ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS The following clinically significant adverse reactions are described in detail in other sections of the prescribing information:oEmbryo-Fetal Toxicity [see Boxed Warning, Warnings and Precautions (5.1, 5.2)]oHematologic Toxicity [see Boxed Warning, Warnings and Precautions (5.3)]oVenous and Arterial Thromboembolism [see Boxed Warning, Warnings and Precautions (5.4)]oIncreased Mortality in Patients with CLL [see Warnings and Precautions (5.5)]oSecond Primary Malignancies [see Warnings and Precautions (5.6)]oIncreased Mortality in Patients with MM When Pembrolizumab Is Added to Thalidomide Analogue and Dexamethasone [see Warnings and Precautions (5.7)]oHepatotoxicity [see Warnings and Precautions (5.8)]oSevere Cutaneous Reactions [see Warnings and Precautions (5.9)]oTumor Lysis Syndrome [see Warnings and Precautions (5.10)]oTumor Flare Reactions [see Warnings and Precautions (5.11)]oImpaired Stem Cell Mobilization [see Warnings and Precautions (5.12)]oThyroid Disorders [see Warnings and Precautions (5.13)]oEarly Mortality in Patients with MCL [see Warnings and Precautions (5.14)]oHypersensitivity [see Warnings and Precautions (5.15)]. oEmbryo-Fetal Toxicity [see Boxed Warning, Warnings and Precautions (5.1, 5.2)]. oHematologic Toxicity [see Boxed Warning, Warnings and Precautions (5.3)]. oVenous and Arterial Thromboembolism [see Boxed Warning, Warnings and Precautions (5.4)]. oIncreased Mortality in Patients with CLL [see Warnings and Precautions (5.5)]. oSecond Primary Malignancies [see Warnings and Precautions (5.6)]. oIncreased Mortality in Patients with MM When Pembrolizumab Is Added to Thalidomide Analogue and Dexamethasone [see Warnings and Precautions (5.7)]. oHepatotoxicity [see Warnings and Precautions (5.8)]. oSevere Cutaneous Reactions [see Warnings and Precautions (5.9)]. oTumor Lysis Syndrome [see Warnings and Precautions (5.10)]. oTumor Flare Reactions [see Warnings and Precautions (5.11)]. oImpaired Stem Cell Mobilization [see Warnings and Precautions (5.12)]. oThyroid Disorders [see Warnings and Precautions (5.13)]. oEarly Mortality in Patients with MCL [see Warnings and Precautions (5.14)]. oHypersensitivity [see Warnings and Precautions (5.15)]. oMM: Most common adverse reactions (>= 20%) include diarrhea, fatigue, anemia, constipation, neutropenia, leukopenia, peripheral edema, insomnia, muscle cramp/spasms, abdominal pain, back pain, nausea, asthenia, pyrexia, upper respiratory tract infection, bronchitis, nasopharyngitis, gastroenteritis, cough, rash, dyspnea, dizziness, decreased appetite, thrombocytopenia, and tremor (6.1).oMDS: Most common adverse reactions (> 15%) include thrombocytopenia, neutropenia, diarrhea, pruritus, rash, fatigue, constipation, nausea, nasopharyngitis, arthralgia, pyrexia, back pain, peripheral edema, cough, dizziness, headache, muscle cramp, dyspnea, pharyngitis, and epistaxis (6.1).oNon-Hodgkins Lymphoma (NHL: MCL, FL or MZL): Most common adverse reactions (>= 15%) included neutropenia, thrombocytopenia, anemia, leukopenia, diarrhea, constipation, nausea, fatigue, pyrexia, cough, upper respiratory tract infection, and rash (6.1).To report SUSPECTED ADVERSE REACTIONS, contact Mylan at 1-877-446-3679 (1-877-4-INFO-RX) or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. oMM: Most common adverse reactions (>= 20%) include diarrhea, fatigue, anemia, constipation, neutropenia, leukopenia, peripheral edema, insomnia, muscle cramp/spasms, abdominal pain, back pain, nausea, asthenia, pyrexia, upper respiratory tract infection, bronchitis, nasopharyngitis, gastroenteritis, cough, rash, dyspnea, dizziness, decreased appetite, thrombocytopenia, and tremor (6.1).. oMDS: Most common adverse reactions (> 15%) include thrombocytopenia, neutropenia, diarrhea, pruritus, rash, fatigue, constipation, nausea, nasopharyngitis, arthralgia, pyrexia, back pain, peripheral edema, cough, dizziness, headache, muscle cramp, dyspnea, pharyngitis, and epistaxis (6.1).. oNon-Hodgkins Lymphoma (NHL: MCL, FL or MZL): Most common adverse reactions (>= 15%) included neutropenia, thrombocytopenia, anemia, leukopenia, diarrhea, constipation, nausea, fatigue, pyrexia, cough, upper respiratory tract infection, and rash (6.1).. 6.1Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.. Newly Diagnosed MM Lenalidomide Capsule Combination Therapy. Data were evaluated from 1613 patients in large phase study who received at least one dose of lenalidomide capsules with low dose dexamethasone (Rd) given for different durations of time (i.e., until progressive disease [Arm Rd Continuous; = 532] or for up to eighteen 28-day cycles [72 weeks, Arm Rd18; = 540] or who received melphalan, prednisone and thalidomide (Arm MPT; = 541) for maximum of twelve 42-day cycles (72 weeks). The median treatment duration in the Rd Continuous arm was 80.2 weeks (range 0.7 to 246.7) or 18.4 months (range 0.16 to 56.7).In general, the most frequently reported adverse reactions were comparable in Arm Rd Continuous and Arm Rd18, and included diarrhea, anemia, constipation, peripheral edema, neutropenia, fatigue, back pain, nausea, asthenia, and insomnia. The most frequently reported Grade or reactions included neutropenia, anemia, thrombocytopenia, pneumonia, asthenia, fatigue, back pain, hypokalemia, rash, cataract, lymphopenia, dyspnea, DVT, hyperglycemia, and leukopenia. The highest frequency of infections occurred in Arm Rd Continuous (75%) compared to Arm MPT (56%). There were more grade and and serious adverse reactions of infection in Arm Rd Continuous than either Arm MPT or Rd18.In the Rd Continuous arm, the most common adverse reactions leading to dose interruption of lenalidomide capsules were infection events (28.8%); overall, the median time to the first dose interruption of lenalidomide capsules was weeks. The most common adverse reactions leading to dose reduction of lenalidomide capsules in the Rd Continuous arm were hematologic events (10.7%); overall, the median time to the first dose reduction of lenalidomide capsules was 16 weeks. In the Rd Continuous arm, the most common adverse reactions leading to discontinuation of lenalidomide capsules were infection events (3.4%).In both Rd arms, the frequencies of onset of adverse reactions were generally highest in the first months of treatment and then the frequencies decreased over time or remained stable throughout treatment, except for cataracts. The frequency of onset of cataracts increased over time with 0.7% during the first months and up to 9.6% by the 2nd year of treatment with Rd Continuous.Table summarizes the adverse reactions reported for the Rd Continuous, Rd18, and MPT treatment arms.Table 4: All Adverse Reactions in >= 5% and Grade 3/4 Adverse Reactions in >= 1% of Patients with MM in the Rd Continuous or Rd18Adverse reactions included in combined adverse reaction terms:Abdominal Pain: Abdominal pain, abdominal pain upper, abdominal pain lower, gastrointestinal pain Pneumonias: Pneumonia, lobar pneumonia, pneumonia pneumococcal, bronchopneumonia, pneumocystis jiroveci pneumonia, pneumonia legionella, pneumonia staphylococcal, pneumonia klebsiella, atypical pneumonia, pneumonia bacterial, pneumonia escherichia, pneumonia streptococcal, pneumonia viral Sepsis: Sepsis, septic shock, urosepsis, escherichia sepsis, neutropenic sepsis, pneumococcal sepsis, staphylococcal sepsis, bacterial sepsis, meningococcal sepsis, enterococcal sepsis, klebsiella sepsis, pseudomonal sepsis Rash: Rash, rash pruritic, rash erythematous, rash maculo-papular, rash generalized, rash papular, exfoliative rash, rash follicular, rash macular, drug rash with eosinophilia and systemic symptoms, erythema multiforme, rash pustular Deep Vein Thrombosis: Deep vein thrombosis, venous thrombosis limb, venous thrombosis Note: subject with multiple occurrences of an adverse reaction is counted only once under the applicable Body System/Adverse Reaction.All Adverse ReactionsAll treatment-emergent adverse events in at least 5% of subjects in the Rd Continuous or Rd18 Arms and at least 2% higher frequency (%) in either the Rd Continuous or Rd18 Arms compared to the MPT Arm.Grade 3/4 Adverse ReactionsAll grade or treatment-emergent adverse events in at least 1% of subjects in the Rd Continuous or Rd18 Arms and at least 1% higher frequency (%) in either the Rd Continuous or Rd18 Arms compared to the MPT Arm.Body SystemAdverse ReactionRd Continuous(N 532)Rd18(N 540)MPT(N 541)Rd Continuous(N 532)Rd18(N 540)MPT(N 541)General disorders and administration site conditionsFatigue- adverse reactions in which at least one was considered to be life-threatening (if the outcome of the reaction was death, it is included with death cases). 173 (33)177 (33)154 (28)39 (7)46 (9)31 (6)Asthenia150 (28)123 (23)124 (23)41 (8)33 (6)32 (6)PyrexiaSerious treatment-emergent adverse events in at least 1% of subjects in the Rd Continuous or Rd18 Arms and at least 1% higher frequency (%) in either the Rd Continuous or Rd18 Arms compared to the MPT Arm. 114 (21)102 (19)76 (14)13 (2)7 (1)7 (1)Non-cardiac chest painFootnote b not applicable. 29 (5)31 (6)18 (3)< 1%< 1%< 1%Gastrointestinal disordersDiarrhea242 (45)208 (39)89 (16)21 (4)18 (3)8 (1)Abdominal pain 109 (20)78 (14)60 (11)7 (1)9 (2)< 1%Dyspepsia 57 (11)28 (5)36 (7)< 1%< 1%0 (0)Musculoskeletal and connective tissue disordersBack pain 170 (32)145 (27)116 (21)37 (7)34 (6)28 (5)Muscle spasms 109 (20)102 (19)61 (11)< 1%< 1%< 1%Arthralgia 101 (19)71 (13)66 (12)9 (2)8 (1)8 (1)Bone pain 87 (16)77 (14)62 (11)16 (3)15 (3)14 (3)Pain in extremity 79 (15)66 (12)61 (11)8 (2)8 (1)7 (1)Musculoskeletal pain 67 (13)59 (11)36 (7)< 1%< 1%< 1%Musculoskeletal chest pain 60 (11)51 (9)39 (7)6 (1)< 1%< 1%Muscular weakness 43 (8)35 (6)29 (5)< 1%8 (1)< 1%Neck pain 40 (8)19 (4)10 (2)< 1%< 1%< 1%Infections and infestationsBronchitis 90 (17)59 (11)43 (8)9 (2)6 (1)< 1%Nasopharyngitis 80 (15)54 (10)33 (6)0 (0)0 (0)0 (0)Urinary tract infection 76 (14)63 (12)41 (8)8 (2)8 (1)< 1%Upper respiratory tract infection 69 (13)53 (10)31 (6)< 1%8 (1)< 1%Pneumonia adverse reactions in which at least one resulted in fatal outcome. 93 (17)87 (16)56 (10)60 (11)57 (11)41 (8)Respiratory tract infection 35 (7)25 (5)21 (4)7 (1)< 1%< 1%Influenza 33 (6)23 (4)15 (3)< 1%< 1%0 (0)Gastroenteritis 32 (6)17 (3)13 (2)0 (0)< 1%< 1%Lower respiratory tract infection29 (5)14 (3)16 (3)10 (2)< 1%< 1%Rhinitis 29 (5)24 (4)14 (3)0 (0)0 (0)0 (0)Cellulitis 5%< 5%< 5%8 (2)< 1%< 1%Sepsis 33 (6)26 (5)18 (3)26 (5)20 (4)13 (2)Nervous system disordersHeadache 75 (14)52 (10)56 (10)< 1%< 1%< 1%Dysgeusia 39 (7)45 (8)22 (4)< 1%0 (0)< 1%Blood and lymphatic system disordersPreferred terms for the blood and lymphatic system disorders body system were included by medical judgment as known adverse reactions for Rd Continuous/Rd18, and have also been reported as serious.Anemia233 (44)193 (36)229 (42)97 (18)85 (16)102 (19)Neutropenia186 (35)178 (33)328 (61)148 (28)143 (26)243 (45)Thrombocytopenia104 (20)100 (19)135 (25)44 (8)43 (8)60 (11)Febrile neutropenia7 (1)17 (3)15 (3)6 (1)16 (3)14 (3)Pancytopenia< 1%6 (1)7 (1)< 1%< 1%< 1%Respiratory, thoracic and mediastinal disordersCough 121 (23)94 (17)68 (13)< 1%< 1%< 1%Dyspnea Footnote a not applicable. 117 (22)89 (16)113 (21)30 (6)22 (4)18 (3)Epistaxis 32 (6)31 (6)17 (3)< 1%< 1%0 (0)Oropharyngeal pain 30 (6)22 (4)14 (3)0 (0)0 (0)0 (0)Dyspnea exertional 27 (5)29 (5)< 5%6 (1)< 1%0 (0)Metabolism and nutrition disordersDecreased appetite123 (23)115 (21)72 (13)14 (3)7 (1)< 1%Hypokalemia 91 (17)62 (11)38 (7)35 (7)20 (4)11 (2)Hyperglycemia62 (12)52 (10)19 (4)28 (5)23 (4)9 (2)Hypocalcemia57 (11)56 (10)31 (6)23 (4)19 (4)8 (1)Dehydration 25 (5)29 (5)17 (3)8 (2)13 (2)9 (2)Gout 5%< 5%< 5%8 (2)0 (0)0 (0)Diabetes mellitus 5%< 5%< 5%8 (2)< 1%< 1%Hypophosphatemia 5%< 5%< 5%7 (1)< 1%< 1%Hyponatremia 5%< 5%< 5%7 (1)13 (2)6 (1)Skin and subcutaneous tissue disordersRash139 (26)151 (28)105 (19)39 (7)38 (7)33 (6)Pruritus 47 (9)49 (9)24 (4)< 1%< 1%< 1%Psychiatric disordersInsomnia147 (28)127 (24)53 (10)< 1%6 (1)0 (0)Depression58 (11)46 (9)30 (6)10 (2)< 1%< 1%Vascular disordersDeep vein thrombosis 55 (10)39 (7)22 (4)30 (6)20 (4)15 (3)Hypotension 51 (10)35 (6)36 (7)11 (2)8 (1)6 (1)Injury, Poisoning, and Procedural ComplicationsFall 43 (8)25 (5)25 (5)< 1%6 (1)6 (1)Contusion 33 (6)24 (4)15 (3)< 1%< 1%0 (0)Eye disordersCataract73 (14)31 (6)< 1%31 (6)14 (3)< 1%Cataract subcapsular 5%< 5%< 5%7 (1)0 (0)0 (0)InvestigationsWeight decreased72 (14)78 (14)48 (9)11 (2)< 1%< 1%Cardiac disordersAtrial fibrillation 37 (7)25 (5)25 (5)13 (2)9 (2)6 (1)Myocardial infarction (including acute) 5%< 5%< 5%10 (2)< 1%< 1%Renal and Urinary disordersRenal failure (including acute) 49 (9)54 (10)37 (7)28 (5)33 (6)29 (5)Neoplasms benign, malignant and unspecified (including cysts and polyps)Squamous cell carcinoma 5%< 5%< 5%8 (2)< 1%0 (0)Basal cell carcinoma 5%< 5%< 5%< 1%< 1%0 (0) Newly Diagnosed MM Lenalidomide Capsule Maintenance Therapy Following Auto-HSCT. Data were evaluated from 1018 patients in two randomized trials who received at least one dose of lenalidomide capsules 10 mg daily as maintenance therapy after auto-HSCT until progressive disease or unacceptable toxicity. The mean treatment duration for lenalidomide capsule treatment was 30.3 months for Maintenance Study and 24.0 months for Maintenance Study (overall range across both studies from 0.1 to 108 months). As of the cut-off date of Mar 2015, 48 patients (21%) in the Maintenance Study lenalidomide capsules arm were still on treatment and none of the patients in the Maintenance Study lenalidomide capsules arm were still on treatment at the same cut-off date.The adverse reactions listed from Maintenance Study included events reported post-transplant (completion of high-dose melphalan/auto-HSCT), and the maintenance treatment period. In Maintenance Study 2, the adverse reactions were from the maintenance treatment period only. In general, the most frequently reported adverse reactions (more than 20% in the lenalidomide capsules arm) across both studies were neutropenia, thrombocytopenia, leukopenia, anemia, upper respiratory tract infection, bronchitis, nasopharyngitis, cough, gastroenteritis, diarrhea, rash, fatigue, asthenia, muscle spasm and pyrexia. The most frequently reported Grade or reactions (more than 20% in the lenalidomide capsules arm) included neutropenia, thrombocytopenia, and leukopenia. The serious adverse reactions lung infection and neutropenia (more than 4.5%) occurred in the lenalidomide capsules arm.For lenalidomide capsules, the most common adverse reactions leading to dose interruption were hematologic events (29.7%, data available in Maintenance Study only). The most common adverse reaction leading to dose reduction of lenalidomide capsules were hematologic events (17.7%, data available in Maintenance Study only). The most common adverse reactions leading to discontinuation of lenalidomide capsules were thrombocytopenia (2.7%) in Maintenance Study and neutropenia (2.4%) in Maintenance Study 2.The frequencies of onset of adverse reactions were generally highest in the first months of treatment and then the frequencies decreased over time or remained stable throughout treatment.Table summarizes the adverse reactions reported for the lenalidomide capsules and placebo maintenance treatment arms.Table 5: All Adverse Reactions in >= 5% and Grade 3/4 Adverse Reactions in >= 1% of Patients with MM in the Lenalidomide Capsules vs Placebo ArmsAdverse Reactions for combined ADR terms (based on relevant TEAE PTs included in Maintenance Studies and [per MedDRA 15.1]): Pneumonias: Bronchopneumonia, Lobar pneumonia, Pneumocystis jiroveci pneumonia, Pneumonia, Pneumonia klebsiella, Pneumonia legionella, Pneumonia mycoplasmal, Pneumonia pneumococcal, Pneumonia streptococcal, Pneumonia viral, Lung disorder, Pneumonitis Sepsis: Bacterial sepsis, Pneumococcal sepsis, Sepsis, Septic shock, Staphylococcal sepsis Peripheral neuropathy: Neuropathy peripheral, Peripheral motor neuropathy, Peripheral sensory neuropathy, Polyneuropathy Deep vein thrombosis: Deep vein thrombosis, Thrombosis, Venous thrombosis Body System Adverse ReactionMaintenance Study 1Maintenance Study 2All Adverse ReactionsAll treatment-emergent AEs in at least 5% of patients in the Lenalidomide Capsule Maintenance group and at least 2% higher frequency (%) than the Placebo Maintenance group.Grade 3/4 Adverse ReactionsAll grade or treatment-emergent AEs in at least 1% of patients in the Lenalidomide Capsule Maintenance group and at least 1% higher frequency (%) than the Placebo Maintenance group.All Adverse ReactionsGrade 3/4 Adverse ReactionsLenalidomide Capsules(N 224)n (%)Placebo(N 221)n (%)Lenalidomide Capsules(N 224)n (%)Placebo (N 221)n (%)Lenalidomide Capsules(N 293)n (%)Placebo(N 280)n (%)Lenalidomide Capsules(N 293)n (%)Placebo(N 280)n (%)Blood and lymphatic system disordersNeutropeniaAll serious treatment-emergent AEs in at least 1% of patients in the Lenalidomide Capsule Maintenance group and at least 1% higher frequency (%) than the Placebo Maintenance group. ADRs where at least one was considered to be life-threatening (if the outcome of the event was death, it is included with death cases) 177 (79)94 (43)133 (59)73 (33)178 (61)33 (12)158 (54)21 (8)Thrombocytopenia 162 (72)101 (46)84 (38)67 (30)69 (24)29 (10)38 (13)8 (3)Leukopenia 51 (23)25 (11)45 (20)22 (10)93 (32)21 (8)71 (24)5 (2)Anemia47 (21)27 (12)23 (10)18 (8)26 (9)15 (5)11 (4)3 (1)Lymphopenia40 (18)29 (13)37 (17)26 (12)13 (4)3 (1)11 (4)< 1%Pancytopenia Footnote a not applicable for either study 1%0 (0)0 (0)0 (0)12 (4)< 1%7 (2)< 1%Febrile neutropenia 39 (17)34 (15)39 (17)34 (15)7 (2)< 1%5 (2)< 1%Infections and infestations- All adverse reactions under Body System of Infections and Infestation except for rare infections of Public Health interest will be considered listed Upper respiratory tract infectionFootnote b not applicable for either study 60 (27)35 (16)7 (3)9 (4)32 (11)18 (6)< 1%0 (0)Neutropenic infection40 (18)19 (9)27 (12)14 (6)0 (0)0 (0)0 (0)0 (0)Pneumonias 31 (14)15 (7)23 (10)7 (3)50 (17)13 (5)27 (9)5 (2)Bronchitis 10 (4)9 (4)< 1%5 (2)139 (47)104 (37)4 (1)< 1%Nasopharyngitis (2)< 1%0 (0)0 (0)102 (35)84 (30)< 1%0 (0)Gastroenteritis (0)0 (0)0 (0)0 (0)66 (23)55 (20)6 (2)0 (0)Rhinitis 1%0 (0)0 (0)0 (0)44 (15)19 (7)0 (0)0 (0)Sinusitis (4)3 (1)0 (0)0 (0)41 (14)26 (9)0 (0)< 1%Influenza (4)5 (2)< 1%< 1%39 (13)19 (7)3 (1)0 (0)Lung infection 21 (9)< 1%19 (8)< 1%9 (3)4 (1)< 1%0 (0)Lower respiratory tract infection 13 (6)5 (2)6 (3)4 (2)4 (1)4 (1)0 (0)< 1%Infection 12 (5)6 (3)9 (4)5 (2)17 (6)5 (2)0 (0)0 (0)Urinary tract infection (4)5 (2)4 (2)4 (2)22 (8)17 (6)< 1%0 (0)Lower respiratory tract infection bacterial (3)< 1%4 (2)0 (0)0 (0)0 (0)0 (0)0 (0)Bacteremia (2)0 (0)4 (2)0 (0)0 (0)0 (0)0 (0)0 (0)Herpes zoster 11 (5)10 (5)3 (1)< 1%29 (10)25 (9)6 (2)< 1%Sepsis -ADRs where at least one resulted in fatal outcome 1%< 1%0 (0)0 (0)6 (2)< 1%4 (1)< 1%Gastrointestinal disordersDiarrhea122 (54)83 (38)22 (10)17 (8)114 (39)34 (12)7 (2)0 (0)Nausea 33 (15)22 (10)16 (7)10 (5)31 (11)28 (10)0 (0)0 (0)Vomiting17 (8)12 (5)8 (4)5 (2)16 (5)15 (5)< 1%0 (0)Constipation 12 (5)8 (4)0 (0)0 (0)37 (13)25 (9)< 1%0 (0)Abdominal pain (4)7 (3)< 1%4 (2)31 (11)15 (5)< 1%< 1%Abdominal pain upper (0)0 (0)0 (0)0 (0)20 (7)12 (4)< 1%0 (0)General disorders and administration site conditionsAsthenia0 (0)< 1%0 (0)0 (0)87 (30)53 (19)10 (3)< 1%Fatigue51 (23)30 (14)21 (9)9 (4)31 (11)15 (5)3 (1)0 (0)Pyrexia 17 (8)10 (5)< 1%< 1%60 (20)26 (9)< 1%0 (0)Skin and subcutaneous tissue disordersDry skin (4)4 (2)0 (0)0 (0)31 (11)21 (8)0 (0)0 (0)Rash71 (32)48 (22)11 (5)5 (2)22 (8)17 (6)3 (1)0 (0)Pruritus9 (4)4 (2)3 (1)0 (0)21 (7)25 (9)< 1%0 (0)Nervous system disordersParesthesia 1%0 (0)0 (0)0 (0)39 (13)30 (11)< 1%0 (0)Peripheral neuropathy 34 (15)30 (14)8 (4)8 (4)29 (10)15 (5)4 (1)< 1%Headache 11 (5)8 (4)5 (2)< 1%25 (9)21 (8)0 (0)0 (0)InvestigationsAlanine aminotransferase increased16 (7)3 (1)8 (4)0 (0)5 (2)5 (2)0 (0)< 1%Aspartate aminotransferase increased 13 (6)5 (2)6 (3)0 (0)< 1%5 (2)0 (0)0 (0)Metabolism and nutrition disordersHypokalemia24 (11)13 (6)16 (7)12 (5)12 (4)< 1%< 1%0 (0)Dehydration9 (4)5 (2)7 (3)3 (1)0 (0)0 (0)0 (0)0 (0)Hypophosphatemia 16 (7)15 (7)13 (6)14 (6)0 (0)< 1%0 (0)0 (0)Musculoskeletal and connective tissue disordersMuscle spasms (0)< 1%0 (0)0 (0)98 (33)43 (15)< 1%0 (0)Myalgia (3)8 (4)3 (1)5 (2)19 (6)12 (4)< 1%< 1%Musculoskeletal pain 1%< 1%0 (0)0 (0)19 (6)11 (44)0 (0)0 (0)Hepatobiliary disordersHyperbilirubinemia 34 (15)19 (9)4 (2)< 1%4 (1)< 1%< 1%0 (0)Respiratory, thoracic and mediastinal disordersCough 23 (10)12 (5)3 (1)< 1%80 (27)56 (20)0 (0)0 (0)Dyspnea 15 (7)9 (4)8 (4)4 (2)17 (6)9 (3)< 1%0 (0)Rhinorrhea (0)3 (1)0 (0)0 (0)15 (5)6 (2)0 (0)0 (0)Pulmonary embolism (0)0 (0)0 (0)0 (0)3 (1)0 (0)< 1%0 (0)Vascular disordersDeep vein thrombosis (4)< 1%5 (2)< 1%7 (2)< 1%4 (1)< 1%Neoplasms benign, malignant and unspecified (including cysts and polyps)Myelodysplastic syndrome (2)0 (0)< 1%0 (0)3 (1)0 (0)< 1%0 (0)Note: Adverse Events (AEs) are coded to Body System/Adverse Reaction using MedDRA v15.1. subject with multiple occurrences of an adverse reaction is counted only once under the applicable Body System/Adverse Reaction. After At Least One Prior Therapy for MM. Data were evaluated from 703 patients in two studies who received at least one dose of lenalidomide capsules/dexamethasone (353 patients) or placebo/dexamethasone (350 patients).In the lenalidomide capsules/dexamethasone treatment group, 269 patients (76%) had at least one dose interruption with or without dose reduction of lenalidomide capsules compared to 199 patients (57%) in the placebo/dexamethasone treatment group. Of these patients who had one dose interruption with or without dose reduction, 50% in the lenalidomide capsules/dexamethasone treatment group had at least one additional dose interruption with or without dose reduction compared to 21% in the placebo/dexamethasone treatment group. Most adverse reactions and Grade 3/4 adverse reactions were more frequent in patients who received the combination of lenalidomide capsules/dexamethasone compared to placebo/dexamethasone.Tables 6, 7, and summarize the adverse reactions reported for lenalidomide capsules/dexamethasone and placebo/dexamethasone groups.Table 6: Adverse Reactions Reported in >= 5% of Patients and with >= 2% Difference in Proportion of Patients with MM Between the Lenalidomide Capsules/Dexamethasone and Placebo/Dexamethasone GroupsBody SystemAdverse ReactionLenalidomide Capsules/Dex(N 353)n (%)Placebo/Dex(N 350)n (%)Blood and lymphatic system disordersNeutropenia- adverse reactions in which at least one was considered to be life-threatening (if the outcome of the reaction was death, it is included with death cases). 149 (42)22 (6)Anemia- adverse reactions in which at least one resulted in fatal outcome. 111 (31)83 (24)Thrombocytopenia 76 (22)37 (11)Leukopenia28 (8)4 (1)Lymphopenia19 (5)5 (1)General disorders and administration site conditionsFatigue155 (44)146 (42)Pyrexia97 (27)82 (23)Peripheral edema93 (26)74 (21)Chest pain29 (8)20 (6)Lethargy24 (7)8 (2)Gastrointestinal disordersConstipation143 (41)74 (21)Diarrhea 136 (39)96 (27)Nausea 92 (26)75 (21)Vomiting 43 (12)33 (9)Abdominal pain 35 (10)22 (6)Dry mouth25 (7)13 (4)Musculoskeletal and connective tissue disordersMuscle cramp118 (33)74 (21)Back pain91 (26)65 (19)Bone pain48 (14)39 (11)Pain in limb42 (12)32 (9)Nervous system disordersDizziness82 (23)59 (17)Tremor75 (21)26 (7)Dysgeusia54 (15)34 (10)Hypoesthesia36 (10)25 (7)Neuropathy23 (7)13 (4)Respiratory, thoracic and mediastinal disordersDyspnea83 (24)60 (17)Nasopharyngitis62 (18)31 (9)Pharyngitis48 (14)33 (9)Bronchitis40 (11)30 (9)Infections and infestationsUpper respiratory tract infection87 (25)55 (16)Pneumonia 48 (14)29 (8)Urinary tract infection30 (8)19 (5)Sinusitis26 (7)16 (5)Skin and subcutaneous system disordersRash75 (21)33 (9)Sweating increased35 (10)25 (7)Dry skin33 (9)14 (4)Pruritus27 (8)18 (5)Metabolism and nutrition disordersAnorexia55 (16)34 (10)Hypokalemia48 (14)21 (6)Hypocalcemia31 (9)10 (3)Appetite decreased24 (7)14 (4)Dehydration23 (7)15 (4)Hypomagnesemia24 (7)10 (3)InvestigationsWeight decreased69 (20)52 (15)Eye disordersBlurred vision61 (17)40 (11)Vascular disordersDeep vein thrombosis 33 (9)15 (4)Hypertension28 (8)20 (6)Hypotension25 (7)15 (4) Table 7: Grade 3/4 Adverse Reactions Reported in >= 2% Patients and with >= 1% Difference in Proportion of Patients with MM Between the Lenalidomide Capsules/Dexamethasone and Placebo/Dexamethasone GroupsBody SystemAdverse ReactionLenalidomide Capsules/Dex(N 353)n (%)Placebo/Dex(N 350)n (%)Blood and lymphatic system disordersNeutropenia- adverse reactions in which at least one was considered to be life-threatening (if the outcome of the reaction was death, it is included with death cases). 118 (33)12 (3)Thrombocytopenia- adverse reactions in which at least one resulted in fatal outcome. 43 (12)22 (6)Anemia 35 (10)20 (6)Leukopenia14 (4)< 1%Lymphopenia10 (3)4 (1)Febrile neutropenia (2)0 (0)General disorders and administration site conditionsFatigue23 (7)17 (5)Vascular disordersDeep vein thrombosis 29 (8)12 (3)Infections and infestationsPneumonia 30 (8)19 (5)Urinary tract infection5 (1)< 1%Metabolism and nutrition disordersHypokalemia17 (5)5 (1)Hypocalcemia13 (4)6 (2)Hypophosphatemia9 (3)0 (0)Respiratory, thoracic and mediastinal disordersPulmonary embolism 14 (4)< 1%Respiratory distress (1)0 (0)Musculoskeletal and connective tissue disordersMuscle weakness20 (6)10 (3)Gastrointestinal disordersDiarrhea 11 (3)4 (1)Constipation7 (2)< 1%Nausea (2)< 1%Cardiac disordersAtrial fibrillation 13 (4)4 (1)Tachycardia6 (2)< 1%Cardiac failure congestive (1)< 1%Nervous system disordersSyncope10 (3)< 1%Dizziness7 (2)< 1%Eye disordersCataract6 (2)< 1%Cataract unilateral5 (1)0 (0)Psychiatric disorderDepression10 (3)6 (2) Table 8: Serious Adverse Reactions Reported in >= 1% Patients and with >= 1% Difference in Proportion of Patients with MM Between the Lenalidomide Capsules/Dexamethasone and Placebo/Dexamethasone GroupsBody SystemAdverse ReactionLenalidomide Capsules/Dex(N 353)n (%)Placebo/Dex(N 350)n (%)Blood and lymphatic system disordersFebrile neutropenia- adverse reactions in which at least one was considered to be life-threatening (if the outcome of the reaction was death, it is included with death cases). (2)0 (0)Vascular disordersDeep vein thrombosis 26 (7)11 (3)Infections and infestationsPneumonia- adverse reactions in which at least one resulted in fatal outcome. 33 (9)21 (6)Respiratory, thoracic, and mediastinal disordersPulmonary embolism 13 (4)< 1%Cardiac disordersAtrial fibrillation 11 (3)< 1%Cardiac failure congestive (1)0 (0)Nervous system disordersCerebrovascular accident (2)< 1%Gastrointestinal disordersDiarrhea (2)< 1%Musculoskeletal and connective tissue disordersBone pain4 (1)0 (0)Median duration of exposure among patients treated with lenalidomide capsules/dexamethasone was 44 weeks while median duration of exposure among patients treated with placebo/dexamethasone was 23 weeks. This should be taken into consideration when comparing frequency of adverse reactions between two treatment groups lenalidomide capsules/dexamethasone vs placebo/dexamethasone.. Venous and Arterial Thromboembolism. [See Boxed Warning, Warnings and Precautions (5.4).]VTE and ATE are increased in patients treated with lenalidomide capsules.Deep vein thrombosis (DVT) was reported as serious (7.4%) or severe (8.2%) adverse drug reaction at higher rate in the lenalidomide capsules/dexamethasone group compared to 3.1% and 3.4% in the placebo/dexamethasone group, respectively in the studies in patients with at least prior therapy with discontinuations due to DVT adverse reactions reported at comparable rates between groups. In the NDMM study, DVT was reported as an adverse reaction (all grades: 10.3%, 7.2%, 4.1%), as serious adverse reaction (3.6%, 2.0%, 1.7%), and as Grade 3/4 adverse reaction (5.6%, 3.7%, 2.8%) in the Rd Continuous, Rd18, and MPT Arms, respectively. Discontinuations and dose reductions due to DVT adverse reactions were reported at comparable rates between the Rd Continuous and Rd18 Arms (both 1%). Interruption of lenalidomide capsule treatment due to DVT adverse reactions was reported at comparable rates between the Rd Continuous (2.3%) and Rd18 (1.5%) arms. Pulmonary embolism (PE) was reported as serious adverse drug reaction (3.7%) or Grade 3/4 (4.0%) at higher rate in the lenalidomide capsules/dexamethasone group compared to 0.9% (serious or grade 3/4) in the placebo/dexamethasone group in the studies in patients with, at least prior therapy, with discontinuations due to PE adverse reactions reported at comparable rates between groups. In the NDMM study, the frequency of adverse reactions of PE was similar between the Rd Continuous, Rd18, and MPT Arms for adverse reactions (all grades: 3.9%, 3.3%, and 4.3%, respectively), serious adverse reactions (3.8%, 2.8%, and 3.7%, respectively), and grade 3/4 adverse reactions (3.8%, 3.0%, and 3.7%, respectively).Myocardial infarction was reported as serious (1.7%) or severe (1.7%) adverse drug reaction at higher rate in the lenalidomide capsules/dexamethasone group compared to 0.6% and 0.6% respectively in the placebo/dexamethasone group. Discontinuation due to MI (including acute) adverse reactions was 0.8% in lenalidomide capsules/dexamethasone group and none in the placebo/dexamethasone group. In the NDMM study, myocardial infarction (including acute) was reported as an adverse reaction (all grades: 2.4%, 0.6%, and 1.1%), as serious adverse reaction, (2.3%, 0.6%, and 1.1%), or as severe adverse reaction (1.9%, 0.6%, and 0.9%) in the Rd Continuous, Rd18, and MPT Arms, respectively.Stroke (CVA) was reported as serious (2.3%) or severe (2.0%) adverse drug reaction in the lenalidomide capsules/dexamethasone group compared to 0.9% and 0.9% respectively in the placebo/dexamethasone group. Discontinuation due to stroke (CVA) was 1.4% in lenalidomide capsules/dexamethasone group and 0.3% in the placebo/dexamethasone group. In the NDMM study, CVA was reported as an adverse reaction (all grades: 0.8%, 0.6%, and 0.6%), as serious adverse reaction (0.8%, 0.6%, and 0.6%), or as severe adverse reaction (0.6%, 0.6%, 0.2%) in the Rd Continuous, Rd18, and MPT arms respectively.. Other Adverse Reactions. After At Least One Prior Therapy for MM:In these studies, the following adverse drug reactions (ADRs) not described above that occurred at >= 1% rate and of at least twice of the placebo percentage rate were reported:Blood and Lymphatic System Disorders: pancytopenia, autoimmune hemolytic anemiaCardiac Disorders: bradycardia, myocardial infarction, angina pectorisEndocrine Disorders: hirsutismEye Disorders: blindness, ocular hypertensionGastrointestinal Disorders: gastrointestinal hemorrhage, glossodyniaGeneral Disorders and Administration Site Conditions: malaiseInvestigations: liver function tests abnormal, alanine aminotransferase increasedNervous System Disorders: cerebral ischemiaPsychiatric Disorders: mood swings, hallucination, loss of libidoReproductive System and Breast Disorders: erectile dysfunctionRespiratory, Thoracic and Mediastinal Disorders: cough, hoarsenessSkin and Subcutaneous Tissue Disorders: exanthem, skin hyperpigmentation. Myelodysplastic Syndromes. total of 148 patients received at least dose of 10 mg lenalidomide capsules in the del 5q MDS clinical study. At least one adverse reaction was reported in all of the 148 patients who were treated with the 10 mg starting dose of lenalidomide capsules. The most frequently reported adverse reactions were related to blood and lymphatic system disorders, skin and subcutaneous tissue disorders, gastrointestinal disorders, and general disorders and administrative site conditions.Thrombocytopenia (61.5%; 91/148) and neutropenia (58.8%; 87/148) were the most frequently reported adverse reactions. The next most common adverse reactions observed were diarrhea (48.6%; 72/148), pruritus (41.9%; 62/148), rash (35.8%; 53/148) and fatigue (31.1%; 46/148). Table summarizes the adverse reactions that were reported in >= 5% of the lenalidomide capsule-treated patients in the del 5q MDS clinical study. Table 10 summarizes the most frequently observed Grade and Grade adverse reactions regardless of relationship to treatment with lenalidomide capsules. In the single-arm studies conducted, it is often not possible to distinguish adverse reactions that are drug-related and those that reflect the patients underlying disease.Table 9: Summary of Adverse Reactions Reported in >= 5% of the Lenalidomide Capsule-Treated Patients in del 5q MDS Clinical StudyBody SystemAdverse ReactionBody System and adverse reactions are coded using the MedDRA dictionary. Body System and adverse reactions are listed in descending order of frequency for the Overall column. patient with multiple occurrences of an adverse reaction is counted only once under the applicable Body System/Adverse Reaction. 