LENALIDOMIDE by Alvogen, Inc. LENALIDOMIDE capsule

LENALIDOMIDE by

Drug Labeling and Warnings

LENALIDOMIDE by is a Prescription medication manufactured, distributed, or labeled by Alvogen, Inc.. Drug facts, warnings, and ingredients follow.

Drug Details [pdf]

  • BOXED WARNING (What is this?)

    WARNING: EMBRYO-FETAL TOXICITY, HEMATOLOGIC TOXICITY, and VENOUS and ARTERIAL THROMBOEMBOLISM

    Embryo-Fetal Toxicity

    Do not use lenalidomide capsules 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 lenalidomide capsules treatment. Females of reproductive potential must use 2 forms of contraception or continuously abstain from heterosexual sex during and for 4 weeks after lenalidomide capsules treatment [see Warnings and Precautions (5.1), Medication Guide (17)]. To avoid embryo-fetal exposure to lenalidomide, lenalidomide capsules are only available through a restricted distribution program, the Lenalidomide REMS program (5.2).

    Information about the Lenalidomide REMS program is available at www.lenalidomiderems.com or by calling the toll-free number 1-888-423-5436.

    Hematologic Toxicity (Neutropenia and Thrombocytopenia)

    Lenalidomide capsules can cause significant neutropenia and thrombocytopenia. Eighty percent of patients with del 5q 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 myelodysplastic syndromes 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[see Dosage and Administration (2.2)].

    Venous and Arterial Thromboembolism

    Lenalidomide capsules have 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 multiple myeloma who were treated with lenalidomide capsules 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[see Warnings and Precautions (5.4)].

  • 1 INDICATIONS AND USAGE

    1.1 Multiple Myeloma

    Lenalidomide capsules in combination with dexamethasone are indicated for the treatment of adult patients with multiple myeloma (MM).

    1.2 Myelodysplastic Syndromes

    Lenalidomide capsules are indicated for the treatment of adult patients with transfusion-dependent anemia due to low- or intermediate-1-risk myelodysplastic syndromes (MDS) associated with a deletion 5q cytogenetic abnormality with or without additional cytogenetic abnormalities.

    1.6 Limitations of Use

    Lenalidomide capsules are not indicated and are not recommended for the treatment of patients with CLL outside of controlled clinical trials [see Warnings and Precautions (5.5)].

  • 2 DOSAGE AND ADMINISTRATION

    2.1 Recommended Dosage for Multiple Myeloma

    Lenalidomide Capsules Combination Therapy

    The recommended starting dose of lenalidomide capsules is 25 mg orally once daily on Days 1 to 21 of repeated 28-day cycles in combination with dexamethasone. Refer to Section 14.1 for specific dexamethasone dosing. For patients greater than 75 years old, the starting dose of dexamethasone may be reduced [see Clinical Studies (14.1)]. Treatment should be continued until disease progression or unacceptable toxicity.

    In patients who are not eligible for auto-HSCT, treatment should continue until disease progression orunacceptable toxicity. For patients who are auto-HSCT-eligible, hematopoietic stem cell mobilization shouldoccur within 4 cycles of a lenalidomide-containing therapy [see Warnings and Precautions (5.12)].

    Dose Adjustments for Hematologic Toxicities During MM Treatment

    Dose modification guidelines, as summarized in Table 1 below, are recommended to manage Grade 3 or 4 neutropenia or thrombocytopenia or other Grade 3 or 4 toxicity judged to be related to lenalidomide capsules.

    Table 1: Dose Adjustments for Hematologic Toxicities for MM

    Platelet counts

    Thrombocytopenia in MM

    When PlateletsRecommended Course

    Days 1 to 21 of repeated 28-day cycle

    Fall below 30,000/mcL Interrupt lenalidomide capsules treatment, follow CBC weekly
    Return to at least 30,000/mcL Resume lenalidomide capsules at next lower dose. Do not dose below 2.5 mg daily
    For each subsequent drop below 30,000/mcL Interrupt lenalidomide capsules treatment
    Return to at least 30,000/mcL Resume lenalidomide capsules at next lower dose. Do not dose below 2.5 mg daily

    Absolute Neutrophil counts (ANC)

    Neutropenia in MM

    When NeutrophilsRecommended Course

    Days 1 to 21 of repeated 28-day cycle

    Fall below 1,000/mcL Interrupt lenalidomide capsules treatment, follow CBC weekly
    Return to at least 1,000/mcL and neutropenia is the only toxicity Resume lenalidomide capsules at 25 mg daily or initial starting dose
    Return to at least 1,000/mcL and if other toxicity Resume lenalidomide capsules at next lower dose. Do not dose below 2.5 mg daily
    For each subsequent drop below 1,000/mcL Interrupt lenalidomide capsules treatment
    Return to at least 1,000/mcL Resume lenalidomide capsules at next lower dose. Do not dose below 2.5 mg daily

    2.2 Recommended Dosage for Myelodysplastic Syndromes

    The recommended starting dose of lenalidomide capsules is 10 mg daily. Treatment is continued or modified based upon clinical and laboratory findings. Continue treatment until disease progression or unacceptable toxicity.

    Dose Adjustments for Hematologic Toxicities During MDS Treatment

    Patients who are dosed initially at 10 mg and who experience thrombocytopenia should have their dosage adjusted as follows:

    Platelet counts

    If thrombocytopenia develops WITHIN 4 weeks of starting treatment at 10 mg daily in MDS

    If baseline is at least 100,000/mcL
    When PlateletsRecommended Course
    Fall below 50,000/mcL Interrupt lenalidomide capsules treatment
    Return to at least 50,000/mcL Resume lenalidomide capsules at 5 mg daily
    If baseline is below 100,000/mcL
    When PlateletsRecommended Course
    Fall to 50% of the baseline value Interrupt lenalidomide capsules treatment
    If baseline is at least 60,000/mcL and returns to at least 50,000/mcL Resume lenalidomide capsules at 5 mg daily
    If baseline is below 60,000/mcL and returns to at least 30,000/mcL Resume lenalidomide capsules at 5 mg daily

    If thrombocytopenia develops AFTER 4 weeks of starting treatment at 10 mg daily in MDS

    When PlateletsRecommended Course
    Fall below 30,000/mcL or below 50,000/mcL with platelet transfusions Interrupt lenalidomide capsules treatment
    Return to at least 30,000/mcL (without hemostatic failure) Resume lenalidomide capsules at 5 mg daily

    Patients who experience thrombocytopenia at 5 mg daily should have their dosage adjusted as follows:

    If thrombocytopenia develops during treatment at 5 mg daily in MDS

    When PlateletsRecommended Course
    Fall below 30,000/mcL or below 50,000/mcL with platelet transfusions Interrupt lenalidomide capsules treatment
    Return to at least 30,000/mcL (without hemostatic failure) Resume lenalidomide capsules at 2.5 mg daily

    Patients who are dosed initially at 10 mg and experience neutropenia should have their dosage adjusted as follows:

    Absolute Neutrophil counts (ANC)

    If neutropenia develops WITHIN 4 weeks of starting treatment at 10 mg daily in MDS

    If baseline ANC is at least 1,000/mcL
    When NeutrophilsRecommended Course
    Fall below 750/mcL Interrupt lenalidomide capsules treatment
    Return to at least 1,000/mcL Resume lenalidomide capsules at 5 mg daily
    If baseline ANC is below 1,000/mcL
    When NeutrophilsRecommended Course
    Fall below 500/mcL Interrupt lenalidomide capsules treatment
    Return to at least 500/mcL Resume lenalidomide capsules at 5 mg daily

    If neutropenia develops AFTER 4 weeks of starting treatment at 10 mg daily in MDS

    When NeutrophilsRecommended Course
    Fall below 500/mcL for at least 7 days or below 500/mcL associated with fever (at least 38.5°C) Interrupt lenalidomide capsules treatment
    Return to at least 500/mcL Resume lenalidomide capsules at 5 mg daily

    Patients who experience neutropenia at 5 mg daily should have their dosage adjusted as follows:

    If neutropenia develops during treatment at 5 mg daily in MDS

    When NeutrophilsRecommended Course
    Fall below 500/mcL for at least 7 days or below 500/mcL associated with fever (at least 38.5°C) Interrupt lenalidomide capsules treatment
    Return to at least 500/mcL Resume lenalidomide capsules at 2.5 mg daily

    2.5 Dosage Modifications for Non-Hematologic Adverse Reactions

    For non-hematologic Grade 3/4 toxicities judged to be related to lenalidomide capsules, hold treatment and restart at the physician's discretion at next lower dose level when toxicity has resolved to Grade 2 or below.

    Permanently discontinue lenalidomide capsules for angioedema, anaphylaxis, Grade 4 rash, skin exfoliation, bullae, or any other severe dermatologic reactions [see Warnings and Precautions (5.9, 5.15)].

    2.6 Recommended Dosage for Patients with Renal Impairment

    The recommendations for dosing patients with renal impairment are shown in the following table [see Clinical Pharmacology (12.3)].

    Table 3: Dose Adjustments for Patients with Renal Impairment
    Renal Function (Cockcroft-Gault)Dose in Lenalidomide Capsules Combination Therapy for MMDose in Lenalidomide Capsules for MDS
    CLcr 30 to 60 mL/min10 mg once daily5 mg once daily
    CLcr below 30 mL/min (not requiring dialysis)15 mg every other day2.5 mg once daily
    CLcr below 30 mL/min (requiring dialysis)5 mg once daily. On dialysis days, administer the dose following dialysis.2.5 mg once daily. On dialysis days, administer the dose following dialysis.

    Lenalidomide Capsules Combination Therapy for MM: For CLcr of 30 to 60 mL/min, consider escalating the dose to 15 mg after 2 cycles if the patient tolerates the 10 mg dose of lenalidomide without dose-limiting toxicity.

    Lenalidomide Capsules for MDS: Base subsequent lenalidomide capsules dose increase or decrease on individual patient treatment tolerance [see Dosage and Administration (2.2)].

    2.7 Administration

    Advise patients to take lenalidomide capsules orally at about the same time each day, either with or without food. Advise patients to swallow lenalidomide capsules whole with water and not to open, break, or chew them.

  • 3 DOSAGE FORMS AND STRENGTHS

    Capsules:

    • 2.5 mg: A dark blue opaque cap/ light orange opaque body, capsule shell size No. 4 imprinted in black ink with “LP” on the cap and “637” on the body and filled with white powder.
    • 5 mg: A green opaque cap/ light caramel opaque body, capsule shell size No. 2 imprinted in black ink with “LP” on the cap and “638” on the body and filled with white powder.
    • 10 mg: A gold opaque cap/ gray opaque body, capsule shell size No. 0 imprinted in black ink with “LP” on the cap and “639” on the body and filled with white powder.
    • 15 mg: A caramel opaque cap/ grey opaque body, capsule shell size No. 2 imprinted in black ink with “LP” on the cap and “640” on the body and filled with white powder.
    • 20 mg: A warm brick red opaque cap/ light gray opaque body, capsule shell size No. 1 imprinted in black ink with “LP” on the cap and “641” on the body and filled with white powder.
    • 25 mg: A white opaque cap/ white opaque body, capsule shell size No. 0 imprinted in black ink with “LP” on the cap and “642” on the body and filled with white powder.
  • 4 CONTRAINDICATIONS

    4.1 Pregnancy

    Lenalidomide can cause fetal harm when administered to a pregnant female. Limb abnormalities were seen in the offspring of monkeys that were dosed with lenalidomide during organogenesis. This effect was seen at all doses tested. Due to the results of this developmental monkey study, and lenalidomide's structural similarities to thalidomide, a known human teratogen, lenalidomide is contraindicated in females who are pregnant [see Boxed Warning]. 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 a fetus [see Warnings and Precautions (5.1, 5.2), Use in Special Populations (8.1, 8.3)].

    4.2 Severe Hypersensitivity Reactions

    Lenalidomide capsules are contraindicated in patients who have demonstrated severe hypersensitivity (e.g., angioedema, Stevens-Johnson syndrome, toxic epidermal necrolysis) to lenalidomide [see Warnings and Precautions (5.9, 5.15)].

  • 5 WARNINGS AND PRECAUTIONS

    5.1 Embryo-Fetal Toxicity

    Lenalidomide capsules are a thalidomide analogue and are contraindicated for use during pregnancy. Thalidomide is a known human teratogen that causes life-threatening human birth defects or embryo-fetal death [see Use in Specific Populations (8.1)]. An embryo-fetal development study in monkeys indicates that lenalidomide produced malformations in the offspring of female monkeys who received the drug during pregnancy, similar to birth defects observed in humans following exposure to thalidomide during pregnancy.

    Lenalidomide capsules are only available through the Lenalidomide REMS program [see Warnings and Precautions (5.2)].

    Females of Reproductive Potential

    Females of reproductive potential must avoid pregnancy for at least 4 weeks before beginning lenalidomide capsules therapy, during therapy, during dose interruptions and for at least 4 weeks after completing therapy.

    Females must commit either to abstain continuously from heterosexual sexual intercourse or to use two methods of reliable birth control, beginning 4 weeks prior to initiating treatment with lenalidomide capsules, during therapy, during dose interruptions and continuing for 4 weeks following discontinuation of lenalidomide capsules therapy.

    Two negative pregnancy tests must be obtained prior to initiating therapy. The first test should be performed within 10 to 14 days and the second test within 24 hours prior to prescribing lenalidomide capsules therapy and then weekly during the first month, then monthly thereafter in females with regular menstrual cycles or every 2 weeks in females with irregular menstrual cycles [see Use in Specific Populations (8.3)].

    Males

    Lenalidomide is present in the semen of patients receiving the drug. Therefore, males must always use a latex or synthetic condom during any sexual contact with females of reproductive potential while taking lenalidomide capsules and for up to 4 weeks after discontinuing lenalidomide capsules, even if they have undergone a successful vasectomy. Male patients taking lenalidomide capsules must not donate sperm and for up to 4 weeks after discontinuing lenalidomide capsules [see Use in Specific Populations (8.3)].

    Blood Donation

    Patients must not donate blood during treatment with lenalidomide capsules and for 4 weeks following discontinuation of the drug because the blood might be given to a pregnant female patient whose fetus must not be exposed to lenalidomide capsules.

    5.2 Lenalidomide REMS Program

    Because of the embryo-fetal risk [see Warnings and Precautions (5.1)], lenalidomide capsules are available only through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS), the Lenalidomide REMS program. 

    Required components of the Lenalidomide REMS program include the following:

    • Prescribers must be certified with the Lenalidomide REMS program by enrolling and complying with the REMS requirements.
    • Patients must sign a Patient-Physician agreement form and comply with the REMS requirements. In particular, female patients of reproductive potential who are not pregnant must comply with the pregnancy testing and contraception requirements [see Use in Specific Populations (8.3)] and males must comply with contraception requirements [see Use in Specific Populations (8.3)].
    • Pharmacies must be certified with the Lenalidomide REMS program, must only dispense to patients who are authorized to receive lenalidomide capsules and comply with REMS requirements.

    Further information about the Lenalidomide REMS program is available at www.lenalidomiderems.com or by telephone at 1-888-423-5436.

    5.3 Hematologic Toxicity

    Lenalidomide capsules 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 medication that may increase risk of bleeding. Patients taking lenalidomide capsules should have their complete blood counts assessed periodically as described below [see Dosage and Administration (2.1, 2.2)].

    Monitor complete blood counts (CBC) in patients taking lenalidomide capsules in combination with dexamethasone for MM every 7 days (weekly) for the first 2 cycles, on Days 1 and 15 of Cycle 3, and every 28 days (4 weeks) thereafter. A dose interruption and/or dose reduction may be required [see Dosage and Administration (2.1)]. In trials for another indication, Grade 3 or 4 neutropenia was reported in up to 59% of lenalidomide-treated patients and Grade 3 or 4 thrombocytopenia in up to 38% of lenalidomide-treated patients.

    Monitor complete blood counts (CBC) in patients taking lenalidomide capsules for MDS weekly for the first 8 weeks and at least monthly thereafter. Grade 3 or 4 hematologic toxicity was seen in 80% of patients enrolled in the MDS study. In the 48% of patients who developed Grade 3 or 4 neutropenia, the median time to onset was 42 days (range, 14 to 411 days), and the median time to documented recovery was 17 days (range, 2 to 170 days). In the 54% of patients who developed Grade 3 or 4 thrombocytopenia, the median time to onset was 28 days (range, 8 to 290 days), and the median time to documented recovery was 22 days (range, 5 to 224 days) [see Boxed Warning and Dosage and Administration (2.2)].

    5.4 Venous and Arterial Thromboembolism

    Venous thromboembolic events (VTE [DVT and PE]) and arterial thromboembolic events (ATE, myocardial infarction and stroke) are increased in patients treated with lenalidomide capsules.

    A significantly increased risk of DVT (7.4%) and of PE (3.7%) occurred in patients with MM after at least one prior therapy who were treated with lenalidomide capsules and dexamethasone therapy compared to patients treated in the placebo and dexamethasone group (3.1% and 0.9%) in clinical trials with varying use of anticoagulant therapies. In the newly diagnosed multiple myeloma (NDMM) study in which nearly all patients received antithrombotic prophylaxis, DVT was reported as a serious adverse reaction (3.6%, 2.0%, and 1.7%) in the Rd Continuous, Rd18, and MPT Arms, respectively. The frequency of serious adverse reactions of PE was similar between the Rd Continuous, Rd18, and MPT Arms (3.8%, 2.8%, and 3.7%, respectively) [see Boxed Warning and Adverse Reactions (6.1)].

