6 ADVERSE REACTIONS

The following adverse reactions are discussed elsewhere in the labeling:

Ocular Disorders [see Warnings and Precautions (5.1)].
Pneumonitis [see Warnings and Precautions (5.2)].
Peripheral Neuropathy [see Warnings and Precautions (5.3)].

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.

The pooled safety population described in Warnings and Precautions reflect exposure to ELAHERE in 682 patients with epithelial ovarian, fallopian tube, or primary peritoneal cancer at 6 mg/kg AIBW administered intravenously once every 3 weeks until disease progression or unacceptable toxicity in Study 0416, Study 0417, Study 0403 (NCT02631876), and Study 0401 (NCT01609556). The median duration of treatment was 4.4 months (range: 1.0 to 30.0). In the pooled safety population, the most common (≥20%) adverse reactions, including laboratory abnormalities, were increased aspartate aminotransferase, fatigue, increased alanine aminotransferase, blurred vision, nausea, increased alkaline phosphatase, diarrhea, abdominal pain, keratopathy, peripheral neuropathy, musculoskeletal pain, decreased lymphocytes, decreased platelets, decreased magnesium, decreased hemoglobin, dry eye, constipation, decreased leukocytes, vomiting, decreased albumin, decreased appetite, and decreased neutrophils.

Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer

Study 0416

The safety of ELAHERE was evaluated in Study 0416, a multicenter, open-label, active-controlled, randomized, two-arm, study in patients (n=453) with platinum-resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer [see Clinical Studies (14)]. Patients received ELAHERE 6 mg/kg AIBW once every 3 weeks until disease progression or unacceptable toxicity. The median duration of treatment was 5 months (range: 0.69 to 27.4).

Serious adverse reactions occurred in 24% of patients treated with ELAHERE. The most common (≥2%) serious adverse reactions were intestinal obstruction (5%), abdominal pain (3%), and pleural effusion (3%). Fatal adverse reactions occurred in 3% of patients, including intestinal obstruction, dyspnea in the setting of subileus, neutropenic sepsis, cardiopulmonary failure, respiratory failure, ischemic stroke, and pulmonary embolus.

Permanent discontinuation of ELAHERE due to adverse reactions occurred in 9% of patients. The most common (≥1%) adverse reactions leading to permanent discontinuation were pneumonitis (2%), blurred vision (1%), and peripheral neuropathy (1%).

Dosage delays of ELAHERE due to an adverse reaction occurred in 54% of patients treated with ELAHERE. Adverse reactions which required dosage delays in ≥3% of patients included blurred vision (22%), keratopathy (19%), dry eye (7%), neutropenia (6%), pneumonitis (6%), photophobia (5%), cataract (4%), and peripheral neuropathy (4%).

Dose reductions of ELAHERE due to an adverse reaction occurred in 34% of patients. Adverse reactions which required dose reductions in ≥3% of patients included blurred vision (14%), keratopathy (10%), peripheral neuropathy (6%), and dry eye (5%).

Tables 4 and 5 summarize adverse reactions and laboratory abnormalities, respectively, occurring in ≥10% of patients who received ELAHERE in Study 0416.

Table 4: Adverse Reactions Occurring in ≥10% of Patients with Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer Who Received ELAHERE in Study 0416
Adverse Reaction	ELAHERE (n=218)		Chemotherapy¥ (n=207)
	All Grades (%)	Grades 3-4 (%)	All Grades (%)	Grades 3-4 (%)
Gastrointestinal disorders
Abdominal pain*	34	3	23	2
Diarrhea	29	1	17	0.5
Constipation	27	0	19	1
Nausea	27	2	29	2
Vomiting	18	3	18	1
Eye disorders
Blurred vision※	45	9	3	0
Keratopathy†	37	11	0	0
Dry eye‡	29	3	5	0
Photophobia	18	0.5	0.5	0
Cataract˄	16	3	0.5	0
General disorders and administration site conditions
Fatigue⸙	47	3	41	7
Nervous system disorders
Peripheral neuropathy¶	37	4	23	4
Headache	14	0	10	0
Musculoskeletal and connective tissue disorders
Musculoskeletal pain♦	31	1	21	2
Metabolism and nutrition disorders
Decreased appetite	18	1	14	1
Respiratory, thoracic, and mediastinal disorders
Pneumonitis±	10	0.5	0.5	0

¥ Chemotherapy: paclitaxel, pegylated liposomal doxorubicin (PLD), topotecan.

