Consumer medicine information

Pomalyst Capsules

Pomalidomide

BRAND INFORMATION

Brand name

Pomalyst

Active ingredient

Pomalidomide

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Pomalyst Capsules.

WHAT IS IN THIS LEAFLET

This leaflet answers some common questions about Pomalyst.

It does not contain all the available information.

It does not take the place of talking to your doctor or pharmacist.

All medicines have risks and benefits. Your doctor has weighed the risks of you taking Pomalyst against the benefits this medicine is expected to have for you.

If you have any concerns about taking this medicine, ask your doctor or pharmacist.

Keep this leaflet with the medicine. You may need to read it again.

WHAT POMALYST IS USED FOR

Pomalyst contains an active substance called pomalidomide.

Pomalyst belongs to a group of medicines called immunomodulating agents.

Pomalyst is used in combination with another medicine called 'dexamethasone' (steroid medicine) to treat adult patients diagnosed with Multiple Myeloma (MM) (a cancer of the bone marrow). It is prescribed for patients whose disease has progressed after two prior therapies.

Pomalyst is also used in combination with dexamethasone and another medicine called 'bortezomib' to treat adult MM patients whose disease has progressed after one therapy.

Ask your doctor if you have any questions about how Pomalyst works or why this medicine has been prescribed for you. Your doctor may have prescribed it for another reason.

This medicine is not addictive.

Pomalyst will only be prescribed to you by a doctor who has experience in medicines to treat cancers of the blood.

BEFORE YOU TAKE POMALYST

When you must not take it

Do not take Pomalyst if you have an allergy to pomalidomide or any of the ingredients listed at the end of this leaflet.

Some of the symptoms of an allergic reaction may include:

  • shortness of breath
  • wheezing or difficulty breathing
  • swelling of the face, lips, tongue or other parts of the body
  • rash, itching or hives on the skin.

If you think you may be allergic to Pomalyst, ask your doctor for advice.

Do not take this medicine if you are pregnant, or think that you are pregnant. Pomalyst may cause birth defects (deformed babies), and may affect your developing baby if you take it during pregnancy.

Do not take this medicine if you are able to become pregnant, unless you are willing to follow the required pregnancy prevention measures (outlined in Celgene's i-access® program - see section 'Before you start to take it').

If you are not sure whether you should start taking this medicine, talk to your doctor.

Before you start to take it

Follow your doctor's instructions carefully.

You will have been given specific instructions by your doctor particularly on the potential effects of pomalidomide on unborn babies.

If you have not fully understood these instructions, ask your doctor again before taking Pomalyst.

Your doctor will have enrolled you in the i-access program to ensure that pomalidomide is used safely.

The i-access® program

Pomalyst (pomalidomide) is structurally related to 'thalidomide', which is known to cause severe life-threatening human birth defects (deformed babies) and death to an unborn baby if taken during pregnancy. If Pomalyst is taken during pregnancy, it may cause birth defects or death to an unborn baby.

To avoid exposure to unborn babies, Pomalyst has restricted availability under a Pregnancy Prevention Program (i-access). This program is designed to ensure that this medicine is always prescribed and taken in the recommended way. Importantly, only patients who are formally enrolled in this program and agree to fully comply with all the requirements of this program can receive Pomalyst.

Some of the requirements of the i-access® program are outlined in the following sections. Your doctor will discuss all the details with you.

  1. For women taking Pomalyst
Before starting this treatment, your doctor will discuss your potential to become pregnant, even if you think this is unlikely e.g. if your periods have stopped.
Follow instructions below if you are able to become pregnant:
- Your doctor will discuss the potential risk to unborn babies if Pomalyst is taken during pregnancy.
- You will be required to have pregnancy tests before treatment, every 4 weeks during treatment, and 4 weeks after stopping treatment.
- Take Pomalyst medicine as soon as you get it from the pharmacy following a negative pregnancy test.
- Use reliable means of contraception for at least 4 weeks before starting Pomalyst treatment, during treatment and treatment interruption, and for at least 4 weeks after Pomalyst treatment has stopped.
Your doctor will tell you what method of contraception to use.
You must stop taking Pomalyst and inform your doctor straight away if:
- You miss or think you have missed a period, or you have unusual menstrual bleeding, or suspect you are pregnant.
- You have heterosexual intercourse without using reliable means of contraception.
Discuss with your doctor if you should breast-feed whilst taking this medicine.
It is not known if Pomalyst is excreted in human milk. Therefore, you should discuss with your doctor whether to discontinue breast-feeding while you are receiving this medicine.
  1. For men taking Pomalyst
Before starting this treatment, discuss with your doctor if your partner is able to become pregnant.
If your partner is able to become pregnant, use barrier methods of contraception (e.g. condoms) even if you are vasectomised, during Pomalyst treatment, during treatment interruption, and for at least 1 week after treatment has stopped.
Tell your doctor immediately if your partner becomes pregnant whilst you are taking this medicine.
Do not donate semen during treatment or during treatment interruption, or for 1 week after stopping treatment.
  1. For all patients taking Pomalyst
Discuss with your doctor if you have or have had any of the following medical conditions:
- Blood clots
- Frequent bleeding or bruising
- Frequent infections
- Peripheral neuropathy (numbness, tingling, weakness, abnormal co-ordination or pain in your hands and feet)
- Abnormal kidney function
- Allergic reactions to thalidomide or lenalidomide
- Hepatitis B virus infection.

If you have not told your doctor about any of the above, tell him/her before you start taking Pomalyst.

Do not donate blood during Pomalyst treatment or during treatment interruption, and for at least 1 week after stopping treatment.

In Australia, patients with myeloma are permanently excluded from donating blood.

Tell your doctor if you have allergies to any other medicines, foods, preservatives or dyes.

Tell your doctor if you smoke. Smoking may affect Pomalyst or may affect how it works.

Your doctor will ask you to have regular blood tests during treatment with Pomalyst. Your doctor may adjust your dose of Pomalyst or stop your treatment based on the results of your blood tests and on your general condition.

Do not give this medicine to a child or adolescent under the age of 18 years. Safety and effectiveness in children younger than 18 years have not been established.

It is important to note that a small number of patients with multiple myeloma may develop additional types of cancer (regardless of their type of therapy). At this stage, it cannot be excluded that this risk may be slightly increased with Pomalyst treatment. Therefore, your doctor will carefully evaluate the benefit and risk when you are prescribed this medicine. Superficial skin cancers have been observed in a small number of multiple myeloma patients treated with Pomalyst.

Taking other medicines

Tell your doctor or pharmacist if you are taking any other medicines or have recently taken any other medicines, including any medicines that you buy without a prescription from a pharmacy, supermarket or health food shop.

Tell your doctor if you are taking medications used to treat depression or obsessive compulsive disorder (OCD). Some of these medicines and Pomalyst may interfere with each other.

HOW TO TAKE POMALYST

Follow all directions given to you by your doctor carefully. They may differ from the information contained in this leaflet.

How much to take

Your doctor will tell you how much Pomalyst to take and for how long you will need to take it. Your doctor will monitor your progress and may adjust your dose.

Your doctor may adjust your dose of Pomalyst or stop your treatment based on the results of your blood tests and on your general condition.

How to take it

Swallow the capsules whole with a full glass of water, once a day as directed by your doctor.

Pomalyst can be taken with or without food.

Do not open, break or chew the capsules.

If powder from the capsules contacts the skin, wash the skin immediately and thoroughly with soap and water. If pomalidomide contacts the mucous membranes e.g. the eyes, flush thoroughly with water.

When to take it

Take your medicine at about the same time each day. If you are on dialysis, on dialysis days take your medicine after dialysis.

How long to take it

Your doctor will tell you how long to continue taking Pomalyst.

If you forget to take it

If it is less than 12 hours before your next dose, skip the dose you missed and take your next dose when you are meant to.

Otherwise, take it as soon as you remember, and then go back to taking your medicine as you would normally.

Do not take a double dose to make up for the dose that you missed.

If you are not sure what to do, ask your doctor or pharmacist.

If you have trouble remembering when to take your medicine, ask your pharmacist for some hints.

