WHEN IT WORKS, GIVE IT FOR 3 YEARS!

Developed under the direction and sponsorship of Novartis Pharmaceuticals Corporation. 3 years of adjuvant therapy with GLEEVEC reduced the risk of recurrence by 54% vs 1 year of therapy in KIT+ GIST patients (median follow-up of 42 months)1 Orchestrate continued success by extending adjuvant treatment in KIT+ GIST1 View Indication and Important Safety Information The results from the Scandinavian Sarcoma Group (SSG) XVIII/AIO Phase 3 trial showed a significant improvement in recurrence-free survival (RFS) when adjuvant treatment with GLEEVEC® (imatinib mesylate) was extended to 3 years vs 1 year of therapy (median follow-up of 42 months). In addition to improving RFS, trial results demonstrated an overall survival (OS) benefit, with mortality reduced by half in the 3-year arm vs the 1-year arm (12 vs 25 deaths, respectively; median follow-up of 48 months). These findings have prompted updates to the FDA-approved Prescribing Information for GLEEVEC and the NCCN guidelines supporting 3 years of adjuvant treatment for appropriate resected patients with KIT+ GIST.1,2 Please consider this information when making clinical decisions and recommendations for your KIT+ GIST patients. Important Safety Information Serious adverse reactions may occur, including edema, cytopenias, severe congestive heart failure, left ventricular dysfunction, hepatotoxicity, hemorrhage, GI disorders, hypereosinophilic toxicity, dermatologic toxicities, hypothyroidism, toxicities from long-term use, fetal harm, and tumor lysis syndrome. Caution should be recommended when driving a car or operating machinery.1 Download latest Prescribing Information In the SSG trial, risk of tumor recurrence was reduced by half with 3 years vs 1 year of adjuvant GLEEVEC therapy (median 42-month follow-up)1 Recurrence events were 68% higher in the 1-year arm vs the 3-year arm (84 vs 50 events) aSSG XVIII/AIO study was a multicenter, open-label, Phase 3 trial conducted to determine the clinical benefits of 3 years (n=198) vs 1 year (n=199) of adjuvant therapy with GLEEVEC 400 mg/day. Inclusion criteria were tumor diameter >5 cm and mitotic count >5/50 high-power fields (HPFs), or tumor diameter >10 cm and any mitotic count, or tumor of any size with mitotic count >10/50 HPFs, or tumor rupture. The primary end point was RFS defined as the time from date of randomization to the date of recurrence or death from any cause. OS was a secondary end point. Median time of follow-up was 42 and 48 months, respectively.1 GIST=gastrointestinal stromal tumor; NCCN=National Comprehensive Cancer Network; RFS=recurrence-free survival; OS=overall survival. In the SSG trial, no new adverse reactions were reported with longer duration of therapy (3-year arm vs 1-year arm)1 •  As in previous trials, the most frequently reported adverse reactions in this clinical trial were diarrhea, fatigue, nausea, edema, decreased hemoglobin, rash, vomiting, and abdominal pain —  14% of patients in the 3-year arm vs 8% of patients in the 1-year arm discontinued treatment due to adverse events (AEs) —  The incidence of serious AEs (Grade ≥3) was 33% in the 3-year arm vs 20% in the 1-year arm Indications and Important Safety Information GLEEVEC® (imatinib mesylate) tablets are indicated for: •  Patients with KIT (CD117)-positive unresectable and/or metastatic malignant gastrointestinal stromal tumors (GIST) •  Adjuvant treatment of adult patients following complete gross resection of KIT (CD117)-positive GIST Important Safety Information •  GLEEVEC is often associated with edema and, occasionally, serious fluid retention. Severe fluid retention was reported in 9% to 13.1% of patients taking GLEEVEC for GIST. Patients should be weighed and monitored regularly for signs and symptoms of fluid retention, which can be serious or life threatening, and be advised to report any rapid, unexpected weight gain. The probability of edema tended to be increased among older patients (>65 years) or those taking higher doses of GLEEVEC. Severe edema was observed in 182 patients (11.1%). If severe fluid retention occurs, manage with diuretic therapy and withhold