Pomalidomid (Capsules) Instructions for Use

ATC Code

L04AX06 (Pomalidomide)

Active Substance

Pomalidomide (Rec.INN registered by WHO)

Clinical-Pharmacological Group

Immunomodulator with antitumor activity

Pharmacotherapeutic Group

Immunosuppressants; other immunosuppressants

Pharmacological Action

Pomalidomide has direct antimyeloma tumoricidal activity, demonstrates an immunomodulatory effect, and inhibits stromal cells that support the growth of myeloma tumor cells.

It selectively inhibits proliferation and induces apoptosis of hematopoietic tumor cells. Furthermore, Pomalidomide inhibits the proliferation of multiple myeloma cell lines resistant to lenalidomide and has synergy with dexamethasone in inducing apoptosis of both lenalidomide-sensitive and lenalidomide-resistant tumor cell lines.

Pomalidomide enhances cellular immunity involving T-cells and natural killer cells and inhibits the production of proinflammatory cytokines (e.g., TNFα and interleukin-6) by monocytes. Pomalidomide also inhibits angiogenesis by blocking endothelial cell migration and adhesion.

Pharmacokinetics

After a single oral dose, the absorption of pomalidomide is at least 73%, and its C_max in plasma is reached within 2 hours.

The systemic exposure of pomalidomide (by AUC) increases almost linearly and proportionally to the dose. With repeated dosing, the accumulation of pomalidomide is 27-31% based on AUC.

When taken with a high-calorie, high-fat meal, the absorption rate of pomalidomide slows, the mean C_max decreases by approximately 27%, but the overall absorption is practically unchanged, the mean AUC decreases by 8%, therefore Pomalidomide can be taken regardless of food intake.

The mean apparent V_d of pomalidomide at steady state ranges from 62-138 L. After administration for 3 days at 2 mg/day, Pomalidomide was detected in the semen of healthy volunteers at a concentration of approximately 67% of the plasma level, which is reached at 4 hours (approximate T_max) after drug intake. In vitro binding of pomalidomide enantiomers to human plasma proteins ranges from 12% to 44% and is concentration-independent.

In healthy volunteers after a single oral dose of [¹⁴C]-pomalidomide (2 mg), the main radioactive component in blood was Pomalidomide (approximately 70% of plasma radioactivity). The amount of metabolites did not exceed 10% relative to the parent compound or total plasma radioactivity.

Hydroxylation followed by glucuronidation or hydrolysis is the main metabolic pathway for excreted radioactivity. In vitro, CYP1A2 and CYP3A4 isoenzymes were found to be the main enzymes involved in the hydroxylation of pomalidomide. CYP2C19 and CYP2D6 isoenzymes were of lesser importance. Pomalidomide is also a substrate of Pgp in vitro.

The mean T_1/2 of pomalidomide from plasma is 9.5 hours in healthy volunteers and 7.5 hours in patients with multiple myeloma. The mean total clearance of the drug is approximately 7-10 L/h. In healthy volunteers after a single oral dose of [¹⁴C]-pomalidomide (2 mg), approximately 73% and 15% of the radioactive dose was excreted renally and via the intestine, respectively, with about 2% and 8% of the carbon-labeled pomalidomide dose excreted renally and via the intestine unchanged.

Pomalidomide undergoes significant biotransformation, and the resulting metabolites are primarily excreted renally. The three main metabolites formed by hydrolysis or hydroxylation followed by glucuronidation account for 23%, 17%, and 12% of the total metabolite content in urine, respectively. The amount of metabolites formed via cytochrome P450 was approximately 43% of the total radioactivity, and non-CYP-dependent hydrolytic metabolites accounted for 25%. Pomalidomide is excreted unchanged at 10% (2% renally and 8% via the intestine).

Indications

In combination with dexamethasone for the treatment of adult patients with relapsed and refractory multiple myeloma who have received at least two prior treatment regimens, including both lenalidomide and bortezomib, and who have demonstrated disease progression on the last therapy.

ICD codes

Dosage Regimen

Administer pomalidomide orally as capsules.

The recommended starting dose is 4 mg once daily on days 1 to 21 of repeated 28-day cycles.

Take capsules with or without food; swallow whole with water. Do not break, chew, or open capsules.