If you take too much (overdose)

In Australia, immediately telephone your doctor or Poisons Information Centre (telephone 13 11 26) for advice, or go to Accident and Emergency at your nearest hospital, if you think that you or anyone else may have taken too much Pomalyst.

In New Zealand, immediately telephone your doctor or the National Poisons Centre (telephone 0800 POISON or 0800 64 766) for advice, or go to Accident and Emergency at your nearest hospital, if you think that you or anyone else may have taken too much Pomalyst.

Do this even if there are no signs of discomfort or poisoning. Keep the telephone numbers for these places handy.

WHILE YOU ARE TAKING POMALYST

Things you must do

Female patients:

  • Tell your doctor immediately if you suspect that you may be pregnant. You should also immediately stop taking Pomalyst in this case.

All patients:

  • Tell any other doctors, dentists, and pharmacists who are treating you that you are taking Pomalyst.
  • If you are about to be started on any new medicine, remind your doctor, dentist or pharmacist that you are taking Pomalyst.
  • Keep all of your doctor's appointments so that your progress can be checked.
    Your doctor will do some tests (blood tests) regularly to make sure the medicine is working and to prevent unwanted side effects.

Things you must not do

Female patients:

  • Do not become pregnant whilst taking Pomalyst.

Male patients:

  • Do not donate semen during treatment or treatment interruption, or for at least 1 week after stopping treatment.

All patients:

  • Do not have sexual intercourse without using effective means of contraception described to you by your doctor.
  • Do not donate blood during treatment or treatment interruption, or for at least 1 week after stopping treatment.
    In Australia, patients with myeloma are permanently excluded from donating blood.
  • Do not stop taking Pomalyst (unless you suspect that you are pregnant) or change the dose without first checking with your doctor.
  • Do not let yourself run out of medicine over the weekend or on holidays.
  • Do not give this medicine to anyone else, even if they have the same condition as you.
  • Do not take this medicine to treat any other complaints unless your doctor or pharmacist tells you to.
  • Do not take this medicine after the expiry date printed on the pack or if the packaging is torn or shows signs of tampering.
    In that case, return it to your pharmacist.

Things to be careful of

Be careful driving or operating machinery until you know how Pomalyst affects you. This medicine may cause dizziness or confusion in some people. If you have any of these symptoms, do not drive, operate machinery or do anything else that could be dangerous.

SIDE EFFECTS

Tell your doctor or pharmacist as soon as possible if you do not feel well while you are taking Pomalyst.

Like all medicines, Pomalyst can have side effects, although not everybody gets them and some are uncommon. Sometimes they are serious, most of the time they are not. You may need medical attention if you get some of the side effects.

Do not be alarmed by the following list of side effects. You may not experience any of them.

Tell your doctor if you notice any of the following and they worry you:

  • Constipation, diarrhoea, feeling sick (nausea), vomiting, decrease in appetite, pain in the lower abdomen or pelvic area, gastrointestinal bleeding.
  • Itchiness or rash.
  • Dizziness or spinning sensation, shaking or tremors, feeling faint or confused.
  • Bone pain or muscle spasms.

The above list mainly includes the more common side effects of your medicine.

Tell your doctor immediately if you notice the following:

  • Heart palpitations or fast heartbeat, chest pains, dizziness or fainting, shortness of breath, weakness or reduced ability to exercise.
    These could be symptoms of atrial fibrillation (irregular heartbeat).
  • Bleeding or bruising more easily than normal,
    Pomalyst can reduce the number of platelets, which are responsible for making the blood clot properly. Your doctor will monitor your blood cell numbers during treatment with Pomalyst.
  • Tiredness, headaches, shortness of breath, dizziness and looking pale
    Pomalyst can reduce the number of red blood cells that carry oxygen around the body.
  • Chest pain and dry cough
    This may be due to a chest infection e.g. pneumonia.
  • Wheezing, shortness of breath or a chronic cough
    These may be symptoms caused by inflammation of the connective tissues in the lungs.
  • Numbness, tingling, abnormal co-ordination or pain in your hands and feet
    This may be due to nerve damage.
  • Blurred, loss of or double vision, difficulty speaking, weakness in an arm or a leg, a change in the way you walk or problems with your balance, persistent numbness, decreased sensation or loss of sensation, memory loss or confusion.
    These may be symptoms of a serious and potentially fatal brain condition known as progressive multifocal leukoencephalopathy (PML).

The above list includes serious side effects that may require medical attention.

If any of the following happens, stop taking Pomalyst and see a doctor immediately or go to Accident and Emergency at your nearest hospital:

  • Shortness of breath, wheezing or difficulty breathing; swelling of the face, lips, mouth, tongue or throat which may cause difficulty in swallowing or breathing; swelling of other parts of the body; rash, itching or hives on the skin; flaking or peeling of the skin.
    These could be symptoms of an allergic reaction.
  • Severe blisters and bleeding in the lips, eyes, mouth, nose and genitals; painful red area on the skin that spreads quickly; peeling of the skin. You may have a high temperature, chills and muscle ache at the same time.
    These could be due to rare but severe skin reactions such as Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis and Drug Reaction with Eosinophilia and Systemic Symptoms.
  • Sudden pain in your chest or difficulty in breathing
    This may be due to blood clots in the artery leading to your lungs. These can happen during treatment, or after treatment has stopped.
  • Chest pain, severe weakness, rapid or irregular heartbeat, and/or sudden, severe shortness of breath.
    This could be due to heart failure, a condition where the heart muscle cannot pump blood strongly enough to supply blood throughout the body.
  • Pain or swelling in your legs, especially in your lower leg or calves
    This may be due to blood clots in the veins of your leg. These can happen during treatment, or after treatment has stopped.
  • Fever, severe chills, rapid breathing, shortness of breath, rapid pulse, confusion, nausea, vomiting, diarrhoea, pain or burning when you urinate, cough, phlegm, sore mouth or throat, or mouth ulcers.
    These could be symptoms of sepsis (blood infection) or other serious infections such as pneumonia.
  • Passing little or no urine, drowsiness, nausea, vomiting or breathlessness.
    These could be symptoms of kidney disease.
  • Yellowing of the skin and/or eyes.
    These are symptoms of jaundice which can result from liver failure or a liver disease called hepatitis.

The above list includes very serious side effects. You may need urgent medical attention or hospitalisation.

Tell your doctor or pharmacist immediately if any of the side effects gets worse, or if you notice any other side effects not listed in this leaflet.

AFTER TAKING POMALYST

Storage

Keep your capsules in a cool dry place where the temperature stays below 25°C.

Keep your capsules in the original pack until it is time to use them.

Keep this medicine where children cannot reach it. A locked cupboard at least one-and-a-half metres above the ground is a good place to store medicines.

Disposal

If your doctor tells you to stop taking this medicine or the expiry date has passed, take any unused Pomalyst capsules to your pharmacist.

Medicines should not be disposed of via wastewater or household waste. These measures will help to protect the environment.

PRODUCT DESCRIPTION

What Pomalyst looks like

The capsules are provided in packs. There are two (2) pack sizes available. A pack will contain either three blisters, each with seven capsules, giving a total of twenty-one (21) capsules per pack or two blisters, each with seven capsules, giving a total of fourteen (14) capsules per pack.

Pomalyst 1 mg capsules are yellow opaque body/dark blue opaque cap capsules with "POML 1 mg" written on them.

Pomalyst 2 mg capsules are orange opaque body/dark blue opaque cap capsules with "POML 2 mg" written on them.

Pomalyst 3 mg capsules are green opaque body/dark blue opaque cap capsules with "POML 3 mg" written on them.

Pomalyst 4 mg capsules are blue opaque body/dark blue opaque cap capsules with "POML 4 mg" written on them.

Ingredients

Pomalyst capsules contain an active ingredient called pomalidomide.

The other ingredients are:

  • mannitol,
  • pregelatinised starch, and
  • sodium stearyl fumarate.

