumab was evaluated in 179 patients who received at least one dose of bevacizumab in a multicenter, open-label study (MO22224) in which patients were randomized (1:1) to bevacizumab with chemotherapy or chemotherapy alone in patients with platinum-resistant recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer that recurred within <6 months from the most recent platinum based therapy [see Clinical Studies (14.8)]. Patients were randomized to receive bevacizumab 10 mg/kg every 2 weeks or 15 mg/kg every 3 weeks. Patients had received no more than 2 prior chemotherapy regimens. The trial excluded patients with evidence of recto-sigmoid involvement by pelvic examination or bowel involvement on CT scan or clinical symptoms of bowel obstruction. Patients were treated until disease progression or unacceptable toxicity. Forty percent of patients on the chemotherapy alone arm received bevacizumab alone upon progression. The demographics of the safety population were similar to the demographics of the efficacy population.

Grades 3–4 adverse reactions occurring at a higher incidence (≥2%) in 179 patients receiving bevacizumab with chemotherapy compared to 181 patients receiving chemotherapy alone were hypertension (6.7% vs. 1.1%) and palmar-plantar erythrodysaesthesia syndrome (4.5% vs. 1.7%). Adverse reactions are presented in Table 6.

Table 6: Grades 2–4 Adverse Reactions Occurring at Higher Incidence (≥5%) in Patients Receiving Bevacizumab with Chemotherapy vs. Chemotherapy Alone in Study MO22224
Adverse Reaction*Bevacizumab with Chemotherapy
(N=179)
Chemotherapy
(N=181)
*
NCI-CTC version 3
Hematology
  Neutropenia 31%25%
Vascular
  Hypertension19%6%
Nervous system
  Peripheral sensory neuropathy18%7%
General
  Mucosal inflammation13%6%
Renal and urinary
  Proteinuria12%0.6%
Skin and subcutaneous tissue
  Palmar-plantar erythrodysaesthesia11%5%
Infections
  Infection11%4%
Respiratory, thoracic and mediastinal
  Epistaxis5%0%

Platinum-Sensitive Recurrent Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer

Study AVF4095g

The safety of bevacizumab was evaluated in 247 patients who received at least one dose of bevacizumab in a double-blind study (AVF4095g) in patients with platinum-sensitive recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer [see Clinical Studies (14.9)]. Patients were randomized (1:1) to receive bevacizumab (15 mg/kg) or placebo every 3 weeks with carboplatin and gemcitabine for 6 to 10 cycles followed by bevacizumab or placebo alone until disease progression or unacceptable toxicity. The demographics of the safety population were similar to the demographics of the efficacy population.

Grades 3–4 adverse reactions occurring at a higher incidence (≥2%) in patients receiving bevacizumab with chemotherapy compared to placebo with chemotherapy were: thrombocytopenia (40% vs. 34%), nausea (4% vs. 1.3%), fatigue (6% vs. 4%), headache (4% vs. 0.9%), proteinuria (10% vs. 0.4%), dyspnea (4% vs. 1.7%), epistaxis (5% vs. 0.4%), and hypertension (17% vs. 0.9%). Adverse reactions are presented in Table 7.

Table 7: Grades 1–5 Adverse Reactions Occurring at Higher Incidence (≥5%) in Patients Receiving Bevacizumab with Chemotherapy vs. Placebo with Chemotherapy in Study AVF4095g
Adverse Reaction*Bevacizumab with Carboplatin and Gemcitabine
(N=247)
Placebo with Carboplatin and Gemcitabine
(N=233)
*
NCI-CTC version 3
General
  Fatigue82%75%
  Mucosal inflammation15%10%
Gastrointestinal
  Nausea72%66%
  Diarrhea38%29%
  Stomatitis15%7%
  Hemorrhoids8%3%
  Gingival bleeding7%0%
Hematology
  Thrombocytopenia58%51%
Respiratory, thoracic and mediastinal
  Epistaxis55%14%
  Dyspnea30%24%
  Cough26%18%
  Oropharyngeal pain16%10%
  Dysphonia13%3%
  Rhinorrhea10%4%
  Sinus congestion8%2%
Nervous system
  Headache49%30%
  Dizziness23%17%
Vascular
  Hypertension42%9%
Musculoskeletal and connective tissue
  Arthralgia28%19%
  Back pain21%13%
Psychiatric
  Insomnia21%15%
Renal and urinary
  Proteinuria20%3%
Injury and procedural
  Contusion17%9%
Infections
  Sinusitis15%9%

