Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

VENCLEXTA is indicated for the treatment of adult patients with chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL).

See Section 4.2 DOSE AND METHOD OF ADMINISTRATION for details of monotherapy and combination use and Section 5.3 Pre-clinical safety data: CLININCAL STUDIES

Acute Myeloid Leukemia

VENCLEXTA is indicated in combination with azacitidine, or decitabine, or low-dose

cytarabine for the treatment of newly-diagnosed acute myeloid leukemia (AML) in adults who

are age 75 years or older, or who have comorbidities that preclude use of intensive induction

chemotherapy.

This indication is approved under accelerated approval based on response rates [see Clinical

Studies]. Continued approval for this indication may be contingent upon verification and description of clinical benefit in confirmatory trials.

Recommended Dosage

Assess patient-specific factors for level of risk of tumor lysis syndrome (TLS) and provide prophylactic hydration and anti-hyperuricemics to patients prior to first dose of VENCLEXTA to reduce risk of TLS.

Instruct patients to take VENCLEXTA tablets with a meal and water at approximately the same time each day. VENCLEXTA tablets should be swallowed whole and not chewed, crushed, or broken prior to swallowing.

Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

All VENCLEXTA dose regimens begin with a 5-week ramp-up.

VENCLEXTA 5-week Dose Ramp-Up Schedule

Administer the VENCLEXTA dose according to a weekly ramp-up schedule over 5 weeks to the recommended daily dose of 400 mg as shown in Table 2. The 5-week ramp-up dosing schedule is designed to gradually reduce tumor burden (debulk) and decrease the risk of TLS.

Table 2. Dosing Schedule for Ramp-Up Phase

The CLL/SLL Starting Pack provides the first 4 weeks of VENCLEXTA according to the ramp-up schedule. The 400 mg dose is achieved using 100 mg tablets supplied in bottles.

VENCLEXTA in Combination with Obinutuzumab

Start obinutuzumab administration at 100 mg on Cycle 1 Day 1, followed by 900 mg on Cycle 1 Day 2. Administer 1000 mg on Days 8 and 15 of Cycle 1 and on Day 1 of each subsequent 28-day cycle, for a total of 6 cycles. Refer to the obinutuzumab prescribing information for recommended obinutuzumab dosing information.

On Cycle 1 Day 22, start VENCLEXTA according to the 5-week ramp-up schedule (see Table 1). After completing the ramp-up schedule on Cycle 2 Day 28, patients should continue VENCLEXTA 400 mg once daily from Cycle 3 Day 1 until the last day of Cycle 12.

VENCLEXTA in Combination with Rituximab

Start rituximab administration after the patient has completed the 5-week dose ramp-up schedule with VENCLEXTA (see Table 1) and has received the 400 mg dose of VENCLEXTA for 7 days. Administer rituximab on Day 1 of each 28-day cycle for 6 cycles, with rituximab dosed at 375 mg/m² intravenously for Cycle 1 and 500 mg/m² intravenously for Cycles 2-6.

Patients should continue VENCLEXTA 400 mg once daily for 24 months from Cycle 1 Day 1 of rituximab.

VENCLEXTA as Monotherapy

The recommended dose of VENCLEXTA is 400 mg once daily after the patient has completed the 5-week dose ramp-up schedule. VENCLEXTA should be taken orally once daily until disease progression or unacceptable toxicity is observed.

Acute Myeloid Leukemia

The dose of VENCLEXTA depends upon the combination agent.

The VENCLEXTA dosing schedule (including ramp-up) is shown in Table 3. Initiate the azacitidine or decitabine or low-dose cytarabine on Day 1.

Table 3. Dosing Schedule for Ramp-up Phase in Patients with AML

Continue VENCLEXTA, in combination with azacitidine or decitabine or low-dose cytarabine,

until disease progression or unacceptable toxicity is observed.

Risk Assessment and Prophylaxis for Tumor Lysis Syndrome

Patients treated with VENCLEXTA may develop tumor lysis syndrome. Refer to the appropriate section below for specific details on management. Assess patient-specific factors for level of risk of tumor lysis syndrome (TLS) and provide prophylactic hydration and anti-hyperuricemics to patients prior to first dose of VENCLEXTA to reduce risk of TLS.

Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

VENCLEXTA can cause rapid reduction in tumor and thus poses a risk for TLS in the initial 5-week ramp-up phase. Changes in blood chemistries consistent with TLS that require prompt management can occur as early as 6 to 8 hours following the first dose of VENCLEXTA and at each dose increase.

The risk of TLS is a continuum based on multiple factors, including tumor burden and comorbidities. Reduced renal function (creatinine clearance [CLcr] <80 mL/min) further increases the risk. Perform tumor burden assessments, including radiographic evaluation (e.g., CT scan), assess blood chemistry (potassium, uric acid, phosphorus, calcium, and creatinine) in all patients and correct pre- existing abnormalities prior to initiation of treatment with VENCLEXTA. The risk may decrease as tumor burden decreases.

Table 4 below describes the recommended TLS prophylaxis and monitoring during VENCLEXTA

treatment based on tumor burden determination from clinical trial data. Consider all patient comorbidities before final determination of prophylaxis and monitoring schedule.

Table 4. Recommended TLS Prophylaxis Based on Tumor Burden in patients with CLL/SLL  

Acute Myeloid Leukemia

·         All patients should have white blood cell count less than 25 × 109/L prior to initiation of VENCLEXTA. Cytoreduction prior to treatment may be required.

·         Prior to first VENCLEXTA dose, provide all patients with prophylactic measures including adequate hydration and anti-hyperuricemic agents and continue during ramp-up phase.

·         Assess blood chemistry (potassium, uric acid, phosphorus, calcium, and creatinine) and correct pre-existing abnormalities prior to initiation of treatment with VENCLEXTA.

·         Monitor blood chemistries for TLS at pre-dose, 6 to 8 hours after each new dose during ramp-up and 24 hours after reaching final dose.

·         For patients with risk factors for TLS (e.g., circulating blasts, high burden of leukemia involvement in bone marrow, elevated pretreatment lactate dehydrogenase (LDH) levels, or reduced renal function) additional measures should be considered, including increased laboratory monitoring and reducing VENCLEXTA starting dose.