The capsule shells contain:

  • 1 mg capsules: gelatine, titanium dioxide, colourants (indigo carmine and yellow iron oxide), white ink (Shellac, titanium dioxide, simethicone, propylene glycol and ammonium hydroxide) and black ink (Shellac, iron oxide black, propylene glycol and strong ammonia solution)
  • 2 mg capsules: gelatine, titanium dioxide, colourants (indigo carmine, yellow iron oxide and erythrosine) and white ink (Shellac, titanium dioxide, simethicone, propylene glycol and strong ammonia solution)
  • 3 mg capsules: gelatine, titanium dioxide, colourants (Indigo carmine and yellow iron oxide) and white ink (Shellac, titanium dioxide, simethicone, propylene glycol and strong ammonia solution)
  • 4 mg capsules: gelatine, titanium dioxide, colourants (Indigo carmine and brilliant blue FCF) and white ink (Shellac, titanium dioxide, simethicone, propylene glycol and strong ammonia solution)

This medicine does not contain lactose.

Supplier

Pomalyst is supplied in Australia by:

Celgene Pty Limited
Level 2, 4 Nexus Court
Mulgrave, VIC 3170
Telephone: 1800 CELGENE
(1800 235 4363)

® = Registered Trademark

This leaflet was updated in May 2022.

Australian Registration Numbers:

Pomalyst (pomalidomide) 1 mg capsules - AUST R 212657

Pomalyst (pomalidomide) 2 mg capsules - AUST R 212654

Pomalyst (pomalidomide) 3 mg capsules - AUST R 212656

Pomalyst (pomalidomide) 4 mg capsules - AUST R 212655

(Celgene V4.0)

Published by MIMS June 2022

BRAND INFORMATION

Brand name

Pomalyst

Active ingredient

Pomalidomide

Schedule

S4

 

1 Name of Medicine

Pomalidomide.

2 Qualitative and Quantitative Composition

Each 1 mg capsule contains 1 mg pomalidomide.
Each 2 mg capsule contains 2 mg pomalidomide.
Each 3 mg capsule contains 3 mg pomalidomide.
Each 4 mg capsule contains 4 mg pomalidomide.
For the full list of excipients, see Section 6.1 List of Excipients.

Description.

Pomalidomide is a yellow solid powder. It is practically insoluble in water over the pH range 1.2-6.8 and is slightly soluble (e.g. acetone, methylene chloride) to practically insoluble (e.g. heptanes, ethanol) in organic solvents. Pomalidomide has a chiral carbon atom and exists as a racemic mixture of the R(+) and S(-) enantiomers.

3 Pharmaceutical Form

Pomalyst (pomalidomide) 1 mg capsules: dark blue/yellow size 3 gelatin capsules marked "POML" in white ink and "1 mg" in black ink. Each 1 mg capsule contains 1 mg of pomalidomide.
Pomalyst (pomalidomide) 2 mg capsules: dark blue/orange size 1 gelatin capsules marked "POML 2 mg" in white ink. Each 2 mg capsule contains 2 mg of pomalidomide.
Pomalyst (pomalidomide) 3 mg capsules: dark blue/green size 1 gelatin capsules marked "POML 3 mg" in white ink. Each 3 mg capsule contains 3 mg of pomalidomide.
Pomalyst (pomalidomide) 4 mg capsules: dark blue/blue size 1 gelatin capsules marked "POML 4 mg" in white ink. Each 4 mg capsule contains 4 mg of pomalidomide.

4 Clinical Particulars

4.1 Therapeutic Indications

Pomalyst, in combination with bortezomib and dexamethasone, is indicated for the treatment of patients with relapsed or refractory multiple myeloma who have received at least one prior treatment regimen including lenalidomide.
Pomalyst, in combination with dexamethasone, is indicated for the treatment of patients with relapsed and refractory multiple myeloma who have received at least two prior treatment regimens, including both lenalidomide and bortezomib, and have demonstrated disease progression on the last therapy.

4.2 Dose and Method of Administration

Treatment must be initiated and monitored under the supervision of a registered Specialist Physician experienced in the management of haematological and oncological malignancies.
Dosing is continued or modified based upon clinical and laboratory findings. Treatment should be discontinued upon progression of disease.

Dosage.

Pomalidomide in combination with bortezomib and dexamethasone.

The recommended starting dose of pomalidomide is 4 mg orally once daily on Days 1-14 for each 21-day cycle.
The recommended dose of bortezomib per 21-day cycle is:
Cycle 1-8: 1.3 mg/m2 on Days 1, 4, 8 and 11; and
Cycle 9 onwards: 1.3 mg/m2 on Days 1 and 8.
The recommended dose of dexamethasone per 21-day cycle is:
Cycles 1-8: 20 mg orally once daily on Days 1, 2, 4, 5, 8, 9, 11 and 12; and
Cycle 9 onwards: 20 mg orally once daily on Days 1, 2, 8 and 9.
For patients greater than 75 years of age, see Dosage adjustment.

Pomalidomide in combination with dexamethasone.

The recommended starting dose of pomalidomide is 4 mg/day taken orally on Days 1-21 of repeated 28-day cycles (21/28 days) until disease progression.
The recommended dose of dexamethasone is 40 mg/day on Days 1, 8, 15 and 22 of each 28-day treatment cycle.
To initiate a cycle of pomalidomide, the platelet count must be ≥ 50 x 109/L and the neutrophil count must be ≥ 1.0 x 109/L.
Monitor patients for haematologic toxicities, especially neutropenia. Monitor complete blood counts weekly for the first 8 weeks and monthly thereafter.

Method of administration.

Pomalidomide should be taken orally about the same time each day. The capsules should not be opened, broken, chewed or crushed. If powder from pomalidomide contacts the skin, wash the skin immediately and thoroughly with soap and water. If pomalidomide contacts the mucous membranes, flush thoroughly with water.
Pomalidomide capsules should be swallowed whole, preferably with water, either with or without food.
In the event of a missed dose, if less than 12 hours has elapsed since missing a dose, the patient can take the dose. If more than 12 hours has elapsed since missing a dose, the patient should not take the dose, but take the next dose at the normal time on the following day.
For information on the administration of other medicinal products given in combination with pomalidomide, refer to their respective PI.

Dosage adjustment.

To initiate a new cycle of pomalidomide, the platelet count must be ≥ 50 x 109/L and the neutrophil count must be ≥ 1.0 x 109/L.
Instructions for dose interruptions and reductions for pomalidomide related to haematologic adverse reactions are outlined in Table 1. For dose adjustments due to toxicity with bortezomib and/or dexamethasone, refer to their respective product information (PI).
Other grade 3/4 toxicities. For venous thromboembolic event (VTE) ≥ Grade 3, withhold dose for the remainder of cycle and initiate anticoagulation therapy. Resume treatment at the same dose level.
For other Grade 3/4 adverse reactions judged to be related to pomalidomide, stop treatment and restart treatment at 1 mg less than the previous dose when an adverse reaction has resolved to ≤ Grade 2 at the physician's discretion.
If toxicities occur after dose reductions to 1 mg, then the medicine should be discontinued.
If strong inhibitors of CYP1A2 are co-administered with pomalidomide, reduce the dose of pomalidomide by 50%.
Discontinuation. Pomalidomide interruption or discontinuation should be considered for Grade 2-3 skin rash. Pomalidomide must be discontinued for angioedema, anaphylaxis, Grade 4 rash, exfoliative or bullous rash or if SJS, TEN or DRESS is suspected, and should not be resumed following discontinuation for these reactions.
Renal impairment. No dose adjustment of pomalidomide is required for patients with renal impairment. Patients on dialysis: on haemodialysis days, patients should take pomalidomide following haemodialysis.
For other medicinal products given in combination with pomalidomide, refer to their respective PI.
Hepatic impairment. Patients with serum total bilirubin > 1.5 ULN were excluded from clinical studies.
Patients with hepatic impairment should be carefully monitored for adverse reactions and a dose reduction or interruption of pomalidomide should be considered as needed.
For other medicinal products given in combination with pomalidomide, refer to their respective PI.
Elderly patients.

Pomalidomide in combination with bortezomib and dexamethasone.

For patients > 75 years of age, the dose of dexamethasone is 10 mg once daily on Days 1, 2, 4, 5, 8, 9, 11, and 12 for cycles 1-8 and 10 mg once daily on Days 1, 2, 8, and 9 from cycle 9 onwards, for each 21-day cycle.
No dose adjustment is required for Pomalyst.
For bortezomib, refer to the respective PI for additional information.

Pomalidomide in combination with dexamethasone.