    Myocardial infarction (1.7%) and stroke (CVA) (2.3%) are increased in patients with MM after at least one prior therapy who were treated with lenalidomide capsules and dexamethasone therapy compared to patients treated with placebo and dexamethasone (0.6%, and 0.9%) in clinical trials. In the NDMM study, myocardial infarction (including acute) was reported as a serious adverse reaction (2.3%, 0.6%, and 1.1%) in the Rd Continuous, Rd18, and MPT Arms, respectively. The frequency of serious adverse reactions of CVA was similar between the Rd Continuous, Rd18, and MPT Arms (0.8%, 0.6 %, and 0.6%, respectively) [see Adverse Reactions (6.1)].

    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).

    In controlled clinical trials that did not use concomitant thromboprophylaxis, 21.5% overall thrombotic events (Standardized MedDRA Query Embolic and Thrombotic events) occurred in patients with refractory and relapsed MM who were treated with lenalidomide capsules and dexamethasone compared to 8.3% thrombosis in patients treated with placebo and dexamethasone. The median time to first thrombosis event was 2.8 months. In the NDMM study in which nearly all patients received antithrombotic prophylaxis, the overall frequency of thrombotic events was 17.4% in patients in the combined Rd Continuous and Rd18 Arms, and was 11.6% in the MPT Arm. The median time to first thrombosis event was 4.3 months in the combined Rd Continuous and Rd18 Arms.

    Thromboprophylaxis is recommended. The regimen of thromboprophylaxis should be based on an assessment of the patient's underlying risks. Instruct patients to report immediately any signs and symptoms suggestive of thrombotic events. ESAs and estrogens may further increase the risk of thrombosis and their use should be based on a benefit-risk decision in patients receiving lenalidomide capsules [see Drug Interactions (7.2)].

    5.5 Increased Mortality in Patients with CLL

    In a prospective randomized (1:1) clinical trial in the first line treatment of patients with chronic lymphocytic leukemia, single agent lenalidomide capsules therapy increased the risk of death as compared to single agent chlorambucil. In an interim analysis, there were 34 deaths among 210 patients on the lenalidomide capsules treatment arm compared to 18 deaths among 211 patients in the chlorambucil treatment arm, and hazard ratio for overall survival was 1.92 [95% CI: 1.08 - 3.41], consistent with a 92% increase in the risk of death. The trial was halted for safety in July 2013.

    Serious adverse cardiovascular reactions, including atrial fibrillation, myocardial infarction, and cardiac failure occurred more frequently in the lenalidomide capsules treatment arm. Lenalidomide capsules are not indicated and not recommended for use in CLL outside of controlled clinical trials.

    5.6 Second Primary Malignancies

    In clinical trials in patients with MM receiving lenalidomide capsules, an increase of hematologic plus solid tumor second primary malignancies (SPM) notably AML and MDS have been observed. An increase in hematologic SPM including AML and MDS occurred in 5.3% of patients with NDMM receiving lenalidomide in combination with oral melphalan compared with 1.3% of patients receiving melphalan without lenalidomide. The frequency of AML and MDS cases in patients with NDMM treated with lenalidomide in combination with dexamethasone without melphalan was 0.4%.

    In a study for another indication, hematologic SPM occurred in 7.5% of patients compared to 3.3% in patients receiving placebo. The incidence of hematologic plus solid tumor (excluding squamous cell carcinoma and basal cell carcinoma) SPM was 14.9%, compared to 8.8% in patients receiving placebo with a median follow-up of 91.5 months. Non-melanoma skin cancer SPM, including squamous cell carcinoma and basal cell carcinoma, occurred in 3.9% of patients receiving lenalidomide maintenance, compared to 2.6% in the placebo arm.

    In patients with relapsed or refractory MM treated with lenalidomide/dexamethasone, the incidence of hematologic plus solid tumor (excluding squamous cell carcinoma and basal cell carcinoma) SPM was 2.3% versus 0.6% in the dexamethasone alone arm. Non-melanoma skin cancer SPM, including squamous cell carcinoma and basal cell carcinoma, occurred in 3.1% of patients receiving lenalidomide/dexamethasone, compared to 0.6% in the dexamethasone alone arm.

    Patients who received lenalidomide-containing therapy until disease progression did not show a higher incidence of invasive SPM than patients treated in the fixed duration lenalidomide-containing arms. Monitor patients for the development of second primary malignancies. Take into account both the potential benefit of lenalidomide capsules and the risk of second primary malignancies when considering treatment with lenalidomide capsules.

    5.7 Increased Mortality in Patients with MM When Pembrolizumab Is Added to a Thalidomide Analogue and Dexamethasone

    In two randomized clinical trials in patients with MM, the addition of pembrolizumab to a thalidomide analogue plus dexamethasone, a use for which no PD-1 or PD-L1 blocking antibody is indicated, 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.

    5.8 Hepatotoxicity

    Hepatic failure, including fatal cases, has occurred in patients treated with lenalidomide in combination with dexamethasone. In clinical trials, 15% of patients experienced hepatotoxicity (with hepatocellular, cholestatic and mixed characteristics); 2% of patients with MM and 1% of patients with myelodysplasia had serious hepatotoxicity events. The mechanism of drug-induced hepatotoxicity is unknown. Pre-existing viral liver disease, elevated baseline liver enzymes, and concomitant medications may be risk factors. Monitor liver enzymes periodically. Stop lenalidomide capsules upon elevation of liver enzymes. After return to baseline values, treatment at a lower dose may be considered.

    5.9 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. DRESS may present with a cutaneous reaction (such as rash or exfoliative dermatitis), eosinophilia, fever, and/or lymphadenopathy with systemic complications such as hepatitis, nephritis, pneumonitis, myocarditis, and/or pericarditis. These events can be fatal. Patients with a prior history of Grade 4 rash associated with thalidomide treatment should not receive lenalidomide capsules. Consider lenalidomide capsules interruption or discontinuation for Grade 2-3 skin rash. Permanently discontinue lenalidomide capsules for Grade 4 rash, exfoliative or bullous rash, or for other severe cutaneous reactions such as SJS, TEN or DRESS [see Dosage and Administration (2.5)].

    5.10 Tumor Lysis Syndrome

    Fatal instances of tumor lysis syndrome (TLS) have been reported during treatment with lenalidomide. The patients at risk of TLS are those with high tumor burden prior to treatment. Monitor patients at risk closely and take appropriate preventive approaches.

    5.11 Tumor Flare Reaction

    Tumor flare reaction (TFR), including fatal reactions, have occurred during investigational use of lenalidomide for CLL and lymphoma, and is characterized by tender lymph node swelling, low grade fever, pain and rash. Lenalidomide capsules are not indicated and not recommended for use in CLL outside of controlled clinical trials.

    Tumor flare reaction may mimic progression of disease (PD).

    Lenalidomide capsules may be continued in patients with Grade 1 and 2 TFR without interruption or modification, at the physician’s discretion. Patients with Grade 1 and 2 TFR may also be treated with corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDs) and/or narcotic analgesics for management of TFR symptoms. In patients with Grade 3 or 4 TFR, it is recommended to withhold treatment with lenalidomide capsules until TFR resolves to ≤ Grade 1. Patients with Grade 3 or 4 TFR may be treated for management of symptoms per the guidance for treatment of Grade 1 and 2 TFR.

    5.12 Impaired Stem Cell Mobilization

    A decrease in the number of CD34+ cells collected after treatment (> 4 cycles) with lenalidomide capsules has been reported. In patients who are auto-HSCT candidates, referral to a transplant center should occur early in treatment to optimize the timing of the stem cell collection. In patients who received more than 4 cycles of a lenalidomide-containing treatment or for whom inadequate numbers of CD 34+ cells have been collected with G-CSF alone, G-CSF with cyclophosphamide or the combination of G-CSF with a CXCR4 inhibitor may be considered.

    5.13 Thyroid Disorders

    Both hypothyroidism and hyperthyroidism have been reported [see Adverse Reactions (6.2)]. Measure thyroid function before start of lenalidomide capsules treatment and during therapy.

    5.15 Hypersensitivity

    Hypersensitivity, including angioedema, anaphylaxis, and anaphylactic reactions to lenalidomide capsules has been reported. Permanently discontinue lenalidomide capsules for angioedema and anaphylaxis [see Dosage and Administration (2.2)].

    5.16 Risk of Allergic Reactions Due to Tartrazine

    This product contains FD&C Yellow No. 5 (tartrazine) which may cause allergic-type reactions (including bronchial asthma) in certain susceptible persons. Although the overall incidence of FD&C Yellow No. 5 (tartrazine) sensitivity in the general population is low, it is frequently seen in patients who also have aspirin hypersensitivity.

  • 6 ADVERSE REACTIONS

    The following clinically significant adverse reactions are described in detail in other sections of the prescribing information:

    • Embryo-Fetal Toxicity [see Boxed Warning, Warnings and Precautions (5.1, 5.2)]
    • Hematologic Toxicity[see Boxed Warning, Warnings and Precautions (5.3)]
    • Venous and Arterial Thromboembolism [see Boxed Warning, Warnings and Precautions (5.4)]
    • Increased Mortality in Patients with CLL [see Warnings and Precautions (5.5)]
    • Second Primary Malignancies [see Warnings and Precautions (5.6)]
    • Increased Mortality in Patients with MM When Pembrolizumab Is Added to a Thalidomide Analogue and Dexamethasone [see Warnings and Precautions (5.7)]
    • Hepatotoxicity [see Warnings and Precautions (5.8)]
    • Severe Cutaneous Reactions [see Warnings and Precautions (5.9)]
    • Tumor Lysis Syndrome [see Warnings and Precautions (5.10)]
    • Tumor Flare Reactions [see Warnings and Precautions (5.11)]
    • Impaired Stem Cell Mobilization [see Warnings and Precautions (5.12)]
    • Thyroid Disorders [see Warnings and Precautions (5.13)]
    • Hypersensitivity [see Warnings and Precautions (5.15)]

    6.1 Clinical Trials Experience

    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.

    Newly Diagnosed MM – Lenalidomide Capsules Combination Therapy:

    Data were evaluated from 1613 patients in a large phase 3 study who received at least one dose of lenalidomide capsules with low dose dexamethasone (Rd) given for 2 different durations of time (i.e., until progressive disease [Arm Rd Continuous; N=532] or for up to eighteen 28-day cycles [72 weeks, Arm Rd18; N=540] or who received melphalan, prednisone and thalidomide (Arm MPT; N=541) for a maximum of twelve 42-day cycles (72 weeks). The median treatment duration in the Rd Continuous arm was 80.2 weeks (range 0.7 to 246.7) or 18.4 months (range 0.16 to 56.7).

    In general, the most frequently reported adverse reactions were comparable in Arm Rd Continuous and Arm Rd18, and included diarrhea, anemia, constipation, peripheral edema, neutropenia, fatigue, back pain, nausea, asthenia, and insomnia. The most frequently reported Grade 3 or 4 reactions included neutropenia, anemia, thrombocytopenia, pneumonia, asthenia, fatigue, back pain, hypokalemia, rash, cataract, lymphopenia, dyspnea, DVT, hyperglycemia, and leukopenia. The highest frequency of infections occurred in Arm Rd Continuous (75%) compared to Arm MPT (56%). There were more grade 3 and 4 and serious adverse reactions of infection in Arm Rd Continuous than either Arm MPT or Rd18.

    In the Rd Continuous arm, the most common adverse reactions leading to dose interruption of lenalidomide capsules were infection events (28.8%); overall, the median time to the first dose interruption of lenalidomide capsules was 7 weeks. The most common adverse reactions leading to dose reduction of lenalidomide capsules in the Rd Continuous arm were hematologic events (10.7%); overall, the median time to the first dose reduction of lenalidomide capsules was 16 weeks. In the Rd Continuous arm, the most common adverse reactions leading to discontinuation of lenalidomide capsules were infection events (3.4%).

    In both Rd arms, the frequencies of onset of adverse reactions were generally highest in the first 6 months of treatment and then the frequencies decreased over time or remained stable throughout treatment, except for cataracts. The frequency of onset of cataracts increased over time with 0.7% during the first 6 months and up to 9.6% by the 2nd year of treatment with Rd Continuous.

    Table 4 summarizes the adverse reactions reported for the Rd Continuous, Rd18, and MPT treatment arms.

    Table 4: All Adverse Reactions in ≥5% and Grade 3/4 Adverse Reactions in ≥1% of Patients with MM in the Rd Continuous or Rd18 Arms*
    Note: A subject with multiple occurrences of an adverse reaction is counted only once under the applicable Body System/Adverse Reaction.
    a All treatment-emergent adverse events in at least 5% of subjects in the Rd Continuous or Rd18 Arms and at least a 2% higher frequency (%) in either the Rd Continuous or Rd18 Arms compared to the MPT Arm.
    b All grade 3 or 4 treatment-emergent adverse events in at least 1% of subjects in the Rd Continuous or Rd18 Arms and at least a 1% higher frequency (%) in either the Rd Continuous or Rd18 Arms compared to the MPT Arm.
    c Serious treatment-emergent adverse events in at least 1% of subjects in the Rd Continuous or Rd18 Arms and at least a 1% higher frequency (%) in either the Rd Continuous or Rd18 Arms compared to the MPT Arm.
    d Preferred terms for the blood and lymphatic system disorders body system were included by medical judgment as known adverse reactions for Rd Continuous/Rd18, and have also been reported as serious.
    e Footnote “a” not applicable.
    f Footnote “b” not applicable.
    @ - adverse reactions in which at least one resulted in a fatal outcome.
    % - adverse reactions in which at least one was considered to be life threatening (if the outcome of the reaction was death, it is included with death cases).
    *Adverse reactions included in combined adverse reaction terms:
    Abdominal Pain: Abdominal pain, abdominal pain upper, abdominal pain lower, gastrointestinal pain
    Pneumonias: Pneumonia, lobar pneumonia, pneumonia pneumococcal, bronchopneumonia, pneumocystis jiroveci pneumonia, pneumonia legionella, pneumonia staphylococcal, pneumonia klebsiella, atypical pneumonia, pneumonia bacterial, pneumonia escherichia, pneumonia streptococcal, pneumonia viral
    Sepsis: Sepsis, septic shock, urosepsis, escherichia sepsis, neutropenic sepsis, pneumococcal sepsis, staphylococcal sepsis, bacterial sepsis, meningococcal sepsis, enterococcal sepsis, klebsiella sepsis, pseudomonal sepsis
    Rash: Rash, rash pruritic, rash erythematous, rash maculo-papular, rash generalized, rash papular, exfoliative rash, rash follicular, rash macular, drug rash with eosinophilia and systemic symptoms, erythema multiforme, rash pustular
    Deep Vein Thrombosis: Deep vein thrombosis, venous thrombosis limb, venous thrombosis

    Body System
    Adverse Reaction

    All Adverse Reactionsa

    Grade 3/4 Adverse Reactionsb

    Rd Continuous
    (N = 532)

    Rd18
    (N = 540)

    MPT
    (N = 541)

    Rd Continuous
    (N = 532)

    Rd18
    (N = 540)

    MPT
    (N = 541)

    General disorders and administration site conditions

      Fatigue%

    173 (33)

    177 (33)

    154 (28)

    39 (7)

    46 (9)

    31 (6)

      Asthenia

    150 (28)

    123 (23)

    124 (23)

    41 (8)

    33 (6)

    32 (6)

      Pyrexiac

    114 (21)

    102 (19)

    76 (14)

    13 (2)

    7 (1)

    7 (1)

      Non-cardiac chest pain f

    29 (5)

    31 (6)

    18 (3)

    <1%

    < 1%

    < 1%

    Gastrointestinal disorders

      Diarrhea

    242 (45)

    208 (39)

    89 (16)

    21 (4)

    18 (3)

    8 (1)

      Abdominal pain% f

    109 (20)

    78 (14)

    60 (11)

    7 (1)

    9 (2)

    < 1%

      Dyspepsia f

    57 (11)

    28 (5)

    36 (7)

    <1%

    < 1%

    0 (0)

    Musculoskeletal and connective tissue disorders

      Back painc

    170 (32)

    145 (27)

    116 (21)

    37 (7)

    34 (6)

    28 (5)

      Muscle spasms f

    109 (20)

    102 (19)

    61 (11)

    < 1%

    < 1%

    < 1%

      Arthralgia f

    101 (19)

    71 (13)

    66 (12)

    9 (2)

    8 (1)

    8 (1)

      Bone pain f

    87 (16)

    77 (14)

    62 (11)

    16 (3)

    15 (3)

    14 (3)

      Pain in extremity f

    79 (15)

    66 (12)

    61 (11)

    8 (2)

    8 (1)

    7 (1)

      Musculoskeletal pain f

    67 (13)

    59 (11)

    36 (7)

    < 1%

    < 1%

    < 1%

      Musculoskeletal chest pain f

    60 (11)

    51 (9)

    39 (7)