※ Blurred vision includes vision blurred, vitreous floaters, visual acuity reduced, diplopia, accommodation disorder, and visual impairment.

† Keratopathy includes corneal disorder, corneal epithelial microcysts, keratitis, keratopathy, corneal deposits, punctate keratitis, and corneal opacity.

‡ Dry eye includes dry eye and lacrimation increased.

˄ Cataract includes cataract and cataract nuclear.

⸙ Fatigue includes fatigue and asthenia.

* Abdominal pain includes abdominal pain, abdominal pain upper, abdominal pain lower, and abdominal discomfort.

¶ Peripheral neuropathy includes neuropathy peripheral, peripheral sensory neuropathy, peripheral motor neuropathy, paresthesia, hypoesthesia, polyneuropathy, neurotoxicity, and peripheral sensorimotor neuropathy.

♦ Musculoskeletal pain includes back pain, myalgia, neck pain, arthralgia, musculoskeletal pain, non-cardiac chest pain, bone pain, pain in extremity, musculoskeletal stiffness, musculoskeletal chest pain, and musculoskeletal discomfort.

± Pneumonitis includes pneumonitis, interstitial lung disease, respiratory failure, and organizing pneumonia.

Clinically relevant adverse reactions occurring in <10% of patients who received ELAHERE in Study 0416 included infusion related reactions/hypersensitivity (8%).

Table 5: Select Laboratory Abnormalities ≥10% for All Grades, in Patients Who Received ELAHERE in Study 0416
Laboratory Abnormality	ELAHERE (n=218)		Chemotherapy (n=207)
	All Grades %	Grades 3-4 %	All Grades %	Grades 3-4 %
Liver Function Tests
Increased aspartate aminotransferase	57	0	14	0
Increased alanine aminotransferase	38	1	15	1
Increased alkaline phosphatase	30	1	13	1
Chemistry
Decreased albumin	21	1	27	2
Decreased magnesium	21	1	29	2
Decreased sodium	16	0	18	0
Decreased potassium	15	1	11	1
Increased calcium	12	0	5	0
Decreased bicarbonate	11	0	11	0
Increased creatinine	10	0	11	0
Hematology*
Decreased lymphocytes	27	3	42	11
Decreased leukocytes	23	1	53	10
Decreased neutrophils	22	1	45	17
Decreased hemoglobin	18	1	63	8
Decreased platelets	17	1	20	5

* The denominator used to calculate the rate varied from 63 to 214 (ELAHERE); 63 to 194 (IC Chemo) based on the number of patients with a baseline value and at least one post-treatment value.

Study 0417

The safety of ELAHERE was evaluated in Study 0417, a single-arm, open-label study in patients (n=106) with platinum-resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer [see Clinical Studies (14)]. Patients received ELAHERE 6 mg/kg AIBW once every 3 weeks until disease progression or unacceptable toxicity. The median duration of treatment was 4.2 months (range: 0.7 to 13.3).

Serious adverse reactions occurred in 31% of patients treated with ELAHERE. The most common (≥2%) serious adverse reactions were intestinal obstruction (8%), ascites (4%), infection (3%), and pleural effusion (3%). Fatal adverse reactions occurred in 2% of patients, including small intestinal obstruction (1%) and pneumonitis (1%).

Permanent discontinuation of ELAHERE due to adverse reactions occurred in 11% of patients. The most common (≥2%) adverse reactions leading to permanent discontinuation were intestinal obstruction (2%) and thrombocytopenia (2%). One patient (0.9%) permanently discontinued ELAHERE due to visual impairment (unilateral decrease to BCVA < 20/200 that resolved to baseline after discontinuation).

Dosage delays of ELAHERE due to an adverse reaction occurred in 39% of patients treated with ELAHERE. Adverse reactions which required dosage delays in ≥3% of patients included blurred vision (15%), keratopathy (11%), neutropenia (6%), dry eye (5%), cataracts (3%), and increased gamma-glutamyltransferase (3%).