10 mg Overall(N 148)Patients with at least one adverse reaction148 (100)Blood and Lymphatic System DisordersThrombocytopenia91 (61)Neutropenia87 (59)Anemia17 (11)Leukopenia12 (8)Febrile Neutropenia8 (5)Skin and Subcutaneous Tissue DisordersPruritus62 (42)Rash53 (36)Dry Skin21 (14)Contusion12 (8)Night Sweats12 (8)Sweating Increased10 (7)Ecchymosis8 (5)Erythema8 (5)Gastrointestinal DisordersDiarrhea72 (49)Constipation35 (24)Nausea35 (24)Abdominal Pain18 (12)Vomiting15 (10)Abdominal Pain Upper12 (8)Dry Mouth10 (7)Loose Stools9 (6)Respiratory, Thoracic and Mediastinal DisordersNasopharyngitis34 (23)Cough29 (20)Dyspnea25 (17)Pharyngitis23 (16)Epistaxis22 (15)Dyspnea Exertional10 (7)Rhinitis10 (7)Bronchitis9 (6)General Disorders and Administration Site ConditionsFatigue46 (31)Pyrexia31 (21)Edema Peripheral30 (20)Asthenia22 (15)Edema15 (10)Pain10 (7)Rigors9 (6)Chest Pain8 (5)Musculoskeletal and Connective Tissue DisordersArthralgia32 (22)Back Pain31 (21)Muscle Cramp27 (18)Pain in Limb16 (11)Myalgia13 (9)Peripheral Swelling12 (8)Nervous System DisordersDizziness29 (20)Headache29 (20)Hypoesthesia10 (7)Dysgeusia9 (6)Peripheral Neuropathy8 (5)Infections and InfestationsUpper Respiratory Tract Infection22 (15)Pneumonia17 (11)Urinary Tract Infection16 (11)Sinusitis12 (8)Cellulitis8 (5)Metabolism and Nutrition DisordersHypokalemia16 (11)Anorexia15 (10)Hypomagnesemia9 (6)InvestigationsAlanine Aminotransferase Increased12 (8)Psychiatric DisordersInsomnia15 (10)Depression8 (5)Renal and Urinary DisordersDysuria10 (7)Vascular DisordersHypertension9 (6)Endocrine DisordersAcquired Hypothyroidism10 (7)Cardiac DisordersPalpitations8 (5) Table 10: Most Frequently Observed Grade and Adverse ReactionsAdverse reactions with frequency >= 1% in the 10 mg Overall group. Grade and are based on National Cancer Institute Common Toxicity Criteria version 2. Regardless of Relationship to Study Drug Treatment in the del 5q MDS Clinical StudyAdverse ReactionsAdverse reactions are coded using the MedDRA dictionary. patient with multiple occurrences of an adverse reaction is counted only once in the adverse reaction category.10 mg(N 148)Patients with at least one Grade 3/4 AE131 (89)Neutropenia79 (53)Thrombocytopenia74 (50)Pneumonia11 (7)Rash10 (7)Anemia9 (6)Leukopenia8 (5)Fatigue7 (5)Dyspnea7 (5)Back Pain7 (5)Febrile Neutropenia6 (4)Nausea6 (4)Diarrhea5 (3)Pyrexia5 (3)Sepsis4 (3)Dizziness4 (3)Granulocytopenia3 (2)Chest Pain3 (2)Pulmonary Embolism3 (2)Respiratory Distress3 (2)Pruritus3 (2)Pancytopenia3 (2)Muscle Cramp3 (2)Respiratory Tract Infection2 (1)Upper Respiratory Tract Infection2 (1)Asthenia2 (1)Multi-organ Failure2 (1)Epistaxis2 (1)Hypoxia2 (1)Pleural Effusion2 (1)Pneumonitis2 (1)Pulmonary Hypertension2 (1)Vomiting2 (1)Sweating Increased2 (1)Arthralgia2 (1)Pain in Limb2 (1)Headache2 (1)Syncope2 (1)In other clinical studies of lenalidomide capsules in MDS patients, the following serious adverse reactions (regardless of relationship to study drug treatment) not described in Table or 10 were reported:Blood and Lymphatic System Disorders: warm type hemolytic anemia, splenic infarction, bone marrow depression, coagulopathy, hemolysis, hemolytic anemia, refractory anemiaCardiac Disorders: cardiac failure congestive, atrial fibrillation, angina pectoris, cardiac arrest, cardiac failure, cardio-respiratory arrest, cardiomyopathy, myocardial infarction, myocardial ischemia, atrial fibrillation aggravated, bradycardia, cardiogenic shock, pulmonary edema, supraventricular arrhythmia, tachyarrhythmia, ventricular dysfunctionEar and Labyrinth Disorders: vertigoEndocrine Disorders: Basedows diseaseGastrointestinal Disorders: gastrointestinal hemorrhage, colitis ischemic, intestinal perforation, rectal hemorrhage, colonic polyp, diverticulitis, dysphagia, gastritis, gastroenteritis, gastroesophageal reflux disease, obstructive inguinal hernia, irritable bowel syndrome, melena, pancreatitis due to biliary obstruction, pancreatitis, perirectal abscess, small intestinal obstruction, upper gastrointestinal hemorrhageGeneral Disorders and Administration Site Conditions: disease progression, fall, gait abnormal, intermittent pyrexia, nodule, rigors, sudden deathHepatobiliary Disorders: hyperbilirubinemia, cholecystitis, acute cholecystitis, hepatic failureImmune System Disorders: hypersensitivityInfections and Infestations: infection bacteremia, central line infection, clostridial infection, ear infection, Enterobacter sepsis, fungal infection, herpes viral infection NOS, influenza, kidney infection, Klebsiella sepsis, lobar pneumonia, localized infection, oral infection, Pseudomonas infection, septic shock, sinusitis acute, sinusitis, Staphylococcal infection, urosepsisInjury, Poisoning and Procedural Complications: femur fracture, transfusion reaction, cervical vertebral fracture, femoral neck fracture, fractured pelvis, hip fracture, overdose, post procedural hemorrhage, rib fracture, road traffic accident, spinal compression fractureInvestigations: blood creatinine increased, hemoglobin decreased, liver function tests abnormal, troponin increasedMetabolism and Nutrition Disorders: dehydration, gout, hypernatremia, hypoglycemiaMusculoskeletal and Connective Tissue Disorders: arthritis, arthritis aggravated, gouty arthritis, neck pain, chondrocalcinosis pyrophosphateNeoplasms Benign, Malignant and Unspecified: acute leukemia, acute myeloid leukemia, bronchoalveolar carcinoma, lung cancer metastatic, lymphoma, prostate cancer metastaticNervous System Disorders: cerebrovascular accident, aphasia, cerebellar infarction, cerebral infarction, depressed level of consciousness, dysarthria, migraine, spinal cord compression, subarachnoid hemorrhage, transient ischemic attackPsychiatric Disorders: confusional stateRenal and Urinary Disorders: renal failure, hematuria, renal failure acute, azotemia, calculus ureteric, renal massReproductive System and Breast Disorders: pelvic painRespiratory, Thoracic and Mediastinal Disorders: bronchitis, chronic obstructive airways disease exacerbated, respiratory failure, dyspnea exacerbated, interstitial lung disease, lung infiltration, wheezingSkin and Subcutaneous Tissue Disorders: acute febrile neutrophilic dermatosisVascular System Disorders: deep vein thrombosis, hypotension, aortic disorder, ischemia, thrombophlebitis superficial, thrombosis. Mantle Cell Lymphoma. In the MCL trial, total of 134 patients received at least dose of lenalidomide capsules. Their median age was 67 (range 43-83) years, 128/134 (96%) were Caucasian, 108/134 (81%) were males and 82/134 (61%) had duration of MCL for at least years.Table 11 summarizes the most frequently observed adverse reactions regardless of relationship to treatment with lenalidomide capsules. Across the 134 patients treated in this study, median duration of treatment was 95 days (1-1002 days). Seventy-eight patients (58%) received or more cycles of therapy, 53 patients (40%) received or more cycles, and 26 patients (19%) received 12 or more cycles. Seventy-six patients (57%) underwent at least one dose interruption due to adverse reactions, and 51 patients (38%) underwent at least one dose reduction due to adverse reactions. Twenty-six patients (19%) discontinued treatment due to adverse reactions.Table 11: Incidence of Adverse Reactions (>= 10%) or Grade 3/4 AE (in at Least Patients) in Mantle Cell Lymphoma- All adverse reactions under Body System of Infections except for rare infections of Public Health interest will be considered listed.Body SystemAdverse ReactionAll Adverse Reactions- MCL trial AEs All treatment emergent AEs with >= 10% of subjects.(N 134)n (%)Grade 3/4 Adverse Reactions- MCL trial Grade 3/4 AEs All treatment-emergent Grade 3/4 AEs in or more subjects.(N 134)n (%)General disorders and administration site conditionsFatigue45 (34)9 (7)Pyrexia- MCL trial Serious AEs All treatment-emergent SAEs in or more subjects. 31 (23)3 (2)Edema peripheral 21 (16)0Asthenia 19 (14)4 (3)General physical health deterioration3 (2)2 (1)Gastrointestinal disordersDiarrhea 42 (31)8 (6)Nausea 40 (30)1 (< 1)Constipation21 (16)1 (< 1)Vomiting 16 (12)1 (< 1)Abdominal pain 13 (10)5 (4)Musculoskeletal and connective tissue disordersBack pain18 (13)2 (1)Muscle spasms17 (13)1 (< 1)Arthralgia11 (8)2 (1)Muscular weakness (6)2 (1)Respiratory, thoracic and mediastinal disordersCough38 (28)1 (< 1)Dyspnea 24 (18)8 (6)Pleural Effusion10 (7)2 (1)Hypoxia3 (2)2 (1)Pulmonary embolism3 (2)2 (1)Respiratory distress (1)2 (1)Oropharyngeal pain13 (10)0Infections and infestationsPneumonia- Adverse reactions where at least one resulted in fatal outcome. 19 (14)12 (9)Upper respiratory tract infection17 (13)0Cellulitis (2)2 (1)Bacteremia (1)2 (1)Staphylococcal sepsis (1)2 (1)Urinary tract infection (4)2 (1)Skin and subcutaneous tissue disordersRash- All adverse reactions under HLT of Rash will be considered listed. 30 (22)2 (1)Pruritus23 (17)1 (< 1)Blood and lymphatic system disordersNeutropenia65 (49)58 (43)Thrombocytopenia- Adverse reactions where at least one was considered to be life-threatening (if the outcome of the event was death, it is included with death cases). 48 (36)37 (28)Anemia 41 (31)15 (11)Leukopenia 20 (15)9 (7)Lymphopenia10 (7)5 (4)Febrile neutropenia (6)8 (6)Metabolism and nutrition disordersDecreased appetite19 (14)1 (< 1)Hypokalemia17 (13)3 (2)Dehydration 10 (7)4 (3)Hypocalcemia4 (3)2 (1)Hyponatremia3 (2)3 (2)Renal and urinary disordersRenal failure (4)2 (1)Vascular disordersHypotension 9 (7)4 (3)Deep vein thrombosis (4)5 (4)Neoplasms benign, malignant and unspecified (including cysts and polyps)Tumor flare13 (10)0Squamous cell carcinoma of skin (3)4 (3)InvestigationsWeight decreased17 (13)0The following adverse reactions which have occurred in other indications including another MCL study and not described above have been reported (1%-10%) in patients treated with lenalidomide capsule monotherapy for mantle cell lymphoma.Cardiac Disorders: Cardiac failure Ear and Labyrinth Disorders: Vertigo General Disorders and Administration Site Conditions: Chills Infections and Infestations: Respiratory tract infection, sinusitis, nasopharyngitis, oral herpes Musculoskeletal and Connective Tissue Disorders: Pain in extremity Nervous System Disorders: Dysgeusia, headache, neuropathy peripheral, lethargy Psychiatric Disorders: Insomnia Skin and Subcutaneous Tissue Disorders: Dry skin, night sweatsThe following serious adverse reactions not described above and reported in or more patients treated with lenalidomide capsule monotherapy for mantle cell lymphoma.Blood and Lymphatic System Disorders: Neutropenia Cardiac Disorders: Myocardial infarction (including acute MI), supraventricular tachycardia Infections and Infestations: Clostridium difficile colitis, sepsis Neoplasms Benign, Malignant and Unspecified (Including Cysts and Polyps): Basal cell carcinoma Respiratory, Thoracic, and Mediastinal Disorders: Chronic obstructive pulmonary disease, pulmonary embolism. Follicular Lymphoma or Marginal Zone Lymphoma. The safety of lenalidomide capsules/rituximab was evaluated in 398 patients with either previously treated follicular lymphoma or marginal zone lymphoma in two clinical trials; AUGMENT (N 176) and MAGNIFY (N 222) [see Clinical Studies (14.4)]. Subjects were 18 years or older in age, had an ECOG PS <= 2, ANC >= 1,000 cells/mm3 and platelets >= 75,000/mm3 (unless secondary to bone marrow involvement by lymphoma), hemoglobin >= g/dL, AST and ALT <= 3x ULN (unless documented liver involvement with lymphoma, and creatinine clearance of >= 30 mL/min. Subjects with active HIV, hepatitis or were not eligible.In the AUGMENT trial, patients received lenalidomide capsules 20 mg daily by mouth on days 1-21 of each 28-day cycle with rituximab 375 mg/m2 weekly (days 1, 8, 15 and 22 in cycle 1) then on day of cycles 2-5 (n 176) or placebo with rituximab 375 mg/m2 weekly (days 1, 8, 15 and 22 in cycle 1) then on day of cycles 2-5 (n 180) for up to 12 cycles. In the MAGNIFY trial, patients received lenalidomide capsules 20 mg by mouth daily, days 1-21 of each 28-day cycle with rituximab 375 mg/m2 weekly (days 1, 8, 15 and 22 in cycle 1) then on day of cycles 3, 5, 7, and 11 in the induction phase of the trial (n 222). In the AUGMENT trial, 88.1% of patients completed at least cycles of lenalidomide capsules/rituximab, and 71% of patients completed 12 cycles. In the ongoing MAGNIFY trial as of May 1, 2017, 62.2% of patients completed at least cycles of lenalidomide capsules/rituximab, and 30.6% of patients completed 12 cycles.Across both clinical trials (AUGMENT and MAGNIFY), patients had median age of 64.5 years (26 to 91); 49% were male; and 81% were White.Fatal adverse reactions occurred in patients (1.5%) receiving lenalidomide capsules/rituximab. Fatal adverse reactions (1 each) included cardio-respiratory arrest, arrhythmia, cardiopulmonary failure, multiple organ dysfunction syndrome, sepsis, and acute kidney injury. Serious adverse reactions occurred in 26% of patients receiving lenalidomide capsules/rituximab in AUGMENT and 29% in MAGNIFY. The most frequent serious adverse reaction that occurred in >= 2.5% of patients in the lenalidomide capsules/rituximab arm was febrile neutropenia (3%). Permanent discontinuation of lenalidomide capsules or rituximab due to an adverse reaction occurred in 14.6% of patients in the lenalidomide capsules/rituximab arm. The most common adverse reaction (in at least 1%) requiring permanent discontinuation of lenalidomide capsules or rituximab was neutropenia (4.8%).The most common adverse reactions occurring in at least 20% of subjects were; neutropenia (48%), fatigue (37%), diarrhea (32%), constipation (27%), nausea (21%), and cough (20%).Table 12: All Grade Adverse Reactions (>= 5%) or Grade 3/4 Adverse Reactions (>= 1%) in Patients with FL and MZL with Difference Between Arms of 1% When Compared to Control Arm in AUGMENT TrialNote: Adverse reactions are coded to body system/adverse reaction using MedDRA 21. patient with multiple occurrences of an adverse reaction is counted only once under the applicable Body System/Adverse reaction.All Adverse ReactionsAll treatment-emergent AEs in at least 5% of patients in the lenalidomide capsules rituximab group and at least 1% higher frequency (%) than the rituximab placebo group (control arm).Grade 3/4 Adverse ReactionsAll grade or treatment-emergent AEs in at least 1% of patients in the lenalidomide capsules rituximab group and at least 1% higher frequency (%) than the rituximab placebo group (control arm).Body System Adverse ReactionAdverse Reactions for combined ADR terms (based on relevant TEAE PTs [per MedDRA version 21.0]):Lenalidomide Capsules Rituximab Arm(N 176)n (%)Rituximab Placebo (Control Arm)(N 180)n (%)Lenalidomide Capsules Rituximab Arm(N 176)n (%)Rituximab Placebo (Control Arm)(N 180)n (%)Infections and infestationsUpper respiratory tract infection32 (18)23 (13)2 (1.1)4 (2.2)Influenza- adverse reactions in which at least one was considered to be life-threatening (if the outcome of the reaction was death, it is included with death cases). 17 (10)8 (4.4)1 (< 1)0 (0)PneumoniaAll serious treatment-emergent AEs in at least 1% of patients in the lenalidomide capsules rituximab group and at least 1% higher frequency (%) than the rituximab placebo group (control arm). Serious ADR reported. 13 (7)6 (3.3)6 (3.4)4 (2.2)Sinusitis13 (7)5 (2.8)0 (0)0 (0)Urinary tract infection 13 (7)7 (3.9)1 (< 1)1 (< 1)Bronchitis8 (4.5)6 (3.3)2 (1.1)0 (0)Gastroenteritis (3.4)4 (2.2)2 (1.1)0 (0)Neoplasms benign, malignant and unspecified (including cysts and polyps)Tumor flare 19 (11)1 (< 1)1 (< 1)0 (0)Blood and lymphatic disordersNeutropenia 102 (58)40 (22)88 (50)23 (13)Leukopenia 36 (20)17 (9)12 (7)3 (1.7)Anemia 28 (16)8 (4.4)8 (4.5)1 (< 1)Thrombocytopenia 26 (15)8 (4.4)4 (2.3)2 (1.1)Lymphopenia8 (4.5)14 (8)5 (2.8)2 (1.1)Febrile Neutropenia (2.8)1 (< 1)5 (2.8)1 (< 1)Metabolism and nutrition disordersDecreased Appetite23 (13)11 (6)2 (1.1)0 (0)Hypokalemia 14 (8)5 (2.8)4 (2.3)0 (0)Hyperuricemia10 (6)8 (4.4)1 (< 1)1 (< 1)Nervous system disordersHeadache26 (15)17 (9)1 (< 1)0 (0)Dizziness15 (9)9 (5)0 (0)0 (0)Vascular disordersHypotension (5)1 (< 1)1 (< 1)0 (0)Thromboembolic eventsThromboembolic events combined term includes the following PTs: pulmonary embolism, deep vein thrombosis, cerebrovascular accident, embolism, and thrombosis. (4.5)2 (1.1)4 (2.3)2 (1.1)Respiratory, thoracic and mediastinal disordersCoughCough combined AE term includes the following PTs: cough and productive cough. 43 (24)35 (19)1 (< 1)0 (0)Dyspnea 19 (11)8 (4.4)2 (1.1)1 (< 1)Oropharyngeal pain10 (6)8 (4.4)0 (0)0 (0)Pulmonary Embolism (2.3)1 (< 1)4 (2.3)1 (< 1)Chronic obstructive pulmonary disease (1.7)0 (0)2 (1.1)0 (0)Respiratory failure (1.1)1 (< 1)2 (1.1)0 (0)Gastrointestinal disordersDiarrhea 55 (31)41 (23)5 (2.8)0 (0)Constipation46 (26)25 (14)0 (0)0 (0)Abdominal painAbdominal pain combined AE term includes the following PTs: abdominal pain and abdominal pain upper. 32 (18)20 (11)2 (1.1)0 (0)Vomiting 17 (10)13 (7)0 (0)0 (0)Dyspepsia16 (9)5 (2.8)0 (0)0 (0)Stomatitis9 (5)7 (3.9)0 (0)0 (0)Skin and subcutaneous tissue disordersRash Rash combined AE term includes the following PTs: rash maculo-papular, rash erythematous, rash macular, rash papular, rash pruritic, and rash generalized. 39 (22)14 (8)5 (2.8)2 (1.1)Pruritus Pruritus combined AE term includes the following PTs: pruritus, pruritus generalized, rash pruritic, and pruritus allergic. 36 (20)9 (5)2 (1.1)0 (0)Dry skin9 (5)6 (3.3)0 (0)0 (0)Dermatitis acneiform8 (4.5)0 (0)2 (1.1)0 (0)Musculoskeletal and connective tissue disordersMuscle Spasms23 (13)9 (5)1 (< 1)1 (< 1)Pain in Extremity (4.5)9 (5)2 (1)0 (0)Renal disordersAcute Kidney Injury adverse reactions in which at least one resulted in fatal outcome. (1.7)0 (0)2 (1.1)0 (0)Cardiac disordersSupraventricular tachycardia (1.1)0 (0)2 (1.1)0 (0)General disorders and administration site conditionsFatigue38 (22)33 (18)2 (1.1)1 (< 1)Pyrexia 37 (21)27 (15)1 (< 1)3 (1.7)Asthenia 24 (14)19 (11)2 (1.1)1 (< 1)Edema Peripheral 23 (13)16 (9)0 (0)0 (0)Chills14 (8)8 (4.4)0 (0)0 (0)Malaise13 (7)10 (6)0 (0)0 (0)Influenza like illness9 (5)7 (3.9)0 (0)0 (0)Psychiatric disordersInsomnia14 (8)11 (6)0 (0)0 (0)InvestigationsAlanine Aminotransferase Increased18 (10)15 (8)3 (1.7)1 (< 1)WBC count decreased16 (9)13 (7)5 (2.8)2 (1.1)Lymphocyte count decreased12 (7)12 (7)6 (3.4)2 (1.1)Blood bilirubin increased10 (6)0 (0)0 (0)0 (0)Weight Decreased12 (7)2 (1.1)0 (0)0 (0) 6.2Postmarketing Experience The following adverse drug reactions have been identified from the worldwide postmarketing experience with lenalidomide capsules. Because these reactions are reported voluntarily from population of uncertain size, it is not always possible to reliably estimate their frequency or establish causal relationship to drug exposure [see Warnings and Precautions Section (5.8, 5.9, 5.10, 5.11, and 5.13)].Endocrine Disorders: Hypothyroidism, hyperthyroidismHepatobiliary Disorders: Hepatic failure (including fatality), toxic hepatitis, cytolytic hepatitis, cholestatic hepatitis, mixed cytolytic/cholestatic hepatitis, transient abnormal liver laboratory tests Immune System Disorders: Angioedema, anaphylaxis, acute graft-versus-host disease (following allogeneic hematopoietic transplant), solid organ transplant rejection Infections and Infestations: Viral reactivation (such as hepatitis virus and herpes zoster), progressive multifocal leukoencephalopathy (PML) Neoplasms Benign, Malignant and Unspecified (Including Cysts and Polyps): Tumor lysis syndrome, tumor flare reaction Respiratory, Thoracic and Mediastinal Disorders: Pneumonitis Skin and Subcutaneous Tissue Disorders: Stevens-Johnson Syndrome, toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms (DRESS).