For patients > 75 years of age, the dose of dexamethasone is 20 mg/day on Days 1, 8, 15 and 22 of each 28-day treatment cycle. For these patients a dose adjustment in Pomalyst is not required.

4.3 Contraindications

Pregnancy.
Females of childbearing potential and male patients unless all of the conditions of the i-access Program have been met (see Section 4.4 Special Warnings and Precautions for Use).
Hypersensitivity to the active substance or to any of the excipients.
For information on contraindications of other medicinal products given in combination with pomalidomide, refer to their respective PI.

4.4 Special Warnings and Precautions for Use

For other medicinal products given in combination with pomalidomide, refer to their respective PI.

Identified precautions.

Pregnancy warning.

A teratogenic effect of pomalidomide in humans cannot be ruled out. Because pomalidomide is a structural analogue of thalidomide, a known human teratogen, the conditions of the i-access Program for pregnancy prevention must be fulfilled for all patients.
The i-access program conditions for pregnancy prevention. Pomalyst has restricted availability under a Pregnancy Prevention Program (i-access). Only physicians and pharmacists registered with this program can prescribe and dispense the product. In addition, Pomalyst must only be dispensed to patients who are registered and meet all the conditions of the program.
Females of non-child bearing potential. A female patient or a female partner of a male patient is considered to have childbearing potential unless she meets at least one of the following criteria:
Age ≥ 50 years and naturally amenorrhoeic for ≥ 1 year*.
Premature ovarian failure confirmed by a specialist gynaecologist.
Previous bilateral salpingo-oophorectomy, or hysterectomy.
XY genotype, Turner syndrome, uterine agenesis.
*Amenorrhoea following cancer therapy does not rule out childbearing potential.
Female patients of non-child bearing potential are only required to comply with the General conditions listed within the pregnancy prevention programme.
Females of child bearing potential. Female patients of child bearing potential must comply with the following requirements on counselling, contraception and pregnancy testing.
If pregnancy occurs in a female treated with pomalidomide, treatment must be stopped and the patient should be referred to a physician specialised or experienced in teratology for evaluation and advice. Similarly, if pregnancy occurs in a partner of a male patient taking pomalidomide, the female partner should be referred to a physician specialised or experienced in teratology for evaluation and advice.

Counselling.

For female patients of childbearing potential, pomalidomide is contraindicated unless all of the following are met:
She understands the potential teratogenic risk to the unborn child.
She understands and agrees to comply with the requirement for effective contraception, without interruption, 4 weeks before starting treatment, throughout the entire duration of treatment including during dose interruptions, and 4 weeks after the end of treatment.
Even if a female of childbearing potential has amenorrhea she must follow all the requirements on effective contraception.
She should be capable of complying with effective contraceptive measures.
She is informed and understands the potential consequences of pregnancy and the need to rapidly consult her physician there is a risk of pregnancy.
She understands the requirement to commence the treatment as soon as pomalidomide is dispensed following a negative pregnancy test.
She understands the requirement and accepts to undergo medically supervised pregnancy testing every 4 weeks.
She acknowledges that she understands the hazards and necessary precautions associated with the use of pomalidomide.

Contraception.

Females of childbearing potential must use one effective method of contraception for 4 weeks before therapy, during therapy, and until 4 weeks after pomalidomide therapy, even in case of dose interruption. If not established on effective contraception, the patient must be referred to an appropriately trained healthcare professional for contraceptive advice in order that contraception can be initiated. Table 2 lists examples of suitable methods of contraception.

Pregnancy testing.

Medically supervised pregnancy tests with a minimum sensitivity of 25 mIU/mL must be performed for females of childbearing potential as outlined below.
Ideally, pregnancy testing, issuing a prescription and dispensing should occur on the same day. For women of childbearing potential, dispensing and commencement of pomalidomide should occur within a maximum of 7 days of a negative pregnancy test.
Prior to starting treatment: A medically supervised pregnancy test should be performed when pomalidomide is prescribed. The test should occur either at the time of consultation, or in the 3 days prior to the visit to the prescriber and at a point where the patient has been using effective contraception for at least 4 weeks. The test should ensure the patient is not pregnant when she starts treatment with pomalidomide.
Follow-up and end of treatment: A medically supervised pregnancy test should be repeated every 4 weeks, including 4 weeks after the end of treatment. These pregnancy tests should be performed on the day of the prescribing visit or in the 3 days prior to the visit to the prescriber.
Male patients. Male patients must comply with the following requirements on counselling and contraception as clinical data has demonstrated the presence of pomalidomide in human semen.

Counselling and contraception.

He understands the potential teratogenic risk if engaged in sexual activity with a woman of childbearing potential.
He understands and complies with the need for the use of a condom, even if he is vasectomised, if engaged in sexual activity with a woman of childbearing potential throughout treatment duration, during dose interruption and for 1 week after discontinuation of treatment.
He understands that if his partner becomes pregnant whilst he is taking pomalidomide or during the 1st week after he discontinues taking pomalidomide, he should inform his treating physician immediately.
He understands that he must not donate sperm during therapy (during dose interruption) or for 1 week following discontinuation of pomalidomide.
Prescribers. Ensure that females of child bearing potential comply with the conditions of the i-access Program, including confirmation that they have an adequate level of understanding of the requirements.
Provide full patient information about the potential teratogenic risk and the strict pregnancy prevention measures as specified in the i-access Program to female patients of childbearing potential and, as appropriate, to male patients.
Ensure that all patients acknowledge and agree to comply with the conditions of the i-access Program.
Sponsor. The sponsor will provide educational material to healthcare professionals to reinforce the warnings about the potential teratogenicity of pomalidomide, to provide advice on contraception before therapy is started, and to provide guidance on the need for pregnancy testing.
General conditions. All patients should be instructed never to give this medicinal product to another person and to return any unused capsules to their pharmacist at the end of treatment.
All patients should not donate blood during therapy including dose interruptions, or for 1 week following discontinuation of pomalidomide. In Australia, patients with myeloma are permanently excluded from donating blood.

Haematological events.

Neutropenia was the most frequently reported Grade 3/4 hematologic adverse reaction in subjects with relapsed/ refractory multiple myeloma, followed by anaemia and thrombocytopenia.
Grade 3 or 4 neutropenia occurred in 41.7% of patients who received Pom + LD-dex, compared with 14.8% who received HD-dex. In Pom + LD-dex treated patients neutropenia did not lead to treatment discontinuation, and was associated with treatment interruption in 21.0% of patients, and with dose reduction in 7.7% of patients.
Grade 3 or 4 febrile neutropenia (FN) was experienced in 6.7% of patients who received Pom + LD-dex, and in no patients who received HD-dex. FN was associated with dose interruption in 3.7% of patients, and with dose reduction in 1.3% of patients, and with no treatment discontinuations.
Grade 3 or 4 thrombocytopenia occurred in 20.7% of patients who received Pom + LD-dex and in 24.2% who received HD-dex. In Pom + LD-dex treated patients, thrombocytopenia led to dose reduction in 6.3% of patients, to dose interruption in 8% of patients and to treatment discontinuation in 0.7% of patients.
Monitor patients for haematologic toxicities, especially neutropenia. Monitor complete blood counts weekly for the first 8 weeks and monthly thereafter. A dose modification may be required (see Section 4.2 Dose and Method of Administration). Patients may require use of blood product support and/or growth factors.

Thromboembolic events.

Patients receiving pomalidomide have developed venous thromboembolic events (VTE) reported as serious adverse events. Anti-coagulation therapy (unless contraindicated) is recommended (such as aspirin, warfarin, heparin or clopidogrel). A decision to take prophylactic measures should be made carefully after an assessment of an individual patient's underlying risk factors.

Peripheral neuropathy.

Patients with ongoing ≥ Grade 2 peripheral neuropathy were excluded from clinical studies with pomalidomide. Appropriate caution should be exercised when considering the treatment of such patients with pomalidomide.

Cardiac dysfunction.

Patients with significant cardiac dysfunction (congestive heart failure [NY Heart Association Class III or IV]; myocardial infarction within 12 months of starting study; unstable or poorly controlled angina pectoris) were excluded from clinical studies with pomalidomide. There is no experience of pomalidomide in patients with pre-existing cardiac dysfunction due to exclusion from clinical trials.