Dose reductions of ELAHERE due to an adverse reaction occurred in 20% of patients. Adverse reactions which required dose reductions in ≥3% of patients included blurred vision (9%) and keratopathy (7%).

Table 6 summarizes the adverse reactions (≥10%) in patients treated with ELAHERE in Study 0417.

Table 6: Adverse Reactions (≥10%) in Patients with Epithelial Ovarian, Fallopian Tube, or Primary Peritoneal Cancer Who Received ELAHERE in Study 0417
Adverse Reaction	All Grades N=106 (%)	Grade 3-4 N=106 (%)
Eye disorders
Blurred Vision※	50	7
Keratopathy†	37	9
Dry eye‡	27	2
Cataract	18	3
Photophobia	17	0
Eye pain§	10	0
General disorders
Fatigue	49	3
Gastrointestinal disorders
Nausea	40	0
Abdominal pain*	36	7
Diarrhea	31	3
Constipation	30	1
Vomiting	19	0
Abdominal distension	11	0
Nervous system disorders
Peripheral neuropathy¶	33	2
Metabolism and nutrition disorders
Decreased appetite	18	1
Musculoskeletal and connective tissue disorders
Arthralgia	17	0
Myalgia	10	0
Respiratory, thoracic, and mediastinal disorders
Dyspnea^	12	0

※ Blurred vision includes vision blurred, vitreous floaters, visual acuity reduced, diplopia, presbyopia, accommodation disorder, visual impairment, and refraction disorder.

† Keratopathy includes corneal disorder, corneal epithelial microcysts, corneal epithelial defect, keratitis, keratopathy, corneal deposits, and punctate keratitis.

‡ Dry eye includes dry eye and lacrimation increased.

§ Eye pain includes eye pain and ocular discomfort.

⸙ Fatigue includes fatigue and asthenia.

* Abdominal pain includes abdominal pain, abdominal pain upper, abdominal pain lower, and abdominal discomfort.

¶ Peripheral neuropathy includes neuropathy peripheral, peripheral sensory neuropathy, peripheral motor neuropathy, paresthesia, hypoesthesia, polyneuropathy, and neurotoxicity.

^ Dyspnea includes dyspnea and exertional dyspnea.

Clinically relevant adverse reactions occurring in <10% of patients who received ELAHERE in Study 0417 included infusion related reactions/hypersensitivity (9%), pneumonitis (8%), and uveitis (1%).

Table 7 summarizes the laboratory abnormalities in Study 0417.

Table 7: Select Laboratory Abnormalities ≥10% for All Grades, or ≥2% for Grades 3-4 in Patients Who Received ELAHERE
Laboratory Abnormality	ELAHERE*
	All Grades (%)	Grade 3-4 (%)
Liver Function Tests
Increased aspartate aminotransferase	50	2
Increased alanine aminotransferase	39	2
Increased alkaline phosphatase	30	1
Hematology*
Decreased lymphocytes	35	7
Decreased leukocytes	26	1
Decreased neutrophils	26	3
Decreased hemoglobin	25	3
Decreased platelets	18	2
Chemistry
Decreased albumin	31	1
Decreased magnesium	27	2
Increased creatinine	16	0
Decreased potassium	15	4

* The denominator used to calculate the rate varied from 98 to 101 based on the number of patients with a baseline value and at least one post-treatment value.

Immunogenicity: Anti-Drug Antibody-Associated Adverse Reactions In studies 0416, 0417, 0401, and 0403 in patients with epithelial ovarian, fallopian tube, or primary peritoneal cancer who received ELAHERE at 6 mg/kg AIBW administered intravenously once every 3 weeks, 9% (57/626) developed anti-drug antibodies. Infusion reactions (including bronchospasm, erythema, eyelid erythema, flushing, hypersensitivity, periorbital edema, rash, allergic rhinitis, face edema) occurred in 26% (15/57) of patients with anti-drug antibodies and in 7% (41/569) who did not develop anti-drug antibodies [see Clinical Pharmacology (12.6)].