Dose Modifications Based on Toxicities

Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

Interrupt dosing or reduce dose for toxicities. See Table 5 and Table 6 for recommended dose

modifications for toxicities related to VENCLEXTA. For patients who have had a dosing interruption greater than 1 week during the first 5 weeks of ramp-up phase or greater than 2 weeks after completing the ramp-up phase, reassess for risk of TLS to determine if reinitiation with a reduced dose is necessary (e.g., all or some levels of the dose ramp-up schedule).

Table 5. Recommended VENCLEXTA Dose Modifications for Toxicities^a in CLL/SLL

Table 6. Dose Modification for Toxicity During VENCLEXTA Treatment in CLL/SLL

Acute Myeloid Leukemia

Monitor blood counts frequently through resolution of cytopenias. Management of some adverse reactions may require dose interruptions or permanent discontinuation of VENCLEXTA. Table 7 shows the dose modification guidelines for hematologic toxicities.

Table 7. Recommended Dose Modifications for Toxicitiesa in AML

Dosage Modifications for Concomitant Use with Strong or Moderate CYP3A Inhibitors or P-gp Inhibitors

Table 8 describes VENCLEXTA contraindication or dosage modification based on concomitant use with a strong or                                    moderate CYP3A inhibitor or P-gp inhibitor [see Drug Interactions] at initiation, during, or after the ramp-up phase.

Resume the VENCLEXTA dosage that was used prior to concomitant use of a strong or moderate CYP3A inhibitor or P-gp inhibitor 2 to 3 days after discontinuation of the inhibitor [see Posology and method of administration  and Drug Interactions].

Table 8. Management of Potential VENCLEXTA Interactions with CYP3A and P-gp Inhibitors

Dosage Modifications for Patients with Severe Hepatic Impairment

Reduce the VENCLEXTA once daily dose by 50% for patients with severe hepatic impairment (Child-Pugh C); monitor these patients more closely for signs of toxicity [see Use in Specific Populations and Clinical Pharmacology].

Missed Dose

If the patient misses a dose of VENCLEXTA within 8 hours of the time it is usually taken, the patient should take the missed dose as soon as possible and resume the normal daily dosing schedule. If a patient misses a dose by more than 8 hours, the patient should not take the missed dose and should resume the usual dosing schedule the next day.

If the patient vomits following dosing, no additional dose should be taken that day. The next prescribed dose should be taken at the usual time.

Use  in  Specific  Populations

Pediatric  Use

Safety and effectiveness have not been established in pediatric patients

In a juvenile toxicology study, mice were administered venetoclax at 10, 30, or 100 mg/kg/day by oral gavage from 7 to 60 days of age. Clinical signs of toxicity included decreased activity, dehydration, skin pallor, and hunched posture at ≥30 mg/kg/day. In addition, mortality and body weight effects occurred at 100 mg/kg/day. Other venetoclax-related effects were reversible decreases in lymphocytes at ≥10 mg/kg/day; a dose of 10 mg/kg/day is approximately 0.06 times the clinical dose of 400 mg on a mg/m2 basis for a 20 kg child.

Geriatric  Use

Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

Of the 352 patients with previously treated CLL/SLL evaluated for safety from 3 open-label trials of VENCLEXTA monotherapy, 57% (201/352) were ≥65 years of age and 18% (62/352) were ≥75 years of age.

No clinically meaningful differences in safety and effectiveness were observed between older and younger patients in the combination and monotherapy studies.

Acute Myeloid Leukemia

Of the 67 patients treated with VENCLEXTA in combination with azacitidine in the clinical trial, 96% were ≥65 years of age and 50% were ≥ 75 years of age. Of the 13 patients treated with VENCLEXTA in combination with decitabine in the clinical trial, 100% were ≥65 years of age and 26% were ≥ 75 years of age. Of the 61 patients treated with VENCLEXTA in combination with low-dose cytarabine, 97% were ≥65 years of age and 66% were ≥75 years of age.

The efficacy and safety data presented in the Adverse Reactions and Clinical Studies sections were obtained from these patients [see Adverse Reactions (6.2) and Clinical Studies (14.2)].

There are insufficient patient numbers to show differences in safety and effectiveness between geriatric and younger patients.

Renal  Impairment

Due to the increased risk of TLS, patients with reduced renal function (CLcr <80 mL/min, calculated by Cockcroft-Gault formula require more intensive prophylaxis and monitoring to reduce the risk of TLS when initiating treatment with VENCLEXTA.

No dose adjustment is recommended for patients with mild or moderate renal impairment (CLcr ≥ 30 mL/min [see Clinical Pharmacology (12.3)]. A recommended dose has not been determined for patients with severe renal impairment (CLcr < 30 mL/min) or patients on dialysis.

Hepatic  Impairment

No dose adjustment is recommended for patients with mild (Child-Pugh A) or moderate (Child-Pugh B) hepatic impairment.

Reduce the dose of VENCLEXTA for patients with severe hepatic impairment (Child-Pugh C); monitor these patients more closely for signs of toxicity [see Posology and method of administration and Clinical Pharmacology].

Method  of  administration

VENCLEXTA should be taken orally once daily until disease progression or unacceptable toxicity is observed. Instruct patients to take VENCLEXTA tablets with a meal and water at approximately the same time each day. VENCLEXTA tablets should be swallowed whole and not chewed, crushed, or broken prior to swallowing.

Tumor   Lysis   Syndrome

Tumor lysis syndrome (TLS), including fatal events and renal failure requiring dialysis, has occurred in patients with previously treated CLL with high tumor burden when treated with VENCLEXTA.

In patients with CLL, the current (5 week) dose ramp-up, TLS prophylaxis and monitoring, the rate of TLS was 2% in the VENCLEXTA CLL monotherapy studies. The rate of TLS remained consistent with VENCLEXTA in combination with rituximab. With a 2 to 3 week dose ramp-up and higher starting dose in patients with CLL/SLL, the TLS rate was 13% and included deaths and renal failure.

VENCLEXTA can cause rapid reduction in tumor and thus poses a risk for TLS at initiation and during the ramp-up phase. Changes in blood chemistries consistent with TLS that require prompt management can occur as early as 6 to 8 hours following the first dose of VENCLEXTA and at each dose increase.

The risk of TLS is a continuum based on multiple factors, including tumor burden and comorbidities. Reduced renal function further increases the risk. Patients should be assessed for risk and should receive appropriate prophylaxis for TLS, including hydration and anti- hyperuricemics. Monitor blood chemistries and manage abnormalities promptly. Interrupt dosing if needed. Employ more intensive measures (intravenous hydration, frequent monitoring, hospitalization) as overall risk increases.