CLINICAL STUDIES SECTION.

14 CLINICAL STUDIES 14.1Multiple Myeloma Randomized, Open-Label Clinical Trial in Patients with Newly Diagnosed MM. randomized multicenter, open-label, 3-arm trial of 1,623 patients, was conducted to compare the efficacy and safety of lenalidomide capsules and low-dose dexamethasone (Rd) given for different durations of time to that of melphalan, prednisone and thalidomide (MPT) in newly diagnosed MM patients who were not candidate for stem cell transplant. In the first arm of the study, Rd was given continuously until progressive disease [Arm Rd Continuous]. In the second arm, Rd was given for up to eighteen 28-day cycles [72 weeks, Arm Rd18]). In the third arm, melphalan, prednisone and thalidomide (MPT) was given for maximum of twelve 42-day cycles (72 weeks). For the purposes of this study, patient who was 65 years of age was not candidate for SCT if the patient refused to undergo SCT therapy or the patient did not have access to SCT due to cost or other reasons. Patients were stratified at randomization by age (<= 75 versus 75 years), stage (ISS Stages and II versus Stage III), and country.Patients in the Rd Continuous and Rd18 arms received lenalidomide capsules 25 mg once daily on Days to 21 of 28-day cycles. Dexamethasone was dosed 40 mg once daily on Days 1, 8, 15, and 22 of each 28-day cycle. For patients over 75 years old, the starting dose of dexamethasone was 20 mg orally once daily on days 1, 8, 15, and 22 of repeated 28-day cycles. Initial dose and regimens for Rd Continuous and Rd18 were adjusted according to age and renal function. All patients received prophylactic anticoagulation with the most commonly used being aspirin.The demographics and disease-related baseline characteristics of the patients were balanced among the arms. In general, study subjects had advanced-stage disease. Of the total study population, the median age was 73 in the arms with 35% of total patients 75 years of age; 59% had ISS Stage I/II; 41% had ISS stage III; 9% had severe renal impairment (creatinine clearance [CLcr] 30 mL/min); 23% had moderate renal impairment (CLcr 30 to 50 mL/min; 44% had mild renal impairment (CLcr 50 to 80 mL/min). For ECOG Performance Status, 29% were Grade 0, 49% Grade 1, 21% Grade 2, 0.4% >= Grade 3.The primary efficacy endpoint, progression-free survival (PFS), was defined as the time from randomization to the first documentation of disease progression as determined by Independent Response Adjudication Committee (IRAC), based on International Myeloma Working Group [IMWG] criteria or death due to any cause, whichever occurred first during the study until the end of the PFS follow-up phase. For the efficacy analysis of all endpoints, the primary comparison was between Rd Continuous and MPT arms. The efficacy results are summarized in the table below. PFS was significantly longer with Rd Continuous than MPT: HR 0.72 (95% CI: 0.61-0.85 < 0.0001). lower percentage of subjects in the Rd Continuous arm compared with the MPT arm had PFS events (52% versus 61%, respectively). The improvement in median PFS time in the Rd Continuous arm compared with the MPT arm was 4.3 months. The myeloma response rate was higher with Rd Continuous compared with MPT (75.1% versus 62.3%); with complete response in 15.1% of Rd Continuous arm patients versus 9.3% in the MPT arm. The median time to first response was 1.8 months in the Rd Continuous arm versus 2.8 months in the MPT arm.For the interim OS analysis with 03 March 2014 data cutoff, the median follow-up time for all surviving patients is 45.5 months, with 697 death events, representing 78% of prespecified events required for the planned final OS analysis (697/896 of the final OS events). The observed OS HR was 0.75 for Rd Continuous versus MPT (95% CI 0.62, 0.90).Table 13: Overview of Efficacy Results Study MM-020 (Intent-to-treat Population)CR complete response; = low-dose dexamethasone; HR hazard ratio; IRAC Independent Response Adjudication Committee; = melphalan; NE not estimable; OS overall survival; = prednisone; PFS progression-free survival; PR partial response; = lenalidomide capsules; Rd Continuous Rd given until documentation of progressive disease; Rd18 Rd given for <= 18 cycles; = thalidomide; VGPR very good partial response; vs versus.Rd Continuous(N 535)Rd18(N 541)MPT(N 547)PFS IRAC (months)Data cutoff date 24 May 2013. Number of PFS events278 (52)348 (64.3)334 (61.1) MedianThe median is based on the Kaplan-Meier estimate. PFS time, months (95% CI)The 95% Confidence Interval (CI) about the median. 25.5 (20.7, 29.4)20.7 (19.4, 22)21.2 (19.3, 23.2) HR [95% CI]Based on Cox proportional hazards model comparing the hazard functions associated with the indicated treatment arms.; p-valueThe p-value is based on the unstratified log-rank test of Kaplan-Meier curve differences between the indicated treatment arms. Rd Continuous vs MPT0.72 (0.61, 0.85);< 0.0001 Rd Continuous vs Rd180.70 (0.60, 0.82) Rd18 vs MPT1.03 (0.89, 1.20)Overall Survival (months)Data cutoff date 3 March 2014. Number of Death events208 (38.9)228 (42.1)261 (47.7) Median OS time, months (95% CI) 58.9 (56, NE)Including patients with no response assessment data or whose only assessment was response not evaluable. 56.7 (50.1, NE)48.5 (44.2, 52) HR [95% CI] Rd Continuous vs MPT0.75 (0.62, 0.90) Rd Continuous vs Rd180.91 (0.75, 1.09) Rd18 vs MPT0.83 (0.69, 0.99)Response RateBest assessment of response during the treatment phase of the study. IRAC, (%) CR81 (15.1)77 (14.2)51 (9.3) VGPR152 (28.4)154 (28.5)103 (18.8) PR169 (31.6)166 (30.7)187 (34.2) Overall response: CR, VGPR, or PR402 (75.1)397 (73.4)341 (62.3) Kaplan-Meier Curves of Progression-free Survival Based on IRAC Assessment (ITT MM Population) Between Arms Rd Continuous, Rd18 and MPT Cutoff date: 24 May 2013 Kaplan-Meier Curves of Overall Survival (ITT MM Population) Between Arms Rd Continuous, Rd18 and MPT Cutoff date: 03 Mar 2014 Kaplan-Meier Curves of Progression-free Survival Based on IRAC Assessment (ITT MM Population) Between Arms Rd Continuous, Rd18 and MPT Cutoff date: 24 May 2013. Kaplan-Meier Curves of Overall Survival (ITT MM Population) Between Arms Rd Continuous, Rd18 and MPT Cutoff date: 03 Mar 2014. Randomized, Placebo-Controlled Clinical Trials Maintenance Following Auto-HSCT. Two multicenter, randomized, double-blind, parallel group, placebo-controlled studies were conducted to evaluate the efficacy and safety of lenalidomide capsule maintenance therapy in the treatment of MM patients after auto-HSCT. In Maintenance Study 1, patients between 18 and 70 years of age who had undergone induction therapy followed by auto-HSCT were eligible. Induction therapy must have occurred within 12 months. Within 90-100 days after auto-HSCT, patients with at least stable disease response were randomized 1:1 to receive either lenalidomide capsules or placebo maintenance. In Maintenance Study 2, patients aged 65 years at diagnosis who had undergone induction therapy followed by auto-HSCT and had achieved at least stable disease response at the time of hematologic recovery were eligible. Within months after auto-HSCT, patients were randomized 1:1 to receive either lenalidomide capsules or placebo maintenance. Patients eligible for both trials had to have CLcr >= 30 mL/minute.In both studies, the lenalidomide capsule maintenance dose was 10 mg once daily on days 1-28 of repeated 28-day cycles, could be increased to 15 mg once daily after months in the absence of dose-limiting toxicity, and treatment was to be continued until disease progression or patient withdrawal for another reason. The dose was reduced, or treatment was temporarily interrupted or stopped, as needed to manage toxicity. dose increase to 15 mg once daily occurred in 135 patients (58%) in Maintenance Study 1, and in 185 patients (60%) in Maintenance Study 2.The demographics and disease-related baseline characteristics of the patients were similar across the two studies and reflected typical MM population after auto-HSCT (see Table 14).Table 14: Baseline Demographic and Disease-Related Characteristics MM Maintenance Studies and 2Data cutoff date 1 March 2015.Maintenance Study 1Maintenance Study 2Lenalidomide CapsulesN 231PlaceboN 229Lenalidomide CapsulesN 307PlaceboN 307Age (years) Median585857.558.1 (Min, Max)(29, 71)(39, 71)(22.7, 68.3)(32.3, 67)Sex, (%) Male121 (52)129 (56)169 (55)181 (59) Female110 (48)100 (44)138 (45)126 (41)ISS Stage at Diagnosis,n (%) Stage or II120 (52)131 (57)232 (76)250 (81) Stage I62 (27)85 (37)128 (42)143 (47) Stage II58 (25)46 (20)104 (34)107 (35) Stage III39 (17)35 (15)66 (21)46 (15) Missing72 (31)63 (28)9 (3)11 (4)CrCl at Post-auto-HSCT,n (%) 50 mL/min23 (10)16 (7)10 (3)9 (3) >= 50 mL/min201 (87)204 (89)178 (58)200 (65) Missing7 (3)9 (4)119 (39)98 (32)The major efficacy endpoint of both studies was PFS defined from randomization to the date of progression or death, whichever occurred first; the individual studies were not powered for an overall survival endpoint. Both studies were unblinded upon the recommendations of their respective data monitoring committees and after surpassing the respective thresholds for preplanned interim analyses of PFS. After unblinding, patients continued to be followed as before. Patients in the placebo arm of Maintenance Study were allowed to cross over to receive lenalidomide capsules before disease progression (76 patients [33%] crossed over to lenalidomide capsules); patients in Maintenance Study were not recommended to cross over. The efficacy results are summarized in the following table. In both studies, the primary analysis of PFS at unblinding was significantly longer with lenalidomide capsules compared to placebo: Maintenance Study HR 0.38 (95% CI: 0.27-0.54 < 0.001) and Maintenance Study HR 0.50 (95% CI: 0.39-0.64 < 0.001). For both studies, PFS was updated with cutoff date of March 2015 as shown in the table and the following Kaplan Meier graphs. With longer follow-up (median 72.4 and 86.0 months, respectively), the updated PFS analyses for both studies continue to show PFS advantage for lenalidomide capsules compared to placebo: Maintenance Study HR 0.38 (95% CI: 0.28-0.50) with median PFS of 68.6 months and Maintenance Study HR 0.53 (95% CI: 0.44-0.64) with median PFS of 46.3 months.Descriptive analysis of OS data with cutoff date of February 2016 are provided in Table 15. Median follow-up time was 81.6 and 96.7 months for Maintenance Study and Maintenance Study 2, respectively. Median OS was 111.0 and 84.2 months for lenalidomide capsules and placebo, respectively, for Maintenance Study 1, and 105.9 and 88.1 months, for lenalidomide capsules and placebo, respectively, for Maintenance Study 2.Table 15: Progression-free Survival and Overall Survival from Randomization in MM Maintenance Studies and (ITT Post-Auto-HSCT Population)Date of Unblinding in Maintenance Study and = 17 December 2009 and July 2010, respectively.Auto-HSCT autologous hematopoietic stem cell transplantation; CI confidence interval; ITT intent-to-treat; NE not estimable; PFS progression-free survival.PFS at time of unblinding for Maintenance Study was based on assessment by an Independent Review Committee. All other PFS analyses were based on assessment by investigator.Note: The median is based on Kaplan-Meier estimate, with 95% CIs about the median overall PFS time. Hazard ratio is based on proportional hazards model stratified by stratification factors comparing the hazard functions associated with treatment arms (lenalidomide capsules:placebo).Maintenance Study 1Maintenance Study 2Lenalidomide CapsulesN 231PlaceboN 229Lenalidomide CapsulesN 307PlaceboN 307PFS at UnblindingPFS Events (%)46 (20)98 (43)103 (34)160 (52)Median in months [95% CI]33.9[NE, NE]19[16.2, 25.6]41.2[38.3, NE]23.0[21.2, 28.0]Hazard Ratio[95% CI]0.38[0.27, 0.54]0.50[0.39, 0.64]Log-rank Test p-value< 0.001< 0.001PFS at Updated Analysis1 March 2015 (Studies and 2)PFS Events (%)97 (42)116 (51)191 (62)248 (81)Median in months [95% CI]68.6[52.8, NE]22.5[18.8, 30.0]46.3[40.1, 56.6]23.8[21.0, 27.3]Hazard Ratio[95% CI]0.38[0.28, 0.50]0.53[0.44, 0.64]OS at Updated Analysis1 Feb 2016 (Studies and 2)OS Events (%)82 (35)114 (50)143 (47)160 (52)Median in months [95% CI]111[101.8, NE]84.2[71.0, 102.7]105.9[88.8, NE]88.1[80.7, 108.4]Hazard Ratio[95% CI]0.59[0.44, 0.78]0.90[0.72, 1.13] Kaplan-Meier Curves of Progression-free Survival from Randomization (ITT Post-Auto-HSCT Population) in MM Maintenance Study Between Lenalidomide Capsules and Placebo Arms (Updated Cutoff Date March 2015)Auto-HSCT autologous hematopoietic stem cell transplantation; CI confidence interval; HR hazard ratio; ITT intent-to-treat; KM Kaplan-Meier; PFS progression-free survival; vs versus.Kaplan-Meier Curves of Progression-free Survival from Randomization (ITT Post-Auto-HSCT Population) in MM Maintenance Study Between Lenalidomide Capsules and Placebo Arms (Updated Cutoff Date March 2015)Auto-HSCT autologous hematopoietic stem cell transplantation; CI confidence interval; HR hazard ratio; ITT intent-to-treat; KM Kaplan-Meier; NE not estimable; PFS progression-free survival; vs versus. Kaplan-Meier Curves of Progression-free Survival from Randomization (ITT Post-Auto-HSCT Population) in MM Maintenance Study Between Lenalidomide Capsules and Placebo Arms (Updated Cutoff Date March 2015). Kaplan-Meier Curves of Progression-free Survival from Randomization (ITT Post-Auto-HSCT Population) in MM Maintenance Study Between Lenalidomide Capsules and Placebo Arms (Updated Cutoff Date March 2015). Randomized, Open-Label Clinical Studies in Patients with MM After At Least One Prior Therapy. Two randomized studies (Studies and 2) were conducted to evaluate the efficacy and safety of lenalidomide capsules. These multicenter, multinational, double-blind, placebo-controlled studies compared lenalidomide capsules plus oral pulse high-dose dexamethasone therapy to dexamethasone therapy alone in patients with MM who had received at least one prior treatment. These studies enrolled patients with absolute neutrophil counts (ANC) >= 1,000/mm3, platelet counts >= 75,000/mm3, serum creatinine <= 2.5 mg/dL, serum SGOT/AST or SGPT/ALT <= x upper limit of normal (ULN), and serum direct bilirubin <= mg/dL.In both studies, patients in the lenalidomide capsules/dexamethasone group took 25 mg of lenalidomide capsules orally once daily on Days to 21 and matching placebo capsule once daily on Days 22 to 28 of each 28-day cycle. Patients in the placebo/dexamethasone group took placebo capsule on Days to 28 of each 28-day cycle. Patients in both treatment groups took 40 mg of dexamethasone orally once daily on Days to 4, to 12, and 17 to 20 of each 28-day cycle for the first cycles of therapy.The dose of dexamethasone was reduced to 40 mg orally once daily on Days to of each 28-day cycle after the first cycles of therapy. In both studies, treatment was to continue until disease progression.In both studies, dose adjustments were allowed based on clinical and laboratory findings. Sequential dose reductions to 15 mg daily, 10 mg daily and mg daily were allowed for toxicity [see Dosage and Administration (2.1)].Table 16 summarizes the baseline patient and disease characteristics in the two studies. In both studies, baseline demographic and disease-related characteristics were comparable between the lenalidomide capsules/dexamethasone and placebo/dexamethasone groups.Table 16: Baseline Demographic and Disease-Related Characteristics MM Studies and 2Study 1Study 2Lenalidomide Capsules/DexN 177Placebo/DexN 176Lenalidomide Capsules/DexN 176Placebo/DexN 175Patient CharacteristicsAge (years) Median64626364 (Min, Max)36, 8637, 8533, 8440, 82Sex Male106 (60%)104 (59%)104 (59%)103 (59%) Female71 (40%)72 (41%)72 (41%)72 (41%)Race/Ethnicity White141 (80%)148 (84%)172 (98%)175 (100%) Other36 (20%)28 (16%)4 (2%)0 (0%)ECOG PerformanceStatus 0-1157 (89%)168 (95%)150 (85%)144 (82%)Disease CharacteristicsMultiple Myeloma Stage (Durie-Salmon) I3%3%6%5% II32%31%28%33% III64%66%65%63%2-microglobulin (mg/L) <= 2.5 mg/L52 (29%)51 (29%)51 (29%)48 (27%) 2.5 mg/L125 (71%)125 (71%)125 (71%)127 (73%)Number of Prior Therapies 138%38%32%33% >= 262%62%68%67%Types of Prior TherapiesStem Cell Transplantation62%61%55%54%Thalidomide42%46%30%38%Dexamethasone81%71%66%69%Bortezomib11%11%5%4%Melphalan33%31%56%52%Doxorubicin55%51%56%57%The primary efficacy endpoint in both studies was time to progression (TTP). TTP was defined as the time from randomization to the first occurrence of progressive disease.Preplanned interim analyses of both studies showed that the combination of lenalidomide capsules/dexamethasone was significantly superior to dexamethasone alone for TTP. The studies were unblinded to allow patients in the placebo/dexamethasone group to receive treatment with the lenalidomide capsules/dexamethasone combination. For both studies, the extended follow-up survival data with crossovers were analyzed. In study 1, the median survival time was 39.4 months (95% CI: 32.9, 47.4) in lenalidomide capsules/dexamethasone group and 31.6 months (95% CI: 24.1, 40.9) in placebo/dexamethasone group, with hazard ratio of 0.79 (95% CI: 0.61-1.03). In study 2, the median survival time was 37.5 months (95% CI: 29.9, 46.6) in lenalidomide capsules/dexamethasone group and 30.8 months (95% CI: 23.5, 40.3) in placebo/dexamethasone group, with hazard ratio of 0.86 (95% CI: 0.65-1.14).Table 17: TTP Results in MM Study and Study 2Study 1Study 2Lenalidomide Capsules/DexN 177Placebo/DexN 176Lenalidomide Capsules/DexN 176Placebo/DexN 175TTPEvents (%)73 (41)120 (68)68 (39)130 (74)Median TTP in months[95% CI]13.9[9.5, 18.5]4.7[3.7, 4.9]12.1[9.5, NE]4.7[3.8, 4.8]Hazard Ratio[95% CI]0.285[0.210, 0.386]0.324[0.240, 0.438]Log-rank Test p-value 3< 0.001< 0.001ResponseComplete Response (CR)n (%)23 (13)1 (1)27 (15)7 (4)Partial Response (RR/PR) (%)84 (48)33 (19)77 (44)34 (19)Overall Response (%)107 (61)34 (19)104 (59)41 (23)p-value< 0.001< 0.001Odds Ratio [95% CI]6.38[3.95, 10.32]4.72[2.98, 7.49] Kaplan-Meier Estimate of Time to Progression -- MM Study Kaplan-Meier Estimate of Time to Progression -- MM Study 2. Kaplan-Meier Estimate of Time to Progression -- MM Study 1. Kaplan-Meier Estimate of Time to Progression -- MM Study 2. 