Copiktra

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  Treatment-related mortality occurred in 15% of COPIKTRA-treated patients

  [see Warnings and Precautions (

  5.1 Treatment-related Mortality

  In a randomized controlled study in patients with relapsed or refractory CLL or SLL, treatment with COPIKTRA caused increased treatment-related mortality

  [see

  Clinical Studies ]

  . With extended follow-up with a median of 63 months, treatment-related deaths occurred in 15% (23/158) of those patients in the overall population. In the indicated patient population, patients with relapsed or refractory CLL or SLL after at least two prior lines of systemic therapy, treatment-related deaths following treatment with COPIKTRA occurred in 14% (13/93) of patients. The most common cause of the treatment-related deaths were infections, which occurred in 9% and 11% of patients with relapsed or refractory CLL following at least one or two prior systemic therapies, respectively

  [see Adverse Reactions ]

  . COPIKTRA is not indicated and is not recommended for any patients in the initial or second-line treatment setting

  [see Indications and Usage ]

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  Fatal and/or serious infections occurred in 31% of COPIKTRA-treated patients. Monitor for signs and symptoms of infection. Withhold COPIKTRA if infection is suspected

  [see Warnings and Precautions (

  5.2 Infections

  Serious, including fatal (18/442; 4%), infections occurred in 31% of patients receiving COPIKTRA 25 mg BID (N = 442).  The most common serious infections were pneumonia, sepsis, and lower respiratory infections.  Median time to onset of any grade infection was 3 months (range: 1 day to 32 months), with 75% of cases occurring within 6 months.

  Treat infections prior to initiation of COPIKTRA.  Advise patients to report any new or worsening signs and symptoms of infection.  For grade 3 or higher infection, withhold COPIKTRA until infection has resolved.  Resume COPIKTRA at the same or reduced dose

  [see Dosage and Administration ]

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  Serious, including fatal,

  Pneumocystis jirovecii

  pneumonia (PJP) occurred in 1% of patients taking COPIKTRA.  Provide prophylaxis for PJP during treatment with COPIKTRA.  Following completion of COPIKTRA treatment, continue PJP prophylaxis until the absolute CD4+ T cell count is greater than 200 cells/µL.  Withhold COPIKTRA in patients with suspected PJP of any grade, and permanently discontinue if PJP is confirmed.

  CMV reactivation/infection occurred in 1% of patients taking COPIKTRA.  Consider prophylactic antivirals during COPIKTRA treatment to prevent CMV infection including CMV reactivation.  For clinical CMV infection or viremia, withhold COPIKTRA until infection or viremia resolves.  If COPIKTRA is resumed, administer the same or reduced dose and monitor patients for CMV reactivation by PCR or antigen test at least monthly

  [see Dosage and Administration ]

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  Fatal and/or serious diarrhea or colitis occurred in 18% of COPIKTRA-treated patients. Monitor for the development of severe diarrhea or colitis. Withhold COPIKTRA

  [see Warnings and Precautions (

  5.3 Diarrhea or Colitis

  Serious, including fatal (1/442; 0.2%), diarrhea or colitis occurred in 18% of patients receiving COPIKTRA 25 mg BID (N = 442).  The median time to onset of any grade diarrhea or colitis was 4 months (range: 1 day to 33 months), with 75% of cases occurring by 8 months.  The median event duration was 0.5 months (range: 1 day to 29 months; 75^thpercentile: 1 month).

  Advise patients to report any new or worsening diarrhea.  For non-infectious diarrhea or colitis, follow the guidelines below:

  For patients presenting with mild or moderate diarrhea (Grade 1-2) (i.e. up to 6 stools per day over baseline) or asymptomatic (Grade 1) colitis, initiate supportive care with antidiarrheal agents as appropriate, continue COPIKTRA at the current dose, and monitor the patient at least weekly until the event resolves.  If the diarrhea is unresponsive to antidiarrheal therapy, withhold COPIKTRA and initiate supportive therapy with enteric acting steroids (e.g. budesonide). Monitor the patient at least weekly.  Upon resolution of the diarrhea, consider restarting COPIKTRA at a reduced dose.