Concomitant use of VENCLEXTA with P-gp inhibitors strong or moderate CYP3A inhibitors increases venetoclax exposure, may increase the risk of TLS at initiation and during ramp-up phase and may requires VENCLEXTA dose adjustment.

Neutropenia

In patients with CLL, Grade 3 or 4 neutropenia developed in 63% to 64% of patients and Grade 4 neutropenia developed in 31% to 33% of patients treated with VENCLEXTA in combination and monotherapy studies (see Tables 10, 12, 14). Febrile neutropenia occurred in 4% to 6% of patients treated with VENCLEXTA in combination and monotherapy studies

In patients with AML, baseline neutrophil counts worsened in 97% to 100% of patients treated with VENCLEXTA in combination with azacitidine or decitabine or low-dose cytarabine. Neutropenia can recur with subsequent cycles of therapy.

Monitor complete blood counts throughout the treatment period. Interrupt dosing or reduce dose for severe neutropenia. Consider supportive measures including antimicrobials for signs of infection and use of growth factors (e.g., G-CSF).

Infections

Fatal and serious infections such as pneumonia and sepsis have occurred in patients treated with VENCLEXTA. Monitor patients closely for signs and symptoms of infection and treat promptly. Withhold VENCLEXTA for Grade 3 and higher infection.

Immunization

Do not administer live attenuated vaccines prior to, during, or after treatment with VENCLEXTA until

B-cell recovery occurs. The safety and efficacy of immunization with live attenuated vaccines during or following VENCLEXTA therapy have not been studied. Advise patients that vaccinations may be less effective.

Embryo-Fetal Toxicity

Based on its mechanism of action and findings in animals, VENCLEXTA may cause embryo-fetal harm when administered to a pregnant woman. In an embryo-fetal study conducted in mice, administration of venetoclax to pregnant animals at exposures equivalent to that observed in patients at the recommended dose of 400 mg daily resulted in post-implantation loss and decreased fetal weight. There are no adequate and well-controlled studies in pregnant woman using VENCLEXTA. Advise females of reproductive potential to avoid pregnancy during treatment. If VENCLEXTA is used during pregnancy or if the patient becomes pregnant while taking VENCLEXTA, the patient should be apprised of the potential hazard to the fetus.

Increased Mortality in Patients with Multiple Myeloma when VENCLEXTA is Added to Bortezomib and Dexamethasone

In a randomized trial (BELLINI; NCT02755597) in patients with relapsed or refractory multiple myeloma, the addition of VENCLEXTA to bortezomib plus dexamethasone, a use for which VENCLEXTA is not indicated, resulted in increased mortality. Treatment of patients with multiple myeloma with VENCLEXTA in combination with bortezomib plus dexamethasone is not recommended outside of controlled clinical trials.

Effect of other drugs on Venclexta

Strong or moderate  CYP3A  Inhibitors or P-gp inhibitors

Concomitant use with a strong or moderate CYP3A inhibitor or a P-gp inhibitor increases venetoclax Cmax and AUCinf, which may increase VENCLEXTA toxicities, including the risk of TLS [see Warnings and Precautions (5)].

Concomitant use with a strong CYP3A inhibitor at initiation and during the ramp-up phase in patients with CLL/SLL is contraindicated.

In patients with CLL/SLL taking a steady daily dosage (after ramp-up phase), consider alternative medications or adjust VENCLEXTA dosage and closely monitor for signs of VENCLEXTA toxicities.

In patients with AML, adjust VENCLEXTA dosage and closely monitor for signs of VENCLEXTA toxicities.

Resume the VENCLEXTA dosage that was used prior to concomitant use with a strong or moderate CYP3A inhibitor or a P-gp inhibitor 2 to 3 days after discontinuation of the inhibitor.

Avoid grapefruit products, Seville oranges, and starfruit during treatment with VENCLEXTA, as they contain inhibitors of CYP3A.

Strong or Moderate CYP3A Inducers

Concomitant use with a strong CYP3A inducer decreases venetoclax Cmax and AUCinf, which may decrease VENCLEXTA efficacy. Avoid concomitant use of VENCLEXTA with strong CYP3A inducers or moderate CYP3A inducers.

Bile acid sequestrants

Avoid co-administration of bile acid sequestrants with VENCLEXTA as this may reduce the absorption of venetoclax. If a bile acid sequestrant must be used, follow the prescribing information for the bile acid sequestrant to reduce the risk for an interaction and administer VENCLEXTA at least 4-6 hours after the sequestrant.

Effects  of   VENCLEXTA on  Other    Drugs

Warfarin

Concomitant use of VENCLEXTA increases warfarin Cmax and AUCinf, which may increase the risk of bleeding. Closely monitor international normalized ratio (INR) in patients using warfarin concomitantly with VENCLEXTA.

P-gp substrates

Concomitant use of VENCLEXTA increases Cmax and AUCinf of P-gp substrates, which may increase toxicities of these substrates. Avoid concomitant use of VENCLEXTA with a P-gp substrate. If a concomitant use is unavoidable, separate dosing ofthe P-gp substrate at least 6 hours before VENCLEXTA.

Pregnancy

Risk  Summary

There are no available data on VENCLEXTA use in pregnant women to inform a drugassociated risk of major birth defects and miscarriage. Based on toxicity observed in mice, VENCLEXTA may cause fetal harm when administered to pregnant women. In mice, venetoclax was fetotoxic at exposures 1.2 times the human clinical exposure based on AUC at the recommended human dose of 400 mg daily. If VENCLEXTA is used during pregnancy or if the patient becomes pregnant while taking VENCLEXTA, the patient should be apprised of the potential risk to a fetus.

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 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 embryo-fetal development studies, venetoclax was administered to pregnant mice and rabbits during the period of organogenesis. In mice, venetoclax was associated with increased post- implantation loss and decreased fetal body weight at 150 mg/kg/day (maternal exposures approximately 1.2 times the human AUC exposure at the recommended dose of 400 mg daily). No teratogenicity was observed in either the mouse or the rabbit.

Lactation

 Risk  Summary

There are no data on the presence of VENCLEXTA in human milk, the effects of VENCLEXTA on the breastfed child, or the effects of VENCLEXTA on milk production. Venetoclax was present in the milk when administered to lactating rats (see Data)

Because many drugs are excreted in human milk and because the potential for serious adverse reactions in a breastfed child from VENCLEXTA is unknown, advise nursing women to discontinue breastfeeding during treatment with VENCLEXTA.