    6 (1)

    < 1%

    < 1%

      Muscular weakness f

    43 (8)

    35 (6)

    29 (5)

    < 1%

    8 (1)

    < 1%

      Neck pain f

    40 (8)

    19 (4)

    10 (2)

    < 1%

    < 1%

    < 1%

    Infections and infestations

      Bronchitisc

    90 (17)

    59 (11)

    43 (8)

    9 (2)

    6 (1)

    < 1%

      Nasopharyngitis f

    80 (15)

    54 (10)

    33 (6)

    0 (0)

    0 (0)

    0 (0)

      Urinary tract infection f

    76 (14)

    63 (12)

    41 (8)

    8 (2)

    8 (1)

    < 1%

      Upper respiratory tract infectionc% f

    69 (13)

    53 (10)

    31 (6)

    < 1%

    8 (1)

    < 1%

      Pneumoniac@

    93 (17)

    87 (16)

    56 (10)

    60 (11)

    57 (11)

    41 (8)

      Respiratory tract infection%

    35 (7)

    25 (5)

    21 (4)

    7 (1)

    < 1%

    < 1%

      Influenza f

    33 (6)

    23 (4)

    15 (3)

    < 1%

    < 1%

    0 (0)

      Gastroenteritis f

    32 (6)

    17 (3)

    13 (2)

    0 (0)

    < 1%

    < 1%

      Lower respiratory tract infection

    29 (5)

    14 (3)

    16 (3)

    10 (2)

    < 1%

    < 1%

      Rhinitis f

    29 (5)

    24 (4)

    14 (3)

    0 (0)

    0 (0)

    0 (0)

      Cellulitisc

    < 5%

    < 5%

    < 5%

    8 (2)

    < 1%

    < 1%

      Sepsisc@

    33 (6)

    26 (5)

    18 (3)

    26 (5)

    20 (4)

    13 (2)

    Nervous system disorders

      Headache f

    75 (14)

    52 (10)

    56 (10)

    < 1%

    < 1%

    < 1%

      Dysgeusia f

    39 (7)

    45 (8)

    22 (4)

    < 1%

    0 (0.0)

    < 1%

    Blood and lymphatic system disordersd

      Anemia

    233 (44)

    193 (36)

    229 (42)

    97 (18)

    85 (16)

    102 (19)

      Neutropenia

    186 (35)

    178 (33)

    328 (61)

    148 (28)

    143 (26)

    243 (45)

      Thrombocytopenia

    104 (20)

    100 (19)

    135 (25)

    44 (8)

    43 (8)

    60 (11)

      Febrile neutropenia

    7 (1)

    17 (3)

    15 (3)

    6 (1)

    16 (3)

    14 (3)

      Pancytopenia

    < 1%

    6 (1)

    7 (1)

    < 1%

    < 1%

    < 1%

    Respiratory, thoracic and mediastinal disorders

      Cough f

    121 (23)

    94 (17)

    68 (13)

    < 1%

    < 1%

    < 1%

      Dyspneac,e

    117 (22)

    89 (16)

    113 (21)

    30 (6)

    22 (4)

    18 (3)

      Epistaxis f

    32 (6)

    31 (6)

    17 (3)

    < 1%

    < 1%

    0 (0)

      Oropharyngeal pain f

    30 (6)

    22 (4)

    14 (3)

    0 (0)

    0 (0)

    0 (0)

      Dyspnea exertional e

    27 (5)

    29 (5)

    < 5%

    6 (1)

    < 1%

    0 (0)

    Metabolism and nutrition disorders

      Decreased appetite

    123 (23)

    115 (21)

    72 (13)

    14 (3)

    7 (1)

    < 1%

      Hypokalemia%

    91 (17)

    62 (11)

    38 (7)

    35 (7)

    20 (4)

    11 (2)

      Hyperglycemia

    62 (12)

    52 (10)

    19 (4)

    28 (5)

    23 (4)

    9 (2)

      Hypocalcemia

    57 (11)

    56 (10)

    31 (6)

    23 (4)

    19 (4)

    8 (1)

      Dehydration%

    25 (5)

    29 (5)

    17 (3)

    8 (2)

    13 (2)

    9 (2)

      Gout e

    < 5%

    < 5%

    < 5%

    8 (2)

    0 (0)

    0 (0)

      Diabetes mellitus% e

    < 5%

    < 5%

    < 5%

    8 (2)

    < 1%

    < 1%

      Hypophosphatemia e

    < 5%

    < 5%

    < 5%

    7 (1)

    < 1%

    < 1%

      Hyponatremia% e

    < 5%

    < 5%

    < 5%

    7 (1)

    13 (2)

    6 (1)

    Skin and subcutaneous tissue disorders

      Rash

    139 (26)

    151 (28)

    105 (19)

    39 (7)

    38 (7)

    33 (6)

      Pruritus f

    47 (9)

    49 (9)

    24 (4)

    < 1%

    < 1%

    < 1%

    Psychiatric disorders

      Insomnia

    147 (28)

    127 (24)

    53 (10)

    < 1%

    6 (1)

    0 (0)

      Depression

    58 (11)

    46 (9)

    30 (6)

    10 (2)

    < 1%

    < 1%

    Vascular disorders

      Deep vein thrombosisc% 

    55 (10)

    39 (7)

    22 (4)

    30 (6)

    20 (4)

    15 (3)

      Hypotensionc% 

    51 (10)

    35 (6)

    36 (7)

    11 (2)

    8 (1)

    6 (1)

    Injury, Poisoning, and Procedural Complications

      Fall f

    43 (8)

    25 (5)

    25 (5)

    < 1%

    6 (1)

    6 (1)

      Contusion f

    33 (6)

    24 (4)

    15 (3)

    < 1%

    < 1%

    0 (0)

    Eye disorders

      Cataract

    73 (14)

    31 ( 6)

    < 1%

    31 ( 6)

    14 ( 3)

    < 1%

      Cataract subcapsular e

    < 5%

    < 5%

    < 5%

    7 ( 1)

    0 ( 0)

    0 ( 0)

    Investigations

      Weight decreased

    72 (14)

    78 (14)

    48 (9)

    11 (2)

    < 1%

    < 1%

    Cardiac disorders

      Atrial fibrillationc

    37 (7)

    25 (5)

    25 (5)

    13 (2)

    9 (2)

    6 (1)

      Myocardial infarction (including acute)c ,e

    < 5%

    < 5%

    < 5%

    10 (2)

    < 1%

    < 1%

    Renal and Urinary disorders

      Renal failure (including acute)c@,f

    49 (9)

    54 (10)

    37 (7)

    28 (5)

    33 (6)

    29 (5)

    Neoplasms benign, malignant and unspecified (Including cysts and polyps)

      Squamous cell carcinomac e

    < 5%

    < 5%

    < 5%

    8 (2)

    < 1%

    0 (0)

      Basal cell carcinomac e,f

    < 5%

    < 5%

    < 5%

    < 1%

    < 1%

    0 (0)

    After At Least One Prior Therapy for MM:

    Data were evaluated from 703 patients in two studies who received at least one dose of lenalidomide/ dexamethasone (353 patients) or placebo/dexamethasone (350 patients).

    In the lenalidomide/dexamethasone treatment group, 269 patients (76%) had at least one dose interruption with or without a dose reduction of lenalidomide compared to 199 patients (57%) in the placebo/dexamethasone treatment group. Of these patients who had one dose interruption with or without a dose reduction, 50% in the lenalidomide/dexamethasone treatment group had at least one additional dose interruption with or without a dose reduction compared to 21% in the placebo/dexamethasone treatment group. Most adverse reactions and Grade 3/4 adverse reactions were more frequent in patients who received the combination of lenalidomide/dexamethasone compared to placebo/dexamethasone.

    Tables 6, 7, and 8 summarize the adverse reactions reported for lenalidomide/dexamethasone and placebo/dexamethasone groups.

    Table 6: Adverse Reactions Reported in ≥5% of Patients and with a ≥2% Difference in Proportion of Patients with MM between the Lenalidomide/dexamethasone and Placebo/dexamethasone Groups
    Body System
    Adverse Reaction    		Lenalidomide/Dex
    (N=353)
    n (%)    		Placebo/Dex
    (N=350)
    n (%)
    Blood and lymphatic system disorders
    Neutropenia *149 (42)22 (6)
    Anemia †111 (31)83 (24)
    Thrombocytopenia †76 (22)37 (11)
    Leukopenia 28 (8)4 (1)
    Lymphopenia19 (5)5 (1)
    General disorders and administration site conditions
    Fatigue155 (44)146 (42)
    Pyrexia97 (27)82 (23)
    Peripheral edema93 (26)74 (21)
    Chest pain29 (8)20 (6)
    Lethargy24 (7)8 (2)
    Gastrointestinal disorders
    Constipation143 (41)74 (21)
    Diarrhea †136 (39)96 (27)
    Nausea †92 (26)75 (21)
    Vomiting †43 (12)33 (9)
    Abdominal pain †35 (10)22 (6)
    Dry mouth25 (7)13 (4)
    Musculoskeletal and connective tissue disorders
    Muscle cramp118 (33)74 (21)
    Back pain91 (26)65 (19)
    Bone pain48 (14)39 (11)
    Pain in limb42 (12)32 (9)
    Nervous system disorders
    Dizziness82 (23)59 (17)
    Tremor75 (21)26 (7)
    Dysgeusia54 (15)34 (10)
    Hypoesthesia36 (10)25 (7)
    Neuropathya23 (7)13 (4)
    Respiratory, thoracic and mediastinal disorders
    Dyspnea83 (24)60 (17)
    Nasopharyngitis62 (18)31 (9)
    Pharyngitis48 (14)33 (9)
    Bronchitis 40 (11)30 (9)
    Infectionsb and infestations
    Upper respiratory tract infection 87 (25)55 (16)
    Pneumonia †48 (14)29 (8)
    Urinary tract infection30 (8)19 (5)
    Sinusitis26 (7)16 (5)
    Skin and subcutaneous system disorders
    Rashc75 (21)33 (9)
    Sweating increased35 (10)25 (7)
    Dry skin33 (9)14 (4)
    Pruritus27 (8)18 (5)
    Metabolism and nutrition disorders
    Anorexia55 (16)34 (10)
    Hypokalemia48 (14)21 (6)
    Hypocalcemia31 (9)10 (3)
    Appetite decreased 24 (7)14 (4)
    Dehydration23 (7)15 (4)
    Hypomagnesemia24 (7)10 (3)
    Investigations
    Weight decreased69 (20)52 (15)
    Eye disorders
    Blurred vision61 (17)40 (11)
    Vascular disorders
    Deep vein thrombosis *33 (9)15 (4)
    Hypertension28 (8)20 (6)
    Hypotension25 (7)15 (4)
    Table 7: Grade 3/4 Adverse Reactions Reported in ≥2% Patients and with a ≥1% Difference in Proportion of Patients with MM between the Lenalidomide/dexamethasone and Placebo/dexamethasone groups
    Body System
    Adverse Reaction    		Lenalidomide/Dex
    (N=353)
    n (%)    		Placebo/Dex
    (N=350)
    n (%)
    Blood and lymphatic system disorders
    Neutropenia *118 (33)12 (3)
    Thrombocytopenia †43 (12)22 (6)
    Anemia †35 (10)20 (6)
    Leukopenia14 (4)< 1%
    Lymphopenia10 (3)4 (1)
    Febrile neutropenia *8 (2)0 (0)
    General disorders and administration site conditions
    Fatigue23 (7)17 (5)
    Vascular disorders
    Deep vein thrombosis *29 (8)12 (3)
    Infections and infestations
    Pneumonia †30 (8)19 (5)
    Urinary tract infection 5 (1)< 1%
    Metabolism and nutrition disorders
    Hypokalemia17 (5)5 (1)
    Hypocalcemia13 (4)6 (2)
    Hypophosphatemia9 (3)0 (0)
    Respiratory, thoracic and mediastinal disorders
    Pulmonary embolism †14 (4)< 1%
    Respiratory distress †4 (1)0 (0)
    Musculoskeletal and connective tissue disorders
    Muscle weakness 20 (6)10 (3)
    Gastrointestinal disorders
    Diarrhea †11 (3)4 (1)
    Constipation7 (2)< 1%
    Nausea †6 (2)< 1%
    Cardiac disorders
    Atrial fibrillation †13 (4)4 (1)
    Tachycardia 6 (2)< 1%
    Cardiac failure congestive †5 (1)< 1%
    Nervous system disorders
    Syncope10 (3)< 1%
    Dizziness7 (2)< 1%
    Eye disorders
    Cataract6 (2)< 1%
    Cataract unilateral5 (1)0 (0)
    Psychiatric disorder
    Depression10 (3)6 (2)
    Table 8: Serious Adverse Reactions Reported in ≥1% Patients and with a ≥1% Difference in Proportion of Patients with MM between the Lenalidomide/dexamethasone and Placebo/dexamethasone Groups
    Body System
    Adverse Reaction    		Lenalidomide/Dex
    (N=353)
    n (%)    		Placebo/Dex
    (N=350)
    n (%)
    For Tables 6, 7 and 8 above:
  • * adverse reactions in which at least one was considered to be life threatening (if the outcome of the reaction was death, it is included with death cases).
  • † adverse reactions in which at least one resulted in a fatal outcome.
    		•
    Blood and lymphatic system disorders
    Febrile neutropenia*6 (2)0 (0)
    Vascular disorders
    Deep vein thrombosis *26 (7)11 (3)
    Infections and infestations
    Pneumonia†33 (9)21 (6)
    Respiratory, thoracic, and mediastinal disorders
    Pulmonary embolism †13 (4)< 1%
    Cardiac disorders
    Atrial fibrillation †11 (3)< 1%
    Cardiac failure congestive †5 (1)0 (0)
    Nervous system disorders
    Cerebrovascular accident †7 (2)< 1%
    Gastrointestinal disorders
    Diarrhea †6 (2)< 1%
    Musculoskeletal and connective tissue disorders
    Bone pain4 (1)0 (0)

    Median duration of exposure among patients treated with lenalidomide/dexamethasone was 44 weeks while median duration of exposure among patients treated with placebo/dexamethasone was 23 weeks. This should be taken into consideration when comparing frequency of adverse reactions between two treatment groups lenalidomide/dexamethasone vs. placebo/dexamethasone.

    Venous and Arterial Thromboembolism [see Boxed Warning, Warnings and Precautions (5.4)]

    VTE and ATE are increased in patients treated with lenalidomide capsules.

    Deep vein thrombosis (DVT) was reported as a serious (7.4%) or severe (8.2%) adverse drug reaction at a higher rate in the lenalidomide/dexamethasone group compared to 3.1% and 3.4% in the placebo/dexamethasone group, respectively in the 2 studies in patients with at least 1 prior therapy with discontinuations due to DVT adverse reactions reported at comparable rates between groups. In the NDMM study, DVT was reported as an adverse reaction (all grades: 10.3%, 7.2%, 4.1%), as a serious adverse reaction (3.6%, 2.0%, 1.7%), and as a Grade 3/4 adverse reaction (5.6%, 3.7%, 2.8%) in the Rd Continuous, Rd18, and MPT Arms, respectively. Discontinuations and dose reductions due to DVT adverse reactions were reported at comparable rates between the Rd Continuous and Rd18 Arms (both <1%). Interruption of lenalidomide capsules treatment due to DVT adverse reactions was reported at comparable rates between the Rd Continuous (2.3%) and Rd18 (1.5%) arms. Pulmonary embolism (PE) was reported as a serious adverse drug reaction (3.7%) or Grade 3/4 (4.0%) at a higher rate in the lenalidomide/dexamethasone group compared to 0.9% (serious or grade 3/4) in the placebo/dexamethasone group in the 2 studies in patients with, at least 1 prior therapy, with discontinuations due to PE adverse reactions reported at comparable rates between groups. In the NDMM study, the frequency of adverse reactions of PE was similar between the Rd Continuous, Rd18, and MPT Arms for adverse reactions (all grades: 3.9%, 3.3%, and 4.3%, respectively), serious adverse reactions (3.8%, 2.8%, and 3.7%, respectively), and grade 3/4 adverse reactions (3.8%, 3.0%, and 3.7%, respectively).

    Myocardial infarction was reported as a serious (1.7%) or severe (1.7%) adverse drug reaction at a higher rate in the lenalidomide/dexamethasone group compared to 0.6% and 0.6% respectively in the placebo/dexamethasone group. Discontinuation due to MI (including acute) adverse reactions was 0.8% in lenalidomide/dexamethasone group and none in the placebo/dexamethasone group. In the NDMM study, myocardial infarction (including acute) was reported as an adverse reaction (all grades: 2.4%, 0.6%, and 1.1%), as a serious adverse reaction, (2.3%, 0.6%, and 1.1%), or as a severe adverse reaction (1.9%, 0.6%, and 0.9%) in the Rd Continuous, Rd18, and MPT Arms, respectively.

    Stroke (CVA) was reported as a serious (2.3%) or severe (2.0%) adverse drug reaction in the lenalidomide/dexamethasone group compared to 0.9% and 0.9% respectively in the placebo/dexamethasone group. Discontinuation due to stroke (CVA) was 1.4% in lenalidomide/dexamethasone group and 0.3% in the placebo/dexamethasone group. In the NDMM study, CVA was reported as an adverse reaction (all grades: 0.8%, 0.6%, and 0.6%), as a serious adverse reaction (0.8%, 0.6%, and 0.6%), or as a severe adverse reaction (0.6%, 0.6%, 0.2%) in the Rd Continuous, Rd18, and MPT arms respectively.

