Boramilan^® (Lyophilisate) Instructions for Use

ATC Code

L01XG01 (Bortezomib)

Active Substance

Bortezomib (Rec.INN registered by WHO)

Clinical-Pharmacological Group

Antineoplastic drug

Pharmacotherapeutic Group

Antineoplastic agent

Pharmacological Action

Bortezomib is a highly selective reversible inhibitor of the 26S proteasome activity, representing a modified boric acid.

The 26S proteasome is present in the nucleus and cytosol of all eukaryotic cells and is a key component that catalyzes the breakdown of major proteins involved in controlling the cell life cycle. Bortezomib inhibits the chymotrypsin-like action of the proteasome, causes inhibition of proteolysis and leads to apoptosis.

Myeloma cells are almost 1000 times more susceptible to apoptosis induced by bortezomib than normal plasma cells.

The main factor explaining the ability of the proteasome inhibitor bortezomib to destroy myeloma cells is its ability to block the activation of NF-kB. In normal cells, NF-kB (which exists as a p50-p65 dimer) is bound to the inhibitory protein IkB, which keeps it in an inactive form in the cytosol. Some tumors contain activated forms of NF-kB, and the proteasome plays an important role in this activation, as it catalyzes the proteolytic generation of the NF-kB p50 subunit from the inactive precursor p150 and the destruction of the inhibitory protein IkB. Activated NF-kB, penetrating into the nucleus, helps the cell survive and proliferate. By inhibiting the proteasome and, consequently, inhibiting the activation of NF-kB, Bortezomib helps to reduce the number of anti-apoptotic factors, inflammatory molecules, cell adhesion molecules (which allow connecting cells to attach to bone marrow cells) and cytokines (which stimulate the growth of myeloma cells).

Bortezomib causes a slowdown in the growth of human tumors in many experimental models, including multiple myeloma.

Pharmacokinetics

After a single intravenous administration, the concentration of bortezomib in blood plasma decreases in a biphasic manner, with the AUC characterized by a rapid initial distribution phase and a longer terminal elimination phase.

The T_1/2 of bortezomib in the initial distribution phase ranges from 5 to 15 hours.

The bioavailability of bortezomib is dose-dependent in the dose range from 1.45 to 2 mg/m², and in the dose range of 1-1.3 mg/m² it increases proportionally to the dose.

With repeated administration of bortezomib, a decrease in its clearance is observed, leading to a corresponding increase in T_1/2 in the elimination phase and AUC_0-24. Repeated administrations do not affect the kinetics of the initial distribution of bortezomib, and the values of C_max and T_1/2 in this phase do not change. After the third dose in the first treatment cycle, the mean elimination time of bortezomib in the terminal phase increases from 5.45 to 19.7 hours, and AUC_0-24 increases from 30.1 to 54 h*ng/ml.

At bortezomib concentrations of 0.01-1 μg/ml, binding to plasma proteins is 82.9%. The fraction of bortezomib bound to plasma proteins does not depend on its concentration.

Bortezomib metabolism occurs mainly with the participation of CYP3A4 and CYP2C19 isoenzymes. Only a small amount of the intact substance is excreted in the urine; unchanged Bortezomib is not detected in bile and feces.

Indications

Multiple myeloma.

Mantle cell lymphoma in patients who have previously received at least 1 line of therapy.

ICD codes

Dosage Regimen

Administer Boramilan^® as an intravenous bolus over 3 to 5 seconds.

The standard dose for multiple myeloma and mantle cell lymphoma is 1.3 mg/m².

Administer twice weekly on days 1, 4, 8, and 11 of a 21-day treatment cycle.

Follow each two-week administration period with a 10-day rest period (days 12 to 21).

Maintain a minimum interval of 72 hours between consecutive doses.

For moderate to severe hepatic impairment (bilirubin >1.5 × ULN) or serum creatinine >1.4 mg/dL, reduce the initial dose to 0.7 mg/m² in the first cycle.

Consider subsequent dose escalation to 1.0 mg/m² or further reduction to 0.5 mg/m² based on patient tolerance.

Manage hematological toxicities (Grade 3 neutropenia, thrombocytopenia) by withholding therapy until resolution, then resume at a reduced dose.

For Grade 3 non-hematological toxicities (excluding neuropathy), withhold treatment until symptoms resolve to Grade 1 or baseline, then restart at a 25% dose reduction.

For Grade 1 peripheral neuropathy with pain or Grade 2 peripheral neuropathy, reduce the dose to 1.0 mg/m².

For Grade 2 with pain or Grade 3 peripheral neuropathy, withhold treatment until resolution, then re-initiate at a reduced dose of 0.7 mg/m².

Discontinue treatment for Grade 4 peripheral neuropathy.

The duration of therapy depends on treatment response and tolerability.