Study GOG-0213

The safety of bevacizumab was evaluated in an open-label, controlled study (GOG-0213) in 325 patients with platinum-sensitive recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer, who have not received more than one previous regimen of chemotherapy [see Clinical Studies (14.9)]. Patients were randomized (1:1) to receive carboplatin and paclitaxel for 6 to 8 cycles or bevacizumab (15 mg/kg every 3 weeks) with carboplatin and paclitaxel for 6 to 8 cycles followed by bevacizumab as a single agent until disease progression or unacceptable toxicity. The demographics of the safety population were similar to the demographics of the efficacy population.

Grades 3–4 adverse reactions occurring at a higher incidence (≥2%) in patients receiving bevacizumab with chemotherapy compared to chemotherapy alone were: hypertension (11% vs. 0.6%), fatigue (8% vs. 3%), febrile neutropenia (6% vs. 3%), proteinuria (8% vs. 0%), abdominal pain (6% vs. 0.9%), hyponatremia (4% vs. 0.9%), headache (3% vs. 0.9%), and pain in extremity (3% vs. 0%). Adverse reactions are presented in Table 8.

Table 8: Grades 1–5 Adverse Reactions Occurring at Higher Incidence (≥5%) in Patients Receiving Bevacizumab with Chemotherapy vs. Chemotherapy Alone in Study GOG-0213
Adverse Reaction*Bevacizumab with Carboplatin and Paclitaxel
(N=325)
Carboplatin and Paclitaxel
(N=332)
*
NCI-CTC version 3
Musculoskeletal and connective tissue
  Arthralgia45%30%
  Myalgia29%18%
  Pain in extremity25%14%
  Back pain17%10%
  Muscular weakness13%8%
  Neck pain9%0%
Vascular
  Hypertension42%3%
Gastrointestinal
  Diarrhea39%32%
  Abdominal pain33%28%
  Vomiting33%25%
  Stomatitis33%16%
Nervous system
  Headache38%20%
  Dysarthria14%2%
  Dizziness13%8%
Metabolism and nutrition
  Decreased appetite35%25%
  Hyperglycemia31%24%
  Hypomagnesemia27%17%
  Hyponatremia17%6%
  Weight loss15%4%
  Hypocalcemia12%5%
  Hypoalbuminemia11%6%
  Hyperkalemia9%3%
Respiratory, thoracic and mediastinal
  Epistaxis33%2%
  Dyspnea30%25%
  Cough30%17%
  Rhinitis allergic17%4%
  Nasal mucosal disorder14%3%
Skin and subcutaneous tissue
  Exfoliative rash23%16%
  Nail disorder10%2%
  Dry skin7%2%
Renal and urinary
  Proteinuria17%1%
  Increased blood creatinine13%5%
Hepatic
  Increased aspartate aminotransferase15%9%
General
  Chest pain8%2%
Infections
  Sinusitis7%2%

6.2 Immunogenicity

As with all therapeutic proteins, there is a potential for immunogenicity. The detection of antibody formation is highly dependent on the sensitivity and the specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors, including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies in the studies described below with the incidence of antibodies in other studies or to other bevacizumab products may be misleading.

In clinical studies for adjuvant treatment of a solid tumor, 0.6% (14/2233) of patients tested positive for treatment-emergent anti-bevacizumab antibodies as detected by an electrochemiluminescent (ECL) based assay. Among these 14 patients, three tested positive for neutralizing antibodies against bevacizumab using an enzyme-linked immunosorbent assay (ELISA). The clinical significance of these anti-bevacizumab antibodies is not known.

6.3 Postmarketing Experience

The following adverse reactions have been identified during postapproval use of bevacizumab products. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

General: Polyserositis

Cardiovascular: Pulmonary hypertension, Mesenteric venous occlusion

Gastrointestinal: Gastrointestinal ulcer, Intestinal necrosis, Anastomotic ulceration

Hemic and lymphatic: Pancytopenia

Hepatobiliary disorders: Gallbladder perforation

Musculoskeletal and Connective Tissue Disorders: Osteonecrosis of the jaw

Renal: Renal thrombotic microangiopathy (manifested as severe proteinuria)

Respiratory: Nasal septum perforation

Vascular: Arterial (including aortic) aneurysms, dissections, and rupture

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