GO ALL IN PREPARED

Recommendations for managing potential
risks of INREBIC® treatment

GO ALL IN PREPARED

Recommendations for managing potential
risks of INREBIC® treatment

Management of encephalopathy, including Wernicke’s encephalopathy (WE)1

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MEASURING

  • Assess thiamine levels prior to starting INREBIC®
  • Do not start INREBIC® in patients with thiamine deficiency
  • Replete thiamine prior to treatment initiation
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MONITORING

  • While on INREBIC® treatment, all patients should receive prophylaxis with daily 100 mg oral thiamine and should have thiamine levels assessed as clinically indicated
  • Monitor for signs and symptoms of WE, which may include ataxia, mental status changes, and ophthalmoplegia (eg, nystagmus, diplopia)
  • Any change in mental status, confusion, or memory impairment should raise concern for potential encephalopathy, including WE, and prompt a full evaluation including a neurologic examination, assessment of thiamine levels, and imaging
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MANAGING

  • If encephalopathy is suspected, immediately discontinue treatment with INREBIC® and initiate parenteral thiamine treatment
  • Monitor until symptoms resolve or improve, and thiamine levels normalize

Management of select adverse reactions to INREBIC® using dose modifications1

Recommended dose modifications

ADVERSE REACTION DOSE MODIFICATION DOSE RESTART
Hematologic toxicity Grade 4
thrombocytopenia Grade 3
thrombocytopenia with bleeding Grade 4
neutropenia		 Interrupt dose until toxicity has resolved to ≤Grade 2 or baseline Restart 100 mg daily below the last given dose
Nonhematologic toxicity ≥Grade 3 nausea, vomiting, or diarrhea not responding to supportive measures within 48 hours ≥Grade 3 other nonhematologic toxicities ≥Grade 3 ALT, AST, or bilirubin* Interrupt dose until toxicity has resolved to ≤Grade 1 or baseline Restart 100 mg daily below the last given dose

See US Prescribing Information for complete dosing information.

ALT, alanine aminotransferase; AST, aspartate aminotransferase.

*Monitor ALT, AST, and bilirubin (total and direct) more frequently following the dose reduction. If reoccurrence of a ≥Grade 3 elevation, discontinue treatment with INREBIC®.

Additional management guidance for gastrointestinal adverse reactions1

  • Consider providing appropriate prophylactic antiemetic therapy (eg, 5-HT3 receptor antagonists) during INREBIC® treatment
  • Treat diarrhea with antidiarrheal medications promptly at the first onset of symptoms
  • Administration of INREBIC® with a high-fat meal may reduce the incidence of nausea and vomiting
  • INREBIC® may be taken with or without food

Timing of gastrointestinal treatment-emergent adverse reactions (all grades)† in the INREBIC® (400 mg qd) arm (n=96) for Cycles 1-62

INREBIC® adverse reactions graph
INREBIC® adverse reactions graph

†Adverse reactions were coded using MedDRA version 20.1.

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Most patients remained on INREBIC® in the pivotal trial1

  • Permanent discontinuations due to adverse reactions occurred in 14% of patients
  • The most frequent reasons for permanent discontinuation (≥2% of patients) included cardiac failure (3%),
    thrombocytopenia (2%), myocardial ischemia (2%), diarrhea (2%), and increased blood creatinine (2%)

Average daily dose of INREBIC® in the pivotal trial3

Limitations of analysis: This is a post-hoc analysis without intention to make statistical inferences.

Average daily dose during Cycles 1-6 for patients in the INREBIC® (400 mg qd) arm

Average INREBIC® daily dose graph
Average INREBIC® daily dose graph

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IMPORTANT SAFETY INFORMATION

WARNING: ENCEPHALOPATHY INCLUDING WERNICKE’S
Serious and fatal encephalopathy, including Wernicke’s, has occurred in patients treated with INREBIC. Wernicke’s encephalopathy is a neurologic emergency. Assess thiamine levels in all patients prior to starting INREBIC. Do not start INREBIC in patients with thiamine deficiency; replete thiamine prior to treatment initiation. While on treatment all patients should receive prophylaxis with daily oral thiamine and should have thiamine levels assessed as clinically indicated. If encephalopathy is suspected, immediately discontinue INREBIC and initiate parenteral thiamine. Monitor until symptoms resolve or improve and thiamine levels normalize.