Tumour lysis syndrome.

Tumour lysis syndrome (TLS) may occur in patients treated with pomalidomide. Patients at risk for TLS are those with high tumour burden and those with pre-existing renal impairment prior to treatment. These patients should be monitored closely and appropriate precautions taken.

Second primary malignancies.

Second primary malignancies have been reported in patients receiving pomalidomide. The clinical significance of these observations is unclear. Physicians should carefully evaluate patients before and during treatment using standard cancer screening for occurrence of SPM and institute treatment as indicated.

Allergic reactions and serious skin reactions.

Patients with a prior history of serious allergic reactions associated with thalidomide or lenalidomide were excluded from clinical studies. Such patients may be prone to a higher risk of hypersensitivity and should not receive pomalidomide (see Section 4.3 Contraindications).
Angioedema, anaphylaxis and severe dermatologic reactions including Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS) have been reported. DRESS may present with a cutaneous reaction (such as rash or exfoliative dermatitis), eosinophilia, fever, and/or lymphadenopathy with systemic complications such as hepatitis, nephritis, pneumonitis, myocarditis, and/or pericarditis. These events can be fatal.
Pomalidomide interruption or discontinuation should be considered for Grade 2-3 skin rash. Pomalidomide must be discontinued for angioedema, anaphylaxis, Grade 4 rash, exfoliative or bullous rash or if SJS, TEN or DRESS is suspected, and should not be resumed following discontinuation for these reactions.

Dizziness and confusion.

Dizziness and confusion have been reported. Instruct patients to exercise caution in situations where dizziness or confusion may be a problem.

Interstitial lung disease (ILD).

ILD and related events, including cases of pneumonitis, have been observed with pomalidomide. Careful assessment of patients with an acute onset or unexplained worsening of pulmonary symptoms should be performed to exclude ILD. Pomalidomide should be interrupted pending investigation of these symptoms and if ILD is confirmed, appropriate treatment should be initiated. Pomalidomide should only be resumed after a thorough evaluation of the benefits and the risks.

Infection.

Reactivation of hepatitis B has been reported rarely in patients receiving pomalidomide in combination with dexamethasone who have previously been infected with the hepatitis B virus (HBV). Some of these cases have progressed to acute hepatic failure, resulting in discontinuation of pomalidomide. Caution should be exercised when pomalidomide in combination with dexamethasone is used in patients previously infected with HBV. These patients should be closely monitored for signs and symptoms of active HBV infection throughout therapy.

Progressive multifocal leukoencephalopathy.

Cases of progressive multifocal leukoencephalopathy (PML), including fatal cases, have been reported with pomalidomide in combination with immunosuppressive therapy including dexamethasone. PML was reported several months to several years after starting the treatment with pomalidomide. Physicians should consider PML in the differential diagnosis in patients with new or worsening neurological, cognitive or behavioural signs or symptoms and appropriate diagnostic measures for PML are recommended. If PML is suspected, further pomalidomide dosing must be suspended until PML has been excluded. If PML is confirmed, pomalidomide must be permanently discontinued.

Use in hepatic impairment.

Markedly elevated levels of alanine aminotransferase and bilirubin have been observed in patients treated with pomalidomide (see Section 4.8 Adverse Effects (Undesirable Effects)). There have also been cases of hepatitis that resulted in discontinuation of pomalidomide. Regular monitoring of liver function is recommended.

Use in the elderly.

The effects of age on the pharmacokinetics of pomalidomide have not been studied. Pomalidomide has been used in multiple myeloma patients up to 87 years of age in the Phase III clinical trial. For patients > 75 years of age, a lower dose of dexamethasone is recommended (see Section 4.2 Dose and Method of Administration).

Paediatric use.

There is no experience in treating children and adolescents with pomalidomide. Therefore, pomalidomide should not be used in the paediatric age group (0-18 years).

Effects on laboratory tests.

See Section 4.2 Dose and Method of Administration.

4.5 Interactions with Other Medicines and Other Forms of Interactions

Effect of other medicinal products on pomalidomide.

Pomalidomide is partly metabolized by CYP1A2 and CYP3A4/5. It is also a substrate for P-glycoprotein.
Co-administration of pomalidomide with the strong CYP3A4/5 and P-gp inhibitor ketoconazole, or the strong CYP3A4/5 inducer carbamazepine, had no clinically relevant effect on exposure to pomalidomide.
Data from a study to evaluate the contribution of a CYP1A2 inhibitor to metabolism changes (see Section 5.2 Pharmacokinetic Properties, Metabolism) supports dose adjustment of pomalidomide (see Section 4.2 Dose and Method of Administration).
Cigarette smoking reduces pomalidomide AUC by 32% due to CYP1A2 induction (see Section 5.2 Pharmacokinetic Properties, Metabolism). Advise patients that smoking may reduce the efficacy of pomalidomide.
Pomalidomide is not a substrate of organic anion transporting polypeptides OATP1B1 or OATP1B3.

Effect of pomalidomide on other medicinal products.

The potential for such drug-drug interactions has not been evaluated clinically.

In vitro studies.

Pomalidomide does not inhibit CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP2E1 or CYP3A4/5 in vitro. In addition, pomalidomide does not induce CYP1A2, CYP2B6, CYP2C9, CYP2C19 or CYP3A4/5 in vitro.
Pomalidomide is not an inhibitor of P-glycoprotein (P-gp), and had little to no inhibitory effect on breast cancer resistant protein (BCRP), Organic Anion Transporter Protein (OATP)1B1, OATP1B3, Organic Anion Transporters OAT1 and OAT3 and Organic Cation Transporter OCT2 based on in vitro studies.

Dexamethasone.

Co-administration of multiple doses of 4 mg pomalidomide with 20 mg to 40 mg dexamethasone (a weak to moderate inducer of several CYP enzymes including CYP3A) to patients with multiple myeloma had no effect on the pharmacokinetics of pomalidomide compared with pomalidomide administered alone. Dexamethasone is a weak to moderate enzyme inducer and its effect on warfarin is unknown. Close monitoring of warfarin concentration is advised during treatment.

Other forms of interaction.

During the pivotal clinical study CC-4047-MM-003 pomalidomide was administered without regard to food. In addition, PK data support that co-administration of pomalidomide with a high-fat and high-calorie meal has a minimal effect on the overall extent of absorption (see Section 5.2 Pharmacokinetic Properties).
Therefore, pomalidomide can be administered without regard to food intake (see Section 4.2 Dose and Method of Administration).

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

In a fertility and early embryonic development study in rats, pomalidomide was administered to males and females at dosages of 25, 250, and 1000 mg/kg/day. Uterine examination on Gestation Day 13 showed a decrease in mean number of viable embryos and an increase in postimplantation loss at all dosage levels. Therefore, the NOAEL for these observed effects was < 25 mg/kg/day 99-fold higher exposure at the lowest dose tested relative to a 4 mg dose. When treated males on this study were mated with untreated females, all uterine parameters were comparable to the controls. Based on these results, the observed effects were attributed to the treatment of females.
(Category X)
A teratogenic effect of pomalidomide in humans cannot be ruled out. Because pomalidomide is a structural analogue of thalidomide, a known human teratogen, the conditions of the i-access Program for pregnancy prevention must be fulfilled for all patients. See Section 4.3 Contraindications; Section 4.4 Special Warnings and Precautions for Use.
Pomalidomide crossed the placenta and was detected in fetal blood following administration to pregnant rabbits. Pomalidomide was found to be teratogenic and induce embryofetal lethality in reproductive toxicity studies in rats and rabbits. Teratogenicity was seen at all doses. Both skeletal (including rotated fore- and/or hind limbs and unattached or absent digits) and visceral (including absent urinary bladder, intraventricular septal defect) malformations were observed. Exposures at the LOEL in rats and rabbits were 85-fold and similar to, respectively, the exposure expected with a 4 mg clinical dose.
 It is not known if pomalidomide is excreted in human milk. Pomalidomide was detected in milk of lactating rats following administration to the mother. Because of the potential for adverse reactions in nursing infants from pomalidomide, a decision should be made whether to discontinue nursing or to discontinue the medicine, taking into account the importance of the medicine to the mother.