GLEEVEC until the event has resolved, and then resume, depending on the initial severity of the event •  Cytopenias have been reported. Complete blood counts should be performed weekly for the first month, biweekly for the second month, and periodically thereafter as clinically indicated (eg, every 2 to 3 months). Dose reduction, treatment interruption, or in rare cases discontinuation of treatment may be required for severe neutropenia or thrombocytopenia (see full Prescribing Information for dose adjustment recommendations) •  Severe congestive heart failure and left ventricular dysfunction have been reported. Most of the patients with reported cardiac events have had other comorbidities and risk factors, including advanced age and previous medical history of cardiac disease. Patients with cardiac disease or risk factors for cardiac disease or history of renal failure should be monitored carefully, and any patient with signs or symptoms consistent with cardiac or renal failure should be evaluated and treated •  Hepatotoxicity, occasionally severe, may occur. Cases of fatal liver failure and severe liver injury requiring liver transplants have been reported with both short-term and long-term use of GLEEVEC. Assess liver function before initiation of treatment and monthly thereafter, or as clinically indicated. A 25% decrease in the recommended dose should be used for patients with severe hepatic impairment. If severe hepatotoxicity occurs, GLEEVEC should be withheld until the event has resolved and then resumed, depending on the initial severity of the event •  When GLEEVEC is combined with chemotherapy, liver toxicity in the form of transaminase elevation and hyperbilirubinemia has been observed. Additionally, there have been reports of acute liver failure. Monitoring of hepatic function is recommended •  In the Phase 3 unresectable or metastatic GIST studies, 13% of patients reported hemorrhage (NCI Grades 3/4) at any site. In the Phase 2 unresectable or metastatic GIST study, 5% of patients were reported to have severe gastrointestinal (GI) bleeds and/or intratumoral bleeds. GI tumor sites may have been the source of GI bleeds; therefore, GI symptoms should be monitored at the start of therapy •  In patients with hypereosinophilic syndrome with occult infiltration of HES cells within the myocardium, cardiogenic shock and left ventricular dysfunction have been associated with HES cell degranulation upon initiation of GLEEVEC. The condition was reported to be reversible with the administration of systemic steroids, circulatory support measures, and temporarily withholding GLEEVEC •  Bullous dermatologic reactions (eg, erythema multiforme and Stevens-Johnson syndrome) have also been reported. In some cases, the reaction recurred upon rechallenge. Several postmarketing reports describe patients able to tolerate the reintroduction of GLEEVEC at a lower dose, with or without concomitant corticosteroids or antihistamines following resolution or improvement of the bullous reaction •  Clinical cases of hypothyroidism have been reported in thyroidectomy patients undergoing levothyroxine replacement during treatment with GLEEVEC. TSH levels should be closely monitored in such patients •  Consider potential toxicities—specifically liver, kidney, and cardiac toxicity—and immunosuppression from long-term use •  Fetal harm can occur when administered to a pregnant woman. Therefore, women of reproductive potential should be advised not to become pregnant while taking GLEEVEC tablets and to avoid breastfeeding while taking GLEEVEC because of the potential for serious adverse reactions in nursing infants. Sexually active female patients taking GLEEVEC should use highly effective contraception. If the patient does become pregnant while taking GLEEVEC, the patient should be advised of the potential hazard to the fetus •  Growth retardation has been reported in children and preadolescents receiving GLEEVEC. The long-term effects of prolonged treatment with GLEEVEC on growth in children are unknown; therefore, monitoring of growth in children taking GLEEVEC is recommended •  Cases of tumor lysis syndrome (TLS), including