    Other Adverse Reactions: After At Least One Prior Therapy for MM

    In these 2 studies, the following adverse drug reactions (ADRs) not described above that occurred at ≥1% rate and of at least twice of the placebo percentage rate were reported:

    Blood and lymphatic system disorders: pancytopenia, autoimmune hemolytic anemia

    Cardiac disorders: bradycardia, myocardial infarction, angina pectoris

    Endocrine disorders: hirsutism

    Eye disorders: blindness, ocular hypertension

    Gastrointestinal disorders: gastrointestinal hemorrhage, glossodynia

    General disorders and administration site conditions: malaise

    Investigations: liver function tests abnormal, alanine aminotransferase increased

    Nervous system disorders: cerebral ischemia

    Psychiatric disorders: mood swings, hallucination, loss of libido

    Reproductive system and breast disorders: erectile dysfunction

    Respiratory, thoracic and mediastinal disorders: cough, hoarseness

    Skin and subcutaneous tissue disorders: exanthem, skin hyperpigmentation

    Myelodysplastic Syndromes:

    A total of 148 patients received at least 1 dose of 10 mg lenalidomide capsules in the del 5q MDS clinical study. At least one adverse reaction was reported in all of the 148 patients who were treated with the 10 mg starting dose of lenalidomide capsules. The most frequently reported adverse reactions were related to blood and lymphatic system disorders, skin and subcutaneous tissue disorders, gastrointestinal disorders, and general disorders and administrative site conditions.

    Thrombocytopenia (61.5%; 91/148) and neutropenia (58.8%; 87/148) were the most frequently reported adverse reactions. The next most common adverse reactions observed were diarrhea (48.6%; 72/148), pruritus (41.9%; 62/148), rash (35.8%; 53/148) and fatigue (31.1%; 46/148). Table 9 summarizes the adverse reactions that were reported in ≥ 5% of the lenalidomide capsules treated patients in the del 5q MDS clinical study. Table 10 summarizes the most frequently observed Grade 3 and Grade 4 adverse reactions regardless of relationship to treatment with lenalidomide capsules. In the single-arm studies conducted, it is often not possible to distinguish adverse reactions that are drug-related and those that reflect the patient’s underlying disease.

    Table 9: Summary of Adverse Reactions Reported in ≥5% of the Lenalidomide Capsules Treated Patients in del 5q MDS Clinical Study
    Body System
    Adverse Reaction *    		10 mg Overall
    (N=148)
  • * Body System and adverse reactions are coded using the MedDRA dictionary. Body System and adverse reactions are listed in descending order of frequency for the Overall column. A patient with multiple occurrences of an adverse reaction is counted only once under the applicable Body System/Adverse Reaction.
    		•
    Patients with at least one adverse reaction148 (100)
    Blood and Lymphatic System Disorders
      Thrombocytopenia91 (61)
      Neutropenia87 (59)
      Anemia17 (11)
      Leukopenia12 (8)
      Febrile Neutropenia8 (5)
    Skin and Subcutaneous Tissue Disorders
      Pruritus62 (42)
      Rash 53 (36)
      Dry Skin21 (14)
      Contusion12 (8)
      Night Sweats12 (8)
      Sweating Increased10 (7)
      Ecchymosis8 (5)
      Erythema8 (5)
    Gastrointestinal Disorders
      Diarrhea 72 (49)
      Constipation 35 (24)
      Nausea 35 (24)
      Abdominal Pain 18 (12)
      Vomiting 15 (10)
      Abdominal Pain Upper 12 (8)
      Dry Mouth 10 (7)
      Loose Stools 9 (6)
    Respiratory, Thoracic and Mediastinal Disorders
      Nasopharyngitis34 (23)
      Cough29 (20)
      Dyspnea25 (17)
      Pharyngitis23 (16)
      Epistaxis22 (15)
      Dyspnea Exertional10 (7)
      Rhinitis10 (7)
      Bronchitis9 (6)
    General Disorders and Administration Site Conditions
      Fatigue 46 (31)
      Pyrexia 31 (21)
      Edema Peripheral 30 (20)
      Asthenia 22 (15)
      Edema 15 (10)
      Pain 10 (7)
      Rigors 9 (6)
      Chest Pain 8 (5)
    Musculoskeletal and Connective Tissue Disorders
      Arthralgia 32 (22)
      Back Pain 31 (21)
      Muscle Cramp 27 (18)
      Pain in Limb 16 (11)
      Myalgia 13 (9)
      Peripheral Swelling 12 (8)
    Nervous System Disorders
      Dizziness 29 (20)
      Headache 29 (20)
      Hypoesthesia 10 (7)
      Dysgeusia 9 (6)
      Peripheral Neuropathy 8 (5)
    Infections and Infestations
      Upper Respiratory Tract Infection22 (15)
      Pneumonia17 (11)
      Urinary Tract Infection16 (11)
      Sinusitis12 (8)
      Cellulitis8 (5)
    Metabolism and Nutrition Disorders
      Hypokalemia16 (11)
      Anorexia15 (10)
      Hypomagnesemia9 (6)
    Investigations
      Alanine Aminotransferase Increased12 (8)
    Psychiatric Disorders
      Insomnia15 (10)
      Depression8 (5)
    Renal and Urinary Disorders
      Dysuria10 (7)
    Vascular Disorders
      Hypertension9 (6)
    Endocrine Disorders
      Acquired Hypothyroidism10 (7)
    Cardiac Disorders
      Palpitations8 (5)
    Table 10: Most Frequently Observed Grade 3 and 4 Adverse Reactions * Regardless of Relationship to Study Drug Treatment in the del 5q MDS Clinical Study
    Adverse Reactions †10 mg
    (N=148)
  • * Adverse reactions with frequency ≥1% in the 10 mg Overall group. Grade 3 and 4 are based on National Cancer Institute Common Toxicity Criteria version 2.
  • † Adverse reactions are coded using the MedDRA dictionary. A patient with multiple occurrences of an adverse reaction is counted only once in the adverse reaction category.
    		•
    Patients with at least one Grade 3/4 AE131 (89)
      Neutropenia79 (53)
      Thrombocytopenia74 (50)
      Pneumonia11 (7)
      Rash10 (7)
      Anemia9 (6)
      Leukopenia8 (5)
      Fatigue7 (5)
      Dyspnea7 (5)
      Back Pain7 (5)
      Febrile Neutropenia6 (4)
      Nausea6 (4)
      Diarrhea5 (3)
      Pyrexia5 (3)
      Sepsis4 (3)
      Dizziness4 (3)
      Granulocytopenia3 (2)
      Chest Pain3 (2)
      Pulmonary Embolism3 (2)
      Respiratory Distress3 (2)
      Pruritus3 (2)
      Pancytopenia3 (2)
      Muscle Cramp3 (2)
      Respiratory Tract Infection2 (1)
      Upper Respiratory Tract Infection2 (1)
      Asthenia2 (1)
      Multi-organ Failure2 (1)
      Epistaxis2 (1)
      Hypoxia2 (1)
      Pleural Effusion2 (1)
      Pneumonitis2 (1)
      Pulmonary Hypertension2 (1)
      Vomiting2 (1)
      Sweating Increased2 (1)
      Arthralgia2 (1)
      Pain in Limb2 (1)
      Headache2 (1)
      Syncope2 (1)

    In other clinical studies of lenalidomide capsules in MDS patients, the following serious adverse reactions (regardless of relationship to study drug treatment) not described in Table 9 or 10 were reported:

    Blood and lymphatic system disorders: warm type hemolytic anemia, splenic infarction, bone marrow depression, coagulopathy, hemolysis, hemolytic anemia, refractory anemia

    Cardiac disorders: cardiac failure congestive, atrial fibrillation, angina pectoris, cardiac arrest, cardiac failure, cardio-respiratory arrest, cardiomyopathy, myocardial infarction, myocardial ischemia, atrial fibrillation aggravated, bradycardia, cardiogenic shock, pulmonary edema, supraventricular arrhythmia, tachyarrhythmia, ventricular dysfunction

    Ear and labyrinth disorders: vertigo

    Endocrine disorders: Basedow's disease

    Gastrointestinal disorders: gastrointestinal hemorrhage, colitis ischemic, intestinal perforation, rectal hemorrhage, colonic polyp, diverticulitis, dysphagia, gastritis, gastroenteritis, gastroesophageal reflux disease, obstructive inguinal hernia, irritable bowel syndrome, melena, pancreatitis due to biliary obstruction, pancreatitis, perirectal abscess, small intestinal obstruction, upper gastrointestinal hemorrhage

    General disorders and administration site conditions: disease progression, fall, gait abnormal, intermittent pyrexia, nodule, rigors, sudden death

    Hepatobiliary disorders: hyperbilirubinemia, cholecystitis, acute cholecystitis, hepatic failure

    Immune system disorders: hypersensitivity

    Infections and infestations: infection bacteremia, central line infection, clostridial infection, ear infection, Enterobacter sepsis, fungal infection, herpes viral infection NOS, influenza, kidney infection, Klebsiella sepsis, lobar pneumonia, localized infection, oral infection, Pseudomonas infection, septic shock, sinusitis acute, sinusitis, Staphylococcal infection, urosepsis

    Injury, poisoning and procedural complications: femur fracture, transfusion reaction, cervical vertebral fracture, femoral neck fracture, fractured pelvis, hip fracture, overdose, post procedural hemorrhage, rib fracture, road traffic accident, spinal compression fracture

    Investigations: blood creatinine increased, hemoglobin decreased, liver function tests abnormal, troponin I increased

    Metabolism and nutrition disorders: dehydration, gout, hypernatremia, hypoglycemia

    Musculoskeletal and connective tissue disorders: arthritis, arthritis aggravated, gouty arthritis, neck pain, chondrocalcinosis pyrophosphate

    Neoplasms benign, malignant and unspecified: acute leukemia, acute myeloid leukemia, bronchoalveolar carcinoma, lung cancer metastatic, lymphoma, prostate cancer metastatic

    Nervous system disorders: cerebrovascular accident, aphasia, cerebellar infarction, cerebral infarction, depressed level of consciousness, dysarthria, migraine, spinal cord compression, subarachnoid hemorrhage, transient ischemic attack

    Psychiatric disorders: confusional state

    Renal and urinary disorders: renal failure, hematuria, renal failure acute, azotemia, calculus ureteric, renal mass

    Reproductive system and breast disorders: pelvic pain

    Respiratory, thoracic and mediastinal disorders: bronchitis, chronic obstructive airways disease exacerbated, respiratory failure, dyspnea exacerbated, interstitial lung disease, lung infiltration, wheezing

    Skin and subcutaneous tissue disorders: acute febrile neutrophilic dermatosis

    Vascular system disorders: deep vein thrombosis, hypotension, aortic disorder, ischemia, thrombophlebitis superficial, thrombosis

    6.2 Postmarketing Experience

    The following adverse drug reactions have been identified from the worldwide post-marketing experience with lenalidomide capsules. 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 [see Warnings and Precautions Section (5.8 to 5.11, and 5.13)].

    Endocrine disorders: Hypothyroidism, hyperthyroidism

    Hepatobiliary disorders: Hepatic failure (including fatality), toxic hepatitis, cytolytic hepatitis, cholestatic hepatitis, mixed cytolytic/cholestatic hepatitis, transient abnormal liver laboratory tests

    Immune system disorders: Angioedema, anaphylaxis, acute graft-versus-host disease (following allogeneic hematopoietic transplant), solid organ transplant rejection

    Infections and infestations: Viral reactivation (such as hepatitis B virus and herpes zoster), progressive multifocal leukoencephalopathy (PML)

    Neoplasms benign, malignant and unspecified (including cysts and polyps): Tumor lysis syndrome, tumor flare reaction

    Respiratory, thoracic and mediastinal disorders: Pneumonitis

    Skin and subcutaneous tissue disorders: Stevens-Johnson Syndrome, toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms (DRESS)

  • 7 DRUG INTERACTIONS

    7.1 Digoxin

    When digoxin was co-administered with multiple doses of lenalidomide capsules (10 mg/day) the digoxin Cmax and AUCinf were increased by 14%. Periodically monitor digoxin plasma levels, in accordance with clinical judgment and based on standard clinical practice in patients receiving this medication, during administration of lenalidomide capsules.

    7.2 Concomitant Therapies That May Increase the Risk of Thrombosis

    Erythropoietic agents, or other agents that may increase the risk of thrombosis, such as estrogen containing therapies, should be used with caution after making a benefit-risk assessment in patients receiving lenalidomide capsules [see Warnings and Precautions (5.4)].

    7.3 Warfarin

    Co-administration of multiple doses of lenalidomide capsules (10 mg/day) with a single dose of warfarin (25 mg) had no effect on the pharmacokinetics of lenalidomide or R- and S-warfarin. Expected changes in laboratory assessments of PT and INR were observed after warfarin administration, but these changes were not affected by concomitant lenalidomide capsules administration. 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.

  • 8 USE IN SPECIFIC POPULATIONS

    8.1 Pregnancy

    Pregnancy Exposure Registry

    There is a pregnancy exposure registry that monitors pregnancy outcomes in females exposed to lenalidomide capsules during pregnancy as well as female partners of male patients who are exposed to lenalidomide capsules. This registry is also used to understand the root cause for the pregnancy. Report any suspected fetal exposure to lenalidomide capsules to the FDA via the MedWatch program at 1-800-FDA-1088 and also to the REMS Call Center at 1-888-423-5436.

    Risk Summary

    Based on the mechanism of action [see Clinical Pharmacology (12.1)] and findings from animal studies [see Data], Lenalidomide capsules can cause embryo-fetal harm when administered to a pregnant female and is contraindicated during pregnancy [see Boxed Warning, Contraindications (4.1), Use in Specific Populations (5.1)].

    Lenalidomide capsules is a thalidomide analogue. Thalidomide is a human teratogen, inducing a high frequency of severe and life-threatening birth defects such as amelia (absence of limbs), phocomelia (short limbs), hypoplasticity of the bones, absence of bones, external ear abnormalities (including anotia, micropinna, small or absent external auditory canals), facial palsy, eye abnormalities (anophthalmos, microphthalmos), and congenital heart defects. Alimentary tract, urinary tract, and genital malformations have also been documented and mortality at or shortly after birth has been reported in about 40% of infants.

    Lenalidomide caused thalidomide-type limb defects in monkey offspring. Lenalidomide crossed the placenta after administration to pregnant rabbits and pregnant rats [see Data]. 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 a fetus.

    If pregnancy does occur during treatment, immediately discontinue the drug. Under these conditions, refer patient to an obstetrician/gynecologist experienced in reproductive toxicity for further evaluation and counseling. Report any suspected fetal exposure to lenalidomide capsules to the FDA via the MedWatch program at 1-800-FDA-1088 and also to the REMS Call Center at 1-888-423-5436.

    The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. The estimated background risk in the U.S. general population of major birth defects is 2% to 4% and of miscarriage is 15% to 20% of clinically recognized pregnancies.

    Data

    Animal data

    In an embryo-fetal developmental toxicity study in monkeys, teratogenicity, including thalidomide-like limb defects, occurred in offspring when pregnant monkeys received oral lenalidomide during organogenesis. Exposure (AUC) in monkeys at the lowest dose was 0.17 times the human exposure at the maximum recommended human dose (MRHD) of 25 mg. Similar studies in pregnant rabbits and rats at 20 times and 200 times the MRHD respectively, produced embryo lethality in rabbits and no adverse reproductive effects in rats.

    In a pre- and post-natal development study in rats, animals received lenalidomide from organogenesis through lactation. The study revealed a few adverse effects on the offspring of female rats treated with lenalidomide at doses up to 500 mg/kg (approximately 200 times the human dose of 25 mg based on body surface area). The male offspring exhibited slightly delayed sexual maturation and the female offspring had slightly lower body weight gains during gestation when bred to male offspring. As with thalidomide, the rat model may not adequately address the full spectrum of potential human embryo-fetal developmental effects for lenalidomide.

    Following daily oral administration of lenalidomide from Gestation Day 7 through Gestation Day 20 in pregnant rabbits, fetal plasma lenalidomide concentrations were approximately 20% to 40% of the maternal Cmax. Following a single oral dose to pregnant rats, lenalidomide was detected in fetal plasma and tissues; concentrations of radioactivity in fetal tissues were generally lower than those in maternal tissues. These data indicated that lenalidomide crossed the placenta.

    8.2 Lactation

    Risk Summary

    There is no information regarding the presence of lenalidomide in human milk, the effects of lenalidomide capsules on the breastfed child, or the effects of lenalidomide capsules on milk production. Because many drugs are excreted in human milk and because of the potential for adverse reactions in breastfed children from lenalidomide capsules, advise women not to breastfeed during treatment with lenalidomide capsules.

