*For patients with CrCl <60, see recommended dosing for renal impairment.
For dose adjustments due to toxicity with rituximab, refer to the product prescribing information.
Jacklyn Gideon, MSN, AGPCNP-BC, an Advanced Practice Nurse at the University of Chicago, talks about 12-cycle, fixed-duration dosing in the Phase III AUGMENT trial.
[Non KOL Voiceover talent]
REVLIMID (lenalidomide) in combination with a rituximab product is indicated for the treatment of adult patients with previously treated follicular lymphoma or marginal zone lymphoma.
REVLIMID is not indicated and is not recommended for the treatment of patients with chronic lymphocytic leukemia (CLL) outside of controlled clinical trials.
REVLIMID is only available through a restricted distribution program, Lenalidomide REMS.
REVLIMID has a Boxed Warning for embryo-fetal toxicity, hematologic toxicity, and venous and arterial thromboembolism.
Please see additional Important Safety Information, including Boxed WARNING for REVLIMID at the end of this video.
Hello, my name is Jacklyn Gideon and I’m an Advanced Practice Nurse at the University of Chicago. I’ve been working in hematology and oncology for almost 10 years, and today I’m going to talk with you about R2 dosing.
PFS BENEFIT EXTENDED BEYOND TREATMENT DURATION
R2 is indicated for previously treated follicular and marginal zone lymphoma and has a 12-cycle fixed duration of treatment. This indication is supported by data from the Phase III AUGMENT trial.
In the AUGMENT trial, a total of 358 patients with previously treated follicular or marginal zone lymphoma were randomized 1 to 1 to R2 or rituximab plus placebo for a total of 12 treatment cycles. The dosing information for REVLIMID and rituximab is on your screen.
Patients had received at least 2 prior doses of rituximab, but none of the patients were rituximab refractory. Highlights of the baseline patient characteristics are shown here.
The primary endpoint of the trial was progression-free survival.
This combination therapy has a 12-cycle fixed-duration dosing schedule. In follicular lymphoma, the starting dose of REVLIMID is 20 mg per day. REVLIMID is taken orally on days 1 through 21 of 28-day cycles followed by 7 days without REVLIMID. This is repeated for up to 12 cycles.
375 mg per meter squared of rituximab is administered intravenously on days 1, 8, 15, and 22 of the first cycle and day 1 of cycles 2 through 5.
Following this dosing schedule, R2 demonstrated a median of 39.4 months of progression-free survival with this fixed-duration dosing schedule compared with 14.1 months of progression-free survival for patients receiving rituximab alone in the AUGMENT trial.
The results of the trial suggest that R2 showed a progression-free survival benefit beyond the 12-month treatment duration.
STUDIED IN A BROAD RANGE OF PREVIOUSLY TREATED PATIENTS
In the AUGMENT trial, R2 was studied in a broad range of patients, including some who are typically considered more difficult to treat.
Patients with renal impairment may also receive treatment with R2. However, they should receive a lower starting dose of REVLIMID.
SAFETY PROFILE FOR R2 VS RITUXIMAB
When considering a long-term treatment strategy for follicular lymphoma, it’s also important to consider potential adverse reactions.
Let’s talk about the adverse reactions seen in the AUGMENT trial.
Neutropenia was the most commonly reported adverse reaction with R2 and was observed in 58% of patients, including 50% who had Grade 3 or 4 reactions. Incidences of Grade 3 or 4 neutropenia resolved in a median of 9 days. Febrile neutropenia was also reported in 3 percent of patients receiving R2 versus less than 1 percent of patients receiving rituximab.
Other commonly reported adverse reactions were diarrhea, constipation, cough, fatigue, rash, pyrexia, leukopenia, and pruritus.
Blood cell counts may fluctuate over the course of treatment, so it is important to monitor regularly. You may have to modify or interrupt the dose of REVLIMID, and you can find recommended dose modifications and dose interruptions in the full Prescribing Information. Dose modifications may help patients stay on treatment for all 12 cycles.
There are other important considerations when dosing R2. REVLIMID is primarily excreted through the kidneys, so renal function should also be monitored.
Patients in the R2 arm of the trial received an average of 11.2 cycles of treatment with appropriate growth factor support, dose modifications, and/or interruptions. Overall, 71% of patients receiving R2 completed all 12 cycles of treatment vs. 62% receiving rituximab plus placebo, and the most common reasons for discontinuation were progressive disease, adverse events, or withdrawal from the trial.