Data

Animal Data

Venetoclax was administered (single dose; 150 mg/kg oral) to lactating rats 8 to 10 days parturition. Venetoclax in milk was 1.6 times lower than in plasma. Parent drug (venetoclax) represented the majority of the total drug-related material in milk, with trace levels of three metabolites.

 Females  and  Males  of  Reproductive  Potential

VENCLEXTA may cause fetal harm. Pregnancy  Testing

Conduct pregnancy testing in females of reproductive potential before initiation of VENCLEXTA.

Contraception

Advise females of reproductive potential to use effective contraception during treatment with VENCLEXTA and for at least 30 days after the last dose.

Infertility

Based on findings in animals, male fertility may be compromised by treatment with VENCLEXTA.

No studies on the effects of VENCLEXTA on the ability to drive and use machines have been performed.

VENCLEXTA has no or negligible influence on the ability to drive and use machines.

The following serious adverse events are discussed in greater detail in other sections of the labeling:

·         Tumor Lysis Syndrome

·         Neutropenia

Because clinical trials are conducted under widely variable conditions, adverse event rates observed in clinical trials of a drug cannot be directly compared with rates of clinical trials of another drug and may not reflect the rates observed in practice.

Clinical     Trial  Experience with CLL/SLL

MURANO

The safety of VENCLEXTA in combination with rituximab (VEN+R) versus bendamustine in combination with rituximab (B+R), was evaluated in an open-label randomized study, in patients with CLL who had received at least one prior therapy.

Patients randomized to VEN+R completed the scheduled ramp-up (5 weeks) and received

VENCLEXTA 400 mg once daily in combination with rituximab for 6 cycles followed by single agent VENCLEXTA for a total of 24 months after ramp-up. Patients randomized to B+R received 6 cycles (28 days per cycle) for a total of 6 months. Details of the study treatment are described in Section 14 [see Clinical Studies (14.1)].

At the time of analysis, the median duration of exposure was 22 months in the VEN+R arm compared with 6 months in the B+R arm.

In the VEN+R arm, fatal adverse reactions that occurred in the absence of disease progression and within 30 days of the last VENCLEXTA treatment and/or 90 days of last rituximab were reported in 2% (4/194) of patients. Serious adverse reactions were reported in 46% of patients in the VEN+R arm, with most frequent (≥5%) being pneumonia (9%).

In the VEN+R arm, adverse reactions led to treatment discontinuation in 16% of patients, dose reduction in 15%, and dose interruption in 71%. In the B+R arm, adverse reactions led to treatment discontinuation in 10% of patients, dose reduction in 15%, and dose interruption in 40%. In the VEN+R arm, neutropenia led to dose interruption of VENCLEXTA in 46% of patients and discontinuation in 3%, and thrombocytopenia led to discontinuation in 3% of patients.

Table 9 and Table 10 present adverse reactions and laboratory abnormalities, respectively, identified in the MURANO trial. The MURANO trial was not designed to demonstrate a statistically significant difference in adverse reaction rates for VEN+R as compared with B+R, for any specific adverse reaction or laboratory abnormality.

Table 9. Common (≥10%) Adverse Reactions Reported with ≥5% Higher All-Grade or ≥2% Higher Grade ≥3 Incidence in Patients Treated with VEN+R Compared with B+R

Other adverse reactions (all Grades) reported in ≥10% of patients in the VEN+R arm in MURANO, and other important adverse reactions are presented below:

Blood & lymphatic system disorders: anemia (16%), thrombocytopenia (15%), febrile neutropenia (4%)

Gastrointestinal disorders: nausea (21%), constipation (14%), abdominal pain (13%), mucositis (10%), vomiting (8%)

Respiratory disorders: cough (22%)

General disorders and administration site conditions: fatigue (22%), pyrexia (15%)

Skin disorders: rash (13%)

Nervous system and psychiatric disorders: headache (11%), insomnia (11%)

Infections & infestations: pneumonia (10%)

During treatment with single agent VENCLEXTA after completion of VEN+R combination treatment, the most common all grade adverse reactions (≥10% patients) reported were upper respiratory tract infection (21%), diarrhea (19%), neutropenia (16%), and lower respiratory tract infections (11%).The most common grade 3 or 4 adverse reaction (≥2% patients) were neutropenia (12%) and anemia (3%).

Laboratory Abnormalities

Table 10 describes common treatment-emergent laboratory abnormalities identified in the MURANO trial.

Table 10. Common (≥10%) New or Worsening Laboratory Abnormalities Occurring at ≥5% (Any Grade) or ≥2% (Grade 3 or 4) Higher Incidence with VEN+R Compared with B+R

New Grade 4 laboratory abnormalities reported in ≥2% of patients treated with VEN+R included neutropenia (31%), lymphopenia (16%), leukopenia (6%), thrombocytopenia (6%), hyperuricemia (4%), hypocalcemia (2%), hypoglycemia (2%), and hypermagnesemia (2%).

Monotherapy Studies (M13-982, M14-032, and M12-175)

The safety of single agent VENCLEXTA at the 400 mg recommended daily dose following a dose ramp-up schedule is based on pooled data from three single-arm trials (M13-982, M14-032, and M12-175). In the pooled dataset, consisting of 352 patients with previously treated CLL or SLL, the median age was 66 years (range: 28 to 85 years), 93% were white, and 68% were male. The median number of prior therapies was 3 (range: 0 to 15). The median duration of treatment with VENCLEXTA at the time of data analysis was 14.5 months (range: 0 to 50 months). Fifty-two percent of patients received VENCLEXTA for more than 60 weeks.

Fatal adverse reactions that occurred in the absence of disease progression and within 30 days of venetoclax treatment were reported in 2% of patients in the VENCLEXTA monotherapy studies, most commonly (2 patients) from septic shock. Serious adverse reactions were reported in 52% of patients, with the most frequent (≥5%) being pneumonia (9%), febrile neutropenia (5%), and sepsis (5%).

Adverse reactions led to treatment discontinuation in 9% of patients, dose reduction in 13%, and dose interruption in 36%. The most frequent adverse reactions leading to drug discontinuation were thrombocytopenia and autoimmune hemolytic anemia. The most frequent adverse reaction (≥5%) leading to dose reductions or interruptions was neutropenia (8%).