Adhere strictly to the prescribed schedule. If a dose is missed, take it as soon as remembered on the same day. If missed entirely, skip the dose; do not double the next dose.

Dose adjustments are based on clinical and laboratory findings, particularly absolute neutrophil count and platelet count.

For grade 3 or 4 hematologic toxicities, interrupt treatment and monitor blood counts weekly.

Resume therapy at a reduced dose of 3 mg daily once counts recover to required levels.

For recurrence of grade 3 or 4 toxicity after dose reduction, interrupt again and subsequently reduce to 2 mg daily.

Permanently discontinue for inability to tolerate the 2 mg dose.

For severe non-hematologic toxicities, withhold treatment until resolved, then consider resuming at physician’s discretion, potentially at a reduced dose.

Concomitant use of strong CYP1A2 inhibitors (e.g., ciprofloxacin, fluvoxamine) requires a 50% dose reduction to 2 mg daily. Monitor patients closely.

No initial dose adjustment is required for patients with renal or hepatic impairment; however, monitor these patients closely for adverse reactions.

Adverse Reactions

Infections and infestations very common – bacterial, viral, and fungal infection, including opportunistic infections; common – neutropenic sepsis, respiratory tract infections, upper respiratory tract infections, herpes zoster; frequency unknown – hepatitis B virus reactivation.

Benign, malignant and unspecified neoplasms (including cysts and polyps) uncommon – basal cell carcinoma of the skin, squamous cell carcinoma of the skin.

Blood and lymphatic system disorders very common – neutropenia, thrombocytopenia, leukopenia, anemia; common – febrile neutropenia, pancytopenia.

Allergic reactions common – angioedema, urticaria.

Metabolism and nutrition disorders common – hyperkalemia, hyponatremia, hyperuricemia; uncommon – tumor lysis syndrome.

Psychiatric disorders common – confusion.

Nervous system disorders common – lethargy, peripheral sensory neuropathy, dizziness, tremor, intracranial hemorrhage; uncommon – stroke.

Ear and labyrinth disorders common – vertigo.

Cardiac disorders common – cardiac failure, atrial fibrillation, myocardial infarction, deep vein thrombosis.

Respiratory, thoracic and mediastinal disorders very common – dyspnea, cough, pneumonia; common – pulmonary embolism, epistaxis, nasopharyngitis, interstitial lung disease, bronchopneumonia, bronchitis.

Gastrointestinal disorders very common – decreased appetite, diarrhea, nausea, constipation; common – vomiting, gastrointestinal hemorrhage, increased ALT; uncommon – hyperbilirubinemia, hepatitis.

Skin and subcutaneous tissue disorders common – rash, pruritus; frequency unknown – DRESS syndrome, toxic epidermal necrolysis, Stevens-Johnson syndrome.

Musculoskeletal and connective tissue disorders very common – bone pain, muscle spasms.

Renal and urinary disorders common – renal failure, urinary retention.

General disorders and administration site conditions very common – fatigue, pyrexia, peripheral edema; common – pelvic pain, increased blood uric acid.

Contraindications

Hypersensitivity to pomalidomide; pregnancy, breastfeeding; women with preserved reproductive potential, except when all necessary conditions of the Pregnancy Prevention Program are met; men who are unable or unwilling to adhere to the required contraceptive measures; age under 18 years.

With caution Pomalidomide should be prescribed to patients with renal and/or hepatic impairment, deep vein thrombosis (including history), advanced stage disease and/or high tumor burden due to the potential risk of tumor lysis syndrome, neuropathy (including history), presence of risk factors for thromboembolism (heart or lung disease, high blood pressure, elevated blood cholesterol, smokers), with concurrent use of drugs that increase the risk of thrombosis (including drugs with erythropoietic activity, hormone replacement therapy).

Use in Pregnancy and Lactation

Contraindicated for use during pregnancy.

Women with preserved reproductive potential must use one highly effective method of contraception for 4 weeks before starting treatment, during treatment, and for 4 weeks after completion of pomalidomide treatment, even in case of treatment interruption. The exception is patients who have been completely abstinent from sexual intercourse for a long time, confirmed monthly. If an effective method of contraception has not been selected for the patient, she should be referred to a gynecologist for selection and initiation of a contraceptive method.

