- 1. Name of the medicinal product
- 2. Qualitative and quantitative composition
- 3. Pharmaceutical form
- 4. Clinical particulars
- 4.1 Therapeutic indications
- 4.2 Posology and method of administration
- 4.3 Contraindications
- 4.4 Special warnings and precautions for use
- 4.5 Interaction with other medicinal products and other forms of interaction
- 4.6 Fertility, pregnancy and lactation
- 4.7 Effects on ability to drive and use machines
- 4.8 Undesirable effects
- 4.9 Overdose
- 5. Pharmacological properties
- 5.1 Pharmacodynamic properties
- 5.2 Pharmacokinetic properties
- 5.3 Preclinical safety data
- 6. Pharmaceutical particulars
- 6.1 List of excipients
- 6.2 Incompatibilities
- 6.3 Shelf life
- 6.4 Special precautions for storage
- 6.5 Nature and contents of container
- 6.6 Special precautions for disposal and other handling
- 7. Marketing authorisation holder
- 8. Marketing authorisation number(s)
- 9. Date of first authorisation/renewal of the authorisation
- 10. Date of revision of the text
- Legal category
This medicinal product is subject to additional monitoring. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse reactions. See section 4.8 for how to report adverse reactions.
Myelofibrosis (MF)Jakavi is indicated for the treatment of disease-related splenomegaly or symptoms in adult patients with primary myelofibrosis (also known as chronic idiopathic myelofibrosis), post polycythaemia vera myelofibrosis or post essential thrombocythaemia myelofibrosis.
Polycythaemia vera (PV)Jakavi is indicated for the treatment of adult patients with polycythaemia vera who are resistant to or intolerant of hydroxyurea.
Starting doseThe recommended starting dose of Jakavi in myelofibrosis is 15 mg twice daily for patients with a platelet count between 100,000/mm3 and 200,000/mm3 and 20 mg twice daily for patients with a platelet count of >200,000/mm3. The recommended starting dose of Jakavi in polycythaemia vera is 10 mg given orally twice daily.There is limited information to recommend a starting dose for patients with platelet counts between 50,000/mm3 and <100,000/mm3. The maximum recommended starting dose in these patients is 5 mg twice daily and the patients should be titrated cautiously.
Dose modificationsDoses may be titrated based on safety and efficacy. Treatment should be discontinued for platelet counts less than 50,000/mm3 or absolute neutrophil counts less than 500/mm3. In PV, treatment should also be interrupted when haemoglobin is below 8 g/dl. After recovery of blood counts above these levels, dosing may be re-started at 5 mg twice daily and gradually increased based on careful monitoring of complete blood cell count, including a white blood cell count differential.Dose reductions should be considered if the platelet count decreases below 100,000/mm3, with the goal of avoiding dose interruptions for thrombocytopenia. In PV, dose reductions should also be considered if haemoglobin decreases below 12 g/dl and is recommended if it decreases below 10 g/dl.If efficacy is considered insufficient and blood counts are adequate, doses may be increased by a maximum of 5 mg twice daily, up to the maximum dose of 25 mg twice daily.The starting dose should not be increased within the first four weeks of treatment and thereafter no more frequently than at 2-week intervals.The maximum dose of Jakavi is 25 mg twice daily.
Dose adjustment with concomitant strong CYP3A4 inhibitors or fluconazoleWhen Jakavi is administered with strong CYP3A4 inhibitors or dual inhibitors of CYP2C9 and CYP3A4 enzymes (e.g. fluconazole) the unit dose of Jakavi should be reduced by approximately 50%, to be administered twice daily (see section 4.5).More frequent monitoring (e.g. twice a week) of haematology parameters and of clinical signs and symptoms of Jakavi-related adverse drug reactions is recommended while on strong CYP3A4 inhibitors or dual inhibitors of CYP2C9 and CYP3A4 enzymes.
Renal impairmentNo specific dose adjustment is needed in patients with mild or moderate renal impairment.In patients with severe renal impairment (creatinine clearance less than 30 ml/min) the recommended starting dose based on platelet count for MF patients should be reduced by approximately 50% to be administered twice daily. The recommended starting dose for PV patients with severe renal impairment is 5 mg twice daily. Patients should be carefully monitored with regard to safety and efficacy during Jakavi treatment.There are limited data to determine the best dosing options for patients with end-stage renal disease (ESRD) on haemodialysis. Pharmacokinetic/pharmacodynamic simulations based on available data in this population suggest that the starting dose for MF patients with ESRD on haemodialysis is a single dose of 15-20 mg or two doses of 10 mg given 12 hours apart, to be administered post-dialysis and only on the day of haemodialysis. A single dose of 15 mg is recommended for MF patients with platelet count between 100,000/mm3 and 200,000/mm3. A single dose of 20 mg or two doses of 10 mg given 12 hours apart is recommended for MF patients with platelet count of >200,000/mm3. Subsequent doses (single administration or two doses of 10 mg given 12 hours apart) should be administered only on haemodialysis days following each dialysis session. The recommended starting dose for PV patients with ESRD on haemodialysis is a single dose of 10 mg or two doses of 5 mg given 12 hours apart, to be administered post-dialysis and only on the day of haemodialysis. These dose recommendations are based on simulations and any dose modification in ESRD should be followed by careful monitoring of safety and efficacy in individual patients. No data is available for dosing patients who are undergoing peritoneal dialysis or continuous venovenous haemofiltration (see section 5.2).