Adverse Reactions

From the hematopoietic and lymphatic system: very common – thrombocytopenia, anemia, neutropenia; common – leukopenia, lymphopenia; uncommon – pancytopenia, febrile neutropenia, hemolytic anemia, thrombocytopenic purpura, lymphadenopathy; rare – DIC syndrome.

From the cardiovascular system: common – cardiac arrest, cardiogenic shock, myocardial infarction, angina pectoris, development and exacerbation of chronic heart failure, ventricular hypokinesia, pulmonary edema (including acute), sinus arrest, complete AV block, tachycardia (including sinus and supraventricular), arrhythmia, atrial fibrillation, palpitations, decreased blood pressure, orthostatic and postural hypotension, phlebitis, hematoma, increased blood pressure; uncommon – atrial flutter, bradycardia, intracerebral hemorrhage, intracranial hemorrhage, subarachnoid hemorrhage, vasculitis, stroke, pulmonary congestion, pulmonary hypertension, petechiae, ecchymosis, purpura, vein discoloration, vein swelling, wound bleeding, flushing; rare – decreased left ventricular ejection fraction, cardiac tamponade, pericarditis, ventricular arrhythmias, pulmonary embolism, peripheral vascular embolism.

From the respiratory system: very common – dyspnea; common – exertional dyspnea, epistaxis, cough, rhinorrhea; uncommon – respiratory arrest, hypoxia, pleural effusion, bronchospasm, respiratory alkalosis, tachypnea, wheezing, nasal congestion, hoarseness, rhinitis, pulmonary hyperventilation, orthopnea, chest pain, sinus pain, throat tightness, hemoptysis; rare – pneumonitis, pneumonia (including interstitial), acute respiratory distress syndrome, acute diffuse infiltrative lung disease, pulmonary hypertension, respiratory failure, alveolar pulmonary hemorrhage.

From the digestive system: very common – nausea, vomiting, diarrhea, constipation, decreased appetite; common – abdominal pain, stomatitis, dyspepsia, loose stools, flatulence, hiccups, throat and pharynx pain, dry mouth; uncommon – acute pancreatitis, paralytic ileus, colitis, melena, gastrointestinal bleeding, enteritis, dysphagia, belching, spleen pain, esophagitis, gastritis, gastroesophageal reflux, oral mucosal petechiae, salivary gland hypersecretion, tongue coating, tongue discoloration, tongue ulceration, increased appetite; rare – ischemic colitis.

From the hepatobiliary system: uncommon – hepatitis, liver hemorrhage, hypoproteinemia, hyperbilirubinemia, increased ALT and AST activity; rare – liver failure.

From the nervous system: very common – peripheral neuropathy, paresthesia, headache; common – polyneuropathy, dizziness (excluding vertigo), taste perversion, dysesthesia, hypesthesia, tremor; uncommon – paraplegia, seizures, peripheral motor neuropathy, syncope, paresis, impaired concentration, loss of taste, drowsiness, cognitive disorders, jerky movements, postural dizziness, mononeuropathy, speech disorders, restless legs syndrome; rare – encephalopathy, autonomic neuropathy, reversible leukoencephalopathy syndrome; very rare – symmetrical muscle weakness, tingling sensations and decreased sensitivity first in the legs, then in the arms, face; in severe cases, complete loss of sensation and immobilization (paralysis) with impaired breathing may occur – signs of autoimmune peripheral nerve damage (Guillain-Barré syndrome; demyelinating polyneuropathy).

Mental disorders: common – confusion, depression, insomnia, anxiety; uncommon – agitation, delirium, hallucinations, excited state, mood swings, mental status changes, sleep disorders, irritability, unusual dreams.

From the urinary system: common – renal function impairment, dysuria; uncommon – renal failure (including acute), oliguria, renal colic, hematuria, proteinuria, urinary retention, frequent urination, difficult urination, low back pain, urinary incontinence.

From the hearing organ: common – vertigo; uncommon – tinnitus, hearing impairment; rare – bilateral deafness.

From the organ of vision: common – blurred vision, eye pain; uncommon – eye hemorrhage, visual disturbances, dry eyes, conjunctivitis, photophobia, eye irritation, increased lacrimation, conjunctival hyperemia; rare – ophthalmic herpes, optic neuropathy, blindness.

From the immune system: uncommon – hypersensitivity; rare – angioedema.

From the endocrine system: uncommon – impaired ADH secretion.

From metabolism: common – dehydration, hypokalemia, hyperglycemia; uncommon – hyperkalemia, cachexia, hypercalcemia, hypocalcemia; hypernatremia, hyponatremia, hypoglycemia, hyperuricemia, vitamin B₁₂ deficiency, hypomagnesemia, hypophosphatemia.