In accordance with accepted practice, pregnancy tests with a minimum sensitivity of 25 mIU/ml should be performed under physician supervision for all women with preserved reproductive potential, including those who are completely and long-term abstinent from sexual intercourse.

Given the potential adverse effects of pomalidomide on newborns, either breastfeeding or drug administration should be discontinued, taking into account the importance of breastfeeding and treatment for the mother.

Use in Hepatic Impairment

No adjustment of the initial pomalidomide dose is required in patients with hepatic impairment.

Use in Renal Impairment

No dose adjustment of pomalidomide is required in patients with renal impairment.

Pediatric Use

Contraindicated for use in patients under 18 years of age.

Geriatric Use

No dose adjustment is required in elderly patients.

Special Precautions

Treatment with pomalidomide should be initiated and conducted under the supervision of an experienced hematologist or oncologist.

Strict adherence to all requirements of the Pregnancy Prevention Program must apply to all patients unless the absence of reproductive potential is reliably proven.

The use of combined oral contraceptives is not recommended for patients with multiple myeloma due to the increased risk of thromboembolic complications during treatment with pomalidomide and dexamethasone. The increased risk of thromboembolism persists for 4-6 weeks after discontinuation of combined contraceptives. The effectiveness of hormonal contraceptives may be reduced with concurrent administration of dexamethasone.

The use of subcutaneous hormonal implants or intrauterine systems releasing levonorgestrel is associated with an increased risk of infectious complications at the time of insertion and with irregular vaginal bleeding. Patients with neutropenia using these contraceptive methods should be prophylactically prescribed antibiotics.

The use of copper-releasing intrauterine systems is generally not recommended due to the high risk of infectious complications at implantation and increased blood loss during menstruation, which may exacerbate neutropenia or thrombocytopenia.

Pomalidomide may be present in the patient’s semen during treatment. As a precaution and considering special patient groups with potentially increased elimination time, e.g., those with hepatic impairment, all men taking Pomalidomide should consider the potential risk of teratogenic effects of pomalidomide during sexual intercourse with a pregnant woman or a woman with preserved reproductive potential. Condoms must be used during sexual intercourse with a pregnant woman or a woman with preserved reproductive potential not using reliable contraception, during treatment, treatment interruptions, and for 7 days after treatment suspension and/or completion. This recommendation also applies to men after vasectomy, who should also use a condom during sexual intercourse with a pregnant woman or a woman with preserved reproductive potential, as even in the absence of spermatozoa, his semen may contain Pomalidomide. If a partner becomes pregnant during his treatment with pomalidomide or within 7 days after discontinuing pomalidomide therapy, the man should immediately inform his treating physician, and his partner is advised to consult a teratologist for examination and counseling.

Patients are not permitted to donate blood, semen, or sperm throughout the treatment period (including treatment interruptions) and for 7 days after completion of pomalidomide intake.

In patients with relapsed/refractory multiple myeloma, grade 3 or 4 adverse events most frequently reported are neutropenia; followed by anemia and thrombocytopenia. Patients should be monitored for adverse hematological reactions, especially neutropenia. Patients should be informed to promptly report fever. Physicians should monitor patients for symptoms of increased bleeding, including nosebleeds, especially with concomitant therapy with drugs that increase the risk of bleeding. A complete blood count should be performed before starting treatment, then weekly for the first 8 weeks of treatment, and then once a month. Dose adjustment of pomalidomide, use of blood substitutes and/or growth factor preparations may be required.

Venous thromboembolic events (mainly deep vein thrombosis and pulmonary embolism) and arterial thrombotic events (myocardial infarction and stroke) have developed in patients treated with pomalidomide in combination with dexamethasone. Patients with risk factors for thromboembolism, including prior thrombosis, should be closely monitored. All possible measures should be taken to minimize risk factors (e.g., smoking, hypertension, hyperlipidemia). Patients and physicians should monitor for signs and symptoms of thromboembolism. Patients should be warned to seek medical attention if symptoms such as shortness of breath, chest pain, swelling of the upper and lower extremities occur. In the absence of contraindications, treatment with anticoagulants (such as acetylsalicylic acid, warfarin, heparin, or clopidogrel) is recommended, especially in patients with additional risk factors for thrombosis.