Hepatic impairmentIn patients with any hepatic impairment the recommended starting dose based on platelet count should be reduced by approximately 50% to be administered twice daily. Subsequent doses should be adjusted based on careful monitoring of safety and efficacy. Patients diagnosed with hepatic impairment while receiving Jakavi should have complete blood counts, including a white blood cell count differential, monitored at least every one to two weeks for the first 6 weeks after initiation of therapy with Jakavi and as clinically indicated thereafter once their liver function and blood counts have been stabilised. Jakavi dose can be titrated to reduce the risk of cytopenia.
Older people (≥65 years)No additional dose adjustments are recommended for older people.
Paediatric populationThe safety and efficacy of Jakavi in children aged up to 18 years have not been established. No data are available (see section 5.1).
Treatment discontinuationTreatment may be continued as long as the benefit-risk remains positive. However the treatment should be discontinued after 6 months if there has been no reduction in spleen size or improvement in symptoms since initiation of therapy.It is recommended that, for patients who have demonstrated some degree of clinical improvement, ruxolitinib therapy be discontinued if they sustain an increase in their spleen length of 40% compared with baseline size (roughly equivalent to a 25% increase in spleen volume) and no longer have tangible improvement in disease-related symptoms.
Method of administrationJakavi is to be taken orally, with or without food.If a dose is missed, the patient should not take an additional dose, but should take the next usual prescribed dose.
MyelosuppressionTreatment with Jakavi can cause haematological adverse drug reactions, including thrombocytopenia, anaemia and neutropenia. A complete blood count, including a white blood cell count differential, must be performed before initiating therapy with Jakavi. Treatment should be discontinued in patients with platelet count less than 50,000/mm3 or absoute neutrophil count less than 500/mm3 (see section 4.2).It has been observed that patients with low platelet counts (<200,000/mm3) at the start of therapy are more likely to develop thrombocytopenia during treatment.Thrombocytopenia is generally reversible and is usually managed by reducing the dose or temporarily withholding Jakavi (see sections 4.2 and 4.8). However, platelet transfusions may be required as clinically indicated.Patients developing anaemia may require blood transfusions. Dose modifications or interruption for patients developing anaemia may also be considered.Patients with a haemoglobin level below 10.0 g/dl at the beginning of the treatment have a higher risk of developing a haemoglobin level below 8.0 g/dl during treatment compared to patients with a higher baseline haemoglobin level (79.3% versus 30.1%). More frequent monitoring of haematology parameters and of clinical signs and symptoms of Jakavi-related adverse drug reactions is recommended for patients with baseline haemoglobin below 10.0 g/dl.Neutropenia (absolute neutrophil count <500) was generally reversible and was managed by temporarily withholding Jakavi (see sections 4.2 and 4.8).Complete blood counts should be monitored as clinically indicated and dose adjusted as required (see sections 4.2 and 4.8).
InfectionsPatients should be assessed for the risk of developing serious bacterial, mycobacterial, fungal and viral infections. Tuberculosis has been reported in patients receiving Jakavi for MF. Before starting treatment, patients should be evaluated for active and inactive (latent) tuberculosis, as per local recommendations. This can include medical history, possible previous contact with tuberculosis, and/or appropriate screening such as lung x-ray, tuberculin test and/or interferon-gamma release assay, as applicable. Prescribers are reminded of the risk of false negative tuberculin skin test results, especially in patients who are severely ill or immunocompromised. Jakavi therapy should not be started until active serious infections have resolved. Physicians should carefully observe patients receiving Jakavi for signs and symptoms of infections and initiate appropriate treatment promptly (see section 4.8).Hepatitis B viral load (HBV-DNA titre) increases, with and without associated elevations in alanine aminotransferase and aspartate aminotransferase, have been reported in patients with chronic HBV infections taking Jakavi. The effect of Jakavi on viral replication in patients with chronic HBV infection is unknown. Patients with chronic HBV infection should be treated and monitored according to clinical guidelines.
Herpes zosterPhysicians should educate patients about early signs and symptoms of herpes zoster, advising that treatment should be sought as early as possible.
Progressive multifocal leukoencephalopathyProgressive multifocal leukoencephalopathy (PML) has been reported with Jakavi treatment for MF. Physicians should be particularly alert to symptoms suggestive of PML that patients may not notice (e.g., cognitive, neurological or psychiatric symptoms or signs). Patients should be monitored for any of these new or worsening symptoms or signs, and if such symptoms/signs occur, referral to a neurologist and appropriate diagnostic measures for PML should be considered. If PML is suspected, further dosing must be suspended until PML has been excluded.
Non-melanoma skin cancerNon-melanoma skin cancers (NMSCs) have been reported in patients treated with ruxolitinib. Most of these patients had histories of extended treatment with hydroxyurea and prior NMSC or pre-malignant skin lesions. A causal relationship to ruxolitinib has not been established. Periodic skin examination is recommended for patients who are at increased risk for skin cancer.
Renal impairmentThe starting dose of Jakavi should be reduced in patients with severe renal impairment. For patients with end-stage renal disease on haemodialysis the starting dose for MF patients should be based on platelet counts (see section 4.2). Subsequent doses (single dose of 20 mg or two doses of 10 mg given 12 hours apart in MF patients; single dose of 10 mg or two doses of 5 mg given 12 hours apart in PV patients) should be administered only on haemodialysis days following each dialysis session. Additional dose modifications should be made with careful monitoring of safety and efficacy (see sections 4.2 and 5.2).