4.7 Effects on Ability to Drive and Use Machines

Patients should be warned that confusion, fatigue, dizziness and depressed level of consciousness have been reported with pomalidomide usage and if affected, patients should be instructed not to drive cars, use machines or perform hazardous tasks while being treated with pomalidomide.

4.8 Adverse Effects (Undesirable Effects)

Tabulated summary of adverse events.

Pomalidomide in combination with bortezomib and dexamethasone.

In the phase III, randomised study (CC-4047-MM-007), data was evaluated from 548 patients who received at least 1 dose of pomalidomide, bortezomib or low-dose dexamethasone.
In the Pom + Btz + LD-dex arm, the most frequently reported adverse events were peripheral sensory neuropathy (47.8%), neutropenia (46.8%), fatigue (37.1%), thrombocytopenia and constipation (36.7% each), and peripheral oedema and diarrhea (33.8% each).
In the Btz + LD-dex arm, the most commonly reported adverse events were thrombocytopenia (38.1%), peripheral sensory neuropathy (37.0%), diarrhea (30.0%), anaemia (27.0%), and fatigue (26.3%).
The most frequently occurring adverse events in the two treatment arms were consistent with the known safety profiles of pomalidomide, bortezomib and dexamethasone.
A list of the treatment-emergent adverse events (TEAEs) that occurred at a frequency greater than or equal to 10% in any arm are provided in Table 3.

Pomalidomide in combination with dexamethasone.

In the randomised study (CC-4047-MM-003), 302 patients with relapsed and refractory MM were exposed to 4 mg pomalidomide administered once daily for 21 days of each 28-day cycle in combination with a weekly low dose of dexamethasone. The most commonly reported adverse events were blood and lymphatic system disorders including anaemia (45.7%), neutropenia (45.3%) and thrombocytopenia (27%); general disorders and administration site conditions including fatigue (28.3%), pyrexia (21%) and peripheral oedema (13%); and infections and infestations including pneumonia (10.7%).
Adverse events tended to occur more frequently within the first 2 cycles of treatment with pomalidomide.
Table 4 shows the adverse events that occurred at a frequency of greater than or equal to 10% in either of the arms in study CC-4047-MM-003.

Tabulated list of adverse reactions.

The adverse drug reactions (ADRs) listed below have been assessed as being at least possibly related to treatment. The relatedness to treatment has been determined by: biological/ pharmacological plausibility for a drug-event relationship, known morbidities of target population and disease being treated, adverse reactions suspected with medicines of this class, weight of evidence (e.g. positive rechallenge, positive dechallenge, time to onset, lack of confounding factors) and medical judgment.
Frequencies are defined in accordance with current guidance, as: very common (≥ 1/10), common (≥ 1/100 to < 1/10); and uncommon (≥ 1/1,000 to < 1/100).

Pomalidomide in combination with bortezomib and dexamethasone.

The ADRs observed in patients treated with pomalidomide in combination with bortezomib and dexamethasone are listed in Table 5 by system organ class (SOC) and frequency for all ADRs and grade 3/4 ADRs.
The most commonly reported blood and lymphatic system disorders were neutropenia (46.8%), thrombocytopenia (36.7%) and anaemia (28.4%). The most frequently reported adverse reaction was peripheral sensory neuropathy (47.8%). The most commonly reported Grade 3 or 4 adverse reactions were blood and lymphatic system disorders including neutropenia (41.7%), thrombocytopenia (27.3%) and anaemia (14.0%).

Pomalidomide in combination with dexamethasone.

The ADRs observed in patients treated with pomalidomide/dexamethasone are listed in Table 6 by system organ class and frequency for all ADRs and Grade 3/4 ADRs.
The most commonly reported Grade 3 or 4 adverse reactions were blood and lymphatic system disorders including neutropenia (41.7%), anaemia (27%) and thrombocytopenia (20.7%); infections and infestations including pneumonia (9%); and general disorders and administration site conditions including fatigue (4.7%), pyrexia (3%) and peripheral oedema (1.3%). The most commonly reported serious adverse reaction was pneumonia (9.3%).

Description of selected adverse reactions.

Infection. Infection was the most common non-haematological toxicity.
In patients receiving combination therapy with pomalidomide in clinical studies, infection occurred in 55.0-80.2% of patients (24.0-30.9% of which were Grade 3 or 4). Upper respiratory tract infection and pneumonia were the most frequently occurring infections. Fatal infections (Grade 5) occurred in 2.7-4.0% of treated patients. Infections led to pomalidomide discontinuation in 2.0-2.9% of patients.
Thromboembolic events. In patients receiving combination therapy with pomalidomide in clinical studies, venous thromboembolic events (VTE) occurred in 3.3-11.5% of patients (1.3-5.4% Grade 3 or 4). VTE was reported as serious in 1.7-4.3% of patients, no fatal reactions were reported, and VTE was associated with pomalidomide discontinuation in up to 1.8% of patients.
Prophylaxis with acetylsalicylic acid (and other anticoagulants in high risk subjects) was mandatory for all patients in clinical studies. Anticoagulation therapy (unless contraindicated) is recommended.
Peripheral neuropathy.

Pomalidomide in combination with bortezomib and dexamethasone.

Patients with ongoing peripheral neuropathy ≥ Grade 2 with pain within 14 days prior to randomisation were excluded from clinical studies.
In study CC-4047-MM-007, peripheral neuropathy occurred in 55.4% of patients who received pomalidomide in combination with bortezomib and low-dose dexamethasone (Pom + Btz + LD-dex) and 43.3% of patients receiving bortezomib and low-dose dexamethasone (Btz + LD-dex). Peripheral neuropathy was reported as Grade 3 or 4 in 11.5% of patients in the Pom + Btz + LD-dex arm and 5.2% in the Btz + LD-dex arm. Exposure-adjusted rates were comparable across treatment arms.
Approximately 30% of the patients experiencing peripheral neuropathy had a history of neuropathy at baseline. Peripheral neuropathy led to discontinuation of any study drug in 37 (13.3%) subjects in the POM + BTZ + LD-dex arm, and 26 (9.6%) subjects in the BTZ + LD-dex arm.

Pomalidomide in combination with dexamethasone.

Patients with ongoing peripheral neuropathy ≥ Grade 2 were excluded from clinical studies. Peripheral neuropathy, mostly Grade 1 or 2 occurred in 12.3% patients in the Pom + LD-dex arm, and 10.7% of patients in the comparative HD-dex arm. Grade 3 or 4 reactions occurred in 1.0% of patients in the Pom + LD-dex arm and in 1.3% of patients in the HD-dex arm. In patients treated with Pom + LD-dex, no peripheral neuropathy reactions were reported as being serious and peripheral neuropathy led to dose discontinuation in 0.3% of patients.

Post-marketing data.

The following adverse drug reactions have been identified from the worldwide post-marketing experience with pomalidomide.
Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Infections and infestations.

Viral reactivation (such as hepatitis B virus and herpes zoster), progressive multifocal leukoencephalopathy (PML) (also see Section 4.4 Special Warnings and Precautions for Use).

Neoplasms benign, malignant and unspecified (incl. cysts and polyps).

Tumour lysis syndrome, basal cell carcinoma, and squamous cell carcinoma of the skin.

Blood and lymphatic system disorders.

Pancytopenia.

Immune system disorders.

Allergic reactions (e.g. angioedema, anaphylaxis, urticaria).

Endocrine disorders.

Hypothyroidism.

Respiratory, thoracic and mediastinal disorders.

Interstitial lung disease (ILD), pneumonitis.

Gastrointestinal disorders.

Gastrointestinal haemorrhage.

Hepatobiliary disorders.

Hepatitis, increased liver function tests.

Skin and subcutaneous tissue disorders.

Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS).

Reporting of suspected adverse reactions.

Reporting suspected adverse reactions after registration 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 at www.tga.gov.au/reporting-problems.

4.9 Overdose

Pomalidomide doses as high as 50 mg as a single dose in healthy volunteers and 10 mg as once daily multiple doses in multiple myeloma patients have been studied without reported serious adverse events related to overdose. Pomalidomide was removed by haemodialysis. No specific information is available on the treatment of overdose with pomalidomide.
In the event of overdose, supportive care is advised. In Australia, for information on the management of overdose, contact the Poisons Information Centre on 13 11 26. In New Zealand, contact the National Poisons Centre on 0800 POISON or 0800 764 766 for advice on management.