The use of erythropoietic agents is associated with a risk of thrombotic complications, including thromboembolism. Therefore, erythropoietic drugs, as well as other agents that may increase the risk of thromboembolism, should be used with caution.

Complications in the form of cardiac failure, including congestive heart failure and pulmonary edema, were noted mainly in patients with pre-existing heart failure or risk factors for heart disease. Caution should be exercised when deciding to prescribe pomalidomide treatment to such patients, including regular check-ups to detect symptoms of heart failure.

The greatest risk of tumor lysis syndrome is in patients with a high tumor burden at the start of treatment. Close monitoring of such patients with appropriate prophylactic measures is necessary.

The occurrence of primary malignancies of other sites, such as non-melanoma skin cancer, has been reported in patients receiving Pomalidomide. Patients should be thoroughly examined before and during treatment using standard cancer screening methods to detect primary tumors of other sites and, if necessary, appropriate treatment should be prescribed.

Angioedema and severe skin reactions, including Stevens-Johnson syndrome, toxic epidermal necrolysis, and DRESS syndrome, have been reported during the use of pomalidomide. Patients should be informed about the signs and symptoms of these reactions and warned to seek immediate medical attention if such symptoms appear. Pomalidomide treatment should be discontinued if exfoliative or bullous rash develops or if Stevens-Johnson syndrome, toxic epidermal necrolysis, and DRESS syndrome are suspected. Treatment should not be resumed after resolution of the aforementioned reactions.

Patients with a history of serious allergic reactions to thalidomide or lenalidomide may have an increased risk of hypersensitivity reactions and should not receive Pomalidomide. Consideration should be given to interrupting or discontinuing pomalidomide treatment in case of grade 2-3 skin rash. If angioedema develops, Pomalidomide must be discontinued.

Reports of dizziness and confusion occurring during pomalidomide administration have been received. Patients should avoid situations where dizziness and confusion could be problematic and not take other medications that may cause similar disturbances without prior medical consultation.

Interstitial lung disease and other similar phenomena, including cases of pneumonitis, have been observed during treatment with pomalidomide. Patients with acute symptoms or unexplained worsening of pulmonary symptoms should undergo a thorough examination to rule out interstitial lung disease. During this examination, pomalidomide treatment should be suspended, and if interstitial lung disease is confirmed, appropriate therapy should be initiated. Pomalidomide treatment may be resumed only after a careful benefit-risk assessment.

Marked increases in ALT activity and bilirubin concentration have been observed in patients taking Pomalidomide. Cases of hepatitis leading to discontinuation of pomalidomide treatment have also been reported. Regular monitoring of liver function is recommended during the first 6 months of pomalidomide therapy and thereafter as clinically indicated.

Rare cases of hepatitis B virus reactivation have been reported in patients previously infected with hepatitis B virus during treatment with pomalidomide in combination with dexamethasone. In several cases, hepatitis progressed to acute liver failure, resulting in Pomalidomide being discontinued. Before starting treatment with pomalidomide, a test for the presence and activity of hepatitis B virus must be performed. For patients with a positive test for hepatitis B virus, consultation with a physician experienced in treating patients with viral hepatitis B is recommended. Caution should be exercised when using pomalidomide and dexamethasone concomitantly in patients with a history of viral hepatitis B. Such patients should be closely monitored throughout the course of therapy for timely detection of symptoms and signs of active disease caused by the hepatitis B virus.

Effect on the Ability to Drive Vehicles and Operate Machinery

Pomalidomide has a minor or moderate influence on the ability to drive vehicles and operate machinery.

Some side effects of pomalidomide, such as fatigue, lethargy, confusion, and dizziness, may adversely affect the ability to drive a car and perform potentially hazardous activities requiring increased concentration and speed of psychomotor reactions.

If such adverse events occur, one should refrain from performing these activities.

Drug Interactions

Pomalidomide is partially metabolized by CYP1A2 and CYP3A4/5 isoenzymes and is a substrate for Pgp.

If a strong inhibitor of the CYP1A2 isoenzyme (e.g., ciprofloxacin, enoxacin, or fluvoxamine) is used concomitantly with pomalidomide, the dose of pomalidomide should be reduced by 50%.

It is recommended to monitor warfarin concentration during combination therapy.

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.