WARNINGS AND PRECAUTIONS

Encephalopathy, including Wernicke’s: Serious and fatal encephalopathy, including Wernicke’s encephalopathy, has occurred in INREBIC-treated patients. Serious cases were reported in 1.3% (8/608) of patients treated with INREBIC in clinical trials and 0.16% (1/608) of cases were fatal. Wernicke’s encephalopathy is a neurologic emergency resulting from thiamine (Vitamin B1) deficiency. Signs and symptoms of Wernicke’s encephalopathy may include ataxia, mental status changes, and ophthalmoplegia (e.g., nystagmus, diplopia). Any change in mental status, confusion, or memory impairment should raise concern for potential encephalopathy, including Wernicke’s, and prompt a full evaluation including a neurologic examination, assessment of thiamine levels, and imaging. Assess thiamine levels in all patients prior to starting INREBIC. Do not start INREBIC in patients with thiamine deficiency. However, if thiamine levels are low, replete thiamine prior to starting treatment. While on treatment all patients should receive prophylaxis with oral thiamine and should have thiamine levels assessed as clinically indicated. If encephalopathy is suspected, immediately discontinue INREBIC and initiate parenteral thiamine. Monitor until symptoms resolve or improve and thiamine levels normalize.

Anemia: New or worsening Grade 3 anemia occurred in 34% of INREBIC-treated patients. The median time to onset of the first Grade 3 anemia was approximately 2 months, with 75% of cases occurring within 3 months. Mean hemoglobin levels reached a nadir after 12 to 16 weeks with partial recovery and stabilization after 16 weeks. Red blood cell transfusions were received by 51% of INREBIC-treated patients and permanent discontinuation of INREBIC due to anemia occurred in 1% of patients. Consider dose reduction for patients who become red blood cell transfusion dependent.

Thrombocytopenia: New or worsening Grade 3 or higher thrombocytopenia during the randomized treatment period occurred in 12% of INREBIC-treated patients. The median time to onset of the first Grade 3 thrombocytopenia was approximately 1 month, with 75% of cases occurring within 4 months. Platelet transfusions were received by 3.1% of INREBIC-treated patients. Permanent discontinuation of treatment due to thrombocytopenia and bleeding that required clinical intervention both occurred in 2.1% of INREBIC-treated patients. Obtain a complete blood count (CBC) at baseline, periodically during treatment, and as clinically indicated. For Grade 3 thrombocytopenia with active bleeding or Grade 4 thrombocytopenia, interrupt INREBIC until resolved to Grade 2 or lower or to baseline. Restart dose at 100 mg daily below the last given dose and monitor platelets as clinically indicated.

Gastrointestinal Toxicity: Gastrointestinal toxicities are the most frequent adverse reactions in INREBIC-treated patients. During the randomized treatment period, diarrhea occurred in 66% of patients, nausea in 62% of patients, and vomiting in 39% of patients. Grade 3 diarrhea occurred in 5% and Grade 3 vomiting in 3.1%. The median time to onset of any grade nausea, vomiting, and diarrhea was 1 day, with 75% of cases occurring within 2 weeks of treatment. Consider providing appropriate prophylactic antiemetic therapy (e.g., 5-HT3 receptor antagonists) during INREBIC treatment. Treat diarrhea with antidiarrheal medications promptly at the first onset of symptoms. For Grade 3 or higher nausea, vomiting, or diarrhea not responsive to supportive measures within 48 hours, interrupt INREBIC until resolved to Grade 1 or lower or to baseline. Restart dose at 100 mg daily below the last given dose. Monitor thiamine levels and replete as needed.