    8.3 Females and Males of Reproductive Potential

    Pregnancy Testing

    Lenalidomide capsules can cause fetal harm when administered during pregnancy [see Use in Specific Populations (8.1)]. Verify the pregnancy status of females of reproductive potential prior to initiating lenalidomide capsules therapy and during therapy. Advise females of reproductive potential that they must avoid pregnancy 4 weeks before therapy, while taking lenalidomide capsules, during dose interruptions and for at least 4 weeks after completing therapy.

    Females of reproductive potential must have 2 negative pregnancy tests before initiating lenalidomide capsules. The first test should be performed within 10 to 14 days, and the second test within 24 hours prior to prescribing lenalidomide capsules. Once treatment has started and during dose interruptions, pregnancy testing for females of reproductive potential should occur weekly during the first 4 weeks of use, then pregnancy testing should be repeated every 4 weeks in females with regular menstrual cycles. If menstrual cycles are irregular, the pregnancy testing should occur every 2 weeks. Pregnancy testing and counseling should be performed if a patient misses her period or if there is any abnormality in her menstrual bleeding. Lenalidomide capsules treatment must be discontinued during this evaluation.

    Contraception

    Females

    Females of reproductive potential must commit either to abstain continuously from heterosexual sexual intercourse or to use 2 methods of reliable birth control simultaneously: one highly effective form of contraception - tubal ligation, IUD, hormonal (birth control pills, injections, hormonal patches, vaginal rings, or implants), or partner's vasectomy, and 1 additional effective contraceptive method - male latex or synthetic condom, diaphragm, or cervical cap. Contraception must begin 4 weeks prior to initiating treatment with lenalidomide capsules, during therapy, during dose interruptions, and continuing for 4 weeks following discontinuation of lenalidomide capsules therapy. Reliable contraception is indicated even where there has been a history of infertility, unless due to hysterectomy. Females of reproductive potential should be referred to a qualified provider of contraceptive methods, if needed.

    Males

    Lenalidomide is present in the semen of males who take lenalidomide capsules. Therefore, males must always use a latex or synthetic condom during any sexual contact with females of reproductive potential while taking lenalidomide capsules and for up to 4 weeks after discontinuing lenalidomide capsules, even if they have undergone a successful vasectomy. Male patients taking lenalidomide capsules must not donate sperm and for up to 4 weeks after discontinuing lenalidomide capsules.

    8.4 Pediatric Use

    Safety and effectiveness have not been established in pediatric patients.

    8.5 Geriatric Use

    MM In Combination: Overall, of the 1613 patients in the NDMM study who received study treatment, 94% (1521/1613) were 65 years of age or older, while 35% (561/1613) were over 75 years of age. The percentage of patients over age 75 was similar between study arms (Rd Continuous: 33%; Rd18: 34%; MPT: 33%). Overall, across all treatment arms, the frequency in most of the adverse reaction categories (e.g., all adverse reactions, grade 3/4 adverse reactions, serious adverse reactions) was higher in older (> 75 years of age) than in younger (≤75 years of age) subjects. Grade 3 or 4 adverse reactions in the General Disorders and Administration Site Conditions body system were consistently reported at a higher frequency (with a difference of at least 5%) in older subjects than in younger subjects across all treatment arms. Grade 3 or 4 adverse reactions in the Infections and Infestations, Cardiac Disorders (including cardiac failure and congestive cardiac failure), Skin and Subcutaneous Tissue Disorders, and Renal and Urinary Disorders (including renal failure) body systems were also reported slightly, but consistently, more frequently (<5% difference), in older subjects than in younger subjects across all treatment arms. For other body systems (e.g., Blood and Lymphatic System Disorders, Infections and Infestations, Cardiac Disorders, Vascular Disorders), there was a less consistent trend for increased frequency of grade 3/4 adverse reactions in older vs younger subjects across all treatment arms. Serious adverse reactions were generally reported at a higher frequency in the older subjects than in the younger subjects across all treatment arms.

    MM After At Least One Prior Therapy: Of the 703 MM patients who received study treatment in Studies 1 and 2, 45% were age 65 or over while 12% of patients were age 75 and over. The percentage of patients age 65 or over was not significantly different between the lenalidomide/dexamethasone and placebo/dexamethasone groups. Of the 353 patients who received lenalidomide/dexamethasone, 46% were age 65 and over. In both studies, patients > 65 years of age were more likely than patients ≤ 65 years of age to experience DVT, pulmonary embolism, atrial fibrillation, and renal failure following use of lenalidomide capsules. No differences in efficacy were observed between patients over 65 years of age and younger patients.

    Of the 148 patients with del 5q MDS enrolled in the major study, 38% were age 65 and over, while 33% were age 75 and over. Although the overall frequency of adverse reactions (100%) was the same in patients over 65 years of age as in younger patients, the frequency of serious adverse reactions was higher in patients over 65 years of age than in younger patients (54% vs. 33%). A greater proportion of patients over 65 years of age discontinued from the clinical studies because of adverse reactions than the proportion of younger patients (27% vs. 16%). No differences in efficacy were observed between patients over 65 years of age and younger patients.

    Since elderly patients are more likely to have decreased renal function, care should be taken in dose selection. Monitor renal function.

    8.6 Renal Impairment

    Adjust the starting dose of lenalidomide capsules based on the creatinine clearance value and for patients on dialysis [see Dosage and Administration (2.6)].

  • 10 OVERDOSAGE

    There is no specific experience in the management of lenalidomide overdose in patients with MM or MDS. In dose-ranging studies in healthy subjects, some were exposed to up to 200 mg (administered 100 mg BID) and in single-dose studies, some subjects were exposed to up to 400 mg. Pruritus, urticaria, rash, and elevated liver transaminases were the primary reported AEs. In clinical trials, the dose-limiting toxicity was neutropenia and thrombocytopenia.

  • 11 DESCRIPTION

    Lenalidomide capsules, a thalidomide analogue, is an immunomodulatory agent with antiangiogenic and antineoplastic properties. The chemical name is 3-(4-amino-1-oxo 1,3-dihydro-2H-isoindol-2-yl) piperidine-2,6-dione and it has the following chemical structure:

    structure

    3-(4-amino-1-oxo 1,3-dihydro-2H-isoindol-2-yl) piperidine-2,6-dione

    The empirical formula for lenalidomide is C13H13N3O3, and the gram molecular weight is 259.3.

    Lenalidomide is an off-white to pale-yellow solid powder. It is soluble in organic solvent/water mixtures, and buffered aqueous solvents. Lenalidomide is more soluble in organic solvents and low pH solutions. Solubility was significantly lower in less acidic buffers, ranging from about 0.4 to 0.5 mg/ml. Lenalidomide has an asymmetric carbon atom and can exist as the optically active forms S(-) and R(+), and is produced as a racemic mixture with a net optical rotation of zero.

    Lenalidomide capsules are available in 2.5 mg, 5 mg, 10 mg, 15 mg, 20 mg, and 25 mg capsules for oral administration.

    Each capsule contains lenalidomide as the active ingredient and the following inactive ingredients: croscarmellose sodium, lactose anhydrous, magnesium stearate and microcrystalline cellulose.

    The 2.5 mg capsule shell contains gelatin, red iron oxide, yellow iron oxide, titanium dioxide, FD&C blue #1, FD&C red #3, FD&C red #40 and black ink.

    The 5 mg capsule shell contains gelatin, titanium dioxide, black iron oxide, red iron oxide, yellow iron oxide, FD&C blue #1, FD&C yellow #6 and black ink.

    The 10 mg capsule shell contains gelatin, titanium dioxide, FD&C blue #1, FD&C red #40, FD&C yellow #6, FD&C yellow #5 and black ink.

    The 15 mg capsule shell contains gelatin, titanium dioxide, FD&C blue #1, FD&C red #40, FD&C yellow #5, black iron oxide, red iron oxide, yellow iron oxide and black ink.

    The 20 mg capsule shell contains gelatin, titanium dioxide, FD&C blue #1, FD&C red #40, red iron oxide, yellow iron oxide and black ink.

    The 25 mg capsule shell contains gelatin, titanium dioxide and black ink.

    The black imprinting ink contains shellac, strong ammonia solution, black iron oxide.

  • 12 CLINICAL PHARMACOLOGY

    12.1 Mechanism of Action

    Lenalidomide is an analogue of thalidomide with immunomodulatory, antiangiogenic, and antineoplastic properties. Cellular activities of lenalidomide are mediated through its target cereblon, a component of a cullin ring E3 ubiquitin ligase enzyme complex. In vitro, in the presence of drug, substrate proteins (including Aiolos, Ikaros, and CK1α) are targeted for ubiquitination and subsequent degradation leading to direct cytotoxic and immunomodulatory effects. Lenalidomide inhibits proliferation and induces apoptosis of certain hematopoietic tumor cells including MM and del (5q) myelodysplastic syndromes in vitro. Lenalidomide causes a delay in tumor growth in some in vivo nonclinical hematopoietic tumor models including MM. Immunomodulatory properties of lenalidomide include increased number and activation of T cells and natural killer (NK) cells leading to direct and enhanced antibody-dependent cell-mediated cytotoxicity (ADCC) via increased secretion of interleukin-2 and interferon-gamma, increased numbers of NKT cells, and inhibition of pro-inflammatory cytokines (e.g., TNF-α and IL-6) by monocytes. In MM cells, the combination of lenalidomide and dexamethasone synergizes the inhibition of cell proliferation and the induction of apoptosis.

    12.2 Pharmacodynamics

    Cardiac Electrophysiology

    The effect of lenalidomide on the QTc interval was evaluated in 60 healthy male subjects in a thorough QT study. At a dose two times the maximum recommended dose, lenalidomide did not prolong the QTc interval. The largest upper bound of the two-sided 90% CI for the mean differences between lenalidomide and placebo was below 10 ms.

    12.3 Pharmacokinetics

    Absorption

    Following single and multiple doses of lenalidomide capsules in patients with MM or MDS, the maximum plasma concentrations occurred between 0.5 and 6 hours post-dose. The single and multiple dose pharmacokinetic disposition of lenalidomide is linear with AUC and Cmax values increasing proportionally with dose. Multiple doses of lenalidomide capsules at the recommended dosage does not result in drug accumulation.

    Administration of a single 25 mg dose of lenalidomide capsules with a high-fat meal in healthy subjects reduces the extent of absorption, with an approximate 20% decrease in AUC and 50% decrease in Cmax. In the trials where the efficacy and safety were established for lenalidomide capsules, the drug was administered without regard to food intake. Lenalidomide capsules can be administered with or without food.

    Distribution

    In vitro [14C]-lenalidomide binding to plasma proteins is approximately 30%.

    Lenalidomide is present in semen at 2 hours (1379 ng/ejaculate) and 24 hours (35 ng/ejaculate) after the administration of lenalidomide capsule 25 mg daily.

    Elimination

    The mean half-life of lenalidomide is 3 hours in healthy subjects and 3 to 5 hours in patients with MM or MDS.

    Metabolism

    Lenalidomide undergoes limited metabolism. Unchanged lenalidomide is the predominant circulating component in humans. Two identified metabolites are 5-hydroxy-lenalidomide and N-acetyl-lenalidomide; each constitutes less than 5% of parent levels in circulation.

    Excretion

    Elimination is primarily renal. Following a single oral administration of [14C]-lenalidomide 25 mg to healthy subjects, approximately 90% and 4% of the radioactive dose was eliminated within ten days in urine and feces, respectively. Approximately 82% of the radioactive dose was excreted as lenalidomide in the urine within 24 hours. Hydroxy-lenalidomide and N-acetyl-lenalidomide represented 4.6% and 1.8% of the excreted dose, respectively. The renal clearance of lenalidomide exceeds the glomerular filtration rate.

    Specific Populations

    Renal Impairment: Eight subjects with mild renal impairment (creatinine clearance (CLcr) 50 to 79 mL/min calculated using Cockcroft-Gault), 9 subjects with moderate renal impairment (CLcr 30 to 49 mL/min), 4 subjects with severe renal impairment (CLcr < 30 mL/min), and 6 patients with end stage renal disease (ESRD) requiring dialysis were administered a single 25 mg dose of lenalidomide capsules. Three healthy subjects of similar age with normal renal function (CLcr > 80 mL/min) were also administered a single 25 mg dose of lenalidomide capsules. As CLcr decreased, half-life increased and drug clearance decreased linearly. Patients with moderate and severe impairment had a 3-fold increase in half-life and a 66% to 75% decrease in drug clearance compared to healthy subjects. Patients on hemodialysis (n=6) had an approximate 4.5-fold increase in half-life and an 80% decrease in drug clearance compared to healthy subjects. Approximately 30% of the drug in body was removed during a 4-hour hemodialysis session.

    Adjust the starting dose of lenalidomide capsules in patients with renal impairment based on the CLcr value [see Dosage and Administration (2.6)].

    Hepatic Impairment: Mild hepatic impairment (defined as total bilirubin > 1 to 1.5 times upper limit normal (ULN) or any aspartate transaminase greater than ULN) did not influence the disposition of lenalidomide. No pharmacokinetic data is available for patients with moderate to severe hepatic impairment.

    Other Intrinsic Factors: Age (39 to 85 years), body weight (33 to 135 kg), sex, race, and type of hematological malignancies (MM or MDS) did not have a clinically relevant effect on lenalidomide clearance in adult patients.

    Drug Interactions

    Co-administration of a single dose or multiple doses of dexamethasone (40 mg) had no clinically relevant effect on the multiple dose pharmacokinetics of lenalidomide capsules (25 mg).

    Co-administration of lenalidomide capsules (25 mg) after multiple doses of a P-gp inhibitor such as quinidine (600 mg twice daily) did not significantly increase the Cmax or AUC of lenalidomide.

    Co-administration of the P-gp inhibitor and substrate temsirolimus (25 mg), with lenalidomide capsules (25 mg) did not significantly alter the pharmacokinetics of lenalidomide, temsirolimus, or sirolimus (metabolite of temsirolimus).

    In vitro studies demonstrated that lenalidomide capsules are a substrate of P-glycoprotein (P-gp). Lenalidomide capsules are not a substrate of human breast cancer resistance protein (BCRP), multidrug resistance protein (MRP) transporters MRP1, MRP2, or MRP3, organic anion transporters (OAT) OAT1 and OAT3, organic anion transporting polypeptide 1B1 (OATP1B1), organic cation transporters (OCT) OCT1 and OCT2, multidrug and toxin extrusion protein (MATE) MATE1, and organic cation transporters novel (OCTN) OCTN1 and OCTN2. Lenalidomide is not an inhibitor of P-gp, bile salt export pump (BSEP), BCRP, MRP2, OAT1, OAT3, OATP1B1, OATP1B3, or OCT2. Lenalidomide does not inhibit or induce CYP450 isoenzymes. Also, lenalidomide does not inhibit bilirubin glucuronidation formation in human liver microsomes with UGT1A1 genotyped as UGT1A1*1/*1, UGT1A1*1/*28, and UGT1A1*28/*28.

  • 13 NONCLINICAL TOXICOLOGY

    13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

    Carcinogenicity studies with lenalidomide have not been conducted.

    Lenalidomide was not mutagenic in the bacterial reverse mutation assay (Ames test) and did not induce chromosome aberrations in cultured human peripheral blood lymphocytes, or mutations at the thymidine kinase (tk) locus of mouse lymphoma L5178Y cells. Lenalidomide did not increase morphological transformation in Syrian Hamster Embryo assay or induce micronuclei in the polychromatic erythrocytes of the bone marrow of male rats.

    A fertility and early embryonic development study in rats, with administration of lenalidomide up to 500 mg/kg (approximately 200 times the human dose of 25 mg, based on body surface area) produced no parental toxicity and no adverse effects on fertility.

  • 14 CLINICAL STUDIES

    14.1 Multiple Myeloma

    Randomized, Open-Label Clinical Trial in Patients with Newly Diagnosed MM:

    A randomized multicenter, open-label, 3-arm trial of 1,623 patients, was conducted to compare the efficacy and safety of lenalidomide capsules and low-dose dexamethasone (Rd) given for 2 different durations of time to that of melphalan, prednisone and thalidomide (MPT) in newly diagnosed MM patients who were not a candidate for stem cell transplant. In the first arm of the study, Rd was given continuously until progressive disease [Arm Rd Continuous]. In the second arm, Rd was given for up to eighteen 28-day cycles [72 weeks, Arm Rd18]). In the third arm, melphalan, prednisone and thalidomide (MPT) was given for a maximum of twelve 42-day cycles (72 weeks). For the purposes of this study, a patient who was < 65 years of age was not a candidate for SCT if the patient refused to undergo SCT therapy or the patient did not have access to SCT due to cost or other reasons. Patients were stratified at randomization by age (≤75 versus >75 years), stage (ISS Stages I and II versus Stage III), and country.

    Patients in the Rd Continuous and Rd18 arms received lenalidomide capsules 25 mg once daily on Days 1 to 21 of 28-day cycles. Dexamethasone was dosed 40 mg once daily on Days 1, 8, 15, and 22 of each 28-day cycle. For patients over > 75 years old, the starting dose of dexamethasone was 20 mg orally once daily on days 1,8,15, and 22 of repeated 28-day cycles. Initial dose and regimens for Rd Continuous and Rd18 were adjusted according to age and renal function. All patients received prophylactic anticoagulation with the most commonly used being aspirin.