Hepatic impairmentThe starting dose of Jakavi should be reduced by approximately 50% in patients with hepatic impairment. Further dose modifications should be based on the safety and efficacy of the medicinal product (see sections 4.2 and 5.2).
InteractionsIf Jakavi is to be co-administered with strong CYP3A4 inhibitors or dual inhibitors of CYP3A4 and CYP2C9 enzymes (e.g. fluconazole), the unit dose of Jakavi should be reduced by approximately 50%, to be administered twice daily (for monitoring frequency see sections 4.2 and 4.5).The concomitant use of cytoreductive therapies or haematopoietic growth factors with Jakavi has not been studied. The safety and efficacy of these co-administrations are not known (see section 4.5).
Withdrawal effectsFollowing interruption or discontinuation of Jakavi, symptoms of MF may return over a period of approximately one week. There have been cases of patients discontinuing Jakavi who sustained more severe events, particularly in the presence of acute intercurrent illness. It has not been established whether abrupt discontinuation of Jakavi contributed to these events. Unless abrupt discontinuation is required, gradual tapering of the dose of Jakavi may be considered, although the utility of the tapering is unproven. ExcipientsJakavi contains lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicinal product.
Interactions resulting in dose reduction of ruxolitinib
CYP3A4 inhibitorsStrong CYP3A4 inhibitors (such as, but not limited to, boceprevir, clarithromycin, indinavir, itraconazole, ketoconazole, lopinavir/ritonavir, ritonavir, mibefradil, nefazodone, nelfinavir, posaconazole, saquinavir, telaprevir, telithromycin, voriconazole)In healthy subjects co-administration of Jakavi (10 mg single dose) with a strong CYP3A4 inhibitor, ketoconazole, resulted in ruxolitinib Cmax and AUC that were higher by 33% and 91%, respectively, than with ruxolitinib alone. The half-life was prolonged from 3.7 to 6.0 hours with concurrent ketoconazole administration.When administering Jakavi with strong CYP3A4 inhibitors the unit dose of Jakavi should be reduced by approximately 50%, to be administered twice daily. Patients should be closely monitored (e.g. twice weekly) for cytopenias and dose titrated based on safety and efficacy (see section 4.2).
Dual CYP2C9 and CYP3A4 inhibitorsOn the basis of in silico modelling 50% dose reduction should be considered when using medicinal products which are dual inhibitors of CYP2C9 and CYP3A4 enzymes (e.g. fluconazole).
Enzyme inducersCYP3A4 inducers (such as, but not limited to, avasimibe, carbamazepine, phenobarbital, phenytoin, rifabutin, rifampin (rifampicin), St.John's wort (Hypericum perforatum))Patients should be closely monitored and the dose titrated based on safety and efficacy (see section 4.2).In healthy subjects given ruxolitinib (50 mg single dose) following the potent CYP3A4 inducer rifampicin (600 mg daily dose for 10 days), ruxolitinib AUC was 70% lower than after administration of Jakavi alone. The exposure of ruxolitinib active metabolites was unchanged. Overall, the ruxolitinib pharmacodynamic activity was similar, suggesting the CYP3A4 induction resulted in minimal effect on the pharmacodynamics. However, this could be related to the high ruxolitinib dose resulting in pharmacodynamic effects near Emax. It is possible that in the individual patient, an increase of the ruxolitinib dose is needed when initiating treatment with a strong enzyme inducer.
Other interactions to be considered affecting ruxolitinib
Mild or moderate CYP3A4 inhibitors (such as, but not limited to, ciprofloxacin, erythromycin, amprenavir, atazanavir, diltiazem, cimetidine)In healthy subjects co-administration of ruxolitinib (10 mg single dose) with erythromycin 500 mg twice daily for four days resulted in ruxolitinib Cmax and AUC that were higher by 8% and 27%, respectively, than with ruxolitinib alone.No dose adjustment is recommended when ruxolitinib is co-administered with mild or moderate CYP3A4 inhibitors (e.g. erythromycin). However, patients should be closely monitored for cytopenias when initiating therapy with a moderate CYP3A4 inhibitor.
Effects of ruxolitinib on other medicinal products
Substances transported by P-glycoprotein or other transportersRuxolitinib may inhibit P-glycoprotein and breast cancer resistance protein (BCRP) in the intestine. This may result in increased sytemic exposure of substrates of these transporters, such as dabigatran etexilate, ciclosporin, rosuvastatin and potentially digoxin. Therapeutic drug monitoring (TDM) or clinical monitoring of the affected substance is advised.It is possible that the potential inhibition of P-gp and BCRP in the intestine can be minimised if the time between administrations is kept apart as long as possible.
Haematopoietic growth factorsThe concurrent use of haematopoietic growth factors and Jakavi has not been studied. It is not known whether the Janus Associated Kinase (JAK) inhibition by Jakavi reduces the efficacy of the haematopoietic growth factors or whether the haematopoietic growth factors affect the efficacy of Jakavi (see section 4.4).