14.2Myelodysplastic Syndromes (MDS) with Deletion 5q Cytogenetic Abnormality The efficacy and safety of lenalidomide capsules were evaluated in patients with transfusion-dependent anemia in low- or intermediate-1-risk MDS with 5q (q31-33) cytogenetic abnormality in isolation or with additional cytogenetic abnormalities, at dose of 10 mg once daily or 10 mg once daily for 21 days every 28 days in an open-label, single-arm, multi-center study. The major study was not designed nor powered to prospectively compare the efficacy of the dosing regimens. Sequential dose reductions to mg daily and mg every other day, as well as dose delays, were allowed for toxicity [see Dosage and Administration (2.2)].This major study enrolled 148 patients who had RBC transfusion dependent anemia. RBC transfusion dependence was defined as having received >= units of RBCs within weeks prior to study treatment. The study enrolled patients with absolute neutrophil counts (ANC) >= 500/mm3, platelet counts >= 50,000/mm3, serum creatinine <= 2.5 mg/dL, serum SGOT/AST or SGPT/ALT <= x upper limit of normal (ULN), and serum direct bilirubin <= mg/dL. Granulocyte colony-stimulating factor was permitted for patients who developed neutropenia or fever in association with neutropenia. Baseline patient and disease-related characteristics are summarized in Table 18.Table 18: Baseline Demographic and Disease-Related Characteristics in the MDS StudyOverall(N 148)Age (years) Median71 Min, Max37, 95Gendern(%) Male51(34.5) Female97(65.5)Racen(%) White143(96.6) Other5(3.4)Duration of MDS (years) Median2.5 Min, Max0.1, 20.7Del (q31-33) Cytogenetic Abnormalityn(%) Yes148(100) Other cytogenetic abnormalities37(25.2)IPSS ScoreIPSS Risk Category: Low (combined score 0), Intermediate-1 (combined score 0.5 to 1), Intermediate-2 (combined score 1.5 to 2.0), High (combined score >= 2.5); Combined score (Marrow blast score Karyotype score Cytopenia score).n(%)Low (0)55(37.2)Intermediate-1 (0.5-1.0)65(43.9)Intermediate-2 (1.5-2.0)6(4.1)High (>= 2.5)2(1.4)Missing20(13.5)FAB ClassificationFrench-American-British (FAB) classification of MDS. from central reviewn(%)RA77(52)RARS16(10.8)RAEB30(20.3)CMML3(2)The frequency of RBC transfusion independence was assessed using criteria modified from the International Working Group (IWG) response criteria for MDS. RBC transfusion independence was defined as the absence of any RBC transfusion during any consecutive rolling 56 days (8 weeks) during the treatment period.Transfusion independence was seen in 99/148 (67%) patients (95% CI [59, 74]). The median duration from the date when RBC transfusion independence was first declared (i.e., the last day of the 56-day RBC transfusion-free period) to the date when an additional transfusion was received after the 56-day transfusion-free period among the 99 responders was 44 weeks (range of to 67 weeks). Ninety percent of patients who achieved transfusion benefit did so by completion of three months in the study.RBC transfusion independence rates were unaffected by age or gender.The dose of lenalidomide capsules was reduced or interrupted at least once due to an adverse event in 118 (79.7%) of the 148 patients; the median time to the first dose reduction or interruption was 21 days (mean, 35.1 days; range, 2-253 days), and the median duration of the first dose interruption was 22 days (mean, 28.5 days; range, 2-265 days). second dose reduction or interruption due to adverse events was required in 50 (33.8%) of the 148 patients. The median interval between the first and second dose reduction or interruption was 51 days (mean, 59.7 days; range, 15-205 days) and the median duration of the second dose interruption was 21 days (mean, 26 days; range, 2-148 days). 14.3Mantle Cell Lymphoma A multicenter, single-arm, open-label trial of single-agent lenalidomide capsules was conducted to evaluate the safety and efficacy of lenalidomide capsules in patients with mantle cell lymphoma who have relapsed after or were refractory to bortezomib or bortezomib-containing regimen. Patients with creatinine clearance >= 60 mL/min were given lenalidomide capsules at dose of 25 mg once daily for 21 days every 28 days. Patients with creatinine clearance >= 30 mL/min and 60 mL/min were given lenalidomide capsules at dose of 10 mg once daily for 21 days every 28 days. Treatment was continued until disease progression, unacceptable toxicity, or withdrawal of consent.The trial included patients who were at least 18 years of age with biopsy-proven MCL with measurable disease by CT scan. Patients were required to have received prior treatment with an anthracycline or mitoxantrone, cyclophosphamide, rituximab, and bortezomib, alone or in combination. Patients were required to have documented refractory disease (defined as without any response of PR or better during treatment with bortezomib or bortezomib-containing regimen), or relapsed disease (defined as progression within one year after treatment with bortezomib or bortezomib-containing regimen). At enrollment patients were to have an absolute neutrophil counts (ANC) >= 1500/mm3, platelet counts >= 60,000/mm3, serum SGOT/AST or SGPT/ALT <= 3x upper limit of normal (ULN) unless there was documented evidence of liver involvement by lymphoma, serum total bilirubin <= 1.5 ULN except in cases of Gilberts syndrome or documented liver involvement by lymphoma, and calculated creatinine clearance (Cockcroft-Gault formula) >= 30 mL/min.The median age was 67 years (43-83), 81% were male and 96% were Caucasian. The table below summarizes the baseline disease-related characteristics and prior anti-lymphoma therapy in the Mantle Cell Lymphoma trial.Table 19: Baseline Disease-related Characteristics and Prior Anti-Lymphoma Therapy in Mantle Cell Lymphoma TrialBaseline Disease Characteristics and Prior Anti-Lymphoma TreatmentTotal Patients(N 134)ECOG Performance StatusECOG Eastern Cooperative Oncology Group. (%) 043 (32) 173 (54) 217 (13) 31 (< 1)Advanced MCL Stage, (%) III27 (20) IV97 (72)High or Intermediate MIPI ScoreMIPI MCL International Prognostic Index., (%)90 (67)High Tumor BurdenHigh tumor burden is defined as at least one lesion that is >= cm in diameter or lesions that are >= cm in diameter., (%)77 (57)Bulky DiseaseBulky disease is defined as at least one lesion that is >= cm in the longest diameter., (%)44 (33)Extranodal Disease, (%)101 (75)Number of Prior Systemic Anti-Lymphoma Therapies, (%) Median (range)4 (2, 10) 10 (0) 229 (22) 334 (25) >= 471 (53)Number of Subjects Who Received Prior Regimen Containing, (%):Anthracycline/mitoxantrone133 (99)Cyclophosphamide133 (99)Rituximab134 (100)Bortezomib134 (100)Refractory to Prior Bortezomib, (%)81 (60)Refractory to Last Prior Therapy, (%)74 (55)Prior Autologous Bone Marrow or Stem Cell Transplant, (%)39 (29)The efficacy endpoints in the MCL trial were overall response rate (ORR) and duration of response (DOR). Response was determined based on review of radiographic scans by an independent review committee according to modified version of the International Workshop Lymphoma Response Criteria (Cheson, 1999). The DOR is defined as the time from the initial response (at least PR) to documented disease progression. The efficacy results for the MCL population were based on all evaluable patients who received at least one dose of study drug and are presented in Table 20. The median time to response was 2.2 months (range 1.8 to 13 months).Table 20: Response Outcomes in the Pivotal Mantle Cell Lymphoma TrialResponse Analyses (N 133)N (%)95% CIOverall Response Rate (IWRC) (CR CRu PR)34 (26)(18.4, 33.9) Complete Response (CR CRu)9 (7)(3.1, 12.5) CR1 (1) CRu8 (6) Partial Response (PR)25 (19)Duration of Response (months)Median95% CIDuration of Overall Response (CR CRu PR)(N 34)16.6(7.7, 26.7). 14.4 Follicular and Marginal Zone Lymphoma The efficacy of lenalidomide capsules with rituximab in patients with relapsed or refractory follicular and marginal zone lymphoma was evaluated in the AUGMENT (NCT01938001) and MAGNIFY (NCT01996865) trials.AUGMENT is randomized, double-blind, multicenter trial (n 358) in which patients with relapsed or refractory follicular or marginal zone lymphoma were randomized 1:1 to receive lenalidomide capsules and rituximab or rituximab and placebo. AUGMENT included patients diagnosed with Grade 1, 2, or 3a follicular lymphoma, who received at least prior systemic therapy, were refractory or relapsed, not rituximab-refractory, had at least one measurable nodal or extranodal lesion by CT or MRI scan, and had adequate bone marrow, liver, and renal function. Randomization was stratified by follicular versus marginal zone lymphoma, previous rituximab therapy, and time since other anti-lymphoma therapy. In AUGMENT, lenalidomide capsules were administered orally 20 mg once daily for Days to 21 of repeating 28-day cycles for maximum of 12 cycles or until unacceptable toxicity. The dose of rituximab was 375 mg/m2 every week in Cycle (Days 1, 8, 15, and 22) and on Day of every 28-day cycle from Cycles through 5. All dosage calculations for rituximab were based on the patients body surface area (BSA), using actual patient weight. Dose adjustments for lenalidomide capsules were allowed based on clinical and laboratory findings. patient with moderate renal insufficiency (>= 30 to 60 mL/minute) received lower lenalidomide capsules starting dose of 10 mg daily on the same schedule. After cycles, the lenalidomide capsule dose could be increased to 15 mg once daily on Days to 21 of each 28-day cycle if the patient tolerated the medication.MAGNIFY is an open-label, multicenter trial (n 232) in which patients with relapsed or refractory follicular, marginal zone, or mantle cell lymphoma received 12 induction cycles of lenalidomide capsules and rituximab. MAGNIFY included patients diagnosed with Grade 1, 2, 3a, 3b follicular (including transformed), marginal zone, or mantle cell lymphoma Stage to IV who were previously treated for their lymphoma, had been refractory or had relapse after their last treatment, had at least one measurable nodal or extranodal lesion by CT or MRI scan, and had adequate bone marrow, liver, and renal function. Patients refractory to rituximab were also included. The information from the subjects who received at least dose of initial therapy in the first 12 induction cycles (n 222) in the MAGNIFY trial was included in the evaluation of the efficacy of lenalidomide capsules/rituximab in patients with relapsed or refractory follicular and marginal zone lymphoma. In MAGNIFY, lenalidomide capsules 20 mg were given on Days 1-21 of repeated 28-day cycles for up to 12 cycles or until unacceptable toxicity, progression, or withdrawal of consent. The dose of rituximab was 375 mg/m2 every week in Cycle (Days 1, 8, 15, and 22) and on Day of every other 28-day cycle (Cycles 3, 5, 7, 9, and 11) up to 12 cycles therapy. All dosage calculations for rituximab were based on the patient BSA and actual weight. Dose adjustments were allowed based on clinical and laboratory findings.The demographic and disease-related baseline characteristics in the AUGMENT and MAGNIFY trials are shown in the following table.Table 21: Baseline Demographics and Disease-Related Characteristics of Patients with FL and MZL in AUGMENT and MAGNIFY TrialsData Cutoff: 22 June 2018 (AUGMENT) and May 2017 (MAGNIFY).ECOG Eastern Cooperative Oncology Group; FLIPI follicular lymphoma international prognostic indexAUGMENT TrialMAGNIFY TrialParameterLenalidomide Capsules Rituximab(N 178)Rituximab Placebo(Control Arm)(N 180)Lenalidomide Capsules Rituximab(N 222)Age (years) Median (Max, Min)64 (26, 86)62 (35, 88)65 (35, 91)Age distribution, (%) 65 years96 (54)107 (59)103 (46) >= 65 years82 (46)73 (41)119 (54)Sex, (%) Male75 (42)97 (54)122 (55) Female103 (58)83 (46)100 (45)Race White118 (66)115 (64)206 (93) Other races54 (30)64 (36)14 (6) Not collected or reported6 (3)1 (0.6)2 (1)Body Surface Area (BSA, m2) Median (Max, Min)1.8 (1.4, 3.1)1.8 (1.3, 2.7)2 (1.3, 2.6)Disease Type FL or MZL Follicular lymphoma147 (83)148 (82)177 (80) Marginal zone lymphoma31 (17)32 (18)45 (20)MZL subtype at diagnosis (investigator), (%) MALT14 (45)16 (50)10 (22) Nodal8 (26)10 (31)25 (56) Splenic9 (29)6 (19)10 (22)FL stage at diagnosis (investigator), (%) FL Grade 1-2125 (85)123 (83)149 (84) FL Grade 3a22 (15)25 (17)28 (16)FLIPI score at baseline (calculated), (%)Not Collected Low risk (0,1)52 (29)67 (37) Intermediate risk (2)55 (31)58 (32) High risk (>= 3)69 (39)54 (30) Missing2 (1)1 (0.6)ECOG score at baseline, (%) 0116 (65)128 (71)102 (46) 160 (34)50 (28)113 (51) 22 (1)2 (1)7 (3)High tumor burdenDefined by GELF criteria. at baseline, (%) Yes97 (54)86 (48)148 (67) No81 (46)94 (52)74 (33)Number of prior systemic anti-lymphoma therapies 1102 (57)97 (54)94 (42)Patient had either (n 2) or prior systemic therapy. 176 (43)83 (46)128 (58)In AUGMENT, efficacy was established in the intent-to-treat (ITT) population based on progression-free survival by Independent Review Committee using modified 2007 International Working Group response criteria. Efficacy results are summarized in Table 22.Table 22: Efficacy Results for Patients in the AUGMENT Trial (ITT FL and MZL Population)ParameterLenalidomide Capsules Rituximab(N 178)Rituximab Placebo (N 180)PFSPatients with event, (%)68 (38.2)115 (63.9) Death6 (8.8)2 (1.7) Progression of disease62 (91.2)113 (98.3)PFS, medianMedian estimate is from Kaplan-Meier analysis. [95% CI] (months)39.4 [22.9, NE]14.1 [11.4, 16.7]HRhazard ratio and its CI were estimated from Cox proportional hazard model adjusting for the stratification 3: previous rituximab treatment (yes, no), time since last anti-lymphoma therapy (<= 2, 2 years), and disease histology (FL, MZL). [95% CI]0.46 [0.34, 0.62]p-valuep-value from log-rank test stratified by factors noted above: previous rituximab treatment (yes, no), time since last anti-lymphoma therapy (<= 2, 2 years), and disease histology (FL, MZL). 0.0001Objective response (CR PR), (%) [95% CI]Exact confidence interval for binomial distribution.138 (77.5) [70.7, 83.4]96 (53.3) [45.8, 60.8] Kaplan-Meier Curves of Progression-free Survival by IRC Assessment Between Arms in AUGMENT Trial (ITT FL and MZL Population)a Stratification factors included: previous rituximab treatment (y/n), time since last anti-lymphoma therapy (<= years, 2 years), and disease histology (FL or MZL). CI confidence interval; HR hazard ratio; KM Kaplan-Meier; PFS progression-free survival. Follicular Lymphoma. In AUGMENT, the objective response by IRC assessment for patients with follicular lymphoma was 80% (118/147) [95% CI: 73%, 86%]) in lenalidomide capsules with rituximab arm compared to 55% (82/148) [95% CI: 47, 64] in control arm.In MAGNIFY, the overall response by investigator assessment was 59% (104/177) [95% CI: 51, 66] for patients with follicular lymphoma. Median duration of response was not reached with median follow-up time of 7.9 months [95% CI: 4.6, 9.2].. Marginal Zone Lymphoma. In AUGMENT, the objective response by IRC assessment for patients with marginal zone lymphoma was 65% (20/31) [95% CI: 45%, 81%] in lenalidomide capsules with rituximab arm compared to 44% (14/32) [95% CI: 26%, 62%] in control arm.In MAGNIFY, the overall response by investigator assessment was 51% (23/45) [95% CI: 36, 66] for patients with marginal zone lymphoma. Median duration of response was not reached with median follow-up time of 11.5 months [95% CI: 8.0, 18.9]. Kaplan-Meier Curves of Progression-free Survival by IRC Assessment Between Arms in AUGMENT Trial (ITT FL and MZL Population).