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Pharmacotherapeutic group: Immunomodulating agent; ATC code: L04AX06.

Mechanism of action.

Pomalidomide has direct anti-myeloma tumouricidal activity, immunomodulatory activities and inhibits stromal cell support for multiple myeloma (MM) tumour cell growth. Specifically, pomalidomide inhibits proliferation and induces apoptosis of haematopoietic tumour cells. Additionally, pomalidomide inhibits the proliferation of lenalidomide-resistant multiple myeloma cell lines and synergises with dexamethasone in both lenalidomide-sensitive and lenalidomide-resistant cell lines to induce tumour cell apoptosis. Pomalidomide enhances T cell- and natural killer (NK) cell-mediated immunity and inhibits production of pro-inflammatory cytokines (e.g. TNF-α and IL-6) by monocytes. Pomalidomide demonstrated anti-angiogenic activity in a mouse tumour model and the in vitro umbilical cord model.
Pomalidomide binds directly to the protein cereblon (CRBN), which is part of an E3 ligase complex that includes DNA damage-binding protein 1 (DDB1), cullin 4 (CUL4) and Roc1, altering the substrate specificity of the enzyme complex. E3 ubiquitin ligases are responsible for the poly-ubiquitination of a variety of substrate proteins, and may partially explain the pleiotropic cellular effects observed with pomalidomide treatment.
In the presence of pomalidomide in vitro, the haematopoietic transcription factors Aiolos and Ikaros are targeted for ubiquitination and subsequent degradation leading to direct cytotoxic and immunomodulatory effects. In vivo, pomalidomide therapy led to a reduction in the levels of Ikaros in patients with relapsed lenalidomide-refractory multiple myeloma.

Clinical trials.

Pomalidomide in combination with bortezomib and dexamethasone. A randomised, open label, phase III, two-arm, multi-centre clinical study (CC-4047-MM-007) evaluated the efficacy and safety of pomalidomide in combination with bortezomib and low-dose dexamethasone (Pom + Btz + LD-dex) versus bortezomib and low-dose dexamethasone (Btz + LD-dex) in previously treated patients with relapsed or refractory multiple myeloma. The patients had received at least one prior treatment, one of which must have been a lenalidomide-containing regimen.
A total of 559 patients were randomised in the study: 281 in the Pom + Btz + LD-dex arm and 278 in the Btz + LD-dex arm. 54% of patients were male with a median age for the overall population of 68 years (min, max: 27, 89 years). Approximately 70% of patients were refractory to lenalidomide (71.2% in Pom + Btz + LD-dex; 68.7% in Btz + LD-dex). Approximately 40% of patients were in first relapse and approximately 73% of patients had received bortezomib as prior treatment.
Patients in the Pom + Btz + LD-dex arm were administered 4 mg pomalidomide orally on Days 1 to 14 of each 21-day cycle. Low-dose dexamethasone 20 mg was administered once per day on Days 1, 2, 4, 5, 8, 9, 11 and 12 of a 14-day cycle for Cycles 1 through 8, then once per day on Days 1, 2, 8 and 9 of each subsequent 21-day cycle from Cycle 9 onwards. Patients who were > 75 years of age received dexamethasone 10 mg using the same treatment schedule as younger patients. Bortezomib (1.3 mg/m2/dose) was administered on Days 1, 4, 8 and 11 of the 21-day cycle for Cycles 1 through 8, then same dose on Days 1 and 8 of the 21-day cycle for Cycle 9 onwards.
For the Btz + LD-dex arm, bortezomib and dexamethasone followed the same dose and schedule as in the Pom + Btz + LD-dex arm. Treatment continued until disease progression or unacceptable toxicity. Doses were reduced, treatment was temporarily interrupted or stopped as needed to manage toxicity.
The primary efficacy endpoint was progression free survival (PFS). PFS was defined as the time between randomisation and disease progression, or death. Response was assessed by an Independent Response Adjudication Committee (IRAC) according to the International Myeloma Working Group (IMWG) criteria using the intent-to-treat population (ITT) as the primary analysis. For the ITT population, after a median follow-up of 15.9 months, median PFS time was 11.20 months (95% CI: 9.66, 13.73) in the Pom + Btz + LD-dex arm. In the Btz + LD-dex arm, median PFS time was 7.1 months (95% CI: 5.88, 8.48).
Summary of overall efficacy data are presented in Table 7 using a cut-off date of 26 October 2017.
The median duration of treatment was 38.3 weeks in the Pom + Btz + LD-dex arm and 21.4 weeks in the Btz and LD-dex arm.
The PFS advantage was more pronounced in patients who had received only one prior line of therapy. In patients who received 1 prior antimyeloma line, median PFS was 20.73 months (95% CI: 15.11, 27.99) in the Pom + Btz + LD-dex arm and 11.63 months (95% CI: 7.52, 15.74) in the Btz + LD-dex arm. A 46% risk reduction was observed with Pom + Btz + LD-dex treatment (HR = 0.54, 95% CI: 0.36, 0.82).
In the interim analysis for overall survival (OS) completed per protocol at the time of final PFS analysis, using a cut-off of 26 October 2017 (median follow-up period of 15.9 months and an overall event rate of 31.5%), the difference in OS between treatment arms (HR = 0.98, 95% CI: 0.73, 1.32; p = 0.894) did not cross the prespecified superiority boundary. In an updated interim analysis for OS with a cut-off date of 15 September 2018, after a median follow-up period of 26.2 months and an overall response event rate of 43.3%, the median OS time from Kaplan-Meier estimates was 40.5 months for the Pom + Btz + LD-dex arm and 30.5 months for the Btz + LD-dex arm; HR = 0.91, 95% CI: 0.70, 1.18.
The Kaplan-Meier curve for PFS for the ITT population is provided in Figure 1.

Quality of life.

Patient-reported global Quality of Life (QoL) domain of the Quality of Life Core (QLQ-C30) was maintained during treatment, with no clinically meaningful differences in mean changes from baseline across all treatment cycles between the Pom + Btz + LD-dex and Btz + LD-dex groups. The proportion of patients experiencing a clinically meaningful worsening of the global QoL domain, as well as the time to the first clinically meaningful worsening were also similar between both treatment groups.
The findings of the analyses suggest that treatment with Pom + Btz + LD-dex, as compared to Btz + LD-dex, did not compromise the HRQoL of patients.
Pomalidomide in combination with dexamethasone. The efficacy and safety of pomalidomide in combination with dexamethasone were evaluated in a Phase III multi-centre, randomised, open label study (CC-4047-MM-003). In this study, pomalidomide plus low dose dexamethasone therapy (Pom + LD-dex) was compared to high dose dexamethasone alone (HD-dex) in previously treated adult patients with relapsed and refractory multiple myeloma (MM). To be included in the study, the patients should have received at least two prior treatment regimens, have failed both lenalidomide and bortezomib, and have demonstrated disease progression on the last therapy. A total of 455 subjects were enrolled in the study: 302 in the Pom + LD-dex arm and 153 in the HD-dex arm. The majority of subjects were male (59%) and white (79%) and the median age for the overall population was 64 years (min, max: 35, 87 years).
Patients in the Pom + LD-dex arm were administered 4 mg pomalidomide orally on Days 1 to 21 of each 28-day cycle. LD-dex (40 mg) was administered once per day on Days 1, 8, 15 and 22 of a 28-day cycle. For the HD-dex arm, dexamethasone (40 mg) was administered once per day on Days 1 through 4, 9 through 12, and 17 through 20 of a 28-day cycle. Subjects > 75 years of age started treatment with 20 mg dexamethasone using the same schedule. Treatment continued until subjects had disease progression.
The primary efficacy endpoint was PFS according to the IMWG criteria. For the ITT population, median PFS time by IRAC review as of data cut off date (01 March 2013) was 16.0 weeks in the Pom + LD-dex arm and 8.1 weeks in the HD-dex arm (p < 0.001). The estimated 26 week event free survival rate was 33.03% ± 2.79% in the Pom + LD-dex arm and 12.37% ± 2.94% in the HD-dex arm (p < 0.001).
Progression-free survival was evaluated in several relevant subgroups. In most of the subgroup evaluated, PFS was generally consistent with that observed in the ITT population for both treatment groups.
OS was one of the secondary study endpoints. A total of 145 (48.0%) of the Pom + LD-dex subjects and 82 (53.6%) of the HD-dex subjects had died as of the data cut off date (01 March 2013). Median OS time from Kaplan-Meier estimates was 55.4 weeks for the Pom + LD-dex and 35.1 weeks for the HD-dex arm (p = 0.028). The 1-year event free rate was 51.11% ± 3.30% for the Pom + LD-dex arm and 39.44% ± 4.51% for the HD-dex arm (p = 0.028).
Results for the efficacy evaluable population are consistent with those observed in the ITT population. The PFS and OS for the ITT population are summarised in Table 8. The Kaplan-Meier curves for PFS and OS for the ITT population are provided in Figures 2 and 3, respectively.