    The demographics and disease-related baseline characteristics of the patients were balanced among the 3 arms. In general, study subjects had advanced-stage disease. Of the total study population, the median age was 73 in the 3 arms with 35% of total patients > 75 years of age; 59% had ISS Stage I/II; 41% had ISS stage III; 9% had severe renal impairment (creatinine clearance [CLcr] < 30 mL/min); 23% had moderate renal impairment (CLcr > 30 to 50 mL/min; 44% had mild renal impairment (CLcr >50 to 80 mL/min). For ECOG Performance Status, 29% were Grade 0, 49% Grade 1, 21% Grade 2, 0.4% ≥ Grade 3.

    The primary efficacy endpoint, progression-free survival (PFS), was defined as the time from randomization to the first documentation of disease progression as determined by Independent Response Adjudication Committee (IRAC), based on International Myeloma Working Group [IMWG] criteria or death due to any cause, whichever occurred first during the study until the end of the PFS follow-up phase. For the efficacy analysis of all endpoints, the primary comparison was between Rd Continuous and MPT arms. The efficacy results are summarized in the table below. PFS was significantly longer with Rd Continuous than MPT: HR 0.72 (95% CI: 0.61-0.85 p <0.0001). A lower percentage of subjects in the Rd Continuous arm compared with the MPT arm had PFS events (52% versus 61%, respectively). The improvement in median PFS time in the Rd Continuous arm compared with the MPT arm was 4.3 months. The myeloma response rate was higher with Rd Continuous compared with MPT (75.1% versus 62.3%); with a complete response in 15.1% of Rd Continuous arm patients versus 9.3% in the MPT arm. The median time to first response was 1.8 months in the Rd Continuous arm versus 2.8 months in the MPT arm.

    For the interim OS analysis with 03 March 2014 data cutoff, the median follow-up time for all surviving patients is 45.5 months, with 697 death events, representing 78% of prespecified events required for the planned final OS analysis (697/896 of the final OS events). The observed OS HR was 0.75 for Rd Continuous versus MPT (95% CI = 0.62, 0.90).

    Table 13: Overview of Efficacy Results – Study MM-020 (Intent-to-treat Population)

    Rd Continuous

    (N = 535)

    Rd18

    (N = 541)

    MPT

    (N = 547)

    PFS – IRAC (months)g

      Number of PFS events

    278 (52)

    348 (64.3)

    334 (61.1)

      Mediana PFS time, months (95% CI)b

    25.5 (20.7, 29.4)

    20.7 (19.4, 22)

    21.2 (19.3, 23.2)

      HR [95% CI]c; p-valued

        Rd Continuous vs MPT

    0.72 (0.61, 0.85);

    <0.0001

        Rd Continuous vs Rd18

    0.70 (0.60, 0.82)

        Rd18 vs MPT

    1.03 (0.89, 1.20)

    Overall Survival (months)h

      Number of Death events

    208 (38.9)

    228 (42.1)

    261 (47.7)

      Mediana OS time, months (95% CI)b

    58.9 (56, NE)f

    56.7 (50.1, NE)

    48.5 (44.2, 52)

      HR [95% CI]c

        Rd Continuous vs MPT

    0.75 (0.62, 0.90)

        Rd Continuous vs Rd18

    0.91 (0.75, 1.09)

        Rd18 vs MPT

    0.83 (0.69, 0.99)

    Response Ratee – IRAC, n (%)g

      CR

    81 (15.1)

    77 (14.2)

    51 (9.3)

      VGPR

    152 (28.4)

    154 (28.5)

    103 (18.8)

      PR

    169 (31.6)

    166 (30.7)

    187 (34.2)

      Overall response: CR, VGPR, or PR

    402 (75.1)

    397 (73.4)

    341 (62.3)

    CR = complete response; d = low-dose dexamethasone; HR = hazard ratio; IRAC = Independent Response Adjudication Committee; M = melphalan; NE = not estimable; OS = overall survival; P = prednisone; PFS = progression-free survival; PR = partial response; R = lenalidomide capsules; Rd Continuous = Rd given until documentation of progressive disease; Rd18 = Rd given for ≤ 18 cycles; T = thalidomide; VGPR = very good partial response; vs = versus.

    a The median is based on the Kaplan-Meier estimate.

    b The 95% Confidence Interval (CI) about the median.

    c Based on Cox proportional hazards model comparing the hazard functions associated with the indicated treatment arms.

    d The p-value is based on the unstratified log-rank test of Kaplan-Meier curve differences between the indicated treatment arms.

    e Best assessment of response during the treatment phase of the study.

    f Including patients with no response assessment data or whose only assessment was "response not evaluable."

    g Data cutoff date = 24 May 2013.

    h Data cutoff date = 3 March 2014.

    Kaplan-Meier Curves of Progression-free Survival Based on IRAC Assessment (ITT MM Population)
    Between Arms Rd Continuous, Rd18 and MPT
    Cutoff date: 24 May 2013

    figure-itt-mm-1

    CI = confidence interval; d = low-dose dexamethasone; HR = hazard ratio; IRAC = Independent Response Adjudication Committee; M = melphalan; P = prednisone; R = lenalidomide capsules;
    Rd Continuous = Rd given until documentation of progressive disease; Rd18 = Rd given for ≤ 18 cycles; T = thalidomide.

    Kaplan-Meier Curves of Overall Survival (ITT MM Population)
    Between Arms Rd Continuous, Rd18 and MPT
    Cutoff date: 03 Mar 2014

    figure-itt-mm-2

    CI = confidence interval; d = low-dose dexamethasone; HR = hazard ratio; M= melphalan; P =prednisone; R = lenalidomide capsules;
    Rd Continuous =Rd given until documentation of progressive disease; Rd18 = Rd given for ≤18 cycles; T = thalidomide.

    Randomized, Open-Label Clinical Studies in Patients with MM After At Least One Prior Therapy

    Two randomized studies (Studies 1 and 2) were conducted to evaluate the efficacy and safety of lenalidomide capsules. These multicenter, multinational, double-blind, placebo-controlled studies compared lenalidomide capsules plus oral pulse high-dose dexamethasone therapy to dexamethasone therapy alone in patients with MM who had received at least one prior treatment. These studies enrolled patients with absolute neutrophil counts (ANC) ≥ 1000/mm3, platelet counts ≥ 75,000/mm3, serum creatinine ≤ 2.5 mg/dL, serum SGOT/AST or SGPT/ALT ≤ 3 x upper limit of normal (ULN), and serum direct bilirubin ≤ 2 mg/dL.

    In both studies, patients in the lenalidomide/dexamethasone group took 25 mg of lenalidomide capsules orally once daily on Days 1 to 21 and a matching placebo capsule once daily on Days 22 to 28 of each 28-day cycle. Patients in the placebo/dexamethasone group took 1 placebo capsule on Days 1 to 28 of each 28-day cycle. Patients in both treatment groups took 40 mg of dexamethasone orally once daily on Days 1 to 4, 9 to 12, and 17 to 20 of each 28-day cycle for the first 4 cycles of therapy.

    The dose of dexamethasone was reduced to 40 mg orally once daily on Days 1 to 4 of each 28-day cycle after the first 4 cycles of therapy. In both studies, treatment was to continue until disease progression.

    In both studies, dose adjustments were allowed based on clinical and laboratory findings. Sequential dose reductions to 15 mg daily, 10 mg daily and 5 mg daily were allowed for toxicity [see Dosage and Administration (2.1)].

    Table 16 summarizes the baseline patient and disease characteristics in the two studies. In both studies, baseline demographic and disease-related characteristics were comparable between the lenalidomide/dexamethasone and placebo/dexamethasone groups.

    Table 16: Baseline Demographic and Disease-Related Characteristics - MM Studies 1 and 2

    Study 1Study 2
    Lenalidomide/Dex

    N=177    		Placebo/Dex

    N=176    		Lenalidomide/Dex

    N=176    		Placebo/Dex

    N=175
    Patient Characteristics
    Age (years)
    Median64626364
    Min, Max36, 8637, 8533, 8440, 82
    Sex
    Male106 (60%)104 (59%)104 (59%)103 (59%)
    Female71 (40%)72 (41%)72 (41%)72 (41%)
    Race/Ethnicity
    White141(80%)148 (84%)172 (98%)175 (100%)
    Other36 (20%)28 (16%)4 (2%)0 (0%)
    ECOG Performance
    Status 0-1157 (89%)168 (95%)150 (85%)144 (82%)
    Disease Characteristics
    Multiple Myeloma Stage (Durie-Salmon)
    I3%3%6%5%
    II32%31%28%33%
    III64%66%65%63%
    β2-microglobulin (mg/L)
    ≤ 2.5 mg/L52 (29%)51 (29%)51 (29%)48 (27%)
    > 2.5 mg/L125 (71%)125 (71%)125 (71%)127 (73%)
    Number of Prior Therapies
    138%38%32%33%
    ≥ 262%62%68%67%
    Types of Prior Therapies
    Stem Cell Transplantation62%61%55%54%
    Thalidomide42%46%30%38%
    Dexamethasone81%71%66%69%
    Bortezomib11%11%5%4%
    Melphalan33%31%56%52%
    Doxorubicin55%51%56%57%

    The primary efficacy endpoint in both studies was time to progression (TTP). TTP was defined as the time from randomization to the first occurrence of progressive disease.

    Preplanned interim analyses of both studies showed that the combination of lenalidomide/dexamethasone was significantly superior to dexamethasone alone for TTP. The studies were unblinded to allow patients in the placebo/dexamethasone group to receive treatment with the lenalidomide/dexamethasone combination. For both studies, the extended follow-up survival data with crossovers were analyzed. In study 1, the median survival time was 39.4 months (95% CI: 32.9, 47.4) in lenalidomide/dexamethasone group and 31.6 months (95% CI: 24.1, 40.9) in placebo/dexamethasone group, with a hazard ratio of 0.79 (95% CI: 0.61-1.03). In study 2, the median survival time was 37.5 months (95% CI: 29.9, 46.6) in lenalidomide/dexamethasone group and 30.8 months (95% CI: 23.5, 40.3) in placebo/dexamethasone group, with a hazard ratio of 0.86 (95% CI: 0.65-1.14).

    Table 17: TTP Results in MM Study 1 and Study 2

    Study 1Study 2
    Lenalidomide/Dex

    N=177    		Placebo/Dex

    N=176    		Lenalidomide/Dex

    N=176    		Placebo/Dex

    N=175
    TTP
    Events n (%)73 (41)120 (68)68 (39)130 (74)
    Median TTP in months [95% CI]13.9 [9.5, 18.5]4.7 [3.7, 4.9]12.1 [9.5, NE]4.7 [3.8, 4.8]
    Hazard Ratio [95% CI]0.285 [0.210, 0.386]0.324 [0.240, 0.438]
    Log-rank Test p-value 3<0.001<0.001
    Response
    Complete Response (CR) n (%)23 (13)1 (1)27 (15)7 (4)
    Partial Response (RR/PR) n (%)84 (48)33 (19)77 (44)34 (19)
    Overall Response n (%)107 (61)34 (19)104 (59)41 (23)
    p-value<0.001<0.001
    Odds Ratio [95% CI]6.38 [3.95, 10.32]4.72 [2.98, 7.49]

    Kaplan- Meier Estimate of Time to Progression - MM Study 1

    figure-mm-study-1

    Kaplan-Meier Estimate of Time to Progression - MM Study 2

    figure-mm-study-2

    14.2 Myelodysplastic Syndromes (MDS) with a Deletion 5q Cytogenetic Abnormality

    The efficacy and safety of lenalidomide capsules were evaluated in patients with transfusion-dependent anemia in low- or intermediate-1- risk MDS with a 5q (q31-33) cytogenetic abnormality in isolation or with additional cytogenetic abnormalities, at a dose of 10 mg once daily or 10 mg once daily for 21 days every 28 days in an open-label, single-arm, multi-center study. The major study was not designed nor powered to prospectively compare the efficacy of the 2 dosing regimens. Sequential dose reductions to 5 mg daily and 5 mg every other day, as well as dose delays, were allowed for toxicity [see Dosage and Administration (2.2)].

    This major study enrolled 148 patients who had RBC transfusion dependent anemia. RBC transfusion dependence was defined as having received ≥ 2 units of RBCs within 8 weeks prior to study treatment. The study enrolled patients with absolute neutrophil counts (ANC) ≥ 500/mm3, platelet counts ≥ 50,000/mm3, serum creatinine ≤ 2.5 mg/dL, serum SGOT/AST or SGPT/ALT ≤ 3 x upper limit of normal (ULN), and serum direct bilirubin ≤ 2 mg/dL. Granulocyte colony-stimulating factor was permitted for patients who developed neutropenia or fever in association with neutropenia. Baseline patient and disease-related characteristics are summarized in Table 18.

    Table 18: Baseline Demographic and Disease-Related Characteristics in the MDS Study

    Overall (N=148)
    Age (years)
    Median 71
    Min, Max 37, 95
    Gender n(%)
    Male 51 (34.5)
    Female 97 (65.5)
    Race n(%)
    White 143 (96.6)
    Other 5 (3.4)
    Duration of MDS (years)
    Median 2.5
    Min, Max 0.1, 20.7
    Del 5 (q31-33) Cytogenetic Abnormalityn(%)
    Yes 148 (100)
    Other cytogenetic abnormalities 37 (25.2)
    IPSS Score a n(%)
    Low (0) 55 (37.2)
    Intermediate-1 (0.5 to 1.0) 65 (43.9)
    Intermediate-2 (1.5 to 2.0) 6 (4.1)
    High (≥2.5) 2 (1.4)
    Missing 20 (13.5)
    FAB Classificationb from central review n(%)
    RA 77 (52)
    RARS 16 (10.8)
    RAEB 30 (20.3)
    CMML 3 (2)

    a IPSS Risk Category: Low (combined score = 0), Intermediate-1 (combined score = 0.5 to 1), Intermediate-2 (combined score = 1.5 to 2.0), High (combined score ≥ 2.5); Combined score = (Marrow blast score + Karyotype score + Cytopenia score)

    b French-American-British (FAB) classification of MDS.

    The frequency of RBC transfusion independence was assessed using criteria modified from the International Working Group (IWG) response criteria for MDS. RBC transfusion independence was defined as the absence of any RBC transfusion during any consecutive "rolling"56 days (8 weeks) during the treatment period.

    Transfusion independence was seen in 99/148 (67%) patients (95% CI [59, 74]). The median duration from the date when RBC transfusion independence was first declared (i.e., the last day of the 56-day RBC transfusion-free period) to the date when an additional transfusion was received after the 56-day transfusion-free period among the 99 responders was 44 weeks (range of 0 to >67 weeks). Ninety percent of patients who achieved a transfusion benefit did so by completion of three months in the study.

    RBC transfusion independence rates were unaffected by age or gender.

    The dose of lenalidomide capsules was reduced or interrupted at least once due to an adverse event in 118 (79.7%) of the 148 patients; the median time to the first dose reduction or interruption was 21 days (mean, 35.1 days; range, 2 to 253 days), and the median duration of the first dose interruption was 22 days (mean, 28.5 days; range, 2 to 265 days). A second dose reduction or interruption due to adverse events was required in 50 (33.8%) of the 148 patients. The median interval between the first and second dose reduction or interruption was 51 days (mean, 59.7 days; range, 15 to 205 days) and the median duration of the second dose interruption was 21 days (mean, 26 days; range, 2 to 148 days).

  • 15 REFERENCES

    1. OSHA Hazardous Drugs. OSHA [Accessed on 29 January 2013, from http://www.osha.gov/SLTC/hazardousdrugs/index.html]

  • 16 HOW SUPPLIED/STORAGE AND HANDLING

    16.1 How Supplied

    A dark blue opaque cap/ light orange opaque body, capsule shell size No. 4 imprinted in black ink with “LP” on the cap and “637” on the body and filled with white powder.
    2.5 mg bottles of 28 (NDC: 47781-483-28)
    2.5 mg bottles of 100 (NDC: 47781-483-01)

    A green opaque cap/ light caramel opaque body, capsule shell size No. 2 imprinted in black ink with “LP” on the cap and “638” on the body and filled with white powder.
    5 mg bottles of 28 (NDC: 47781-484-28)
    5 mg bottles of 100 (NDC: 47781-484-01)

    A gold opaque cap/ gray opaque body, capsule shell size No. 0 imprinted in black ink with “LP” on the cap and “639” on the body and filled with white powder.
    10 mg bottles of 28 (NDC: 47781-485-28)
    10 mg bottles of 100 (NDC: 47781-485-01)

    A caramel opaque cap/ grey opaque body, capsule shell size No. 2 imprinted in black ink with “LP” on the cap and “640” on the body and filled with white powder.
    15 mg bottles of 21 (NDC: 47781-486-77)
    15 mg bottles of 100 (NDC: 47781-486-01)

    A warm brick red opaque cap/ light gray opaque body, capsule shell size No. 1 imprinted in black ink with “LP” on the cap and “641” on the body and filled with white powder.
    20 mg bottles of 21 (NDC: 47781-487-77)
    20 mg bottles of 100 (NDC: 47781-487-01)

    A white opaque cap/ white opaque body, capsule shell size No. 0 imprinted in black ink with “LP” on the cap and “642” on the body and filled with white powder.
    25 mg bottles of 21 (NDC: 47781-488-77)
    25 mg bottles of 100 (NDC: 47781-488-01)

    16.2 Storage

    Store at 20°C to 25°C (68°F to 77°F); excursions permitted to 15°C to 30°C (59°F to 86°F) [See USP Controlled Room Temperature].