Cytoreductive therapiesThe concomitant use of cytoreductive therapies and Jakavi has not been studied. The safety and efficacy of this co-administration is not known (see section 4.4).A study in healthy subjects indicated that ruxolitinib did not inhibit the metabolism of the oral CYP3A4 substrate midazolam. Therefore, no increase in exposure of CYP3A4 substrates is anticipated when combining them with Jakavi. Another study in healthy subjects indicated that Jakavi does not affect the pharmacokinetics of an oral contraceptive containing ethinylestradiol and levonorgestrel. Therefore, it is not anticipated that the contraceptive efficacy of this combination will be compromised by co-administration of ruxolitinib.
Pregnancy and contraception in femalesThere are no data from the use of Jakavi in pregnant women.Animal studies have shown that ruxolitinib is embryotoxic and foetotoxic. Teratogenicity was not observed in rats or rabbits. However, the exposure margins compared to the highest clinical dose were low and the results are therefore of limited relevance for humans (see section 5.3). The potential risk for humans is unknown. As a precautionary measure, the use of Jakavi during pregnancy is contraindicated (see section 4.3). Women of child-bearing potential should use effective contraception during the treatment with Jakavi. In case pregnancy should occur during treatment with Jakavi, a risk/benefit evaluation must be carried out on an individual basis with careful counselling regarding potential risks to the foetus (see section 5.3).
Breast-feedingJakavi must not be used during breast-feeding (see section 4.3) and breast-feeding should therefore be discontinued when treatment is started. It is unknown whether ruxolitinib and/or its metabolites are excreted in human milk. A risk to the breast-fed child cannot be excluded. Available pharmacodynamic/toxicological data in animals have shown excretion of ruxolitinib and its metabolites in milk (see section 5.3).
FertilityThere are no human data on the effect of ruxolitinib on fertility. In animal studies, no effect on fertility was observed.
Summary of the safety profileThe safety assessment was based on a total of 855 patients (with MF or PV) receiving Jakavi in phase 2 and 3 studies.
MyelofibrosisIn the randomised period of the two pivotal studies, COMFORT-I and COMFORT-II, the median duration of exposure to Jakavi was 10.8 months (range 0.3 to 23.5 months). The majority of patients (68.4%) were treated for at least 9 months. Of 301 patients, 111 (36.9%) had a baseline platelet count of between 100,000/mm3 and 200,000/mm3 and 190 (63.1%) had a baseline platelet count of >200,000/mm3.In these clinical studies, discontinuation due to adverse events, regardless of causality, was observed in 11.3% of patients.The most frequently reported adverse drug reactions were thrombocytopenia and anaemia.Haematological adverse drug reactions (any Common Terminology Criteria for Adverse Events [CTCAE] grade) included anaemia (82.4%), thrombocytopenia (69.8%) and neutropenia (16.6%).Anaemia, thrombocytopenia and neutropenia are dose-related effects.The three most frequent non-haematological adverse drug reactions were bruising (21.3%), dizziness (15.3%) and headache (14.0%).The three most frequent non-haematological laboratory abnormalities were raised alanine aminotransferase (27.2%), raised aspartate aminotransferase (19.9%) and hypercholesterolaemia (16.9%). In phase 3 clinical studies in MF, neither CTCAE grade 3 or 4 hypercholesterolaemia, raised aspartate aminotransferase nor CTCAE grade 4 raised alanine aminotransferase were observed.Long-term safety: As expected with an extended follow-up period, the cumulative frequency of some adverse events increased in the evaluation of the 3-year follow-up safety data (median duration of exposure of 33.2 months in COMFORT-I and COMFORT-II for patients initially randomised to ruxolitinib) from 457 patients with myelofibrosis treated with ruxolitinib during the randomised and extension periods of the two pivotal phase 3 studies. This evaluation included data from patients that were initially randomised to ruxolitinib (N=301) and patients that received ruxolitinib after crossing over from control treatment arms (N=156). With these updated data, therapy discontinuation due to adverse events was observed in 17.1% of patients treated with ruxolitinib.
Polycythaemia veraThe safety of Jakavi was assessed in 110 patients with PV in an open-label, randomised, controlled phase 3 RESPONSE study. The adverse drug reactions listed below reflect the initial study period (up to week 32) with equivalent exposure to ruxolitinib and Best Available Therapy (BAT), corresponding to a median duration of exposure to Jakavi of 7.8 months. The mean age of patients receiving Jakavi was around 60 years.Discontinuation due to adverse events, regardless of causality, was observed in 3.6% of patients treated with Jakavi and 1.8% of patients treated with best available therapy.Haematological adverse reactions (any CTCAE grade) included anaemia (43.6%) and thrombocytopenia (24.5%). Anaemia or thrombocytopenia CTCAE grade 3 and 4 were reported in respectively 1.8% or 5.5%.The three most frequent non-haematological adverse reactions were dizziness (15.5%), constipation (8.2%) and herpes zoster (6.4%).The three most frequent non-haematological laboratory abnormalities (any CTCAE grade) were hypercholesterolaemia (30.0%), raised alanine aminotransferase (22.7%) and raised aspartate aminotransferase (20.9%). These were all CTCAE grade 1 and 2 with the exception of one CTCAE grade 3 raised alanine aminotransferase event.Long-term safety: Patients had a median duration of exposure to Jakavi of 18.6 months (range 0.3 to 35.9 months). With longer exposure, frequency of adverse events increased; however no new safety findings emerged. When adjusted for exposure, the adverse event rates were generally comparable with those observed during the initial study period.