The dose reductions and dose interruptions among patients in the AUGMENT trial are shown on your screen.
This means that many patients were able to complete the recommended dosing schedule with appropriate dose modifications.
Please refer to the Prescribing Information for REVLIMID and rituximab for complete dosing recommendations including instructions for dose reductions and dose interruptions.
You can also refer your patients to the REVLIMID website where they can find resources to help them on their treatment journey.
Here is some Important Safety Information you should keep in mind when caring for patients receiving this treatment. Thanks for watching.
[Non KOL Voiceover talent]
Important Safety Information
WARNING: EMBRYO-FETAL TOXICITY, HEMATOLOGIC TOXICITY, and VENOUS and ARTERIAL THROMBOEMBOLISM
Do not use REVLIMID during pregnancy. Lenalidomide, a thalidomide analogue, caused limb abnormalities in a developmental monkey study. Thalidomide is a known human teratogen that causes severe life-threatening human birth defects. If lenalidomide is used during pregnancy, it may cause birth defects or embryo-fetal death. In females of reproductive potential, obtain 2 negative pregnancy tests before starting REVLIMID treatment. Females of reproductive potential must use 2 forms of contraception or continuously abstain from heterosexual sex during and for 4 weeks after REVLIMID treatment. To avoid embryo-fetal exposure to lenalidomide, REVLIMID is only available through a restricted distribution program, the Lenalidomide REMS program.
Information about the Lenalidomide REMS program is available at www.lenalidomiderems.com or by calling the manufacturer’s toll-free number 1-888-423-5436.
Hematologic Toxicity (Neutropenia and Thrombocytopenia)
REVLIMID can cause significant neutropenia and thrombocytopenia. Eighty percent of patients with del 5q MDS (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 MDS 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.
Venous and Arterial Thromboembolism
REVLIMID has demonstrated a significantly increased risk of deep vein thrombosis (DVT) and pulmonary embolism (PE), as well as risk of myocardial infarction and stroke in patients with MM (multiple myeloma) who were treated with REVLIMID and dexamethasone therapy. Monitor for and advise patients about signs and symptoms of thromboembolism. Advise patients to seek immediate medical care if they develop symptoms such as shortness of breath, chest pain, or arm or leg swelling. Thromboprophylaxis is recommended and the choice of regimen should be based on an assessment of the patient’s underlying risks.
Pregnancy: REVLIMID can cause fetal harm when administered to a pregnant female and is contraindicated in females who are pregnant. If this drug is used during pregnancy or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential risk to the fetus.
Severe Hypersensitivity Reactions: REVLIMID is contraindicated in patients who have demonstrated severe hypersensitivity (e.g., angioedema, Stevens-Johnson syndrome, toxic epidermal necrolysis) to lenalidomide.
WARNINGS AND PRECAUTIONS
Embryo-Fetal Toxicity: See Boxed WARNINGS.
Lenalidomide REMS Program: See Boxed WARNINGS. Prescribers and pharmacies must be certified with the Lenalidomide REMS program by enrolling and complying with the REMS requirements; pharmacies must only dispense to patients who are authorized to receive REVLIMID. Patients must sign a Patient-Physician Agreement Form and comply with REMS requirements; female patients of reproductive potential who are not pregnant must comply with the pregnancy testing and contraception requirements and males must comply with contraception requirements.
Hematologic Toxicity: REVLIMID can cause significant neutropenia and thrombocytopenia. Monitor patients with neutropenia for signs of infection. Advise patients to observe for bleeding or bruising, especially with use of concomitant medications that may increase risk of bleeding. Patients may require a dose interruption and/or dose reduction. FL/MZL: Monitor CBC in patients taking REVLIMID for FL or MZL weekly for the first 3 weeks of Cycle 1 (28 days), every 2 weeks during Cycles 2-4, and then monthly thereafter.
Venous and Arterial Thromboembolism: See Boxed WARNINGS. Venous thromboembolic events (DVT and PE) and arterial thromboses (MI and CVA) are increased in patients treated with REVLIMID. Patients with known risk factors, including prior thrombosis, may be at greater risk and actions should be taken to try to minimize all modifiable factors (e.g., hyperlipidemia, hypertension, smoking). Thromboprophylaxis is recommended and the regimen should be based on the patient’s underlying risks. Erythropoietin-stimulating agents (ESAs) and estrogens may further increase the risk of thrombosis and their use should be based on a benefit-risk decision.