Adverse reactions identified in these trials of single-agent VENCLEXTA are presented in Table 11

Table 11. Adverse Reactions Reported in ≥10% (Any Grade) or ≥5% (Grade ≥3) of Patients with Previously Treated CLL/SLL (VENCLEXTA Monotherapy)

Laboratory Abnormalities

Table 12 describes common laboratory abnormalities reported throughout treatment that were new or worsening from baseline. The most common (>5%) Grade 4 laboratory abnormalities observed with VENCLEXTA monotherapy were hematologic laboratory abnormalities, including neutropenia (33%), leukopenia (11%), thrombocytopenia (15%), and lymphopenia (9%).

Table 12. New or Worsening Laboratory Abnormalities with VENCLEXTA Monotherapy (≥40% Any Grade or ≥10% Grade 3 or 4)

Important Adverse Reactions

Tumor Lysis Syndrome

Tumor lysis syndrome is an important identified risk when initiating VENCLEXTA.

MURANO

In the open-label randomized phase 3 study, the incidence of TLS was 3% (6/194) in patients

treated with VEN+R. After 77/389 patients were enrolled in the study, the protocol was amended

to incorporate the current TLS prophylaxis and monitoring measures described in sections Dosage And Administration.

All events of TLS occurred during the VENCLEXTA ramp-up period and were resolved within two days. All six patients completed the ramp-up and reached the recommended daily dose of 400 mg of VENCLEXTA. No clinical

TLS was observed in patients who followed the current 5-week ramp-up schedule and TLS prophylaxis and monitoring measures described in Dosage And Administration. Rates of laboratory abnormalities relevant to TLS for patients treated with VEN+R are presented in Table 10.

Monotherapy Studies (M13-982 and M14-032)

In 168 patients with CLL treated according to recommendations described in Dosage And Administration , the rate of TLS was 62%. All events either met laboratory TLS criteria (laboratory abnormalities that met ≥2 of the following within 24 hours of each other: potassium >6 mmol/L, uric acid >476 µmol/L, calcium <1.75 mmol/L, or phosphorus >1.5 mmol/L); or were reported as TLS events. The events occurred in patients who had a lymph node(s) ≥5 cm and/or ALC ≥25 x 109/L. All events resolved within 5 days. No TLS with clinical consequences such as acute renal failure, cardiac arrhythmias or sudden death and/or seizures was observed in these patients. All patients had CLcr ≥50 mL/min. Laboratory abnormalities relevant to TLS were hyperkalemia (17% all Grades, 1% Grade ≥3), hyperphosphatemia (14% all Grades, 2% Grade ≥3), hypocalcemia (16% all Grades, 2% Grade ≥3), and hyperuricemia (10% all Grades, <1% Grade ≥3).

In the initial Phase 1 dose-finding trials, which had shorter (2-3 week) ramp-up phase and higher starting doses, the incidence of TLS was 13% (10/77; 5 laboratory TLS, 5 clinical TLS), including 2 fatal events and 3 events of acute renal failure, 1 requiring dialysis. After this experience, TLS risk assessment, dosing regimen, TLS prophylaxis and monitoring measures were revised.

Clinical Trial Experience with AML

The safety of VENCLEXTA (400 mg daily dose) in combination with azacitidine (n=67) or decitabine (n= 13) and VENCLEXTA (600 mg daily dose) in combination with low-dose cytarabine (n= 61) is based on two non-randomized trials of patients with newly-diagnosed AML. The median duration of exposure for patients taking VENCLEXTA in combination with azacitidine and decitabine was 6.5 months (range: 0.1 to 31.9 months) and 8.4 months (range: 0.5 to 22.3 months), respectively. The median duration of exposure for patients taking VENCLEXTA in combination with low dose cytarabine was 3.9 months (range: 0.2 to 29.2 months).

VENCLEXTA in Combination with Azacitidine or Decitabine

Azacitidine

The most common adverse reactions (≥30%) of any grade were nausea, diarrhea, constipation, neutropenia, thrombocytopenia, hemorrhage, peripheral edema, vomiting, fatigue, febrile neutropenia, rash, and anemia.

Serious adverse reactions were reported in 75% of patients. The most frequent serious adverse reactions (≥5%) were febrile neutropenia, pneumonia (excluding fungal), sepsis (excluding fungal), respiratory failure, and multiple organ dysfunction syndrome.

The incidence of fatal adverse drug reactions was 1.5% within 30 days of starting treatment. No reaction had an incidence of ≥2%.

Discontinuations due to adverse reactions occurred in 21% of patients. The most frequent adverse reactions leading to drug discontinuation (≥2%) were febrile neutropenia and pneumonia (excluding fungal).

Dosage interruptions due to adverse reactions occurred in 61% of patients. The most frequent adverse reactions leading to dose interruption (≥5%) were neutropenia, febrile neutropenia, and pneumonia (excluding fungal).

Dosage reductions due to adverse reactions occurred in 12% of patients. The most frequent adverse reaction leading to dose reduction (≥5%) was neutropenia.

Decitabine

The most common adverse reactions (≥30%) of any grade were febrile neutropenia, constipation, fatigue, thrombocytopenia, abdominal pain, dizziness, hemorrhage, nausea, pneumonia hypotension, myalgia, oropharyngeal pain, peripheral edema, pyrexia, and rash.

Serious adverse reactions were reported in 85% of patients. The most frequent serious adverse reactions (≥5%) were febrile neutropenia, sepsis (excluding fungal), pneumonia (excluding fungal), diarrhea, fatigue, cellulitis, and localized infection.

One (8%) fatal adverse drug reaction of bacteremia occurred within 30 days of starting treatment.

Discontinuations due to adverse reactions occurred in 38% of patients. The most frequent adverse reaction leading to drug discontinuation (≥5%) was pneumonia (excluding fungal).

Dosage interruptions due to adverse reactions occurred in 62% of patients. The most frequent adverse reactions leading to dose interruption (≥5%) were febrile neutropenia, neutropenia, and pneumonia (excluding fungal).

Dosage reductions due to adverse reactions occurred in 15% of patients. The most frequent adverse reaction leading to dose reduction (≥5%) was neutropenia.

Adverse reactions reported in patients with newly-diagnosed AML using VENCLEXTA in combination with azacitidine or decitabine are presented in Table 13.

Table 13. Adverse Reactions Reported in ≥30% (Any Grade) or ≥5% (Grade ≥3) of Patients with AML Treated with VENCLEXTA in Combination with Azacitidine or Decitabine

Laboratory Abnormalities

Table 14 describes common laboratory abnormalities reported throughout treatment that were new or worsening from baseline.