5.2 Pharmacokinetic Properties

Absorption.

Pomalidomide is absorbed with a maximum plasma concentration (Cmax) occurring between 2 and 3 hours and is > 70% absorbed following administration of single oral dose. The systemic exposure (AUC) of pomalidomide increases in an approximately dose proportional manner. Following multiple doses, pomalidomide has an accumulation ratio of 27 to 31%.
Coadministration with a high-fat and high-calorie meal slows the rate of absorption, decreasing mean plasma Cmax by approximately 27%, but has minimal effect on the overall extent of absorption with an 8% decrease in mean AUC.

Distribution.

Pomalidomide has a mean apparent volume of distribution (Vd/F) between 62 and 138 L at steady state. Pomalidomide is distributed in semen of healthy subjects at a concentration of approximately 67% of plasma level at 4 hours post-dose (approximately Tmax) after 4 days of once daily dosing at 4 mg. In vitro binding of pomalidomide enantiomers to proteins in human plasma ranges from 12% to 44% and is not concentration-dependent.

Metabolism.

Pomalidomide is the major circulating component (approximately 70% of plasma radioactivity) in vivo in healthy subjects who received a single oral dose of [14C]-pomalidomide (2 mg). No metabolites were present at > 10% relative to parent or total radioactivity in plasma.
Pomalidomide is eliminated in humans via multiple pathways including CYP-mediated metabolism, non-CYP dependent hydrolysis, and excretion of unchanged drug. The predominant metabolic pathways of excreted radioactivity are hydroxylation with subsequent glucuronidation, or hydrolysis.
In vitro, CYP1A2 and CYP3A4 were identified as the primary enzymes involved in the CYP-mediated hydroxylation of pomalidomide, with additional minor contributions from CYP2C19 and CYP2D6.
Co-administration of the strong CYP1A2 inhibitor fluvoxamine with pomalidomide in the presence of ketoconazole, increased mean exposure to pomalidomide by 107% with a 90% confidence interval [91% to 124%] compared to pomalidomide plus ketoconazole. In a second study to evaluate the contribution of a CYP1A2 inhibitor alone to metabolism changes, co-administration of fluvoxamine alone with pomalidomide increased mean exposure to pomalidomide by 125% with a 90% confidence interval [98% to 157%] compared to pomalidomide alone (see Section 4.2 Dose and Method of Administration).
In 14 healthy male subjects who smoked 25 cigarettes per day for a total of 10 days, after single oral dose of 4 mg Pomalyst, Cmax of pomalidomide increased 14% while AUC of pomalidomide decreased 32%, compared to that in 13 healthy male volunteers who were non-smokers.
Pomalidomide is a substrate of P-glycoprotein in vitro, but this did not appear to limit its absorption in humans, where at least 73% of the drug was absorbed.

Excretion.

Pomalidomide is eliminated with a median plasma half-life of approximately 9.5 hours in healthy subjects and approximately 7.5 hours in patients with multiple myeloma. Pomalidomide has a mean total body clearance (CL/F) of approximately 7-10 L/hr.
Following a single oral administration of [14C]-pomalidomide (2 mg) to healthy subjects, approximately 73% and 15% of the radioactive dose was eliminated in urine and faeces, respectively, with approximately 2% and 8% of the dosed radiocarbon eliminated as unchanged pomalidomide in urine and faeces, respectively.

Renal impairment.

Population pharmacokinetic analyses showed that the pomalidomide pharmacokinetic parameters were not remarkably affected in renal impaired patients (defined by creatinine clearance or estimated glomerular filtration rate [eGFR]) relative to patients with normal renal function (CrCl ≥ 60 mL/minute). Mean normalized AUC exposure to pomalidomide was 98.2% with a 90% confidence interval [77.4% to 120.6%] in moderate renal impairment patients (eGFR ≥ 30 to ≤ 45 mL/minute/1.73 m2) relative to patients with normal renal function. Mean normalized AUC exposure to pomalidomide was 100.2% with a 90% confidence interval [79.7% to 127.0%] in severe renal impairment patients not requiring dialysis (CrCl < 30 or eGFR < 30 mL/minute/1.73 m2) relative to patients with normal renal function. Mean normalized AUC exposure to pomalidomide increased by 35.8% with a 90% confidence interval [7.5% to 70.0%] in severe renal impairment patients requiring dialysis (CrCl < 30 mL/minute requiring dialysis) relative to patients with normal renal function. The mean changes in exposure to pomalidomide in each of these renal impairment groups are not of a magnitude that require dosage adjustments.

Hepatic impairment.

The pharmacokinetic parameters were significantly changed in patients with hepatic impairment (defined by Child-Pugh criteria) relative to healthy subjects as described below. The mean increases in exposure to pomalidomide in each of these hepatic impairment groups are not of a magnitude for which adjustments in schedule or dose are required. See Table 9.
Patients with serum bilirubin > 34.2 micromol/L and transaminases > 3 x ULN were excluded from the efficacy studies.

5.3 Preclinical Safety Data

Genotoxicity.

Pomalidomide was not mutagenic in bacterial and mammalian mutation assays, and did not induce chromosomal aberrations in human peripheral blood lymphocytes or micronuclei formation in polychromatic erythrocytes in bone marrow of rats administered doses up to 2000 mg/kg/day.

Carcinogenicity.

Carcinogenicity studies have not been conducted.

6 Pharmaceutical Particulars

6.1 List of Excipients

Pomalyst (pomalidomide) capsules contain mannitol, pregelatinised starch and sodium stearyl fumarate as inactive ingredients.
The capsule shells contain gelatin, titanium dioxide and the following colourants: 1 mg: indigo carmine and yellow iron oxide; 2 mg: indigo carmine, yellow iron oxide and erythrosin; 3 mg: indigo carmine, yellow iron oxide and 4 mg: indigo carmine and brilliant blue FCF.
The white ink used in 1 mg, 2 mg, 3 mg and 4 mg capsules contains shellac, titanium dioxide, simethicone, propylene glycol and strong ammonia solution.
The black ink used in the 1 mg capsule contains shellac, iron oxide black, propylene glycol and strong ammonia solution.

6.2 Incompatibilities

Incompatibilities were either not assessed or not identified as part of the registration of this medicine.

6.3 Shelf Life

4 years.

6.4 Special Precautions for Storage

Store below 25°C. Store in the original package.

6.5 Nature and Contents of Container

Polychlorotrifluoroethylene (PCTFE)/ polyvinylchloride (PVC) blisters with aluminium push through foil.
Pomalyst is available as 1 mg, 2 mg, 3 mg and 4 mg capsules in blister packs containing either 14 capsules or 21 capsules each.

6.6 Special Precautions for Disposal

In Australia, any unused medicine or waste material should be disposed of by taking to your local pharmacy.

6.7 Physicochemical Properties

Chemical Name: (RS)-4-Amino-2-(2,6-dioxo-piperidin-3-yl)- isoindoline-1,3-dione.

Chemical structure.


CAS number.

19171-19-8.
Molecular Formula: C13H11N3O4.
Molecular Weight: 273.24.

7 Medicine Schedule (Poisons Standard)

Schedule 4 (Prescription Only Medicine).

Summary Table of Changes