Tabulated summary of adverse drug reactions from clinical studiesIn the clinical study programme the severity of adverse drug reactions was assessed based on the CTCAE, defining grade 1 = mild, grade 2 = moderate, grade 3 = severe and grade 4=life-threatening.Adverse drug reactions from clinical studies (Table 1) are listed by MedDRA system organ class. Within each system organ class, the adverse drug reactions are ranked by frequency, with the most frequent reactions first. In addition, the corresponding frequency category for each adverse drug reaction is based on the following convention: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000).
Table 1 Frequency category of adverse drug reactions reported in the phase 3 studies (COMFORT-I, COMFORT-II, RESPONSE)
|Adverse drug reaction||Frequency category for MF patients||Frequency category for PV patients|
|Infections and infestations|
|Urinary tract infectionsa,d||Very common||Common|
|Blood and lymphatic system disordersb,d|
|CTCAEc grade 4 (<6.5g/dl)||Very common||Uncommon|
|CTCAEc grade 3 (<8.0 6.5g/dl)||Very common||Uncommon|
|Any CTCAEc grade||Very common||Very common|
|CTCAEc grade 4 (<25,000/mm3)||Common||Uncommon|
|CTCAEc grade 3 (50,000 25,000/mm3)||Common||Common|
|Any CTCAEc grade||Very common||Very common|
|CTCAEc grade 4 (<500/mm3)||Common||-|
|CTCAEc grade 3 (<1,000 500/mm3)||Common||-|
|Any CTCAEc grade||Very common||-|
|Bleeding (any bleeding including intracranial, and gastrointestinal bleeding, bruising and other bleeding)||Very common||Very common|
|Bruising||Very common||Very common|
|Other bleeding (including epistaxis, post-procedural haemorrhage and haematuria)||Common||Very common|
|Metabolism and nutrition disorders|
|Weight gaina||Very common||Common|
|HypercholesterolaemiabCTCAEc grade 1 and 2||Very common||Very common|
|HypertriglyceridaemiabCTCAEc grade 1||-||Very common|
|Nervous system disorders|
|Dizzinessa||Very common||Very common|
|Raised alanine aminotransferaseb|
|CTCAEc grade 3 (> 5x 20 x ULN)||Common||Uncommon|
|Any CTCAEc grade||Very common||Very common|
|Raised aspartate aminotransferaseb|
|Any CTCAEc grade||Very common||Very common|
|a Frequency is based on adverse event data. - A subject with multiple occurrence of an adverse drug reaction (ADR) is counted only once in that ADR category. - ADRs reported are on treatment or up to 28 days post treatment end date. b Frequency is based on laboratory values. - A subject with multiple occurrences of an ADR is counted only once in that ADR category. - ADRs reported are on treatment or up to 28 days post treatment end date. c Common Terminology Criteria for Adverse Events (CTCAE) version 3.0; grade 1 = mild, grade 2 = moderate, grade 3 = severe, grade 4 = life-threatening d These ADRs are discussed in the text. e Frequency is based on all patients exposed to ruxolitinib in clinical studies (N=4755)|
Description of selected adverse drug reactions
AnaemiaIn phase 3 clinical studies in MF, median time to onset of first CTCAE grade 2 or higher anaemia was 1.5 months. One patient (0.3%) discontinued treatment because of anaemia.In patients receiving Jakavi mean decreases in haemoglobin reached a nadir of approximately 10 g/litre below baseline after 8 to 12 weeks of therapy and then gradually recovered to reach a new steady state that was approximately 5 g/litre below baseline. This pattern was observed in patients regardless of whether they had received transfusion during therapy.In the randomised, placebo-controlled study COMFORT-I 60.6% of Jakavi-treated MF patients and 37.7% of placebo-treated MF patients received red blood cell transfusions during randomised treatment. In the COMFORT-II study the rate of packed red blood cell transfusions was 53.4% in the Jakavi arm and 41.1% in the best available therapy arm.In the randomised period of the pivotal studies, anaemia was less frequent in PV patients than in MF patients (43.6% versus 82.4%). In the PV population, the CTCAE grade 3 and 4 events were reported in 1.8%, while in the MF patients the frequency was 42.56%.
ThrombocytopeniaIn the phase 3 clinical studies in MF, in patients who developed grade 3 or 4 thrombocytopenia, the median time to onset was approximately 8 weeks. Thrombocytopenia was generally reversible with dose reduction or dose interruption. The median time to recovery of platelet counts above 50,000/mm3 was 14 days. During the randomised period, platelet transfusions were administered to 4.7% of patients receiving Jakavi and to 4.0% of patients receiving control regimens. Discontinuation of treatment because of thrombocytopenia occurred in 0.7% of patients receiving Jakavi and 0.9% of patients receiving control regimens. Patients with a platelet count of 100,000/mm3 to 200,000/mm3 before starting Jakavi had a higher frequency of grade 3 or 4 thrombocytopenia compared to patients with platelet count >200,000/mm3 (64.2% versus 38.5%).In the randomised period of the pivotal studies, the rate of patients experiencing thrombocytopenia was lower in PV (24.5%) patients compared to MF (69.8%) patients. The frequency of severe (i.e. CTCAE grade 3 and 4) thrombocytopenia was lower in PV (5.5%) than in MF (11.6%) patients.
NeutropeniaIn the phase 3 clinical studies in MF, in patients who developed grade 3 or 4 neutropenia, the median time to onset was 12 weeks. During the randomised period, dose holding or reductions due to neutropenia were reported in 1.0% of patients, and 0.3% of patients discontinued treatment because of neutropenia.In the randomised period of the pivotal study in PV patients, neutropenia was reported in two patients (1.8%) of which one patient developed CTCAE grade 4 neutropenia.