Table 14. New or Worsening Laboratory Abnormalities with VENCLEXTA Reported in ≥40% (Any Grade) or ≥10% (Grade 3 or 4) of Patients with AML Treated with VENCLEXTA in Combination with Azacitidine or Decitabine

VENCLEXTA in Combination with Low-Dose Cytarabine

The most common adverse reactions (≥30%) of any grade were nausea, thrombocytopenia, hemorrhage, febrile neutropenia, neutropenia, diarrhea, fatigue, constipation, and dyspnea.

Serious adverse reactions were reported in 95% of patients. The most frequent serious adverse reactions (≥5%) were febrile neutropenia, sepsis (excluding fungal), hemorrhage, pneumonia (excluding fungal), and device-related infection.

The incidence of fatal adverse drug reactions was 4.9% within 30 days of starting treatment with no reaction having an incidence of ≥2%.

Discontinuations due to adverse reactions occurred in 33% of patients. The most frequent adverse reactions leading to drug discontinuation (≥2%) were hemorrhage and sepsis (excluding fungal).

Dosage interruptions due to adverse reactions occurred in 52% of patients. The most frequent adverse reactions leading to dose interruption (≥5%) were thrombocytopenia, neutropenia, and febrile neutropenia.

Dosage reductions due to adverse reactions occurred in 8% of patients. The most frequent adverse reaction leading to dose reduction (≥2%) was thrombocytopenia.

Adverse reactions reported in patients with newly-diagnosed AML receiving VENCLEXTA in combination with low-dose cytarabine are presented in Table 15.

Table 15. Adverse Reactions Reported in ≥30% (Any Grade) or ≥5% (Grade ≥3) of Patients with AML Treated with VENCLEXTA in Combination with Low-Dose Cytarabine.

Laboratory Abnormalities

Table 16 describes common laboratory abnormalities reported throughout treatment that were new or worsening from baseline.

Table 16. New or Worsening Laboratory Abnormalities with VENCLEXTA Reported in ≥40% (Any Grade) or ≥10% (Grade 3 or 4) of Patients with AML Treated with VENCLEXTA in Combination with Low-Dose Cytarabine

Tumor Lysis Syndrome

Tumor lysis syndrome is an important risk when initiating treatment in patients with AML. The incidence of TLS was 3% (2/61) with VENCLEXTA in combination with low-dose cytarabine with implementation of dose ramp-up schedule in addition to standard prophylaxis and monitoring measures. All events were laboratory TLS, and all patients were able to reach the target dose.

To report any side effects for VENCLEXTA please contact:

Saudi Arabia

The National Pharmacovigilance and Drug Safety Center - Saudi food and drug authority

Fax: +966-11-205-7662

Call NPC at  +966-11-2038222,

Ext: 2317-2356-2353-2354-2334

Toll free phone: 8002490000        

E-mail: npc.drug@sfda.gov.sa

Website: www.sfda.gov.sa/npc 

There is no specific antidote for VENCLEXTA. For patients who experience overdose, closely monitor and provide appropriate supportive treatment; during ramp-up phase interrupt VENCLEXTA and monitor carefully for signs and symptoms of TLS along with other toxicities. Based on Venetoclax large volume of distribution and extensive protein binding, dialysis is unlikely to result in significant removal of Venetoclax.

Pharmacotherapeutic group: other antineoplastic agents, ATC code: not yet assigned

Mechanism  of  action

Venetoclax is a selective and orally bioavailable small-molecule inhibitor of BCL-2, an anti- apoptotic protein. Overexpression of BCL-2 has been demonstrated in CLL and AML cells where it mediates tumor cell survival and has been associated with resistance to chemotherapeutics. Venetoclax helps restore the process of apoptosis by binding directly to the BCL-2 protein, displacing pro-apoptotic proteins like BIM, triggering mitochondrial outer membrane permeabilization and the activation of caspases. In nonclinical studies, venetoclax has demonstrated cytotoxic activity in tumor cells that overexpress BCL-2.

Pharmacodynamic   effects

Based on the exposure response analyses for efficacy, a relationship between drug exposure and a greater likelihood of response was observed in clinical studies in patients with CLL/SLL, and in patients with AML. Based on the exposure response analyses for safety, a relationship between drug exposure and a greater likelihood of some safety events was observed in clinical studies in patients with AML. No exposure-safety relationship was observed in patients with CLL/SLL at doses up to 1200 mg given as monotherapy and up to 600 mg given in combination with rituximab.

Cardiac  Electrophysiology

The effect of multiple doses of VENCLEXTA up to 1200 mg once daily (2 times the maximum

approved recommended dosage) on the QTc interval was evaluated in an open-label, single-arm study in 176 patients with previously treated hematologic malignancies. VENCLEXTA had no large effect on QTc interval (i.e., > 20 ms) and there was no relationship between Venetoclax exposure and change in QTc interval.

Venetoclax mean (± standard deviation) steady state Cmax was 2.1 ± 1.1 mcg/mL and AUC0-24 was 32.8 ± 16.9 mcg•h/mL following administration of 400 mg once daily with a low-fat meal.Venetoclax steady state AUC increased proportionally over the dose range of 150 to 800 mg (0.25 to 1.33 times the maximum approved recommended dosage). The pharmacokinetics of venetoclax does not change over time.

Absorption

Maximum plasma concentration of venetoclax was reached 5 to 8 hours following multiple oral administration under fed conditions.

Effect of food

Administration with a low-fat meal (approximately 512 kilocalories, 25% fat calories, 60% carbohydrate calories, and 15% protein calories) increased venetoclax exposure by approximately 3.4-fold and administration with a high-fat meal (approximately 753 kilocalories, 55% fat calories, 28% carbohydrate calories, and 17% protein calories) increased Venetoclax exposure by 5.1- to 5.3-fold compared with fasting conditions.

Distribution

Venetoclax is highly bound to human plasma protein with unbound fraction in plasma <0.01 across a concentration range of 1-30 micromolar (0.87-26 mcg/mL). The mean blood-to-plasma ratio was 0.57. The apparent volume of distribution (Vdss/F) of venetoclax ranged from 256-321 L in patients.

Metabolism

Venetoclax is predominantly metabolized by CYP3A in vitro. The major metabolite identified in plasma, M27, has an inhibitory activity against BCL-2 that is at least 58-fold lower than venetoclax in vitro and its AUC represented 80% of the parent AUC.