fatal cases, have been reported. The patients at risk for TLS are those with tumors having a high proliferative rate or high tumor burden prior to treatment. These patients should be monitored closely and appropriate precautions taken. Correction of clinically significant dehydration and treatment of high uric acid levels are recommended prior to initiation of GLEEVEC •  Motor vehicle accidents involving patients receiving GLEEVEC have been reported. Patients should be advised that they may experience undesirable effects such as dizziness, blurred vision, or somnolence during treatment with GLEEVEC. Caution should be recommended when driving a car or operating machinery •  In the Phase 2 unresectable or metastatic GIST trial (400 mg/day; 600 mg/day), severe (NCI Grades 3/4) lab abnormalities—including anemia (3%; 9%) and neutropenia (10%; 11%)—were reported among patients receiving GLEEVEC. In Phase 3 unresectable or metastatic GIST trials (400 mg/day; 800 mg/day), the most frequently reported adverse reactions included abdominal pain (14%; 12%), edema (9%; 13%), fatigue (12%; 12%), nausea (9%; 8%), vomiting (9%; 8%), diarrhea (8%; 9%), rash (8%; 9%), myalgia (6%; 4%), anemia (5%; 6%), and anorexia (7%; 5%). The percentages listed represent NCI Grades 3 and above •  In the adjuvant GIST study comparing 12 months of GLEEVEC vs placebo treatment (GLEEVEC; placebo), severe (NCI Grades 3 and above) lab abnormalities included increase in liver enzymes (ALT) (3%; 0%), (AST) (2%; 0%), decreased neutrophil count (3%; 1%), and decrease in hemoglobin (1%; 0%); severe (NCI Grades 3 and above reported at rates >1%) adverse reactions included abdominal pain (3%; 1%), diarrhea (3%; 1%), rash (3%; 0%), fatigue (2%; 1%), nausea (2%; 1%), vomiting (2%; 1%), decreased white blood cell count (1%; 0%), and periorbital edema (1%; 0%). The frequencies of these reported lab abnormalities and severe adverse reactions were similar in a study comparing 12 vs 36 months of GLEEVEC treatment (12 mo; 36 mo), except for liver enzyme AST (2%; 3%), decreased neutrophil count (5%; 5%), decreased white blood cell count (2%; 3%), pain (1%; 3%), infection (2%; 3%), and blurred vision (1%; 1%), which were higher among patients receiving 36 months of adjuvant treatment with GLEEVEC* •  There have also been reports, including fatalities, of cardiac tamponade, cerebral edema, acute respiratory failure, and GI perforation •  GLEEVEC is metabolized by the CYP3A4 isoenzyme and is an inhibitor of CYP3A4, CYP2D6, and CYP2C9. Significant reductions in imatinib concentrations may occur when GLEEVEC is administered concomitantly with agents that are strong CYP3A4 inducers such as rifampin, St. John's wort, and enzyme-inducing antiepileptic drugs, eg, phenytoin. The concomitant use of strong CYP3A4 inducers should be avoided. If patients must be administered a strong CYP3A4 inducer, the dosage of GLEEVEC should be increased by at least 50%, and clinical response should be carefully monitored. Caution is recommended when GLEEVEC is administered with CYP3A4 inhibitors such as ketoconazole, with CYP2D6 substrates that have a narrow therapeutic window, or with CYP3A4 substrates that have a narrow therapeutic window. Other examples of commonly used drugs that may significantly interact with GLEEVEC include acetaminophen, warfarin, erythromycin, and metoprolol. Grapefruit juice should also be avoided in patients taking GLEEVEC. (Please see full Prescribing Information for other potential drug interactions) •  Patients with moderate renal impairment (CrCL=20-39 mL/min) should receive a 50% decrease in the recommended starting dose; future doses can be increased as tolerated. Doses greater than 600 mg are not recommended in patients with mild renal impairment (CrCL=40-59 mL/min). For patients with moderate renal impairment, doses greater than 400 mg are not recommended. GLEEVEC should be used with caution in patients with severe renal impairment Common Side Effects of GLEEVEC Tablets •  Almost all patients who received GLEEVEC in the Phase 3 unresectable or metastatic GIST studies experienced adverse reactions at some time. Overall, the incidence of