SPL MEDGUIDE SECTION.

Medication Guide Lenalidomide Capsules(len lid oh mide)What is the most important information should know about lenalidomide capsules Before you begin taking lenalidomide capsules, you must read and agree to all of the instructions in the Lenalidomide REMS program. Before prescribing lenalidomide capsules, your healthcare provider will explain the Lenalidomide REMS program to you and have you sign the Patient-Physician Agreement Form. Lenalidomide capsules may cause serious side effects including:oPossible birth defects (deformed babies) or death of an unborn baby. Females who are pregnant or who plan to become pregnant must not take lenalidomide capsules. Lenalidomide capsules are similar to the medicine thalidomide. We know thalidomide can cause severe life-threatening birth defects. Lenalidomide capsules have not been tested in pregnant females. Lenalidomide capsules have harmed unborn animals in animal testing. Females must not get pregnant: oFor at least weeks before starting lenalidomide capsulesoWhile taking lenalidomide capsulesoDuring any breaks (interruptions) in your treatment with lenalidomide capsulesoFor at least weeks after stopping lenalidomide capsules Females who can become pregnant:oWill have pregnancy tests weekly for weeks, then every weeks if your menstrual cycle is regular, or every weeks if your menstrual cycle is irregular.oIf you miss your period or have unusual bleeding, you will need to have pregnancy test and receive counseling.oMust agree to use two acceptable forms of birth control at the same time, for at least weeks before, while taking, during any breaks (interruptions) in your treatment, and for at least weeks after stopping lenalidomide capsules.oTalk with your healthcare provider to find out about options for acceptable forms of birth control that you may use to prevent pregnancy before, during, and after treatment with lenalidomide capsules.oIf you had unprotected sex or if you think your birth control has failed, stop taking lenalidomide capsules immediately and call your healthcare provider right away.If you become pregnant while taking lenalidomide capsules, stop taking them right away and call your healthcare provider. If your healthcare provider is not available, you can call the REMS Call Center at 1-888-423-5436. Healthcare providers and patients should report all cases of pregnancy to:oFDA MedWatch at 1-800-FDA-1088, andoThe REMS Call Center at 1-888-423-5436There is pregnancy exposure registry that monitors the outcomes of females who take lenalidomide capsules during pregnancy, or if their male partner takes lenalidomide capsules and they are exposed during pregnancy. You can enroll in this registry by calling the REMS Call Center at the phone number listed above. Lenalidomide can pass into human semen:oMales, including those who have had vasectomy, must always use latex or synthetic condom during any sexual contact with pregnant female or female that can become pregnant while taking lenalidomide capsules, during any breaks (interruptions) in your treatment with lenalidomide capsules, and for up to weeks after stopping lenalidomide capsules.oDo not have unprotected sexual contact with female who is or could become pregnant. Tell your healthcare provider if you do have unprotected sexual contact with female who is or could become pregnant.oDo not donate sperm while taking lenalidomide capsules, during any breaks (interruptions) in your treatment, and for up to weeks after stopping lenalidomide capsules. If female becomes pregnant with your sperm, the baby may be exposed to lenalidomide and may be born with birth defects.Men, if your female partner becomes pregnant, you should call your healthcare provider right away.oLow white blood cells (neutropenia) and low platelets (thrombocytopenia). Lenalidomide capsules cause low white blood cells and low platelets in most people. You may need blood transfusion or certain medicines if your blood counts drop too low. Your healthcare provider should check your blood counts often especially during the first several months of treatment with lenalidomide capsules, and then at least monthly. Tell your healthcare provider if you develop any bleeding or bruising, during treatment with lenalidomide capsules.oBlood clots. Blood clots in the arteries, veins, and lungs happen more often in people who take lenalidomide capsules. This risk is even higher for people with multiple myeloma who take the medicine dexamethasone with lenalidomide capsules. Heart attacks and strokes also happen more often in people who take lenalidomide capsules with dexamethasone. To reduce this increased risk, most people who take lenalidomide capsules will also take blood thinner medicine. Before taking lenalidomide capsules, tell your healthcare provider: oIf you have had blood clot in the past.oIf you have high blood pressure, smoke, or if you have been told you have high level of fat in your blood (hyperlipidemia).oAbout all the medicines you take. Certain other medicines can also increase your risk for blood clots. Call your healthcare provider or get medical help right away if you get any of the following during treatment with lenalidomide capsules: Signs or symptoms of blood clot in the lung, arm, or leg may include: shortness of breath, chest pain, or arm or leg swellingSigns or symptoms of heart attack may include: chest pain that may spread to the arms, neck, jaw, back, or stomach area (abdomen), feeling sweaty, shortness of breath, feeling sick or vomiting Signs or symptoms of stroke may include: sudden numbness or weakness, especially on one side of the body, severe headache or confusion, or problems with vision, speech, or balanceWhat are lenalidomide capsules Lenalidomide capsules are prescription medicine, used to treat adults with:omultiple myeloma (MM)oin combination with the medicine dexamethasone, oroas maintenance treatment after autologous hematopoietic stem cell transplantation (a type of stem cell transplant that uses your own stem cells)oa condition called myelodysplastic syndromes (MDS). Lenalidomide capsules are for the type of MDS with chromosome problem where part of chromosome is missing. This type of MDS is known as deletion 5q MDS. People with this type of MDS may have low red blood cell counts that require treatment with blood transfusions.omantle cell lymphoma (MCL) when the disease comes back or becomes worse after treatment with prior medicines, one of which included bortezomib. MCL is cancer of type of white blood cell called lymphocytes that are in the lymph nodes.ofollicular lymphoma (FL) or marginal zone lymphoma (MZL)oin combination with rituximab product, andowho have previously been treated for their FL or MZL FL and MZL are types of cancer of white blood cells called B-cell lymphocytes that are found in the lymph nodes and spleen. Lenalidomide capsules should not be used to treat people who have chronic lymphocytic leukemia (CLL) unless they are participants in controlled clinical trial. It is not known if lenalidomide capsules are safe and effective in children.Who should not take lenalidomide capsules Do not take lenalidomide capsules if you:oare pregnant, plan to become pregnant, or become pregnant during treatment with lenalidomide capsules. See What is the most important information should know about lenalidomide capsulesoare allergic to lenalidomide or any of the ingredients in lenalidomide capsules. See the end of this Medication Guide for complete list of ingredients in lenalidomide capsules.What should tell my healthcare provider before taking lenalidomide capsules Before you take lenalidomide capsules, tell your healthcare provider about all of your medical conditions, including if you:ohave liver problemsohave kidney problems or receive kidney dialysis treatmentohave thyroid problemsohave had serious skin rash with thalidomide treatment. You should not take lenalidomide capsules.oare breastfeeding. Do not breastfeed during treatment with lenalidomide capsules. It is not known if lenalidomide passes into your breast milk and can harm your baby. Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Lenalidomide capsules and other medicines may affect each other, causing serious side effects. Talk with your healthcare provider before taking any new medicines. Know the medicines you take. Keep list of them to show your healthcare provider and pharmacist.How should take lenalidomide capsulesoTake lenalidomide capsules exactly as prescribed and follow all the instructions of the Lenalidomide REMS program.oSwallow lenalidomide capsules whole with water time day. Do not open, break, or chew your capsules.oLenalidomide capsules may be taken with or without food.oTake lenalidomide capsules at about the same time each day.oDo not open or break lenalidomide capsules or handle them any more than needed.oIf powder from the lenalidomide capsule comes in contact with your skin, wash the skin right away with soap and water.oIf powder from the lenalidomide capsule comes in contact with the inside of your eyes, nose, or mouth, flush well with water.oIf you miss dose of lenalidomide capsules and it has been less than 12 hours since your regular time, take it as soon as you remember. If it has been more than 12 hours, just skip your missed dose. Do not take doses at the same time. oIf you take too many lenalidomide capsules, call your healthcare provider right away.What should avoid while taking lenalidomide capsulesoSee What is the most important information should know about lenalidomide capsulesoFemales: Do not get pregnant and do not breastfeed while taking lenalidomide capsules. oMales: Do not donate sperm while taking lenalidomide capsules, during any breaks (interruptions) in your treatment, and for up to weeks after stopping lenalidomide capsules.oDo not share lenalidomide capsules with other people. They may cause birth defects and other serious problems.oDo not donate blood while you take lenalidomide capsules, during any breaks (interruptions) in your treatment, and for weeks after stopping lenalidomide capsules. If someone who is pregnant gets your donated blood, her baby may be exposed to lenalidomide and may be born with birth defects.What are the possible side effects of lenalidomide capsules Lenalidomide capsules can cause serious side effects, including:oSee What is the most important information should know about lenalidomide capsulesoIncreased risk of death in people who have chronic lymphocytic leukemia (CLL). People with CLL who take lenalidomide capsules have an increased risk of death compared with people who take the medicine chlorambucil. Lenalidomide capsules may cause you to have serious heart problems that can lead to death, including atrial fibrillation, heart attack, or heart failure. You should not take lenalidomide capsules if you have CLL unless you are participating in controlled clinical trial.oRisk of new cancers (malignancies). An increase in new (second) cancers has happened in patients who received lenalidomide capsules and melphalan, or blood stem cell transplant, including certain blood cancers, such as acute myelogenous leukemia (AML), and myelodysplastic syndrome (MDS) and certain other types of cancers of the skin and other organs. Talk with your healthcare provider about your risk of developing new cancers if you take lenalidomide capsules. Your healthcare provider will check you for new cancers during your treatment with lenalidomide capsules.oSevere liver problems, including liver failure and death. Your healthcare provider should do blood tests to check your liver function during your treatment with lenalidomide capsules. Tell your healthcare provider right away if you develop any of the following symptoms of liver problems:oyellowing of your skin or the white part of your eyes (jaundice)odark or brown (tea-colored) urine opain on the upper right side of your stomach area (abdomen)obleeding or bruising more easily than normalofeeling very tiredoSevere skin reactions and severe allergic reactions can happen with lenalidomide capsules and may cause death. Call your healthcare provider right away if you develop any of the following signs or symptoms during treatment with lenalidomide capsules: oa red, itchy, skin rashopeeling of your skin or blistersosevere itchingofever Get emergency medical help right away if you develop any of the following signs or symptoms during treatment with lenalidomide capsules:oswelling of your lips, mouth, tongue, or throatotrouble breathing or swallowingoraised red areas on your skin (hives)oa very fast heartbeatoyou feel dizzy or faintoTumor lysis syndrome (TLS). TLS is caused by the fast breakdown of cancer cells. TLS can cause kidney failure and the need for dialysis treatment, abnormal heart rhythm, seizure and sometimes death. Your healthcare provider may do blood tests to check you for TLS.oWorsening of your tumor (tumor flare reaction) can happen with lenalidomide capsules and may cause death. Tell your healthcare provider if you get any of these symptoms of tumor flare reaction during treatment with lenalidomide capsules: tender swollen lymph nodes, low grade fever, pain, or rash.Your healthcare provider may tell you to decrease your dose, temporarily stop or permanently stop taking lenalidomide capsules if you develop certain serious side effects during treatment with lenalidomide capsules.oThyroid problems. Your healthcare provider may check your thyroid function before you start taking lenalidomide capsules and during treatment with lenalidomide capsules.oRisk of Early Death in MCL. In people who have Mantle Cell Lymphoma (MCL), there may be risk of dying sooner (early death) when taking lenalidomide capsules. Talk with your healthcare provider about any concerns and possible risk factors.The most common side effects of lenalidomide capsules include:odiarrheaorashonauseaoconstipationotiredness or weaknessofeveroitchingoswelling of your arms, hands, legs, feet and skinosleep problems (insomnia)oheadacheomuscle cramps or spasms oshortness of breathocough, sore throat, and other symptoms of cold oupper respiratory tract infection or bronchitisoinflammation of the stomach and intestine (stomach flu)onose bleedoshaking or trembling (tremor)ojoint achesopain in your back or stomach-area (abdomen)These are not all the possible side effects of lenalidomide capsules. Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.How should store lenalidomide capsulesoStore lenalidomide capsules at room temperature between 68F to 77F (20C to 25C).oReturn any unused lenalidomide capsules to your healthcare provider. Keep lenalidomide capsules and all medicines out of the reach of children.General information about the safe and effective use of lenalidomide capsules.Medicines are sometimes prescribed for purposes other than those listed in Medication Guide. Do not take lenalidomide capsules for conditions for which they were not prescribed. Do not give lenalidomide capsules to other people, even if they have the same symptoms you have. They may harm them and may cause birth defects. If you would like more information, talk with your healthcare provider. You can ask your healthcare provider or pharmacist for information about lenalidomide capsules that is written for health professionals.What are the ingredients in lenalidomide capsules Active ingredient: lenalidomideInactive ingredients: colloidal silicon dioxide, croscarmellose sodium, gelatin, microcrystalline cellulose, pregelatinized starch (corn), sodium stearyl fumarate and titanium dioxide. The 10 mg capsules also contain black iron oxide, FD&C Blue No. and yellow iron oxide. The black imprinting ink for the mg, 10 mg and 25 mg capsules contains black iron oxide, potassium hydroxide, propylene glycol, shellac and strong ammonia solution. The red imprinting ink for the 15 mg capsules contains ammonium hydroxide, propylene glycol, red iron oxide, shellac glaze and simethicone. Manufactured for: Mylan Pharmaceuticals Inc., Morgantown, WV 26505 U.S.A.Manufactured by: Mylan Laboratories Limited, Hyderabad -- 500 096, India For more information, call Mylan at 1-877-446-3679 (1-877-4-INFO-RX) or go to www.lenalidomiderems.com.This Medication Guide has been approved by the U.S. Food and Drug Administration.Manufactured for: Mylan Pharmaceuticals Inc. Morgantown, WV 26505 U.S.A.Manufactured by: Mylan Laboratories Limited Hyderabad -- 500 096, India7508905775089058Revised: 5/2022MXI:LENAC:R2pbmh:A/MXI:MG:LENAC:R2mhMXI:LENAC:R2pbmh:B/MXI:MG:LENAC:R2mh. oPossible birth defects (deformed babies) or death of an unborn baby. Females who are pregnant or who plan to become pregnant must not take lenalidomide capsules. Lenalidomide capsules are similar to the medicine thalidomide. We know thalidomide can cause severe life-threatening birth defects. Lenalidomide capsules have not been tested in pregnant females. Lenalidomide capsules have harmed unborn animals in animal testing. Females must not get pregnant: oFor at least weeks before starting lenalidomide capsulesoWhile taking lenalidomide capsulesoDuring any breaks (interruptions) in your treatment with lenalidomide capsulesoFor at least weeks after stopping lenalidomide capsules oFor at least weeks before starting lenalidomide capsules. oWhile taking lenalidomide capsules. oDuring any breaks (interruptions) in your treatment with lenalidomide capsules. oFor at least weeks after stopping lenalidomide capsules. oWill have pregnancy tests weekly for weeks, then every weeks if your menstrual cycle is regular, or every weeks if your menstrual cycle is irregular.. oIf you miss your period or have unusual bleeding, you will need to have pregnancy test and receive counseling.. oMust agree to use two acceptable forms of birth control at the same time, for at least weeks before, while taking, during any breaks (interruptions) in your treatment, and for at least weeks after stopping lenalidomide capsules.. oTalk with your healthcare provider to find out about options for acceptable forms of birth control that you may use to prevent pregnancy before, during, and after treatment with lenalidomide capsules.. oIf you had unprotected sex or if you think your birth control has failed, stop taking lenalidomide capsules immediately and call your healthcare provider right away.. oFDA MedWatch at 1-800-FDA-1088, and. oThe REMS Call Center at 1-888-423-5436. oMales, including those who have had vasectomy, must always use latex or synthetic condom during any sexual contact with pregnant female or female that can become pregnant while taking lenalidomide capsules, during any breaks (interruptions) in your treatment with lenalidomide capsules, and for up to weeks after stopping lenalidomide capsules.. oDo not have unprotected sexual contact with female who is or could become pregnant. Tell your healthcare provider if you do have unprotected sexual contact with female who is or could become pregnant.. oDo not donate sperm while taking lenalidomide capsules, during any breaks (interruptions) in your treatment, and for up to weeks after stopping lenalidomide capsules. If female becomes pregnant with your sperm, the baby may be exposed to lenalidomide and may be born with birth defects.. oLow white blood cells (neutropenia) and low platelets (thrombocytopenia). Lenalidomide capsules cause low white blood cells and low platelets in most people. You may need blood transfusion or certain medicines if your blood counts drop too low. Your healthcare provider should check your blood counts often especially during the first several months of treatment with lenalidomide capsules, and then at least monthly. Tell your healthcare provider if you develop any bleeding or bruising, during treatment with lenalidomide capsules.. oBlood clots. Blood clots in the arteries, veins, and lungs happen more often in people who take lenalidomide capsules. This risk is even higher for people with multiple myeloma who take the medicine dexamethasone with lenalidomide capsules. Heart attacks and strokes also happen more often in people who take lenalidomide capsules with dexamethasone. To reduce this increased risk, most people who take lenalidomide capsules will also take blood thinner medicine. Before taking lenalidomide capsules, tell your healthcare provider: oIf you have had blood clot in the past.oIf you have high blood pressure, smoke, or if you have been told you have high level of fat in your blood (hyperlipidemia).oAbout all the medicines you take. Certain other medicines can also increase your risk for blood clots. oIf you have had blood clot in the past.. oIf you have high blood pressure, smoke, or if you have been told you have high level of fat in your blood (hyperlipidemia).. oAbout all the medicines you take. Certain other medicines can also increase your risk for blood clots.. Signs or symptoms of blood clot in the lung, arm, or leg may include: shortness of breath, chest pain, or arm or leg swellingSigns or symptoms of heart attack may include: chest pain that may spread to the arms, neck, jaw, back, or stomach area (abdomen), feeling sweaty, shortness of breath, feeling sick or vomiting Signs or symptoms of stroke may include: sudden numbness or weakness, especially on one side of the body, severe headache or confusion, or problems with vision, speech, or balance. Signs or symptoms of blood clot in the lung, arm, or leg may include: shortness of breath, chest pain, or arm or leg swelling. Signs or symptoms of heart attack may include: chest pain that may spread to the arms, neck, jaw, back, or stomach area (abdomen), feeling sweaty, shortness of breath, feeling sick or vomiting Signs or symptoms of stroke may include: sudden numbness or weakness, especially on one side of the body, severe headache or confusion, or problems with vision, speech, or balance. omultiple myeloma (MM)oin combination with the medicine dexamethasone, oroas maintenance treatment after autologous hematopoietic stem cell transplantation (a type of stem cell transplant that uses your own stem cells). oin combination with the medicine dexamethasone, or. oas maintenance treatment after autologous hematopoietic stem cell transplantation (a type of stem cell transplant that uses your own stem cells). oa condition called myelodysplastic syndromes (MDS). Lenalidomide capsules are for the type of MDS with chromosome problem where part of chromosome is missing. This type of MDS is known as deletion 5q MDS. People with this type of MDS may have low red blood cell counts that require treatment with blood transfusions.. omantle cell lymphoma (MCL) when the disease comes back or becomes worse after treatment with prior medicines, one of which included bortezomib. MCL is cancer of type of white blood cell called lymphocytes that are in the lymph nodes.. ofollicular lymphoma (FL) or marginal zone lymphoma (MZL)oin combination with rituximab product, andowho have previously been treated for their FL or MZL. oin combination with rituximab product, and. owho have previously been treated for their FL or MZL. FL and MZL are types of cancer of white blood cells called B-cell lymphocytes that are found in the lymph nodes and spleen. oare pregnant, plan to become pregnant, or become pregnant during treatment with lenalidomide capsules. See What is the most important information should know about lenalidomide capsules. oare allergic to lenalidomide or any of the ingredients in lenalidomide capsules. See the end of this Medication Guide for complete list of ingredients in lenalidomide capsules.. ohave liver problems. ohave kidney problems or receive kidney dialysis treatment. ohave thyroid problems. ohave had serious skin rash with thalidomide treatment. You should not take lenalidomide capsules.. oare breastfeeding. Do not breastfeed during treatment with lenalidomide capsules. It is not known if lenalidomide passes into your breast milk and can harm your baby. oTake lenalidomide capsules exactly as prescribed and follow all the instructions of the Lenalidomide REMS program.. oSwallow lenalidomide capsules whole with water time day. Do not open, break, or chew your capsules.. oLenalidomide capsules may be taken with or without food.. oTake lenalidomide capsules at about the same time each day.. oDo not open or break lenalidomide capsules or handle them any more than needed.oIf powder from the lenalidomide capsule comes in contact with your skin, wash the skin right away with soap and water.oIf powder from the lenalidomide capsule comes in contact with the inside of your eyes, nose, or mouth, flush well with water.. oIf powder from the lenalidomide capsule comes in contact with your skin, wash the skin right away with soap and water.. oIf powder from the lenalidomide capsule comes in contact with the inside of your eyes, nose, or mouth, flush well with water.. oIf you miss dose of lenalidomide capsules and it has been less than 12 hours since your regular time, take it as soon as you remember. If it has been more than 12 hours, just skip your missed dose. Do not take doses at the same time. oIf you take too many lenalidomide capsules, call your healthcare provider right away.. oSee What is the most important information should know about lenalidomide capsules. oFemales: Do not get pregnant and do not breastfeed while taking lenalidomide capsules. oMales: Do not donate sperm while taking lenalidomide capsules, during any breaks (interruptions) in your treatment, and for up to weeks after stopping lenalidomide capsules.. oDo not share lenalidomide capsules with other people. They may cause birth defects and other serious problems.. oDo not donate blood while you take lenalidomide capsules, during any breaks (interruptions) in your treatment, and for weeks after stopping lenalidomide capsules. If someone who is pregnant gets your donated blood, her baby may be exposed to lenalidomide and may be born with birth defects.. oSee What is the most important information should know about lenalidomide capsules. oIncreased risk of death in people who have chronic lymphocytic leukemia (CLL). People with CLL who take lenalidomide capsules have an increased risk of death compared with people who take the medicine chlorambucil. Lenalidomide capsules may cause you to have serious heart problems that can lead to death, including atrial fibrillation, heart attack, or heart failure. You should not take lenalidomide capsules if you have CLL unless you are participating in controlled clinical trial.. oRisk of new cancers (malignancies). An increase in new (second) cancers has happened in patients who received lenalidomide capsules and melphalan, or blood stem cell transplant, including certain blood cancers, such as acute myelogenous leukemia (AML), and myelodysplastic syndrome (MDS) and certain other types of cancers of the skin and other organs. Talk with your healthcare provider about your risk of developing new cancers if you take lenalidomide capsules. Your healthcare provider will check you for new cancers during your treatment with lenalidomide capsules.. oSevere liver problems, including liver failure and death. Your healthcare provider should do blood tests to check your liver function during your treatment with lenalidomide capsules. Tell your healthcare provider right away if you develop any of the following symptoms of liver problems:. oyellowing of your skin or the white part of your eyes (jaundice). odark or brown (tea-colored) urine opain on the upper right side of your stomach area (abdomen). obleeding or bruising more easily than normal. ofeeling very tired. oSevere skin reactions and severe allergic reactions can happen with lenalidomide capsules and may cause death. Call your healthcare provider right away if you develop any of the following signs or symptoms during treatment with lenalidomide capsules: oa red, itchy, skin rash. opeeling of your skin or blisters. osevere itching. ofever. Get emergency medical help right away if you develop any of the following signs or symptoms during treatment with lenalidomide capsules:. oswelling of your lips, mouth, tongue, or throat. otrouble breathing or swallowing. oraised red areas on your skin (hives). oa very fast heartbeat. oyou feel dizzy or faint. oTumor lysis syndrome (TLS). TLS is caused by the fast breakdown of cancer cells. TLS can cause kidney failure and the need for dialysis treatment, abnormal heart rhythm, seizure and sometimes death. Your healthcare provider may do blood tests to check you for TLS.. oWorsening of your tumor (tumor flare reaction) can happen with lenalidomide capsules and may cause death. Tell your healthcare provider if you get any of these symptoms of tumor flare reaction during treatment with lenalidomide capsules: tender swollen lymph nodes, low grade fever, pain, or rash.. oThyroid problems. Your healthcare provider may check your thyroid function before you start taking lenalidomide capsules and during treatment with lenalidomide capsules.. oRisk of Early Death in MCL. In people who have Mantle Cell Lymphoma (MCL), there may be risk of dying sooner (early death) when taking lenalidomide capsules. Talk with your healthcare provider about any concerns and possible risk factors.. odiarrhea. orash. onausea. oconstipation. otiredness or weakness. ofever. oitching. oswelling of your arms, hands, legs, feet and skin. osleep problems (insomnia). oheadache. omuscle cramps or spasms oshortness of breath. ocough, sore throat, and other symptoms of cold oupper respiratory tract infection or bronchitis. oinflammation of the stomach and intestine (stomach flu). onose bleed. oshaking or trembling (tremor). ojoint aches. opain in your back or stomach-area (abdomen). oStore lenalidomide capsules at room temperature between 68F to 77F (20C to 25C).. oReturn any unused lenalidomide capsules to your healthcare provider.