From the skin and subcutaneous tissues: very common – skin rash; common – periorbital edema, urticaria, pruritic rash, pruritus, redness, increased sweating, dry skin, eczema; uncommon – erythematous rash, photosensitivity, bruising, generalized pruritus, maculopapular rash, papular rash, psoriasis, generalized rash, eyelid edema, facial edema, dermatitis, alopecia, nail lesions, skin pigmentation changes, atopic dermatitis, hair texture changes, night sweats, ichthyosis, skin nodules; rare – acute febrile neutrophilic dermatosis (Sweet’s syndrome); very rare – Stevens-Johnson syndrome and toxic epidermal necrolysis.

From the musculoskeletal system: very common – myalgia; common – muscle weakness, musculoskeletal pain, limb pain, muscle cramps, arthralgia, bone pain, back pain; uncommon – muscle spasms, muscle twitching, muscle rigidity, joint swelling, joint stiffness, jaw pain.

From the reproductive system: uncommon – testicular pain, erectile dysfunction.

From laboratory parameters: common – increased LDH activity in blood; uncommon – increased ALP activity, increased blood urea concentration, increased GGT activity, increased blood amylase activity, decreased blood bicarbonate concentration, increased C-reactive protein concentration.

Local reactions: uncommon – pain, burning sensation and hyperemia at the injection site, phlebitis; with extravasation – inflammation of the subcutaneous fat.

Other: very common – increased fatigue, increased body temperature, herpes zoster (including disseminated); common – asthenia, weakness, malaise, flu-like symptoms, peripheral edema, edema, secondary infection; uncommon – neuralgia, chills, chest pressure sensation, chest discomfort, groin pain, catheter-associated complications, tumor lysis syndrome, weight gain; rare – herpes meningoencephalitis, septic shock; very rare – progressive multifocal leukoencephalopathy.

Contraindications

Pregnancy, lactation (breastfeeding), childhood, hypersensitivity to bortezomib, boron.

Use in Pregnancy and Lactation

Contraindicated for use during pregnancy and lactation (breastfeeding).

Use in Hepatic Impairment

Use with caution in severe liver dysfunction.

Use in Renal Impairment

Use with caution in severe renal dysfunction.

Pediatric Use

Contraindicated in childhood.

Special Precautions

Use with caution in severe liver and kidney dysfunction, with a history of fainting, diabetic neuropathy, in patients receiving antihypertensive drugs, as well as in dehydration due to diarrhea or vomiting.

If orthostatic hypotension develops, hydration, administration of corticosteroids and/or sympathomimetics is recommended; if necessary, the dose of antihypertensive drugs should be reduced.

Special caution is required when prescribing the drug to patients with risk factors for seizures.

Before starting and during each treatment cycle, a complete blood count with differential and platelet count should be performed.

If the platelet count decreases to <25,000/μl, therapy should be suspended. When the platelet count recovers, treatment should be continued at reduced doses with careful assessment of the potential benefits and risks of treatment. Colony-stimulating factors, platelet and red blood cell transfusions can be used to treat hematological toxicity.

To prevent nausea and vomiting, the use of antiemetics is recommended. If diarrhea occurs, antidiarrheal drugs are prescribed. To prevent or treat dehydration, patients should receive rehydration therapy and maintain water and electrolyte balance.

Due to the possible development of intestinal obstruction, patients with constipation should be dynamically monitored.

If neuropathy occurs, supportive therapy is provided. The frequency of peripheral neuropathy usually peaks at the 5th treatment cycle. If new or worsening symptoms of peripheral neuropathy appear, a dose reduction and change in the bortezomib administration regimen may be required.

Fluid retention may predispose to the development of symptoms of heart failure.

Due to the possible development of hyperuricemia associated with tumor lysis syndrome, it is recommended to determine serum uric acid and creatinine levels in patients during therapy. To prevent hyperuricemia, plenty of fluids are recommended, and if necessary, allopurinol and urine alkalinization.

Caution should be exercised when treating patients with amyloidosis with bortezomib, as the effect of proteasome activity inhibition in diseases accompanied by increased protein content is unknown.

When used in patients receiving oral hypoglycemic drugs, blood glucose levels should be carefully monitored and, if necessary, the dose of hypoglycemic drugs should be adjusted.

When working with bortezomib, standard rules for handling cytotoxic drugs should be observed.

Drug Interactions

Cases of hypoglycemia and hyperglycemia have been reported in diabetic patients taking oral hypoglycemic drugs.

Although there are no data on the interaction of bortezomib with other drugs, patients require careful monitoring when used concomitantly with active inhibitors of CYP3A4 (ketoconazole, ritonavir) and CYP2C19 (fluoxetine) or inducers of CYP3A4 (rifampicin). Use with caution concomitantly with substrates of CYP3A4 and CYP2C19 isoenzymes.

Storage Conditions

Store at 2°C (36°F) to 25°C (77°F). Keep in original packaging, protected from light. Keep out of reach of children.

Dispensing Status

Rx Only

Important Safety Information

This information is for educational purposes only and does not replace professional medical advice. Always consult your doctor before use. Dosage and side effects may vary. Use only as prescribed.