Hepatic Toxicity: Elevations of ALT and AST (all grades) during the randomized treatment period occurred in 43% and 40%, respectively, with Grade 3 or 4 in 1% and 0%, respectively, of INREBIC-treated patients. The median time to onset of any grade transaminase elevation was approximately 1 month, with 75% of cases occurring within 3 months. Monitor hepatic function at baseline, periodically during treatment, and as clinically indicated. For Grade 3 or higher ALT and/or AST elevations (greater than 5 × ULN), interrupt INREBIC dose until resolved to Grade 1 or less or to baseline. Restart dose at 100 mg daily below the last given dose. If reoccurrence of a Grade 3 or higher elevation of ALT/AST, discontinue treatment with INREBIC.

Amylase and Lipase Elevation: Grade 3 or higher amylase and/or lipase elevations developed in 2% and 10% of INREBIC-treated patients, respectively. The median time to onset of any grade amylase or lipase elevation was 15 days, with 75% of cases occurring within 1 month of starting treatment. One patient developed pancreatitis in the fedratinib clinical development program (n=608) and pancreatitis resolved with treatment discontinuation. Monitor amylase and lipase at baseline, periodically during treatment, and as clinically indicated. For Grade 3 or higher amylase and/or lipase elevations, interrupt INREBIC until resolved to Grade 1 or less or to baseline. Restart dose at 100 mg daily below the last given dose.

Major Adverse Cardiac Events (MACE): Another JAK inhibitor has increased the risk of MACE, including cardiovascular death, myocardial infarction, and stroke in patients with rheumatoid arthritis (compared to those treated with TNF blockers), a condition for which INREBIC is not indicated. Consider the benefits and risks of the individual patients prior to initiating or continuing therapy with INREBIC, particularly in patients who are current or past smokers, or have other cardiovascular risk factors. Patients should be informed about the symptoms of serious cardiovascular events and what to do if they occur.

Thrombosis: Another JAK inhibitor has increased the risk of thrombosis, including deep venous thrombosis, pulmonary embolism, and arterial thrombosis in patients with rheumatoid arthritis (compared to those treated with TNF blockers), a condition for which INREBIC is not indicated. In patients with MF treated with INREBIC in clinical trials, the rates of thromboembolic events were similar in INREBIC and placebo treated patients. Promptly evaluate and treat patients with symptoms of thrombosis.

Secondary Malignancies: Another JAK inhibitor has increased the risk of lymphoma and other malignancies excluding nonmelanoma skin cancer (NMSC) (compared to those treated with TNF blockers) in patients with rheumatoid arthritis, a condition for which INREBIC is not indicated. Patients who are current or past smokers are at additional increased risk. Consider the benefits and risks for the individual patient prior to initiating or continuing therapy with INREBIC, particularly in patients with a known malignancy (other than a successfully treated NMSC), patients who develop a malignancy, and patients who are current or past smokers.

ADVERSE REACTIONS

The most common adverse reactions for INREBIC treated vs. placebo were diarrhea (66% vs. 16%), nausea (62% vs. 15%), anemia (40% vs. 14%), and vomiting (39% vs. 5%). Dosage interruptions due to an adverse reaction during the randomized treatment period occurred in 21% of patients who received INREBIC. Adverse reactions requiring dosage interruption in >3% of patients who received INREBIC included diarrhea and nausea. Dosage reductions due to an adverse reaction during the randomized treatment period occurred in 19% of patients who received INREBIC. Adverse reactions requiring dosage reduction in >2% of patients who received INREBIC included anemia (6%), diarrhea (3%), vomiting (3%), and thrombocytopenia (2%).

DRUG INTERACTIONS

Coadministration of INREBIC with a strong CYP3A4 inhibitor increases fedratinib exposure. Increased exposure may increase the risk of adverse reactions. Consider alternative therapies that do not strongly inhibit CYP3A4 activity. Alternatively, reduce the dose of INREBIC when administering with a strong CYP3A4 inhibitor. Avoid INREBIC with strong and moderate CYP3A4 inducers. Coadministration of INREBIC with a dual CYP3A4 and CYP2C19 inhibitor increases fedratinib exposure. Increased exposure may increase the risk of adverse reactions. Due to potential increase of exposure, patients taking concomitant dual CYP3A4 and CYP2C19 inhibitors require more intensive safety monitoring and, if necessary, dose modifications of INREBIC based on adverse reactions. Coadministration of INREBIC with drugs that are CYP3A4, CYP2C19, or CYP2D6 substrates increases the concentrations of these drugs, which may increase the risk of adverse reactions of these drugs. Monitor for adverse reactions and adjust the dose of drugs that are CYP3A4, CYP2C19, or CYP2D6 substrates as necessary when coadministered with INREBIC. Coadministration of INREBIC with drugs that are renally excreted via organic cation transporter (OCT2) and multidrug and toxin extrusion (MATE)1/2-K can decrease renal clearance of those drugs. Monitor for adverse reactions and consider dose modifications for drugs that are renally excreted via OCT2 or MATE1/2-K (e.g., metformin) as necessary when coadministered with INREBIC.