BOXED WARNING SECTION.

WARNING: EMBRYO-FETAL TOXICITY, HEMATOLOGIC TOXICITY, and VENOUS and ARTERIAL THROMBOEMBOLISM Embryo-Fetal Toxicity: Do not use lenalidomide capsules during pregnancy. Lenalidomide, thalidomide analogue, caused limb abnormalities in developmental monkey study. Thalidomide is known human teratogen that causes severe life-threatening human birth defects. If lenalidomide is used during pregnancy, it may cause birth defects or embryo-fetal death. In females of reproductive potential, obtain negative pregnancy tests before starting lenalidomide capsule treatment. Females of reproductive potential must use forms of contraception or continuously abstain from heterosexual sex during and for weeks after lenalidomide capsule treatment [see Warnings and Precautions (5.1), and Medication Guide (17)]. To avoid embryo-fetal exposure to lenalidomide, lenalidomide capsules are only available through restricted distribution program, the Lenalidomide REMS program (5.2).Information about the Lenalidomide REMS program is available at www.lenalidomiderems.com or by calling the toll-free number 1-888-423-5436.Hematologic Toxicity (Neutropenia and Thrombocytopenia): Lenalidomide capsules can cause significant neutropenia and thrombocytopenia. Eighty percent of patients with del 5q myelodysplastic syndromes had to have dose delay/reduction during the major study. Thirty-four percent of patients had to have second dose delay/reduction. Grade or hematologic toxicity was seen in 80% of patients enrolled in the study. Patients on therapy for del 5q myelodysplastic syndromes should have their complete blood counts monitored weekly for the first weeks of therapy and at least monthly thereafter. Patients may require dose interruption and/or reduction. Patients may require use of blood product support and/or growth factors [see Dosage and Administration (2.2)].Venous and Arterial Thromboembolism: Lenalidomide capsules have demonstrated significantly increased risk of deep vein thrombosis (DVT) and pulmonary embolism (PE), as well as risk of myocardial infarction and stroke in patients with multiple myeloma who were treated with lenalidomide capsules and dexamethasone therapy. Monitor for and advise patients about signs and symptoms of thromboembolism. Advise patients to seek immediate medical care if they develop symptoms such as shortness of breath, chest pain, or arm or leg swelling. Thromboprophylaxis is recommended and the choice of regimen should be based on an assessment of the patients underlying risks [see Warnings and Precautions (5.4)].. WARNING: EMBRYO-FETAL TOXICITY, HEMATOLOGIC TOXICITY, and VENOUS and ARTERIAL THROMBOEMBOLISM See full prescribing information for complete boxed warning.EMBRYO-FETAL TOXICITYoLenalidomide, thalidomide analogue, caused limb abnormalities in developmental monkey study similar to birth defects caused by thalidomide in humans. If lenalidomide is used during pregnancy, it may cause birth defects or embryo-fetal death.oPregnancy must be excluded before start of treatment. Prevent pregnancy during treatment by the use of two reliable methods of contraception (5.1).Lenalidomide capsules are available only through restricted distribution program, called the Lenalidomide REMS program (5.2, 17).HEMATOLOGIC TOXICITY. Lenalidomide capsules can cause significant neutropenia and thrombocytopenia (5.3).VENOUS AND ARTERIAL THROMBOEMBOLISMoSignificantly increased risk of deep vein thrombosis (DVT) and pulmonary embolism (PE), as well as risk of myocardial infarction and stroke in patients with multiple myeloma receiving lenalidomide capsules with dexamethasone. Anti-thrombotic prophylaxis is recommended (5.4).. oLenalidomide, thalidomide analogue, caused limb abnormalities in developmental monkey study similar to birth defects caused by thalidomide in humans. If lenalidomide is used during pregnancy, it may cause birth defects or embryo-fetal death.. oPregnancy must be excluded before start of treatment. Prevent pregnancy during treatment by the use of two reliable methods of contraception (5.1).. oSignificantly increased risk of deep vein thrombosis (DVT) and pulmonary embolism (PE), as well as risk of myocardial infarction and stroke in patients with multiple myeloma receiving lenalidomide capsules with dexamethasone. Anti-thrombotic prophylaxis is recommended (5.4).

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenicity studies with lenalidomide have not been conducted.Lenalidomide was not mutagenic in the bacterial reverse mutation assay (Ames test) and did not induce chromosome aberrations in cultured human peripheral blood lymphocytes, or mutations at the thymidine kinase (tk) locus of mouse lymphoma L5178Y cells. Lenalidomide did not increase morphological transformation in Syrian Hamster Embryo assay or induce micronuclei in the polychromatic erythrocytes of the bone marrow of male rats.A fertility and early embryonic development study in rats, with administration of lenalidomide up to 500 mg/kg (approximately 200 times the human dose of 25 mg, based on body surface area) produced no parental toxicity and no adverse effects on fertility.

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action Lenalidomide is an analogue of thalidomide with immunomodulatory, antiangiogenic, and antineoplastic properties. Cellular activities of lenalidomide are mediated through its target cereblon, component of cullin ring E3 ubiquitin ligase enzyme complex. In vitro, in the presence of drug, substrate proteins (including Aiolos, Ikaros, and CK1) are targeted for ubiquitination and subsequent degradation leading to direct cytotoxic and immunomodulatory effects. Lenalidomide inhibits proliferation and induces apoptosis of certain hematopoietic tumor cells including MM, mantle cell lymphoma, and del (5q) myelodysplastic syndromes, follicular lymphoma and marginal zone lymphoma in vitro. Lenalidomide causes delay in tumor growth in some in vivo nonclinical hematopoietic tumor models including MM. Immunomodulatory properties of lenalidomide include increased number and activation of cells and natural killer (NK) cells leading to direct and enhanced antibody-dependent cell-mediated cytotoxicity (ADCC) via increased secretion of interleukin-2 and interferon-gamma, increased numbers of NKT cells, and inhibition of pro-inflammatory cytokines (e.g., TNF- and IL-6) by monocytes. In MM cells, the combination of lenalidomide and dexamethasone synergizes the inhibition of cell proliferation and the induction of apoptosis. The combination of lenalidomide and rituximab increases ADCC and direct tumor apoptosis in follicular lymphoma cells and increases ADCC in marginal zone lymphoma cells compared to rituximab alone in vitro. 12.2 Pharmacodynamics Cardiac Electrophysiology. The effect of lenalidomide on the QTc interval was evaluated in 60 healthy male subjects in thorough QT study. At dose two times the maximum recommended dose, lenalidomide did not prolong the QTc interval. The largest upper bound of the two-sided 90% CI for the mean differences between lenalidomide and placebo was below 10 ms. 12.3 Pharmacokinetics Absorption. Following single and multiple doses of lenalidomide capsules in patients with MM or MDS, the maximum plasma concentrations occurred between 0.5 and hours post-dose. The single and multiple dose pharmacokinetic disposition of lenalidomide is linear with AUC and Cmax values increasing proportionally with dose. Multiple doses of lenalidomide capsules at the recommended dosage does not result in drug accumulation.Administration of single 25 mg dose of lenalidomide capsules with high-fat meal in healthy subjects reduces the extent of absorption, with an approximate 20% decrease in AUC and 50% decrease in Cmax. In the trials where the efficacy and safety were established for lenalidomide capsules, the drug was administered without regard to food intake. Lenalidomide capsules can be administered with or without food.The oral absorption rate of lenalidomide in patients with MCL is similar to that observed in patients with MM or MDS.. Distribution. In vitro [14C]-lenalidomide binding to plasma proteins is approximately 30%.Lenalidomide is present in semen at hours (1379 ng/ejaculate) and 24 hours (35 ng/ejaculate) after the administration of lenalidomide capsules 25 mg daily.. Elimination. The mean half-life of lenalidomide is hours in healthy subjects and to hours in patients with MM, MDS or MCL.. Metabolism. Lenalidomide undergoes limited metabolism. Unchanged lenalidomide is the predominant circulating component in humans. Two identified metabolites are 5-hydroxy-lenalidomide and N-acetyl-lenalidomide; each constitutes less than 5% of parent levels in circulation.. Excretion. Elimination is primarily renal. Following single oral administration of [14C]-lenalidomide 25 mg to healthy subjects, approximately 90% and 4% of the radioactive dose was eliminated within ten days in urine and feces, respectively. Approximately 82% of the radioactive dose was excreted as lenalidomide in the urine within 24 hours. Hydroxy-lenalidomide and N-acetyl-lenalidomide represented 4.6% and 1.8% of the excreted dose, respectively. The renal clearance of lenalidomide exceeds the glomerular filtration rate.. Specific Populations. Renal Impairment Eight subjects with mild renal impairment (creatinine clearance (CLcr) 50 to 79 mL/min calculated using Cockcroft-Gault), subjects with moderate renal impairment (CLcr 30 to 49 mL/min), subjects with severe renal impairment (CLcr 30 mL/min), and patients with end stage renal disease (ESRD) requiring dialysis were administered single 25 mg dose of lenalidomide capsules. Three healthy subjects of similar age with normal renal function (CLcr 80 mL/min) were also administered single 25 mg dose of lenalidomide capsules. As CLcr decreased, half-life increased and drug clearance decreased linearly. Patients with moderate and severe impairment had 3-fold increase in half-life and 66% to 75% decrease in drug clearance compared to healthy subjects. Patients on hemodialysis (n 6) had an approximate 4.5-fold increase in half-life and an 80% decrease in drug clearance compared to healthy subjects. Approximately 30% of the drug in body was removed during 4-hour hemodialysis session.Adjust the starting dose of lenalidomide capsules in patients with renal impairment based on the CLcr value [see Dosage and Administration (2.6) ].. Hepatic Impairment Mild hepatic impairment (defined as total bilirubin 1 to 1.5 times upper limit of normal (ULN) or any aspartate transaminase greater than ULN) did not influence the disposition of lenalidomide. No pharmacokinetic data is available for patients with moderate to severe hepatic impairment.. Other Intrinsic Factors Age (39 to 85 years), body weight (33 to 135 kg), sex, race, and type of hematological malignancies (MM, MDS or MCL) did not have clinically relevant effect on lenalidomide clearance in adult patients.. Drug Interactions. Co-administration of single dose or multiple doses of dexamethasone (40 mg) had no clinically relevant effect on the multiple dose pharmacokinetics of lenalidomide capsules (25 mg).Co-administration of lenalidomide capsules (25 mg) after multiple doses of P-gp inhibitor such as quinidine (600 mg twice daily) did not significantly increase the Cmax or AUC of lenalidomide.Co-administration of the P-gp inhibitor and substrate temsirolimus (25 mg) with lenalidomide capsules (25 mg) did not significantly alter the pharmacokinetics of lenalidomide, temsirolimus, or sirolimus (metabolite of temsirolimus).In vitro studies demonstrated that lenalidomide capsules are substrate of P-glycoprotein (P-gp). Lenalidomide capsules are not substrate of human breast cancer resistance protein (BCRP), multidrug resistance protein (MRP) transporters MRP1, MRP2, or MRP3, organic anion transporters (OAT) OAT1 and OAT3, organic anion transporting polypeptide 1B1 (OATP1B1), organic cation transporters (OCT) OCT1 and OCT2, multidrug and toxin extrusion protein (MATE) MATE1, and organic cation transporters novel (OCTN) OCTN1 and OCTN2. Lenalidomide is not an inhibitor of P-gp, bile salt export pump (BSEP), BCRP, MRP2, OAT1, OAT3, OATP1B1, OATP1B3, or OCT2. Lenalidomide does not inhibit or induce CYP450 isoenzymes. Also, lenalidomide does not inhibit bilirubin glucuronidation formation in human liver microsomes with UGT1A1 genotyped as UGT1A11/1, UGT1A11/28, and UGT1A128/28.

CONTRAINDICATIONS SECTION.

4 CONTRAINDICATIONS oPregnancy (Boxed Warning, 4.1, 5.1, 8.1).oDemonstrated severe hypersensitivity to lenalidomide (4.2, 5.9, 5.15).. oPregnancy (Boxed Warning, 4.1, 5.1, 8.1).. oDemonstrated severe hypersensitivity to lenalidomide (4.2, 5.9, 5.15).. 4.1Pregnancy Lenalidomide capsules can cause fetal harm when administered to pregnant female. Limb abnormalities were seen in the offspring of monkeys that were dosed with lenalidomide during organogenesis. This effect was seen at all doses tested. Due to the results of this developmental monkey study, and lenalidomides structural similarities to thalidomide, known human teratogen, lenalidomide is contraindicated in females who are pregnant [see Boxed Warning]. If this drug is used during pregnancy or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential risk to fetus [see Warnings and Precautions (5.1, 5.2), Use in Special Populations (8.1, 8.3)].. 4.2Severe Hypersensitivity Reactions Lenalidomide capsules are contraindicated in patients who have demonstrated severe hypersensitivity (e.g., angioedema, Stevens-Johnson syndrome, toxic epidermal necrolysis) to lenalidomide [see Warnings and Precautions (5.9, 5.15)].

DESCRIPTION SECTION.

11 DESCRIPTION Lenalidomide capsules, thalidomide analogue, are an immunomodulatory agent with antiangiogenic and antineoplastic properties. The chemical name is 3-(4-Amino-1-oxo 1,3-dihydro-2H-isoindol-2-yl) piperidine-2,6-dione and it has the following chemical structure:The molecular formula for lenalidomide is C13H13N3O3, and the gram molecular weight is 259.27.Lenalidomide is an off-white to pale yellow powder. It is soluble in organic solvent/water mixtures, and buffered aqueous solvents. Lenalidomide is more soluble in organic solvents and low pH solutions. Solubility was significantly lower in less acidic buffers, ranging from about 0.4 to 0.5 mg/mL. Lenalidomide has an asymmetric carbon atom and can exist as the optically active forms S(-) and R(+), and is produced as racemic mixture with net optical rotation of zero.Lenalidomide is available in mg, 10 mg, 15 mg and 25 mg capsules for oral administration. Each capsule contains lenalidomide as the active ingredient and the following inactive ingredients: colloidal silicon dioxide, croscarmellose sodium, gelatin, microcrystalline cellulose, pregelatinized starch (corn), sodium stearyl fumarate and titanium dioxide. The 10 mg capsules also contain black iron oxide, FD&C Blue No. and yellow iron oxide. The black imprinting ink for the mg, 10 mg and 25 mg capsules contains black iron oxide, potassium hydroxide, propylene glycol, shellac and strong ammonia solution. The red imprinting ink for the 15 mg capsules contains ammonium hydroxide, propylene glycol, red iron oxide, shellac glaze and simethicone.. Lenalidomide Structural Formula.

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION oMM combination therapy: 25 mg once daily orally on Days 1-21 of repeated 28-day cycles (2.1).oMM maintenance therapy following auto-HSCT: 10 mg once daily continuously on Days 1-28 of repeated 28-day cycles (2.1).oMDS: 10 mg once daily (2.2).oMCL: 25 mg once daily orally on Days 1-21 of repeated 28-day cycles (2.3).oFL or MZL: 20 mg once daily orally on Days 1-21 of repeated 28-day cycles for up to 12 cycles (2.4).oRenal impairment: Adjust starting dose based on the creatinine clearance value (2.6).oFor concomitant therapy doses, see Full Prescribing Information (2.1, 2.4, 14.1, 14.4).. oMM combination therapy: 25 mg once daily orally on Days 1-21 of repeated 28-day cycles (2.1).. oMM maintenance therapy following auto-HSCT: 10 mg once daily continuously on Days 1-28 of repeated 28-day cycles (2.1).. oMDS: 10 mg once daily (2.2).. oMCL: 25 mg once daily orally on Days 1-21 of repeated 28-day cycles (2.3).. oFL or MZL: 20 mg once daily orally on Days 1-21 of repeated 28-day cycles for up to 12 cycles (2.4).. oRenal impairment: Adjust starting dose based on the creatinine clearance value (2.6).. oFor concomitant therapy doses, see Full Prescribing Information (2.1, 2.4, 14.1, 14.4).. 2.1Recommended Dosage for Multiple Myeloma Lenalidomide Capsule Combination Therapy. The recommended starting dose of lenalidomide capsules is 25 mg orally once daily on Days 1-21 of repeated 28-day cycles in combination with dexamethasone. Refer to Section 14.1 for specific dexamethasone dosing. For patients greater than 75 years old, the starting dose of dexamethasone may be reduced [see Clinical Studies (14.1)]. Treatment should be continued until disease progression or unacceptable toxicity.In patients who are not eligible for auto-HSCT, treatment should continue until disease progression or unacceptable toxicity. For patients who are auto-HSCT-eligible, hematopoietic stem cell mobilization should occur within cycles of lenalidomide capsule-containing therapy [see Warnings and Precautions (5.12)].. Dose Adjustments for Hematologic Toxicities During MM Treatment Dose modification guidelines, as summarized in Table below, are recommended to manage Grade or neutropenia or thrombocytopenia or other Grade or toxicity judged to be related to lenalidomide capsules.Table 1: Dose Adjustments for Hematologic Toxicities for MMPlatelet Counts Thrombocytopenia in MM When PlateletsRecommended Course Days 1-21 of Repeated 28-day Cycle Fall below 30,000/mcLInterrupt lenalidomide capsule treatment, follow CBC weekly Return to at least 30,000/mcLResume lenalidomide capsules at next lower dose. Do not dose below 2.5 mg daily For each subsequent drop below 30,000/mcLInterrupt lenalidomide capsule treatment Return to at least 30,000/mcLResume lenalidomide capsules at next lower dose. Do not dose below 2.5 mg dailyAbsolute Neutrophil Counts (ANC) Neutropenia in MM When NeutrophilsRecommended Course Days 1-21 of Repeated 28-day Cycle Fall below 1,000/mcLInterrupt lenalidomide capsule treatment, follow CBC weekly Return to at least 1,000/mcL and neutropenia is the only toxicityResume lenalidomide capsules at 25 mg daily or initial starting dose Return to at least 1,000/mcL and if other toxicityResume lenalidomide capsules at next lower dose. Do not dose below 2.5 mg daily For each subsequent drop below 1,000/mcLInterrupt lenalidomide capsule treatment Return to at least 1,000/mcLResume lenalidomide capsules at next lower dose. Do not dose below 2.5 mg daily Lenalidomide Capsule Maintenance Therapy Following Auto-HSCT. Following auto-HSCT, initiate lenalidomide capsule maintenance therapy after adequate hematologic recovery (ANC at least 1,000/mcL and/or platelet counts at least 75,000/mcL). The recommended starting dose of lenalidomide capsules is 10 mg once daily continuously (Days 1-28 of repeated 28-day cycles) until disease progression or unacceptable toxicity. After cycles of maintenance therapy, the dose can be increased to 15 mg once daily if tolerated.. Dose Adjustments for Hematologic Toxicities During MM Treatment Dose modification guidelines, as summarized in Table below, are recommended to manage Grade or neutropenia or thrombocytopenia or other Grade or toxicity judged to be related to lenalidomide capsules.Table 2: Dose Adjustments for Hematologic Toxicities for MMPlatelet Counts Thrombocytopenia in MM When PlateletsRecommended Course Fall below 30,000/mcLInterrupt lenalidomide capsule treatment, follow CBC weekly Return to at least 30,000/mcLResume lenalidomide capsules at next lower dose, continuously for Days 1-28 of repeated 28-day cycle If at the mg daily dose, For subsequent drop below 30,000/mcLInterrupt lenalidomide capsule treatment. Do not dose below mg daily for Day to 21 of 28-day cycle Return to at least 30,000/mcLResume lenalidomide capsules at mg daily for Days to 21of 28-day cycle. Do not dose below mg daily for Day to 21 of 28-day cycleAbsolute Neutrophil Counts (ANC) Neutropenia in MM When NeutrophilsRecommended Course Fall below 500/mcLInterrupt lenalidomide capsule treatment, follow CBC weekly Return to at least 500/mcLResume lenalidomide capsules at next lower dose, continuously for Days 1-28 of repeated 28-day cycle If at mg daily dose, For subsequent drop below 500/mcLInterrupt lenalidomide capsule treatment. Do not dose below mg daily for Days to 21 of 28-day cycle Return to at least 500/mcLResume lenalidomide capsules at mg daily for Days to 21 of 28-day cycle. Do not dose below mg daily for Days to 21 of 28-day cycle Fall below 30,000/mcL. Return to at least 30,000/mcL. If at the mg daily dose, For subsequent drop below 30,000/mcL. Return to at least 30,000/mcL. Fall below 500/mcL. Return to at least 500/mcL. If at mg daily dose, For subsequent drop below 500/mcL. Return to at least 500/mcL. 2.2Recommended Dosage for Myelodysplastic Syndromes The recommended starting dose of lenalidomide capsules is 10 mg daily. Treatment is continued or modified based upon clinical and laboratory findings. Continue treatment until disease progression or unacceptable toxicity.. Dose Adjustments for Hematologic Toxicities During MDS Treatment. Patients who are dosed initially at 10 mg and who experience thrombocytopenia should have their dosage adjusted as follows:. Platelet Counts If thrombocytopenia develops WITHIN weeks of starting treatment at 10 mg daily in MDS:If baseline is at least 100,000/mcLWhen PlateletsRecommended CourseFall below 50,000/mcLInterrupt lenalidomide capsule treatmentReturn to at least 50,000/mcLResume lenalidomide capsules at mg dailyIf baseline is below 100,000/mcLWhen PlateletsRecommended CourseFall to 50% of the baseline valueInterrupt lenalidomide capsule treatmentIf baseline is at least 60,000/mcL and returns to at least 50,000/mcLResume lenalidomide capsules at mg dailyIf baseline is below 60,000/mcL and returns to at least 30,000/mcLResume lenalidomide capsules at mg dailyIf thrombocytopenia develops AFTER weeks of starting treatment at 10 mg daily in MDS:When PlateletsRecommended CourseFall below 30,000/mcL or below 50,000/mcL with platelet transfusionsInterrupt lenalidomide capsule treatmentReturn to at least 30,000/mcL (without hemostatic failure)Resume lenalidomide capsules at mg dailyPatients who experience thrombocytopenia at mg daily should have their dosage adjusted as follows:If thrombocytopenia develops during treatment at mg daily in MDS:When PlateletsRecommended CourseFall below 30,000/mcL or below 50,000/mcL with platelet transfusionsInterrupt lenalidomide capsule treatmentReturn to at least 30,000/mcL (without hemostatic failure)Resume lenalidomide capsules at 2.5 mg dailyPatients who are dosed initially at 10 mg and experience neutropenia should have their dosage adjusted as follows:. Absolute Neutrophil Counts (ANC) If neutropenia develops WITHIN weeks of starting treatment at 10 mg daily in MDS:If baseline ANC is at least 1,000/mcLWhen NeutrophilsRecommended CourseFall below 750/mcLInterrupt lenalidomide capsule treatmentReturn to at least 1,000/mcLResume lenalidomide capsules at mg dailyIf baseline ANC is below 1,000/mcLWhen NeutrophilsRecommended CourseFall below 500/mcLInterrupt lenalidomide capsule treatmentReturn to at least 500/mcLResume lenalidomide capsules at mg dailyIf neutropenia develops AFTER weeks of starting treatment at 10 mg daily in MDS:When NeutrophilsRecommended CourseFall below 500/mcL for at least days or below 500/mcL associated with fever (at least 38.5C)Interrupt lenalidomide capsule treatmentReturn to at least 500/mcLResume lenalidomide capsules at mg dailyPatients who experience neutropenia at mg daily should have their dosage adjusted as follows:If neutropenia develops during treatment at mg daily in MDS:When NeutrophilsRecommended CourseFall below 500/mcL for at least days or below 500/mcL associated with fever (at least 38.5C)Interrupt lenalidomide capsule treatmentReturn to at least 500/mcLResume lenalidomide capsules at 2.5 mg daily. 2.3Recommended Dosage for Mantle Cell Lymphoma The recommended starting dose of lenalidomide capsules is 25 mg/day orally on Days 1-21 of repeated 28-day cycles for relapsed or refractory mantle cell lymphoma. Treatment should be continued until disease progression or unacceptable toxicity.Treatment is continued, modified or discontinued based upon clinical and laboratory findings. Dose Adjustments for Hematologic Toxicities During MCL Treatment. Dose modification guidelines as summarized below are recommended to manage Grade or neutropenia or thrombocytopenia or other Grade or toxicities considered to be related to lenalidomide capsules.. Platelet Counts Thrombocytopenia during treatment in MCL:When PlateletsRecommended CourseFall below 50,000/mcLInterrupt lenalidomide capsule treatment and follow CBC weeklyReturn to at least 50,000/mcLResume lenalidomide capsules at mg less than the previous dose. Do not dose below mg daily. Absolute Neutrophil Counts (ANC) Neutropenia during treatment in MCL:When NeutrophilsRecommended CourseFall below 1,000/mcL for at least daysORFalls below 1,000/mcL with an associated temperature at least 38.5CORFalls below 500/mcLInterrupt lenalidomide capsule treatment and follow CBC weeklyReturn to at least 1,000/mcLResume lenalidomide capsules at mg less than the previous dose. Do not dose below mg daily 2.4 Recommended Dosage for Follicular Lymphoma or Marginal Zone Lymphoma The recommended starting dose of lenalidomide capsules is 20 mg orally once daily on Days 1-21 of repeated 28-day cycles for up to 12 cycles of treatment in combination with rituximab product. Refer to Section 14.4 for specific rituximab dosing from the AUGMENT trial. For dose adjustments due to toxicity with rituximab, refer to the product prescribing information.. Dose Adjustments for Hematologic Toxicities During FL or MZL Treatment. Dose modification guidelines, as summarized below, are recommended to manage Grade or neutropenia or thrombocytopenia or other Grade or toxicity judged to be related to lenalidomide capsules.. Platelet Counts Thrombocytopenia during treatment in FL or MZL:When PlateletsRecommended CourseFall below 50,000/mcLInterrupt lenalidomide capsule treatment and follow CBC weekly.Return to at least 50,000/mcLIf patient starting dose was 20 mg daily, resume lenalidomide capsules at mg less than the previous dose. Do not dose below mg daily. If patient starting dose was 10 mg daily, resume at mg less than previous dose. Do not dose below 2.5 mg daily.. Absolute Neutrophil Counts (ANC) Neutropenia during treatment in FL or MZL:When NeutrophilsRecommended CourseFall below 1,000/mcL for at least daysORFalls below 1,000/mcL with an associated temperature at least 38.5CORFalls below 500/mcLInterrupt lenalidomide capsule treatment and follow CBC weekly.Return to at least 1,000/mcLIf patient starting dose was 20 mg daily, resume lenalidomide capsules at mg less than the previous dose. Do not dose below mg daily. If patient starting dose was 10 mg daily, resume at mg less than previous dose. Do not dose below 2.5 mg daily.. 2.5Dosage Modifications for Non-Hematologic Adverse Reactions For non-hematologic Grade 3/4 toxicities judged to be related to lenalidomide capsules, hold treatment and restart at the physicians discretion at next lower dose level when toxicity has resolved to Grade or below.Permanently discontinue lenalidomide capsules for angioedema, anaphylaxis, Grade rash, skin exfoliation, bullae, or any other severe dermatologic reactions [see Warnings and Precautions (5.9, 5.15)].. 2.6Recommended Dosage for Patients with Renal Impairment The recommendations for dosing patients with renal impairment are shown in the following table [see Clinical Pharmacology (12.3)].Table 3: Dose Adjustments for Patients with Renal ImpairmentRenal Function (Cockcroft-Gault)Dose in Lenalidomide Capsule Combination Therapy for MM and MCLDose in Lenalidomide Capsule Combination Therapy for FL and MZLDose in Lenalidomide Capsule Maintenance Therapy Following Auto-HSCT for MM and for MDSCLcr 30 to 60 mL/min10 mg once daily10 mg once daily5 mg once dailyCLcr below 30 mL/min (not requiring dialysis)15 mg every other day5 mg once daily2.5 mg once dailyCLcr below 30 mL/min (requiring dialysis)5 mg once daily. On dialysis days, administer the dose following dialysis.5 mg once daily. On dialysis days, administer the dose following dialysis.2.5 mg once daily. On dialysis days, administer the dose following dialysis.. Lenalidomide Capsule Combination Therapy for MM. For CLcr of 30 to 60 mL/min, consider escalating the dose to 15 mg after cycles if the patient tolerates the 10 mg dose of lenalidomide without dose-limiting toxicity.. Lenalidomide Capsule Maintenance Therapy Following Auto-HSCT for MM and for MCL and MDS. Base subsequent lenalidomide capsule dose increase or decrease on individual patient treatment tolerance [see Dosage and Administration (2.1 2.2, 2.3)].. Lenalidomide Capsule Combination Therapy for FL or for MZL. For patients with CLcr of 30 to 60 mL/min, after cycles, the lenalidomide capsule dose may be increased to 15 mg orally if the patient has tolerated therapy.. 2.7Administration Advise patients to take lenalidomide capsules orally at about the same time each day, either with or without food. Advise patients to swallow lenalidomide capsules whole with water and not to open, break, or chew them.