    16.3 Handling and Disposal

    Care should be exercised in the handling of lenalidomide capsules. Lenalidomide capsules should not be opened or broken. If powder from lenalidomide capsules contacts the skin, wash the skin immediately and thoroughly with soap and water. If lenalidomide capsules contacts the mucous membranes, flush thoroughly with water.

    Procedures for the proper handling and disposal of anticancer drugs should be considered. Several guidelines on the subject have been published.1

    Dispense no more than a 28-day supply.

  • 17 PATIENT COUNSELING INFORMATION

    Advise the patient to read the FDA-approved Patient labeling (Medication Guide)

    Embryo-Fetal Toxicity

    Advise patients that lenalidomide capsules are contraindicated in pregnancy [see Boxed Warning, Contraindications (4.1)]. Lenalidomide capsules are a thalidomide analogue and can cause serious birth defects or death to a developing baby [see Warnings and Precautions (5.1), Use in Specific Populations (8.1)].

    • Advise females of reproductive potential that they must avoid pregnancy while taking lenalidomide capsules and for at least 4 weeks after completing therapy.
    • Initiate lenalidomide capsules treatment in females of reproductive potential only following a negative pregnancy test.
    • Advise females of reproductive potential of the importance of monthly pregnancy tests and the need to use 2 different forms of contraception including at least 1 highly effective form, simultaneously during lenalidomide capsules therapy, during dose interruption and for 4 weeks after she has completely finished taking lenalidomide capsules. Highly effective forms of contraception other than tubal ligation include IUD and hormonal (birth control pills, injections, patch or implants) and a partner’s vasectomy. Additional effective contraceptive methods include latex or synthetic condom, diaphragm and cervical cap.
    • Instruct patient to immediately stop taking lenalidomide capsules and contact her healthcare provider if she becomes pregnant while taking this drug, if she misses her menstrual period, or experiences unusual menstrual bleeding, if she stops taking birth control, or if she thinks FOR ANY REASON that she may be pregnant.
    • Advise patient that if her healthcare provider is not available, she should call the REMS Call Center at 1-888-423-5436 [see Warnings and Precautions (5.1), Use in Specific Populations (8.3)].
    • Advise males to always use a latex or synthetic condom during any sexual contact with females of reproductive potential while taking lenalidomide capsules and for up to 4 weeks after discontinuing lenalidomide capsules, even if they have undergone a successful vasectomy.
    • Advise male patients taking lenalidomide capsules that they must not donate sperm and for up to 4 weeks after discontinuation of lenalidomide capsules [see Warnings and Precautions (5.1), Use in Specific Populations (8.3)].
    • All patients must be instructed to not donate blood while taking lenalidomide capsules, during dose interruptions and for 4 weeks following discontinuation of lenalidomide capsules [see Warnings and Precautions (5.1)].

    Lenalidomide REMS program

    Because of the risk of embryo-fetal toxicity, lenalidomide capsules are only available through a restricted program called the Lenalidomide REMS program [see Warnings and Precautions (5.2)].

    • Patients must sign a Patient-Physician agreement form and comply with the requirements to receive lenalidomide capsules. In particular, females of reproductive potential must comply with the pregnancy testing, contraception requirements and participate in monthly telephone surveys. Males must comply with the contraception requirements [see Use in Specific Populations (8.3)].
    • Lenalidomide capsules are available only from pharmacies that are certified in Lenalidomide REMS program. Provide patients with the telephone number and website for information on how to obtain the product.

    Pregnancy Exposure Registry

    Inform females there is a Pregnancy Exposure Registry that monitors pregnancy outcomes in females exposedto lenalidomide capsules during pregnancy and that they can contact the Pregnancy Exposure Registry bycalling 1-888-423-5436 [see Use in Specific Populations (8.1)].

    Hematologic Toxicity

    Inform patients that lenalidomide capsules are associated with significant neutropenia and thrombocytopenia [see Boxed Warning, Warnings and Precautions (5.3)].

    Venous and Arterial Thromboembolism

    Inform patients of the risk of thrombosis including DVT, PE, MI, and stroke and to report immediately any signs and symptoms suggestive of these events for evaluation [see Boxed Warning, Warnings and Precautions (5.4)].

    Increased Mortality in Patients with CLL

    Inform patients that lenalidomide capsules had increased mortality in patients with CLL and serious adverse cardiovascular reactions, including atrial fibrillation, myocardial infarction, and cardiac failure [see Warnings and Precautions (5.5)].

    Second Primary Malignancies

    Inform patients of the potential risk of developing second primary malignancies during treatment with lenalidomide capsules [see Warnings and Precautions (5.6)].

    Hepatotoxicity

    Inform patients of the risk of hepatotoxicity, including hepatic failure and death, and to report any signs and symptoms associated with this event to their healthcare provider for evaluation [see Warnings and Precautions (5.8)].

    Severe Cutaneous Reactions

    Inform patients of the potential risk for severe skin reactions such as SJS, TEN, and DRESS and report any signs and symptoms associated with these reactions to their healthcare provider for evaluation. Patients with a prior history of Grade 4 rash associated with thalidomide treatment should not receive lenalidomide capsules [see Warnings and Precautions (5.9)].

    Tumor Lysis Syndrome

    Inform patients of the potential risk of tumor lysis syndrome and to report any signs and symptoms associated with this event to their healthcare provider for evaluation [see Warnings and Precautions (5.10)].

    Tumor Flare Reaction

    Inform patients of the potential risk of tumor flare reaction and to report any signs and symptoms associated with this event to their healthcare provider for evaluation [see Warnings and Precautions (5.11)].

    Hypersensitivity

    Inform patients of the potential for severe hypersensitivity reactions such as angioedema and anaphylaxis to lenalidomide capsules. Instruct patients to contact their healthcare provider right away for signs and symptoms of these reactions. Advise patients to seek emergency medical attention for signs or symptoms of severe hypersensitivity reactions [see Warnings and Precautions (5.15)].

    Dosing Instructions

    Inform patients how to take lenalidomide capsules [see Dosage and Administration (2)]

    • Lenalidomide capsules should be taken once daily at about the same time each day,
    • Lenalidomide capsules may be taken either with or without food.
    • The capsules should not be opened, broken, or chewed. Lenalidomide capsules should be swallowed whole with water.
    • Instruct patients that if they miss a dose of lenalidomide capsules, they may still take it up to 12 hours afterthe time they would normally take it. If more than 12 hours have elapsed, they should be instructed to skip the dose for that day. The next day, they should take lenalidomide capsules at the usual time. Warn patientsto not take 2 doses to make up for the one that they missed.

  • SPL UNCLASSIFIED SECTION

    Manufactured by:
    Lotus Pharmaceutical Co., Ltd.
    Nantou City, Nantou County
    54066 Taiwan

    OR

    Manufactured by:
    Haupt Pharma Amareg GmbH
    Regensburg, Bavaria D-93055,
    Germany

    Distributed by:
    Alvogen, Inc.
    Morristown, NJ 07960 USA  

    Product of India

    PI483-00
    Rev. 11/2023

  • MEDICATION GUIDE

    This Medication Guide has been approved by the U.S. Food and Drug Administration.
    Revised: November 2023
    PL483-00
    MEDICATION GUIDE
    Lenalidomide (len" a lid' oh mide)
    Capsules
    What is the most important information I should know about lenalidomide capsules?
    Before you begin taking lenalidomide capsules, you must read and agree to all of the instructions in the Lenalidomide REMS program. Before prescribing lenalidomide capsules, your healthcare provider will explain the Lenalidomide REMS program to you and have you sign the Patient-Physician Agreement Form.
    Lenalidomide capsules may cause serious side effects including:
    • Possible birth defects (deformed babies) or death of an unborn baby. Females who are pregnant or who plan to become pregnant must not take lenalidomide capsules.
      Lenalidomide capsules are similar to the medicine thalidomide. We know thalidomide can cause severe life-threatening birth defects. Lenalidomide capsules have not been tested in pregnant females. Lenalidomide capsules have harmed unborn animals in animal testing.
      Females must not get pregnant:
      • For at least 4 weeks before starting lenalidomide capsules
      • While taking lenalidomide capsules
      • During any breaks (interruptions) in your treatment with lenalidomide capsules
      • For at least 4 weeks after stopping lenalidomide capsules
      Females who can become pregnant:
      • Will have pregnancy tests weekly for 4 weeks, then every 4 weeks if your menstrual cycle is regular, or every 2 weeks if your menstrual cycle is irregular.
      • If you miss your period or have unusual bleeding, you will need to have a pregnancy test and receive counseling.
      • Must agree to use two acceptable forms of birth control at the same time, for at least 4 weeks before, while taking, during any breaks (interruptions) in your treatment, and for at least 4 weeks after stopping lenalidomide capsules.
      • Talk with your healthcare provider to find out about options for acceptable forms of birth control that you may use to prevent pregnancy before, during, and after treatment with lenalidomide capsules.
      • If you had unprotected sex or if you think your birth control has failed, stop taking lenalidomide capsules immediately and call your healthcare provider right away.
      If you become pregnant while taking lenalidomide capsules, stop taking it right away and call your healthcare provider. If your healthcare provider is not available, you can call the REMS Call Center at 1-888-423-5436. Healthcare providers and patients should report all cases of pregnancy to:
      • FDA MedWatch at 1-800-FDA-1088, and
      • The Lenalidomide REMS program at 1-888-423-5436
      There is a pregnancy exposure registry that monitors the outcomes of females who take lenalidomide capsules during pregnancy, or if their male partner takes lenalidomide capsules and they are exposed during pregnancy. You can enroll in this registry by calling the Lenalidomide REMS program at the phone number listed above.
      Lenalidomide can pass into human semen:
      • Males, including those who have had a vasectomy, must always use a latex or synthetic condom during any sexual contact with a pregnant female or a female that can become pregnant while taking lenalidomide capsules, during any breaks (interruptions) in your treatment with lenalidomide capsules, and for up to 4 weeks after stopping lenalidomide capsules.
      • Do not have unprotected sexual contact with a female who is or could become pregnant. Tell your healthcare provider if you do have unprotected sexual contact with a female who is or could become pregnant.
      • Do not donate sperm while taking lenalidomide capsules, during any breaks (interruptions) in your treatment, and for up to 4 weeks after stopping lenalidomide capsules. If a female becomes pregnant with your sperm, the baby may be exposed to lenalidomide capsules and may be born with birth defects.
      Men, if your female partner becomes pregnant, you should call your healthcare provider right away.
    • Low white blood cells (neutropenia) and low platelets (thrombocytopenia). Lenalidomide capsules cause low white blood cells and low platelets in most people. You may need a blood transfusion or certain medicines if your blood counts drop too low. Your healthcare provider should check your blood counts often especially during the first several months of treatment with lenalidomide capsules, and then at least monthly. Tell your healthcare provider if you develop any bleeding or bruising, during treatment with lenalidomide capsules.
    • Blood clots. Blood clots in the arteries, veins, and lungs happen more often in people who take lenalidomide capsules. This risk is even higher for people with multiple myeloma who take the medicine dexamethasone with lenalidomide capsules. Heart attacks and strokes also happen more often in people who take lenalidomide capsules with dexamethasone. To reduce this increased risk, most people who take lenalidomide capsules will also take a blood thinner medicine.
      Before taking lenalidomide capsules, tell your healthcare provider:
      • If you have had a blood clot in the past
      • If you have high blood pressure, smoke, or if you have been told you have a high level of fat in your blood (hyperlipidemia)
      • About all the medicines you take. Certain other medicines can also increase your risk for blood clots
        Call your healthcare provider or get medical help right away if you get any of the following during treatment with lenalidomide capsules:
        • Signs or symptoms of a blood clot in the lung, arm, or leg may include: shortness of breath, chest pain, or arm or leg swelling
        • Signs or symptoms of a heart attack may include: chest pain that may spread to the arms, neck, jaw, back, or stomach area (abdomen), feeling sweaty, shortness of breath, feeling sick or vomiting
        • Signs or symptoms of stroke may include: sudden numbness or weakness, especially on one side of the body, severe headache or confusion, or problems with vision, speech, or balance
    What are lenalidomide capsules?
    Lenalidomide capsules are a prescription medicine, used to treat adults with:
    • multiple myeloma (MM)
      • in combination with the medicine dexamethasone
    • a condition called myelodysplastic syndromes (MDS). Lenalidomide capsules are for the type of MDS with a chromosome problem where part of chromosome 5 is missing. This type of MDS is known as deletion 5q MDS. People with this type of MDS may have low red blood cell counts that require treatment with blood transfusions.
    Lenalidomide capsules should not be used to treat people who have chronic lymphocytic leukemia (CLL) unless they are participants in a controlled clinical trial.
    It is not known if lenalidomide capsules are safe and effective in children.
    Who should not take lenalidomide capsules?
    Do not take lenalidomide capsules if you:
    • are pregnant, plan to become pregnant, or become pregnant during treatment with lenalidomide capsules. See "What is the most important information I should know about lenalidomide capsules?"
    • are allergic to lenalidomide or any of the ingredients in lenalidomide capsules. See the end of this Medication Guide for a complete list of ingredients in lenalidomide capsules.
    What should I tell my healthcare provider before taking lenalidomide capsules?
    Before you take lenalidomide capsules, tell your healthcare provider about all of your medical conditions, including if you:
    • have liver problems
    • have kidney problems or receive kidney dialysis treatment
    • have thyroid problems
    • have had a serious skin rash with thalidomide treatment. You should not take lenalidomide capsules.
    • are lactose intolerant. Lenalidomide capsules contain lactose.
    • are breastfeeding. Do not breastfeed during treatment with lenalidomide capsules. It is not known if lenalidomide passes into your breast milk and can harm your baby.
    Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Lenalidomide capsules and other medicines may affect each other, causing serious side effects. Talk with your healthcare provider before taking any new medicines.
    Know the medicines you take. Keep a list of them to show your healthcare provider and pharmacist.
    How should I take lenalidomide capsules?
    • Take lenalidomide capsules exactly as prescribed and follow all the instructions of the Lenalidomide REMS program
    • Swallow lenalidomide capsules whole with water 1 time a day. Do not open, break, or chew your capsules.
    • Lenalidomide capsules may be taken with or without food.
    • Take lenalidomide capsules at about the same time each day.
    • Do not open or break lenalidomide capsules or handle them any more than needed.
      • If powder from the lenalidomide capsule comes in contact with your skin, wash the skin right away with soap and water.
      • If powder from the lenalidomide capsule comes in contact with the inside of your eyes, nose, or mouth, flush well with water.
    • If you miss a dose of lenalidomide capsules and it has been less than 12 hours since your regular time, take it as soon as you remember. If it has been more than 12 hours, just skip your missed dose. Do not take 2 doses at the same time.
    • If you take too much lenalidomide capsules, call your healthcare provider right away.
    What should I avoid while taking lenalidomide capsules?
    • See "What is the most important information I should know about lenalidomide capsules?"
    • Females: Do not get pregnant and do not breastfeed while taking lenalidomide capsules.
    • Males: Do not donate sperm while taking lenalidomide capsules, during any breaks (interruptions) in your treatment, and for up to 4 weeks after stopping lenalidomide capsules.
    • Do not share lenalidomide capsules with other people. It may cause birth defects and other serious problems.
    • Do not donate blood while you take lenalidomide capsules, during any breaks (interruptions) in your treatment, and for 4 weeks after stopping lenalidomide capsules. If someone who is pregnant gets your donated blood, her baby may be exposed to lenalidomide capsules and may be born with birth defects.
    What are the possible side effects of lenalidomide capsules?
    Lenalidomide capsules can cause serious side effects, including:
    • See "What is the most important information I should know about lenalidomide capsules?"
    • Increased risk of death in people who have chronic lymphocytic leukemia (CLL). People with CLL who take lenalidomide capsules have an increased risk of death compared with people who take the medicine chlorambucil. Lenalidomide capsules may cause you to have serious heart problems that can lead to death, including atrial fibrillation, heart attack, or heart failure. You should not take lenalidomide capsules if you have CLL unless you are participating in a controlled clinical trial.
    • Risk of new cancers (malignancies). An increase in new (second) cancers has happened in patients who received lenalidomide capsules and melphalan, or a blood stem cell transplant, including certain blood cancers, such as acute myelogenous leukemia (AML), and myelodysplastic syndrome (MDS) and certain other types of cancers of the skin and other organs. Talk with your healthcare provider about your risk of developing new cancers if you take lenalidomide capsules. Your healthcare provider will check you for new cancers during your treatment with lenalidomide capsules.
    • Severe liver problems, including liver failure and death. Your healthcare provider should do blood tests to check your liver function during your treatment with lenalidomide capsules. Tell your healthcare provider right away if you develop any of the following symptoms of liver problems:
    • yellowing of your skin or the white part of your eyes (jaundice)
    • dark or brown (tea-colored) urine
    • pain on the upper right side of your stomach area (abdomen)
    • bleeding or bruising more easily than normal
    • feeling very tired
    • Severe skin reactions and severe allergic reactions can happen with lenalidomide capsules and may cause death.
    •   Call your healthcare provider right away if you develop any of the following signs or symptoms during treatment with lenalidomide capsules:
    • a red, itchy, skin rash
    • peeling of your skin or blisters
    • severe itching
    • fever
    •   Get emergency medical help right away if you develop any of the following signs or symptoms during treatment with lenalidomide capsules:
    • swelling of your lips, mouth, tongue, or throat
    • trouble breathing or swallowing
    • raised red areas on your skin (hives)
    • a very fast heartbeat
    • you feel dizzy or faint
    • Tumor lysis syndrome (TLS). TLS is caused by the fast breakdown of cancer cells. TLS can cause kidney failure and the need for dialysis treatment, abnormal heart rhythm, seizure and sometimes death. Your healthcare provider may do blood tests to check you for TLS.
    • Worsening of your tumor (tumor flare reaction) can happen with lenalidomide capsules and may cause death. Tell your healthcare provider if you get any of these symptoms of tumor flare reaction during treatment with lenalidomide capsules: tender swollen lymph nodes, low grade fever, pain, or rash.
    Your healthcare provider may tell you to decrease your dose, temporarily stop or permanently stop taking lenalidomide capsules if you develop certain serious side effects during treatment with lenalidomide capsules.
    • Thyroid problems. Your healthcare provider may check your thyroid function before you start taking lenalidomide capsules and during treatment with lenalidomide capsules.
    The most common side effects of lenalidomide capsules include:
    • diarrhea
    • rash
    • nausea
    • constipation
    • tiredness or weakness
    • fever
    • itching
    • swelling of your arms, hands, legs, feet and skin
    • sleep problems (insomnia)
    • headache
    • muscle cramps or spasms
    • shortness of breath
    • cough, sore throat, and other symptoms of a cold
    • upper respiratory tract infection or bronchitis
    • inflammation of the stomach and intestine ("stomach flu")
    • nose bleed
    • shaking or trembling (tremor)
    • joint aches
    • pain in your back or stomach-area (abdomen)
    These are not all the possible side effects of lenalidomide capsules.
    Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.
    How should I store lenalidomide capsules?
    • Store lenalidomide capsules at room temperature between 68°F to 77°F (20°C to 25°C).
    • Return any unused lenalidomide capsules to Alvogen, Inc. or your healthcare provider.
    Keep lenalidomide capsules and all medicines out of the reach of children.
    General information about the safe and effective use of lenalidomide capsules
    Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not take lenalidomide capsules for conditions for which it was not prescribed. Do not give lenalidomide capsules to other people, even if they have the same symptoms you have. It may harm them and may cause birth defects.
    If you would like more information, talk with your healthcare provider. You can ask your healthcare provider or pharmacist for information about lenalidomide capsules that is written for health professionals.
    What are the ingredients in lenalidomide capsules?
    Active ingredient:     lenalidomide
    Inactive ingredients: croscarmellose sodium, lactose anhydrous, magnesium stearate and microcrystalline cellulose.
    The 2.5 mg capsule shell contains gelatin, red iron oxide, yellow iron oxide, titanium dioxide, FD&C blue #1, FD&C red #3, FD&C red #40 and black ink.
    The 5 mg capsule shell contains gelatin, titanium dioxide, black iron oxide, red iron oxide, yellow iron oxide, FD&C blue #1, FD&C yellow #6 and black ink.
    The 10 mg capsule shell contains gelatin, titanium dioxide, FD&C blue #1, FD&C red #40, FD&C yellow #6, FD&C yellow #5 and black ink.
    The 15 mg capsule shell contains gelatin, titanium dioxide, FD&C blue #1, FD&C red #40, FD&C yellow #5, black iron oxide, red iron oxide, yellow iron oxide and black ink.
    The 20 mg capsule shell contains gelatin, titanium dioxide, FD&C blue #1, FD&C red #40, red iron oxide, yellow iron oxide and black ink.
    The 25 mg capsule shell contains gelatin, titanium dioxide and black ink.
    The black imprinting ink contains shellac, strong ammonia solution, black iron oxide.