Increased Mortality in Patients With CLL: In a clinical trial in the first-line treatment of patients with CLL, single-agent REVLIMID therapy increased the risk of death as compared to single-agent chlorambucil. Serious adverse cardiovascular reactions, including atrial fibrillation, myocardial infarction, and cardiac failure, occurred more frequently in the REVLIMID arm. REVLIMID is not indicated and not recommended for use in CLL outside of controlled clinical trials.
Second Primary Malignancies (SPM): In clinical trials in patients with MM receiving REVLIMID and in patients with FL or MZL receiving REVLIMID + rituximab therapy, an increase of hematologic plus solid tumor SPM, notably AML, have been observed. In patients with MM, MDS was also observed. Monitor patients for the development of SPM. Take into account both the potential benefit of REVLIMID and risk of SPM when considering treatment.
Increased Mortality With Pembrolizumab: In clinical trials in patients with MM, the addition of pembrolizumab to a thalidomide analogue plus dexamethasone resulted in increased mortality. Treatment of patients with MM with a PD-1 or PD-L1 blocking antibody in combination with a thalidomide analogue plus dexamethasone is not recommended outside of controlled clinical trials.
Hepatotoxicity: Hepatic failure, including fatal cases, has occurred in patients treated with REVLIMID + dexamethasone. Pre-existing viral liver disease, elevated baseline liver enzymes, and concomitant medications may be risk factors. Monitor liver enzymes periodically. Stop REVLIMID upon elevation of liver enzymes. After return to baseline values, treatment at a lower dose may be considered.
Severe Cutaneous Reactions: Severe cutaneous reactions including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS) 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. Consider REVLIMID interruption or discontinuation for Grade 2-3 skin rash. Permanently discontinue REVLIMID for Grade 4 rash, exfoliative or bullous rash, or for other severe cutaneous reactions such as SJS, TEN, or DRESS.
Tumor Lysis Syndrome (TLS): Fatal instances of TLS have been reported during treatment with REVLIMID. The patients at risk of TLS are those with high tumor burden prior to treatment. Closely monitor patients at risk and take appropriate preventive approaches.
Tumor Flare Reaction (TFR): TFR, including fatal reactions, have occurred during investigational use of REVLIMID for CLL and lymphoma. Monitoring and evaluation for TFR is recommended in patients with MCL, FL or MZL. Tumor flare may mimic the progression of disease (PD). In patients with Grade 3 or 4 TFR, it is recommended to withhold treatment with REVLIMID until TFR resolves to ≤Grade 1. REVLIMID may be continued in patients with Grade 1 and 2 TFR without interruption or modification, at the physician’s discretion.
Impaired Stem Cell Mobilization: A decrease in the number of CD34+ cells collected after treatment (>4 cycles) with REVLIMID has been reported. Consider early referral to transplant center to optimize timing of the stem cell collection.
Thyroid Disorders: Both hypothyroidism and hyperthyroidism have been reported. Measure thyroid function before starting REVLIMID treatment and during therapy.
Early Mortality in Patients With MCL: In another MCL study, there was an increase in early deaths (within 20 weeks); 12.9% in the REVLIMID arm versus 7.1% in the control arm. Risk factors for early deaths include high tumor burden, MIPI score at diagnosis, and high WBC at baseline (≥10 x 109/L).
Hypersensitivity: Hypersensitivity, including angioedema, anaphylaxis, and anaphylactic reactions to REVLIMID has been reported. Permanently discontinue REVLIMID for angioedema and anaphylaxis.
Follicular Lymphoma/Marginal Zone Lymphoma
Periodically monitor digoxin plasma levels due to increased Cmax and AUC with concomitant REVLIMID therapy. Patients taking concomitant therapies such as ESAs or estrogen-containing therapies may have an increased risk of thrombosis. It is not known whether there is an interaction between dexamethasone and warfarin. Close monitoring of PT and INR is recommended in patients with MM taking concomitant warfarin.
USE IN SPECIFIC POPULATIONS
Please see full Prescribing Information, including Boxed WARNINGS, for REVLIMID.
Please see the rituximab full Prescribing Information for Important Safety Information at www.rituxan.com.
REVLIMID® and its associated logo are registered trademarks of Celgene Corporation, a Bristol Myers Squibb company.
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