PREGNANCY/LACTATION

Consider the benefits and risks of INREBIC for the mother and possible risks to the fetus when prescribing INREBIC to a pregnant woman. Due to the potential for serious adverse reactions in a breastfed child, advise patients not to breastfeed during treatment with INREBIC, and for at least 1 month after the last dose.

RENAL IMPAIRMENT

Reduce INREBIC dose when administered to patients with severe renal impairment. No modification of the starting dose is recommended for patients with mild to moderate renal impairment. Due to potential increase of exposure, patients with preexisting moderate renal impairment require more intensive safety monitoring, and if necessary, dose modifications based on adverse reactions.

Please see full Prescribing Information, including Boxed WARNING.

INDICATION

INREBIC® (fedratinib) is indicated for the treatment of adult patients with intermediate-2 or high-risk primary or secondary (post-polycythemia vera or post-essential thrombocythemia) myelofibrosis (MF).

Information for Vermont prescribers of prescription drugs
References
  1. INREBIC® [package insert]. Summit, NJ: Celgene Corporation; 2024.
  2. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Myeloproliferative Neoplasms V.2.2024. © National Comprehensive Cancer Network, Inc. 2024. All rights reserved. Accessed August 9, 2024. To view the most recent and complete version of the guideline, go online to NCCN.org.
  3. Pardanani A, Harrison C, Cortes JE, et al. Safety and efficacy of fedratinib in patients with primary or secondary myelofibrosis: a randomized clinical trial. JAMA Oncol. 2015;1:643-651.
  4. Protocol for: Pardanani A, Harrison C, Cortes JE, et al. Safety and efficacy of fedratinib in patients with primary or secondary myelofibrosis: a randomized clinical trial. JAMA Oncol. 2015. doi:10.1001/jamaoncol.2015.1590.
  5. Supplemental content for: Pardanani A, Harrison C, Cortes JE, et al. Safety and efficacy of fedratinib in patients with primary or secondary myelofibrosis: a randomized clinical trial. JAMA Oncol. 2015. doi:10.1001/jamaoncol.2015.1590.
  6. Harrison C, Schaap N, Vannucchi AM, et al. Fedratinib induces spleen responses and reduces symptom burden in patients with myeloproliferative neoplasm (MPN)-associated myelofibrosis (MF) and low platelet counts, who were ruxolitinib-naïve or previously treated with ruxolitinib. Poster presented at the 61st Annual Meeting of the American Society of Hematology (ASH); December 7-9, 2019; Orlando, FL.
  7. Data on file. FED-0005. Princeton, NJ: Bristol-Myers Squibb Company; 2022.
  8. Data on file. FED-0006. Princeton, NJ: Bristol-Myers Squibb Company; 2022.
  9. Harrison CN, Schaap N, Vannucchi AM, et al. Fedratinib in patients with myelofibrosis previously treated with ruxolitinib: an updated analysis of the JAKARTA2 study using stringent criteria for ruxolitinib failure. Am J Hematol. 2020;95:594-603.
  10. Data on file. FED-0008. Princeton, NJ: Bristol-Myers Squibb Company; 2022.
  11. Data on file. FED-0009. Princeton, NJ: Bristol-Myers Squibb Company; 2022.
  12. Data on file. FED-0007. Princeton, NJ; Bristol-Myers Squibb Company; 2022.
  13. Data on file. FED-0004. Princeton, NJ; Bristol-Myers Squibb Company; 2022.

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