Elimination

The terminal elimination half-life of venetoclax was approximately 26 hours.

Excretion

After single oral dose of radiolabeled [14C]-venetoclax 200 mg to healthy subjects, > 99.9% of the dose was recovered in feces (20.8% as unchanged) and < 0.1% in urine within 9 days.

Special  Populations

No clinically significant differences in the pharmacokinetics of venetoclax were observed based on age (19 to 90 years), sex, race (White, Black, Asians, and Others), weight, mild to moderate renal impairment (CLcr 30 to 89 mL/min, calculated by Cockcroft-Gault), or mild to moderate hepatic impairment (normal total bilirubin and aspartate transaminase (AST) > upper limit of normal (ULN) or total bilirubin 1 to 3 times ULN). The effect of severe renal impairment (CLcr < 30 mL/min), dialysis, or severe hepatic impairment (total bilirubin > 3 times ULN) on venetoclax pharmacokinetics is unknown.

Renal  Impairment

Patients with reduced renal function (CrCl <80 mL/min) are at increased risk of TLS. These patients may require more intensive prophylaxis and monitoring to reduce the risk of TLS when initiating treatment with VENCLEXTA.

No specific clinical trials have been conducted in subjects with renal impairment. Less than 0.1% of radioactive VENCLEXTA dose was detected in urine. No dose adjustment is needed for patients with mild or moderate renal impairment (CrCl ≥30 mL/min) based on results of the population pharmacokinetic analysis. A recommended dose has not been determined for patients with severe renal impairment (CrCl <30 mL/min) or patients on dialysis.

Hepatic  Impairment

No specific clinical trials have been conducted in subjects with hepatic impairment, however human mass balance study showed that venetoclax undergoes hepatic elimination. Although no dose adjustment is recommended in patients with mild or moderate hepatic impairment based on results of the population pharmacokinetic analysis, a trend for increased adverse events was observed in patients with moderate hepatic impairment; monitor these patients more closely for signs of toxicity during the initiation and dose ramp-up phase. A recommended dose has not been determined for patients with severe hepatic impairment.

Drug  Interactions studies

Clinical Studies

No clinically significant differences in venetoclax pharmacokinetics were observed when coadministered with azacitidine, azithromycin, cytarabine, decitabine, gastric acid reducing agents, or rituximab.

Ketoconazole

Concomitant use of ketoconazole (a strong CYP3A, P-gp and BCRP inhibitor) 400 mg once daily for 7 days increased venetoclax Cmax by 130% and AUCinf by 540%

Ritonavir

Concomitant use of ritonavir (a strong CYP3A, P-gp and OATP1B1/B3 inhibitor) 50 mg once daily for 14 days increased venetoclax Cmax by 140% and AUC by 690%.

Posaconazole

Concomitant use of posaconazole (a strong CYP3A and P-gp inhibitor) 300 mg with Venetoclax 50 mg and 100 mg for 7 days resulted in 61% and 86% higher venetoclax Cmax, respectively, compared with venetoclax 400 mg administered alone. The venetoclax AUC24 was 90% and 144% higher, respectively.

Rifampin

Concomitant use of a single dose of rifampin (an OATP1B1/1B3 and P-gp inhibitor) 600 mg increased venetoclax Cmax by 106% and AUCinf by 78%. Concomitant use of multiple doses of rifampin (as a strong CYP3A inducer) 600 mg once daily for 13 days decreased venetoclax Cmax by 42% and AUCinf by 71%.

Warfarin

Concomitant use of a single 400 mg dose of venetoclax with 5 mg warfarin resulted in 18% to 28% increase in Cmax and AUC∞ of R-warfarin and S-warfarin

Digoxin

Concomitant use of a single dose of venetoclax 100 mg with digoxin (a P-gp substrate) 0.5 mg increased digoxin Cmax by 35% and AUCinf by 9%

In Vitro  Studies

Venetoclax is not an inhibitor or inducer of CYP1A2, CYP2B6, CYP2C19 CYP2D6 or

CYP3A4. Venetoclax is a weak inhibitor of CYP2C8, CYP2C9, and UGT1A1.

Venetoclax is not an inhibitor of UGT1A4, UGT1A6, UGT1A9, or UGT2B7.

Venetoclax is an inhibitor and substrate of P-gp and BCRP and weak inhibitor of OATP1B1.

Venetoclax is not an inhibitor of OATP1B3, OCT1, OCT2, OAT1, OAT3, MATE1, or MATE2K.

Carcinogenesis,  Mutagenesis,  Impairment  of  Fertility

Carcinogenicity studies have not been conducted with venetoclax.

Venetoclax was not mutagenic in an in vitro bacterial mutagenicity (Ames) assay, did not induce numerical or structural aberrations in an in vitro chromosome aberration assay using human peripheral blood lymphocytes, and was not clastogenic in an in vivo mouse bone marrow micronucleus assay at doses up to 835 mg/kg. The M27 metabolite was negative for genotoxic activity in in vitro Ames and chromosome aberration assays.

Fertility and early embryonic development studies were conducted in male and female mice. These studies evaluate mating, fertilization, and embryonic development through implantation. There were no effects of venetoclax on estrus cycles, mating, fertility, corpora lutea, uterine implants or live embryos per litter at dosages up to 600 mg/kg/day. However, a risk to human male fertility exists based on testicular toxicity (germ cell loss) observed in dogs at exposures as low as 0.5 times the human AUC exposure at the recommend dose.

Animal  Toxicology  and / or  Pharmacology

In dogs, venetoclax caused single-cell necrosis in various tissues, including the gallbladder, exocrine pancreas, and stomach with no evidence of disruption of tissue integrity or organ dysfunction; these findings were minimal to mild in magnitude. Following a 4-week dosing period and subsequent 4- week recovery period, minimal single-cell necrosis was still present in some tissues and reversibility has not been assessed following longer periods of dosing or recovery.

In addition, after approximately 3 months of daily dosing in dogs, venetoclax caused progressive white discoloration of the hair coat, due to loss of melanin pigment.