BleedingIn the phase 3 pivotal studies in MF bleeding events (including intracranial and gastrointestinal, bruising and other bleeding events) were reported in 32.6% of patients exposed to Jakavi and 23.2% of patients exposed to the reference treatments (placebo or best available therapy). The frequency of grade 3-4 events was similar for patients treated with Jakavi or reference treatments (4.7% versus 3.1%). Most of the patients with bleeding events during the treatment reported bruising (65.3%). Bruising events were more frequently reported in patients taking Jakavi compared with the reference treatments (21.3% versus 11.6%). Intracranial bleeding was reported in 1% of patients exposed to Jakavi and 0.9% exposed to reference treatments. Gastrointestinal bleeding was reported in 5.0% of patients exposed to Jakavi compared to 3.1% exposed to reference treatments. Other bleeding events (including events such as epistaxis, post-procedural haemorrhage and haematuria) were reported in 13.3% of patients treated with Jakavi and 10.3% treated with reference treatments.In the randomised period of the pivotal study in PV patients, bleeding events (including intracranial and gastrointestinal, bruising and other bleeding events) were reported in 20% of patients treated with Jakavi and 15.3% patients receiving best available therapy. Bruising was reported in similar frequencies in Jakavi and BAT arms (10.9% versus 8.1%). No intracranial bleeding or gastrointestinal haemorrhage events were reported in patients receiving Jakavi. One patient treated with Jakavi experienced a grade 3 bleeding event (post-procedural bleeding); no grade 4 bleeding was reported. Other bleeding events (including events such as epistaxis, post-procedural haemorrhage, gingival bleeding) were reported in 11.8% of patients treated with Jakavi and 6.3% treated with best available therapy.
InfectionsIn the phase 3 pivotal studies in MF, grade 3 or 4 urinary tract infection was reported in 1.0% of patients, herpes zoster in 4.3% and tuberculosis in 1.0%. In phase 3 clinical studies sepsis was reported in 3.0% of patients. An extended follow-up of patients treated with ruxolitinib showed no trends towards an increase in the rate of sepsis over time.In the randomised period of the pivotal study in PV patients, one (0.9%) CTCAE grade 3 and no grade 4 urinary tract infection was reported. The rate of herpes zoster was slightly higher in PV (6.4%) patients than in MF (4.0%) patients. There was one report of CTCAE grade 3 post-herpetic neuralgia amongst the PV patients.
Increased systolic blood pressureIn the phase 3 pivotal clinical studies in MF an increase in systolic blood pressure of 20 mmHg or more from baseline was recorded in 31.5% of patients on at least one visit compared with 19.5% of the control-treated patients. In COMFORT-I (MF patients) the mean increase from baseline in systolic BP was 0-2 mmHg on Jakavi versus a decrease of 2-5 mmHg in the placebo arm. In COMFORT-II mean values showed little difference between the ruxolitinib-treated and the control-treated MF patients.In the randomised period of the pivotal study in PV patients, the mean systolic blood pressure increased by 0.65 mmHg in the Jakavi arm versus a decrease of 2 mmHg in the BAT arm.
Reporting of suspected adverse reactionsReporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.
Mechanism of actionRuxolitinib is a selective inhibitor of the Janus Associated Kinases (JAKs) JAK1 and JAK2 (IC50 values of 3.3 nM and 2.8 nM for JAK1 and JAK2 enzymes, respectively). These mediate the signalling of a number of cytokines and growth factors that are important for haematopoiesis and immune function.Myelofibrosis and polycythaemia vera are myeloproliferative neoplasms known to be associated with dysregulated JAK1 and JAK2 signalling. The basis for the dysregulation is believed to include high levels of circulating cytokines that activate the JAK-STAT pathway, gain-of-function mutations such as JAK2V617F, and silencing of negative regulatory mechanisms. MF patients exhibit dysregulated JAK signalling regardless of JAK2V617F mutation status. Activating mutations in JAK2 (V617F or exon 12) are found in >95% of PV patients.Ruxolitinib inhibits JAK-STAT signalling and cell proliferation of cytokine-dependent cellular models of haematological malignancies, as well as of Ba/F3 cells rendered cytokine-independent by expressing the JAK2V617F mutated protein, with IC50 ranging from 80-320 nM.
Pharmacodynamic effectsRuxolitinib inhibits cytokine-induced STAT3 phosphorylation in whole blood from healthy subjects, MF patients and PV patients. Ruxolitinib resulted in maximal inhibition of STAT3 phosphorylation 2 hours after dosing which returned to near baseline by 8 hours in both healthy subjects and MF patients, indicating no accumulation of either parent or active metabolites.Baseline elevations in inflammatory markers associated with constitutional symptoms such as TNFα, IL-6 and CRP in subjects with MF were decreased following treatment with ruxolitinib. MF patients did not become refractory to the pharmacodynamic effects of ruxolitinib treatment over time. Similarly, patients with PV also presented with baseline elevations in inflammatory markers and these markers were decreased following treatment with ruxolitinib.In a thorough QT study in healthy subjects, there was no indication of a QT/QTc prolonging effect of ruxolitinib in single doses up to a supratherapeutic dose of 200 mg, indicating that ruxolitinib has no effect on cardiac repolarisation.