all grades of adverse reactions and the incidence of severe (CTC Grades 3 and above) adverse reactions were similar between the 2 treatment arms, except for edema and rash/related terms, which were reported more frequently in the 800-mg group. The most frequently reported adverse reactions (400 mg/day; 800 mg/day) (all grades) were edema (77%; 86%), fatigue (69%; 75%), nausea (58%; 65%), abdominal pain (57%; 55%), diarrhea (56%; 58%), rash and related terms (56%; 70%), vomiting (37%; 41%), myalgia (32%; 30%), anemia (32%; 35%), anorexia (31%; 36%), and arthralgia (14%; 12%). Therapy with GLEEVEC was discontinued for adverse reactions in 5% of patients studied* •  In the adjuvant treatment of GIST studies, almost all GLEEVEC- and placebo-treated patients experienced adverse reactions at some time. The most frequently reported adverse reactions were similar to those reported in other clinical studies in other patient populations. In Study 1, comparing 12 months of GLEEVEC treatment vs placebo (all grades), these included (GLEEVEC; placebo) diarrhea (59%; 29%), fatigue (57%; 41%), nausea (53%; 28%), periorbital edema (47%; 15%), decreased hemoglobin (47%; 27%), peripheral edema (27%; 15%), rash (26%; 13%), vomiting (26%; 14%), abdominal pain (21%; 22%), anorexia (17%; 9%), muscle spasms (16%; 3%), white blood cell count decreased (15%; 4%), arthralgia (15%; 15%), and myalgia (12%; 12%).* The frequencies of these reported adverse reactions were similar in Study 2, comparing 12 vs 36 months of GLEEVEC treatment (12 mo; 36 mo), except for decreased hemoglobin (72%; 80%), periorbital edema (59%; 74%), muscle spasms (31%; 49%), decreased white blood cell count (35%; 47%), pain (26%; 46%), peripheral edema (33%; 41%), rash (29%; 39%), arthralgia (9%; 17%), and myalgia (9%; 15%), which were higher among patients receiving 36 months of adjuvant treatment with GLEEVEC. Adverse reactions listed represent the most frequently reported for Study 1 with the addition of adverse reactions with higher rates in Study 2* •  In the adjuvant GIST study comparing GLEEVEC vs placebo, drug was discontinued for adverse events in 17% of GLEEVEC- and 3% of placebo-treated patients. Edema, GI disturbances (nausea, vomiting, abdominal distension, and diarrhea), fatigue, low hemoglobin, and rash were the most frequently reported adverse reactions at the time of discontinuation. In the adjuvant study comparing 12 vs 36 months of GLEEVEC treatment, drug was discontinued for adverse events in 8% of patients treated for 12 months and 14% of patients treated for 36 months* •  Supportive care may help reduce the severity of some mild to moderate adverse reactions. However, in some cases, either a dose reduction or interruption of treatment with GLEEVEC may be necessary •  Doses of 400 mg or 600 mg should be administered once daily, whereas a dose of 800 mg should be administered at 400 mg twice a day. For daily dosing of 800 mg and above, dosing should be accomplished using the 400-mg tablet to reduce exposure to iron •  GLEEVEC tablets should be taken with food and a large glass of water to minimize GI irritation •  Patients should be instructed to take GLEEVEC exactly as prescribed and not to change their dose or stop taking GLEEVEC unless they are told to do so by their doctor. If patients miss a dose, they should be advised to take their dose as soon as possible unless it is almost time for their next dose, in which case the missed dose should not be taken. A double dose should not be taken to make up for any missed dose *For more detailed study information, please see full Prescribing Information. References 1.  GLEEVEC® [prescribing information]. East Hanover, NJ: Novartis Pharmaceuticals Corp; 2013. 2.  The NCCN Soft Tissue Sarcoma Clinical Practice Guidelines in Oncology (Version 3.2012) ©2012 National Comprehensive Cancer Network, Inc. http://www.nccn.org. Accessed May 24, 2012. To view the most recent and complete version of the guidelines, go online to www.nccn.org. Novartis Pharmaceuticals Corporation East Hanover, New Jersey 07936-1080 © 2013 Novartis 4/13 GLI-1062742

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