CLINICAL STUDIES

Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

Combination Therapy

CLL14

CLL14 (BO25323) was a randomized (1:1), multicenter, open label, actively controlled, phase 3 trial (NCT02242942) that evaluated the efficacy and safety of VENCLEXTA in combination with obinutuzumab (VEN+G) versus obinutuzumab in combination with chlorambucil (GClb) for patients with previously untreated CLL with coexisting medical conditions (total Cumulative Illness Rating Scale [CIRS] score > 6 or CLcr < 70 mL/min). The trial required hepatic transaminases and total bilirubin ≤2 times upper limit of normal and excluded patients with Richter’s transformation or any individual organ/system impairment score of 4 by CIRS except eye, ear, nose, and throat organ system.

All patients received obinutuzumab at 1000 mg on Day 1 (the first dose could be split as 100 mg and 900 mg on Days 1 and 2), and on Days 8 and 15 of Cycle 1, and on Day 1 of each subsequent cycle, for a total of 6 cycles. Patients in the VEN+G arm began the 5-week VENCLEXTA ramp-up schedule on Day 22 of Cycle 1, and received VENCLEXTA 400 mg once daily from Cycle 3 Day 1 until the last day of Cycle 12. Patients randomized to the GClb arm received 0.5 mg/kg oral chlorambucil on Day 1 and Day 15 of Cycles 1 to 12. Each cycle was 28 days.

A total of 432 patients were randomized, 216 to each study arm. Baseline demographic and disease characteristics were similar between the study arms. The median age was 72 years (range: 41 to 89 years), 89% were white, 67% were male; 36% and 43% were Binet stage B and C, respectively, and 88% had Eastern Cooperative Oncology Group (ECOG) performance status <2. The median CIRS score was 8.0 (range: 0 to 28) and 58% of patients had CLcr <70 mL/min. A 17p deletion was detected in 8% of patients, TP53 mutations in 7%, 11q deletion in 19%, and unmutated IgVH in 57%.

The major efficacy outcome was progression-free survival (PFS) as assessed by an Independent Review Committee (IRC). The median duration of follow-up for PFS was 28 months (range: 0.1 to 36 months).

Efficacy results for CLL14 are shown in Table 17. The Kaplan-Meier curve for PFS is shown in Figure 1.

Table 17. Efficacy Results in CLL14

 At the time of analysis, median overall survival (OS) had not been reached, with fewer than 10% of patients experiencing an event. The median duration of follow-up for OS was 28 months.

Minimal residual disease (MRD) was evaluated using allele-specific oligonucleotide polymerase chain reaction (ASO-PCR). The definition of negative status was less than one CLL cell per 104 leukocytes. Rates of MRD negativity 3 months after the completion of treatment regardless of response and in patients who achieved CR are shown in Table 18. At this assessment, 134 patients in the VEN+G arm who were MRD negative in peripheral blood had matched bone marrow specimens; of these, 122 patients (91%) were MRD negative in both peripheral blood and bone marrow.

Table 18. Minimal Residual Disease Negativity Rates Three Months After the Completion of Treatment in CLL14

Twelve months after the completion of treatment, MRD negativity rates in peripheral blood were 58% (126/216) in patients treated with VEN+G and 9% (20/216) in patients treated with GClb.

MURANO

MURANO was a randomized (1:1), multicenter, open label study (NCT02005471) that evaluated the efficacy and safety of VENCLEXTA in combination with rituximab (VEN+R) versus bendamustine in combination with rituximab (B+R) in patients with CLL who had received at least one line of prior therapy. Patients in the VEN+R arm completed the 5-week ramp-up schedule and received VENCLEXTA 400 mg once daily for 24 months from Cycle 1 Day 1 of rituximab in the absence of disease progression or unacceptable toxicity. Rituximab was initiated intravenously after the 5-week dose ramp-up at 375 mg/m2 on Day 1 of Cycle 1 and 500 mg/m2 on Day 1 of Cycles 2-6. Each cycle was 28 days. Patients randomized to B+R received bendamustine at 70 mg/m2 on Days 1 and 2 for 6 cycles (28-day cycle) and rituximab at the above described dose and schedule.

A total of 389 patients were randomized: 194 to the VEN+R arm and 195 to the B+R arm.

Baseline demographic and disease characteristics were similar between the VEN+R and B+R arms. The median age was 65 years (range: 22-85 years), 97% were white, 74% were male, and 99% had ECOG performance status <2. Median prior lines of therapy was 1 (range: 1-5); 59% had received 1 prior therapy, 26% had received 2 prior therapies, and 16% had received 3 or more prior therapies. Prior therapies included alkylating agents (94%), anti-CD20 antibodies (77%), B-cell receptor pathway inhibitors (2%), and prior purine analogs (81%, including fludarabine/cyclophosphamide/rituximab in 55%). A 17p deletion was detected in 24% of patients, TP53 mutations in 25%, 11q deletion in 32%, and unmutated IgVH in 63%.

 Efficacy was based on progression-free survival (PFS) as assessed by an Independent Review Committee (IRC). The median follow-up for PFS was 23.4 months (range: 0 to 37.4+ months).

Efficacy results for MURANO are shown in Table 19. The Kaplan-Meier curve for PFS is shown

in Figure 2.

Table 19. IRC-Assessed Efficacy Results in MURANO

Venclexta VENCLEXTA 10 mg film-coated tablets:

Copovidone

Colloidal anhydrous silica

Polysorbate 80

Sodium stearyl fumarate

Calcium phosphate dibasic

Iron oxide yellow

Polyvinyl alcohol

Titanium dioxide

Macrogol

Talc

Venclexta VENCLEXTA 50 mg film-coated tablets:

Copovidone

Colloidal anhydrous silica

Polysorbate 80

Sodium stearyl fumarate

Calcium phosphate dibasic

Iron oxide yellow

Iron oxide red

Iron oxide black

Polyvinyl alcohol

Titanium dioxide

Macrogol

Talc

Venclexta VENCLEXTA 100 mg film-coated tablets:

Copovidone

Colloidal anhydrous silica

Polysorbate 80

Sodium stearyl fumarate

Calcium phosphate dibasic

Iron oxide yellow

Polyvinyl alcohol

Titanium dioxide

Macrogol

Talc

Not applicable.

Don’t store above 30⁰ C

VENCLEXTA is dispensed as follows:

VENCLEXTA 10 mg film-coated tablets are round, biconvex shaped, pale yellow debossed with “V” on one side and “10” on the other side.

VENCLEXTA 50 mg film-coated tablets are oblong, biconvex shaped, beige debossed with “V” on one side and “50” on the other side.

VENCLEXTA 100 mg film-coated tablets are oblong, biconvex shaped, pale yellow debossed with “V” on one side and “100” on the other side.

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.