Clinical efficacy and safety
MyelofibrosisTwo randomised phase 3 studies (COMFORT-I and COMFORT-II) were conducted in patients with MF (primary myelofibrosis, post-polycythaemia vera myelofibrosis or post-essential thrombocythaemia myelofibrosis). In both studies, patients had palpable splenomegaly at least 5 cm below the costal margin and risk category of intermediate-2 or high risk based on the International Working Group (IWG) Consensus Criteria. The starting dose of Jakavi was based on platelet count.COMFORT-I was a double-blind, randomised, placebo-controlled study in 309 patients who were refractory to or were not candidates for available therapy. The primary efficacy endpoint was proportion of subjects achieving ≥35% reduction from baseline in spleen volume at week 24 as measured by Magnetic Resonance Imaging (MRI) or Computed Tomography (CT).Secondary endpoints included duration of maintenance of a ≥35% reduction from baseline in spleen volume, proportion of patients who had ≥50% reduction in total symptom score, changes in total symptom scores from baseline to week 24, as measured by the modified Myelofibrosis Symptom Assessment Form (MFSAF) v2.0 diary, and overall survival.COMFORT-II was an open-label, randomised study in 219 patients. Patients were randomised 2:1 to Jakavi versus best available therapy. In the best available therapy arm, 47% of patients received hydroxyurea and 16% of patients received glucocorticoids. The primary efficacy endpoint was proportion of patients achieving ≥35% reduction from baseline in spleen volume at week 48 as measured by MRI or CT.Secondary endpoints included proportion of patients achieving a ≥35% reduction of spleen volume from baseline at week 24 and duration of maintenance of a ≥35% reduction from baseline spleen volume.In COMFORT-I and COMFORT-II, patient baseline demographics and disease characteristics were comparable between the treatment arms.Table 2 Percentage of patients with ≥35% reduction from baseline in spleen volume at week 24 in COMFORT-I and at week 48 in COMFORT-II (ITT)
|Jakavi (N=155)||Placebo (N=153)||Jakavi (N=144)||Best available therapy (N=72)|
|Time points||Week 24||Week 48|
|Number (%) of subjects with spleen volume reduced by ≥35%||65 (41.9)||1 (0.7)||41 (28.5)||0|
|95% confidence intervals||34.1, 50.1||0, 3.6||21.3, 36.6||0.0, 5.0|
|Jakavi||Placebo||Jakavi||Best available therapy|
|JAK mutation status||Positive (N=113) n (%)||Negative (N=40) n (%)||Positive (N=121) n (%)||Negative (N=27) n (%)||Positive (N=110) n (%)||Negative (N=35) n (%)||Positive (N=49) n (%)||Negative (N=20) n (%)|
|Number (%) of subjects with spleen volume reduced by ≥35%||54 (47.8)||11 (27.5)||1 (0.8)||0||36 (32.7)||5 (14.3)||0||0|
|Time point||After 24 weeks||After 48 weeks|
Polycythaemia veraA randomised, open-label, active-controlled phase 3 study (RESPONSE) was conducted in 222 patients with PV who were resistant to or intolerant of hydroxyurea defined based on the European LeukemiaNet (ELN) international working group published criteria. 110 patients were randomised to the ruxolitinib arm and 112 patients to the BAT arm. The starting dose of Jakavi was 10 mg twice daily. Doses were then adjusted in individual patients based on tolerability and efficacy with a maximum dose of 25 mg twice daily. BAT was selected by the investigator on a patient-by-patient basis and included hydroxyurea (59.5%), interferon/pegylated interferon (11.7%), anagrelide (7.2%), pipobroman (1.8%) and observation (15.3%).Baseline demographics and disease characteristics were comparable between the two treatments arms. The median age was 60 years (range 33 to 90 years). Patients in the ruxolitinib arm had PV diagnosis for a median of 8.2 years and had previously received hydroxyurea for a median of approximately 3 years. Most patients (>80%) had received at least two phlebotomies in the last 24 weeks prior to screening. Comparative data regarding long-term survival and incidence of disease complications is missing.The primary composite endpoint was the proportion of patients achieving both an absence of phlebotomy eligibility (HCT control) and a ≥35% reduction in spleen volume from baseline at week 32. Phlebotomy eligibility was defined as a confirmed HCT of >45%, i.e. at least 3 percentage points higher than the HCT obtained at baseline or a confirmed HCT of >48%, depending on which was lower. Key secondary endpoints included the proportion of patients who achieved the primary endpoint and remained free from progression at week 48, as well as the proportion of patients achieving complete haematological remission at week 32.The study met its primary objective and a higher proportion of patients in the Jakavi group achieved the primary composite endpoint and each of its individual components. Significantly more patients treated with Jakavi (20.9%) achieved a primary response (p<0.0001) compared to BAT (0.9%). Haematocrit control was achieved in 60% of patients in the Jakavi arm compared to 19.6% in the BAT arm and a ≥35% reduction in spleen volume was achieved in 38.2% of patients in the Jakavi arm compared to 0.9% in the BAT arm (Figure 1). 94 (83.9%) patients randomised to the BAT arm crossed over to ruxolitinib treatment at Week 32 or after, limiting the comparison between the two arms after Week 32.Both key secondary endpoints were also met. The proportion of patients achieving a complete haematological remission was 23.6% on Jakavi compared to 8.9% on BAT (p=0.0028) and the proportion of patients achieving a durable primary response at week 48 was 19.1% on Jakavi and 0.9% on BAT.(p<0.0001).