  For patients presenting with abdominal pain, stool with mucus or blood, change in bowel habits, peritoneal signs, or with severe diarrhea (Grade 3) (i.e. > 6 stools per day over baseline) withhold COPIKTRA and initiate supportive therapy with enteric acting steroids (e.g. budesonide) or systemic steroids.  A diagnostic work-up to determine etiology, including colonoscopy, should be performed.  Monitor at least weekly.  Upon resolution of the diarrhea or colitis, restart COPIKTRA at a reduced dose.  For recurrent Grade 3 diarrhea or recurrent colitis of any grade, discontinue COPIKTRA.  Discontinue COPIKTRA for life-threatening diarrhea or colitis

  [see Dosage and Administration ]

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  Fatal and/or serious cutaneous reactions occurred in 5% of COPIKTRA-treated patients. Withhold COPIKTRA

  [see Warnings and Precautions (

  5.4 Cutaneous Reactions

  Serious, including fatal (2/442; 0.5%), cutaneous reactions occurred in 5% of patients receiving COPIKTRA 25 mg BID (N = 442).  Fatal cases included drug reaction with eosinophilia and systemic symptoms (DRESS) and toxic epidermal necrolysis (TEN).  Median time to onset of any grade cutaneous reaction was 3 months (range: 1 day to 29 months, 75th percentile: 6 months), with a median event duration of 1 month (range: 1 day to 37 months, 75th percentile: 2 months).

  Presenting features for the serious events were primarily described as pruritic, erythematous, or maculo-papular.  Less common presenting features include exanthem, desquamation, erythroderma, skin exfoliation, keratinocyte necrosis, and papular rash.  Advise patients to report any new or worsening cutaneous reactions.  Review all concomitant medications and discontinue any medications potentially contributing to the event.  For patients presenting with mild or moderate (Grade 1-2) cutaneous reactions, continue COPIKTRA at the current dose, initiate supportive care with emollients, anti-histamines (for pruritus), or topical steroids, and monitor the patient closely.  Withhold COPIKTRA for severe (Grade 3) cutaneous reaction until resolution.  Initiate supportive care with steroids (topical or systemic) or anti-histamines (for pruritus).  Monitor at least weekly until resolved.  Upon resolution of the event, restart COPIKTRA at a reduced dose.  Discontinue COPIKTRA if severe cutaneous reaction does not improve, worsens, or recurs.  For life-threatening cutaneous reactions, discontinue COPIKTRA. In patients with SJS, TEN, or DRESS of any grade, discontinue COPIKTRA

  [see Dosage and Administration ].

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  Fatal and/or serious pneumonitis occurred in 5% of COPIKTRA-treated patients. Monitor for pulmonary symptoms and interstitial infiltrates. Withhold COPIKTRA

  [see Warnings and Precautions (

  5.5 Pneumonitis

  Serious, including fatal (1/442; 0.2%), pneumonitis without an apparent infectious cause occurred in 5% of patients receiving COPIKTRA 25 mg BID (N = 442).  Median time to onset of any grade pneumonitis was 4 months (range: 9 days to 27 months), with 75% of cases occurring within 9 months).  The median event duration was 1 month, with 75% of cases resolving by 2 months.

  Withhold COPIKTRA in patients who present with new or progressive pulmonary signs and symptoms such as cough, dyspnea, hypoxia, interstitial infiltrates on a radiologic exam, or a decline by more than 5% in oxygen saturation and evaluate for etiology.  If the pneumonitis is infectious, patients may be restarted on COPIKTRA at the previous dose once the infection, pulmonary signs and symptoms resolve.  For moderate non-infectious pneumonitis (Grade 2), treat with systemic corticosteroids, and resume COPIKTRA at a reduced dose upon resolution.  If non-infectious pneumonitis recurs or does not respond to steroid therapy, discontinue COPIKTRA.  For severe or life-threatening non-infectious pneumonitis, discontinue COPIKTRA and treat with systemic steroids

  [see Dosage and Administration ]

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25 mg orally, twice daily. Modify dosage for toxicity. (

Lactation: Advise women not to breastfeed. (