    Manufactured by: Lotus Pharmaceutical Co., Ltd., Nantou City, Nantou County 54066 Taiwan
    OR
    Manufactured by: Haupt Pharma Amareg GmbH, Regensburg, Bavaria D-93055, Germany
    Distributed by: Alvogen, Inc., Morristown, NJ 07960 USA
    Product of India
    For more information, call Alvogen, Inc. at 1-866-770-3024 or go to www.lenalidomiderems.com
  • PACKAGE LABEL PRINCIPAL DISPLAY PANEL SECTION

    NDC: 47781-483-28

    Lenalidomide Capsules
    2.5 mg

    ATTENTION PHARMACIST: Dispense the accompanying Medication Guide to each patient.

    WARNING: POTENTIAL FOR HUMAN BIRTH DEFECTS

    Rx only 28 Capsules

    Container Label 2pt5mg Capsules

  • PACKAGE LABEL PRINCIPAL DISPLAY PANEL

    NDC: 47781-484-28

    Lenalidomide Capsules

    5 mg

    ATTENTION PHARMACIST: Dispense the accompanying Medication Guide to each patient.

    WARNING: POTENTIAL FOR HUMAN BIRTH DEFECTS

    Rx only 28 Capsules

    Container Label 5mg Capsules

  • PACKAGE LABEL PRINCIPAL DISPLAY PANEL

    NDC: 47781-485-28

    Lenalidomide Capsules

    10 mg

    ATTENTION PHARMACIST: Dispense the accompanying Medication Guide to each patient.

    WARNING: POTENTIAL FOR HUMAN BIRTH DEFECTS

    Rx only 28 Capsules

    Container Label 10mg Capsules

  • PACKAGE LABEL PRINCIPAL DISPLAY PANEL

    NDC: 47781-486-77

    Lenalidomide Capsules

    15 mg

    ATTENTION PHARMACIST: Dispense the accompanying Medication Guide to each patient.

    WARNING: POTENTIAL FOR HUMAN BIRTH DEFECTS

    Rx only 21 Capsules

    Container Label 15mg Capsules

  • PACKAGE LABEL PRINCIPAL DISPLAY PANEL SECTION

    NDC: 47781-487-77

    Lenalidomide Capsules
    20 mg

    ATTENTION PHARMACIST: Dispense the accompanying Medication Guide to each patient.

    WARNING: POTENTIAL FOR HUMAN BIRTH DEFECTS

    Rx only 21 Capsules

    Container Label 20mg Capsules

  • PACKAGE LABEL PRINCIPAL DISPLAY PANEL

    NDC: 47781-488-77

    Lenalidomide Capsules

    25 mg

    ATTENTION PHARMACIST: Dispense the accompanying Medication Guide to each patient.

    WARNING: POTENTIAL FOR HUMAN BIRTH DEFECTS

    Rx only 21 Capsules

    Container Label 25mg Capsules

  • INGREDIENTS AND APPEARANCE
    LENALIDOMIDE 
    lenalidomide capsule
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC: 47781-483
    Route of AdministrationORAL
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    LENALIDOMIDE (UNII: F0P408N6V4) (LENALIDOMIDE - UNII:F0P408N6V4) LENALIDOMIDE2.5 mg
    Inactive Ingredients
    Ingredient NameStrength
    CROSCARMELLOSE SODIUM (UNII: M28OL1HH48)  
    ANHYDROUS LACTOSE (UNII: 3SY5LH9PMK)  
    MAGNESIUM STEARATE (UNII: 70097M6I30)  
    MICROCRYSTALLINE CELLULOSE (UNII: OP1R32D61U)  
    GELATIN, UNSPECIFIED (UNII: 2G86QN327L)  
    FERRIC OXIDE RED (UNII: 1K09F3G675)  
    FERRIC OXIDE YELLOW (UNII: EX438O2MRT)  
    TITANIUM DIOXIDE (UNII: 15FIX9V2JP)  
    FD&C BLUE NO. 1 (UNII: H3R47K3TBD)  
    FD&C RED NO. 3 (UNII: PN2ZH5LOQY)  
    FD&C RED NO. 40 (UNII: WZB9127XOA)  
    SHELLAC (UNII: 46N107B71O)  
    AMMONIA (UNII: 5138Q19F1X)  
    FERROSOFERRIC OXIDE (UNII: XM0M87F357)  
    Product Characteristics
    ColorBLUE (DARK BLUE) , ORANGE (LIGHT ORANGE) Scoreno score
    ShapeCAPSULESize14mm
    FlavorImprint Code LP;637
    Contains    
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC: 47781-483-2828 in 1 BOTTLE; Type 0: Not a Combination Product03/06/2023
    2NDC: 47781-483-01100 in 1 BOTTLE; Type 0: Not a Combination Product03/06/2023
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    ANDAANDA21048003/06/2023
    LENALIDOMIDE 
    lenalidomide capsule
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC: 47781-484
    Route of AdministrationORAL
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    LENALIDOMIDE (UNII: F0P408N6V4) (LENALIDOMIDE - UNII:F0P408N6V4) LENALIDOMIDE5 mg
    Inactive Ingredients
    Ingredient NameStrength
    CROSCARMELLOSE SODIUM (UNII: M28OL1HH48)  
    ANHYDROUS LACTOSE (UNII: 3SY5LH9PMK)  
    MAGNESIUM STEARATE (UNII: 70097M6I30)  
    MICROCRYSTALLINE CELLULOSE (UNII: OP1R32D61U)  
    GELATIN, UNSPECIFIED (UNII: 2G86QN327L)  
    TITANIUM DIOXIDE (UNII: 15FIX9V2JP)  
    FERROSOFERRIC OXIDE (UNII: XM0M87F357)  
    FERRIC OXIDE RED (UNII: 1K09F3G675)  
    FERRIC OXIDE YELLOW (UNII: EX438O2MRT)  
    FD&C BLUE NO. 1 (UNII: H3R47K3TBD)  
    FD&C YELLOW NO. 6 (UNII: H77VEI93A8)  
    SHELLAC (UNII: 46N107B71O)  
    AMMONIA (UNII: 5138Q19F1X)  
    Product Characteristics
    ColorGREEN, YELLOW (light caramel) Scoreno score
    ShapeCAPSULESize18mm
    FlavorImprint Code LP;638
    Contains    
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC: 47781-484-2828 in 1 BOTTLE; Type 0: Not a Combination Product09/03/2022
    2NDC: 47781-484-01100 in 1 BOTTLE; Type 0: Not a Combination Product09/03/2022
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    ANDAANDA21048009/03/2022
    LENALIDOMIDE 
    lenalidomide capsule
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC: 47781-485
    Route of AdministrationORAL
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    LENALIDOMIDE (UNII: F0P408N6V4) (LENALIDOMIDE - UNII:F0P408N6V4) LENALIDOMIDE10 mg
    Inactive Ingredients
    Ingredient NameStrength
    CROSCARMELLOSE SODIUM (UNII: M28OL1HH48)  
    ANHYDROUS LACTOSE (UNII: 3SY5LH9PMK)  
    MAGNESIUM STEARATE (UNII: 70097M6I30)  
    MICROCRYSTALLINE CELLULOSE (UNII: OP1R32D61U)  
    GELATIN, UNSPECIFIED (UNII: 2G86QN327L)  
    TITANIUM DIOXIDE (UNII: 15FIX9V2JP)  
    FD&C BLUE NO. 1 (UNII: H3R47K3TBD)  
    FD&C RED NO. 40 (UNII: WZB9127XOA)  
    FD&C YELLOW NO. 6 (UNII: H77VEI93A8)  
    FD&C YELLOW NO. 5 (UNII: I753WB2F1M)  
    SHELLAC (UNII: 46N107B71O)  
    AMMONIA (UNII: 5138Q19F1X)  
    FERROSOFERRIC OXIDE (UNII: XM0M87F357)  
    Product Characteristics
    ColorYELLOW (GOLD) , GRAYScoreno score
    ShapeCAPSULESize22mm
    FlavorImprint Code LP;639
    Contains    
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC: 47781-485-2828 in 1 BOTTLE; Type 0: Not a Combination Product09/03/2022
    2NDC: 47781-485-01100 in 1 BOTTLE; Type 0: Not a Combination Product09/03/2022
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    ANDAANDA21048009/03/2022
    LENALIDOMIDE 
    lenalidomide capsule
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC: 47781-486
    Route of AdministrationORAL
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    LENALIDOMIDE (UNII: F0P408N6V4) (LENALIDOMIDE - UNII:F0P408N6V4) LENALIDOMIDE15 mg
    Inactive Ingredients
    Ingredient NameStrength
    CROSCARMELLOSE SODIUM (UNII: M28OL1HH48)  
    ANHYDROUS LACTOSE (UNII: 3SY5LH9PMK)  
    MAGNESIUM STEARATE (UNII: 70097M6I30)  
    MICROCRYSTALLINE CELLULOSE (UNII: OP1R32D61U)  
    GELATIN, UNSPECIFIED (UNII: 2G86QN327L)  
    TITANIUM DIOXIDE (UNII: 15FIX9V2JP)  
    FD&C BLUE NO. 1 (UNII: H3R47K3TBD)  
    FD&C RED NO. 40 (UNII: WZB9127XOA)  
    FD&C YELLOW NO. 5 (UNII: I753WB2F1M)  
    FERROSOFERRIC OXIDE (UNII: XM0M87F357)  
    FERRIC OXIDE RED (UNII: 1K09F3G675)  
    FERRIC OXIDE YELLOW (UNII: EX438O2MRT)  
    SHELLAC (UNII: 46N107B71O)  
    AMMONIA (UNII: 5138Q19F1X)  
    Product Characteristics
    ColorBROWN (caramel) , GRAYScoreno score
    ShapeCAPSULESize18mm
    FlavorImprint Code LP;640
    Contains    
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC: 47781-486-7721 in 1 BOTTLE; Type 0: Not a Combination Product09/03/2022
    2NDC: 47781-486-01100 in 1 BOTTLE; Type 0: Not a Combination Product09/03/2022
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    ANDAANDA21048009/03/2022
    LENALIDOMIDE 
    lenalidomide capsule
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC: 47781-487
    Route of AdministrationORAL
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    LENALIDOMIDE (UNII: F0P408N6V4) (LENALIDOMIDE - UNII:F0P408N6V4) LENALIDOMIDE20 mg
    Inactive Ingredients
    Ingredient NameStrength
    CROSCARMELLOSE SODIUM (UNII: M28OL1HH48)  
    ANHYDROUS LACTOSE (UNII: 3SY5LH9PMK)  
    MAGNESIUM STEARATE (UNII: 70097M6I30)  
    MICROCRYSTALLINE CELLULOSE (UNII: OP1R32D61U)  
    GELATIN, UNSPECIFIED (UNII: 2G86QN327L)  
    TITANIUM DIOXIDE (UNII: 15FIX9V2JP)  
    FD&C BLUE NO. 1 (UNII: H3R47K3TBD)  
    FD&C RED NO. 40 (UNII: WZB9127XOA)  
    FERRIC OXIDE RED (UNII: 1K09F3G675)  
    FERRIC OXIDE YELLOW (UNII: EX438O2MRT)  
    SHELLAC (UNII: 46N107B71O)  
    AMMONIA (UNII: 5138Q19F1X)  
    FERROSOFERRIC OXIDE (UNII: XM0M87F357)  
    Product Characteristics
    ColorRED (warm brick red) , GRAY (light gray) Scoreno score
    ShapeCAPSULESize19mm
    FlavorImprint Code LP;641
    Contains    
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC: 47781-487-7721 in 1 BOTTLE; Type 0: Not a Combination Product03/06/2023
    2NDC: 47781-487-01100 in 1 BOTTLE; Type 0: Not a Combination Product03/06/2023
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    ANDAANDA21048003/06/2023
    LENALIDOMIDE 
    lenalidomide capsule
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC: 47781-488
    Route of AdministrationORAL
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    LENALIDOMIDE (UNII: F0P408N6V4) (LENALIDOMIDE - UNII:F0P408N6V4) LENALIDOMIDE25 mg
    Inactive Ingredients
    Ingredient NameStrength
    CROSCARMELLOSE SODIUM (UNII: M28OL1HH48)  
    ANHYDROUS LACTOSE (UNII: 3SY5LH9PMK)  
    MAGNESIUM STEARATE (UNII: 70097M6I30)  
    MICROCRYSTALLINE CELLULOSE (UNII: OP1R32D61U)  
    GELATIN, UNSPECIFIED (UNII: 2G86QN327L)  
    TITANIUM DIOXIDE (UNII: 15FIX9V2JP)  
    SHELLAC (UNII: 46N107B71O)  
    AMMONIA (UNII: 5138Q19F1X)  
    FERROSOFERRIC OXIDE (UNII: XM0M87F357)  
    Product Characteristics
    ColorWHITEScoreno score
    ShapeCAPSULESize22mm
    FlavorImprint Code LP;642
    Contains    
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC: 47781-488-7721 in 1 BOTTLE; Type 0: Not a Combination Product09/03/2022
    2NDC: 47781-488-01100 in 1 BOTTLE; Type 0: Not a Combination Product09/03/2022
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    ANDAANDA21048009/03/2022
    Labeler - Alvogen, Inc. (008057330)
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