Figure 1 Patients achieving the primary endpoint and components of the primary endpoint at week 32Symptom burden was assessed using the MPN-SAF total symptom score (TSS) electronic patient diary, which consisted of 14 questions. At week 32, 49% and 64% of patients treated with ruxolitinib achieved a ≥50% reduction in TSS-14 and TSS-5, respectively, compared to only 5% and 11% of patients on BAT.Treatment benefit perception was measured by the Patient Global Impression of Change (PGIC) questionnaire. 66% of patients treated with ruxolitinib compared to 19% treated with BAT reported an improvement as early as four weeks after beginning treatment. Improvement in perception of treatment benefit was also higher in patients treated with ruxolitinib at week 32 (78% versus 33%).
Paediatric populationThe European Medicines Agency has waived the obligation to submit the results of studies with Jakavi in all subsets of the paediatric population for the treatment of MF (see section 4.2 for information on paediatric use).
AbsorptionRuxolitinib is a Biopharmaceutical Classification System (BCS) class 1 compound, with high permeability, high solubility and rapid dissolution characteristics. In clinical studies, ruxolitinib is rapidly absorbed after oral administration with maximal plasma concentration (Cmax) achieved approximately 1 hour post-dose. Based on a human mass balance study, oral absorption of ruxolitinib, as ruxolitinib or metabolites formed under first-pass, is 95% or greater. Mean ruxolitinib Cmax and total exposure (AUC) increased proportionally over a single dose range of 5-200 mg. There was no clinically relevant change in the pharmacokinetics of ruxolitinib upon administration with a high-fat meal. The mean Cmax was moderately decreased (24%) while the mean AUC was nearly unchanged (4% increase) on dosing with a high-fat meal.
DistributionThe mean volume of distribution at steady state is approximately 75 litres in MF and PV patients.At clinically relevant concentrations of ruxolitinib, binding to plasma proteins in vitro is approximately 97%, mostly to albumin. A whole body autoradiography study in rats has shown that ruxolitinib does not penetrate the blood-brain barrier.
BiotransformationRuxolitinib is mainly metabolised by CYP3A4 (>50%), with additional contribution from CYP2C9. Parent compound is the predominant entity in human plasma, representing approximately 60% of the drug-related material in circulation. Two major and active metabolites are present in plasma representing 25% and 11% of parent AUC. These metabolites have one half to one fifth of the parent JAK-related pharmacological activity. The sum total of all active metabolites contributes to 18% of the overall pharmacodynamics of ruxolitinib. At clinically relevant concentrations, ruxolitinib does not inhibit CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6 or CYP3A4 and is not a potent inducer of CYP1A2, CYP2B6 or CYP3A4 based on in vitro studies. In vitro data indicate that ruxolitinib may inhibit P-gp and BCRP.
EliminationRuxolitinib is mainly eliminated through metabolism. The mean elimination half-life of ruxolitinib is approximately 3 hours. Following a single oral dose of [14C]-labelled ruxolitinib in healthy adult subjects, elimination was predominately through metabolism, with 74% of radioactivity excreted in urine and 22% via faeces. Unchanged parent substance accounted for less than 1% of the excreted total radioactivity.
Linearity/non-linearityDose proportionality was demonstrated in the single and multiple dose studies.Special populations
Effects of age, gender or raceBased on studies in healthy subjects, no relevant differences in ruxolitinib pharmacokinetics were observed with regard to gender and race. In a population pharmacokinetic evaluation in MF patients, no relationship was apparent between oral clearance and patient age or race. The predicted oral clearance was 17.7 l/h in women and 22.1 l/h in men, with 39% inter-subject variability in MF patients. Clearance was 12.7 l/h in PV patients, with a 42% inter-subject variability and no relationship was apparent between oral clearance and gender, patient age or race, based on a population pharmacokinetic evaluation in PV patients.
Paediatric populationThe safety and effectiveness of Jakavi in paediatric patients have not been established (see section 5.1, Paediatric population).
Renal impairmentRenal function was determined using both Modification of Diet in Renal Disease (MDRD) and urinary creatinine. Following a single ruxolitinib dose of 25 mg, the exposure of ruxolitinib was similar in subjects with various degrees of renal impairment and in those with normal renal function. However, plasma AUC values of ruxolitinib metabolites tended to increase with increasing severity of renal impairment, and were most markedly increased in the subjects with severe renal impairment. It is unknown whether the increased metabolite exposure is of safety concern. A dose modification is recommended in patients with severe renal impairment and end-stage renal disease (see section 4.2). Dosing only on dialysis days reduces the metabolite exposure, but also the pharmacodynamic effect, especially on the days between dialysis.
Hepatic impairmentFollowing a single ruxolitinib dose of 25 mg in patients with varying degrees of hepatic impairment, the mean AUC for ruxolitinib was increased in patients with mild, moderate and severe hepatic impairment by 87%, 28% and 65%, respectively, compared to patients with normal hepatic function. There was no clear relationship between AUC and the degree of hepatic impairment based on Child-Pugh scores. The terminal elimination half-life was prolonged in patients with hepatic impairment compared to healthy controls (4.1-5.0 hours versus 2.8 hours). A dose reduction of approximately 50% is recommended for patients with hepatic impairment (see section 4.2).
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