DOSAGE FORMS & STRENGTHS SECTION.

3 DOSAGE FORMS AND STRENGTHS Lenalidomide Capsules are available containing mg, 10 mg, 15 mg or 25 mg of lenalidomide.oThe mg capsules are hard-shell gelatin capsules with white opaque cap and white opaque body filled with white to off-white powder. The capsules are axially printed with MYLAN over LL in black ink on both the cap and body. oThe 10 mg capsules are hard-shell gelatin capsules with green opaque cap and light gray opaque body filled with white to off-white powder. The capsules are axially printed with MYLAN over LL 10 in black ink on both the cap and body. oThe 15 mg capsules are hard-shell gelatin capsules with white opaque cap and white opaque body filled with white to off-white powder. The capsules are axially printed with MYLAN over LL 15 in red ink on both the cap and body. oThe 25 mg capsules are hard-shell gelatin capsules with white opaque cap and white opaque body filled with white to off-white powder. The capsules are axially printed with MYLAN over LL 25 in black ink on both the cap and body. oThe mg capsules are hard-shell gelatin capsules with white opaque cap and white opaque body filled with white to off-white powder. The capsules are axially printed with MYLAN over LL in black ink on both the cap and body. oThe 10 mg capsules are hard-shell gelatin capsules with green opaque cap and light gray opaque body filled with white to off-white powder. The capsules are axially printed with MYLAN over LL 10 in black ink on both the cap and body. oThe 15 mg capsules are hard-shell gelatin capsules with white opaque cap and white opaque body filled with white to off-white powder. The capsules are axially printed with MYLAN over LL 15 in red ink on both the cap and body. oThe 25 mg capsules are hard-shell gelatin capsules with white opaque cap and white opaque body filled with white to off-white powder. The capsules are axially printed with MYLAN over LL 25 in black ink on both the cap and body. Capsules: mg, 10 mg, 15 mg, and 25 mg (3).

DRUG INTERACTIONS SECTION.

7 DRUG INTERACTIONS oDigoxin: Monitor digoxin plasma levels periodically due to increased Cmax and AUC with concomitant lenalidomide capsule therapy (7.1).oConcomitant use of erythropoietin stimulating agents or estrogen containing therapies with lenalidomide capsules may increase the risk of thrombosis (7.2).. oDigoxin: Monitor digoxin plasma levels periodically due to increased Cmax and AUC with concomitant lenalidomide capsule therapy (7.1).. oConcomitant use of erythropoietin stimulating agents or estrogen containing therapies with lenalidomide capsules may increase the risk of thrombosis (7.2).. 7.1Digoxin When digoxin was co-administered with multiple doses of lenalidomide capsules (10 mg/day) the digoxin Cmax and AUCinf were increased by 14%. Periodically monitor digoxin plasma levels, in accordance with clinical judgment and based on standard clinical practice in patients receiving this medication, during administration of lenalidomide capsules.. 7.2Concomitant Therapies That May Increase the Risk of Thrombosis Erythropoietic agents, or other agents that may increase the risk of thrombosis, such as estrogen containing therapies, should be used with caution after making benefit-risk assessment in patients receiving lenalidomide capsules [see Warnings and Precautions (5.4)].. 7.3Warfarin Co-administration of multiple doses of lenalidomide capsules (10 mg/day) with single dose of warfarin (25 mg) had no effect on the pharmacokinetics of lenalidomide or R- and S-warfarin. Expected changes in laboratory assessments of PT and INR were observed after warfarin administration, but these changes were not affected by concomitant lenalidomide capsule administration. It is not known whether there is an interaction between dexamethasone and warfarin. Close monitoring of PT and INR is recommended in patients with MM taking concomitant warfarin.

FEMALES & MALES OF REPRODUCTIVE POTENTIAL SECTION.

8.3 Females and Males of Reproductive Potential Pregnancy Testing. Lenalidomide capsules can cause fetal harm when administered during pregnancy [see Use in Specific Populations (8.1)]. Verify the pregnancy status of females of reproductive potential prior to initiating lenalidomide capsule therapy and during therapy. Advise females of reproductive potential that they must avoid pregnancy weeks before therapy, while taking lenalidomide capsules, during dose interruptions and for at least weeks after completing therapy.Females of reproductive potential must have negative pregnancy tests before initiating lenalidomide capsules. The first test should be performed within 10-14 days, and the second test within 24 hours prior to prescribing lenalidomide capsules. Once treatment has started and during dose interruptions, pregnancy testing for females of reproductive potential should occur weekly during the first weeks of use, then pregnancy testing should be repeated every weeks in females with regular menstrual cycles. If menstrual cycles are irregular, the pregnancy testing should occur every weeks. Pregnancy testing and counseling should be performed if patient misses her period or if there is any abnormality in her menstrual bleeding. Lenalidomide capsule treatment must be discontinued during this evaluation.. Contraception. Females Females of reproductive potential must commit either to abstain continuously from heterosexual sexual intercourse or to use methods of reliable birth control simultaneously: one highly effective form of contraception tubal ligation, IUD, hormonal (birth control pills, injections, hormonal patches, vaginal rings, or implants), or partners vasectomy, and additional effective contraceptive method male latex or synthetic condom, diaphragm, or cervical cap. Contraception must begin weeks prior to initiating treatment with lenalidomide capsules, during therapy, during dose interruptions, and continuing for weeks following discontinuation of lenalidomide capsule therapy. Reliable contraception is indicated even where there has been history of infertility, unless due to hysterectomy. Females of reproductive potential should be referred to qualified provider of contraceptive methods, if needed.. Males Lenalidomide is present in the semen of males who take lenalidomide capsules. Therefore, males must always use latex or synthetic condom during any sexual contact with females of reproductive potential while taking lenalidomide capsules and for up to weeks after discontinuing lenalidomide capsules, even if they have undergone successful vasectomy. Male patients taking lenalidomide capsules must not donate sperm and for up to weeks after discontinuing lenalidomide capsules.

GERIATRIC USE SECTION.

8.5 Geriatric Use MM In Combination. Overall, of the 1613 patients in the NDMM study who received study treatment, 94% (1521/1613) were 65 years of age or older, while 35% (561/1613) were over 75 years of age. The percentage of patients over age 75 was similar between study arms (Rd Continuous: 33%; Rd18: 34%; MPT: 33%). Overall, across all treatment arms, the frequency in most of the adverse reaction categories (e.g., all adverse reactions, grade 3/4 adverse reactions, serious adverse reactions) was higher in older (> 75 years of age) than in younger (<= 75 years of age) subjects. Grade or adverse reactions in the General Disorders and Administration Site Conditions body system were consistently reported at higher frequency (with difference of at least 5%) in older subjects than in younger subjects across all treatment arms. Grade or adverse reactions in the Infections and Infestations, Cardiac Disorders (including cardiac failure and congestive cardiac failure), Skin and Subcutaneous Tissue Disorders, and Renal and Urinary Disorders (including renal failure) body systems were also reported slightly, but consistently, more frequently (< 5% difference), in older subjects than in younger subjects across all treatment arms. For other body systems (e.g., Blood and Lymphatic System Disorders, Infections and Infestations, Cardiac Disorders, Vascular Disorders), there was less consistent trend for increased frequency of grade 3/4 adverse reactions in older vs younger subjects across all treatment arms. Serious adverse reactions were generally reported at higher frequency in the older subjects than in the younger subjects across all treatment arms.. MM Maintenance Therapy. Overall, 10% (106/1018) of patients were 65 years of age or older, while no patients were over 75 years of age. Grade or adverse reactions were higher in the lenalidomide capsules arm (more than 5% higher) in the patients 65 years of age or older versus younger patients. The frequency of Grade or adverse reactions in the Blood and Lymphatic System Disorders were higher in the lenalidomide capsules arm (more than 5% higher) in the patients 65 years of age or older versus younger patients. There were not sufficient number of patients 65 years of age or older in lenalidomide capsule maintenance studies who experienced either serious adverse reaction, or discontinued therapy due to an adverse reaction to determine whether elderly patients respond relative to safety differently from younger patients. MM After At Least One Prior Therapy. Of the 703 MM patients who received study treatment in Studies and 2, 45% were age 65 or over while 12% of patients were age 75 and over. The percentage of patients age 65 or over was not significantly different between the lenalidomide capsules/dexamethasone and placebo/dexamethasone groups. Of the 353 patients who received lenalidomide capsules/dexamethasone, 46% were age 65 and over. In both studies, patients 65 years of age were more likely than patients <= 65 years of age to experience DVT, pulmonary embolism, atrial fibrillation, and renal failure following use of lenalidomide capsules. No differences in efficacy were observed between patients over 65 years of age and younger patients.Of the 148 patients with del 5q MDS enrolled in the major study, 38% were age 65 and over, while 33% were age 75 and over. Although the overall frequency of adverse reactions (100%) was the same in patients over 65 years of age as in younger patients, the frequency of serious adverse reactions was higher in patients over 65 years of age than in younger patients (54% vs 33%). greater proportion of patients over 65 years of age discontinued from the clinical studies because of adverse reactions than the proportion of younger patients (27% vs 16%). No differences in efficacy were observed between patients over 65 years of age and younger patients.Of the 134 patients with MCL enrolled in the MCL trial, 63% were age 65 and over, while 22% of patients were age 75 and over. The overall frequency of adverse reactions was similar in patients over 65 years of age and in younger patients (98% vs 100%). The overall incidence of grade and adverse reactions was also similar in these patient groups (79% vs 78%, respectively). The frequency of serious adverse reactions was higher in patients over 65 years of age than in younger patients (55% vs 41%). No differences in efficacy were observed between patients over 65 years of age and younger patients.. FL or MZL in Combination. Overall, 48% (282/590) of patients were 65 years of age or older, while 14% (82/590) of patients were over 75 years of age. The overall frequency of adverse reactions was similar in patients 65 years of age or older and younger patients for both studies pooled (98%). Grade or adverse reactions were higher in the lenalidomide capsules arm (more than 5% higher) in the patients 65 years of age or older versus younger patients (71% versus 59%). The frequency of Grade or adverse reactions were higher in the lenalidomide capsules arm (more than 5% higher) in the patients 65 years of age or older versus younger patients in the Blood and Lymphatic System Disorders (47% versus 40%) and Infections and Infestations (16% versus 11%). Serious adverse reactions were higher in the lenalidomide capsules arm (more than 5% higher) in the patients 65 years of age or older versus younger patients (37% versus 18%). The frequency of serious adverse reactions were higher in the lenalidomide capsules arm (more than 5% higher) in the patients 65 years of age or older versus younger patients in Infections and Infestations (15% versus 6%).Since elderly patients are more likely to have decreased renal function, care should be taken in dose selection. Monitor renal function.

HEPATIC IMPAIRMENT SUBSECTION.

Hepatic Impairment Mild hepatic impairment (defined as total bilirubin 1 to 1.5 times upper limit of normal (ULN) or any aspartate transaminase greater than ULN) did not influence the disposition of lenalidomide. No pharmacokinetic data is available for patients with moderate to severe hepatic impairment.

HOW SUPPLIED SECTION.

16 HOW SUPPLIED/STORAGE AND HANDLING 16.1How Supplied Lenalidomide Capsules are available containing mg, 10 mg, 15 mg or 25 mg of lenalidomide.The mg capsules are hard-shell gelatin capsules with white opaque cap and white opaque body filled with white to off-white powder. The capsules are axially printed with MYLAN over LL in black ink on both the cap and body. They are available as follows:NDC 0378-1936-28bottles of 28 capsulesNDC 0378-1936-01bottles of 100 capsulesThe 10 mg capsules are hard-shell gelatin capsules with green opaque cap and light gray opaque body filled with white to off-white powder. The capsules are axially printed with MYLAN over LL 10 in black ink on both the cap and body. They are available as follows:NDC 0378-1937-28bottles of 28 capsulesNDC 0378-1937-01bottles of 100 capsulesThe 15 mg capsules are hard-shell gelatin capsules with white opaque cap and white opaque body filled with white to off-white powder. The capsules are axially printed with MYLAN over LL 15 in red ink on both the cap and body. They are available as follows:NDC 0378-1941-21bottles of 21 capsulesNDC 0378-1941-01bottles of 100 capsulesThe 25 mg capsules are hard-shell gelatin capsules with white opaque cap and white opaque body filled with white to off-white powder. The capsules are axially printed with MYLAN over LL 25 in black ink on both the cap and body. They are available as follows:NDC 0378-1940-21bottles of 21 capsulesNDC 0378-1940-01bottles of 100 capsules. 16.2Storage Store at 20 to 25C (68 to 77F). [See USP Controlled Room Temperature.]. 16.3Handling and Disposal Care should be exercised in the handling of lenalidomide capsules. Lenalidomide capsules should not be opened or broken. If powder from lenalidomide capsules contacts the skin, wash the skin immediately and thoroughly with soap and water. If lenalidomide contacts the mucous membranes, flush thoroughly with water.Procedures for the proper handling and disposal of anticancer drugs should be considered. Several guidelines on the subject have been published.1 Dispense no more than 28-day supply.Dispense in tight, light-resistant container as defined in the USP using child-resistant closure.

INDICATIONS & USAGE SECTION.

1 INDICATIONS AND USAGE Lenalidomide capsules are thalidomide analogue indicated for the treatment of adult patients with:oMultiple myeloma (MM), in combination with dexamethasone (1.1).oMM, as maintenance following autologous hematopoietic stem cell transplantation (auto-HSCT) (1.1).oTransfusion-dependent anemia due to low- or intermediate-1-risk myelodysplastic syndromes (MDS) associated with deletion 5q abnormality with or without additional cytogenetic abnormalities (1.2).oMantle cell lymphoma (MCL) whose disease has relapsed or progressed after two prior therapies, one of which included bortezomib (1.3).oPreviously treated follicular lymphoma (FL), in combination with rituximab product (1.4).oPreviously treated marginal zone lymphoma (MZL), in combination with rituximab product (1.5).Limitations of Use:oLenalidomide capsules are not indicated and are not recommended for the treatment of patients with chronic lymphocytic leukemia (CLL) outside of controlled clinical trials (1.6).. oMultiple myeloma (MM), in combination with dexamethasone (1.1).. oMM, as maintenance following autologous hematopoietic stem cell transplantation (auto-HSCT) (1.1).. oTransfusion-dependent anemia due to low- or intermediate-1-risk myelodysplastic syndromes (MDS) associated with deletion 5q abnormality with or without additional cytogenetic abnormalities (1.2).. oMantle cell lymphoma (MCL) whose disease has relapsed or progressed after two prior therapies, one of which included bortezomib (1.3).. oPreviously treated follicular lymphoma (FL), in combination with rituximab product (1.4).. oPreviously treated marginal zone lymphoma (MZL), in combination with rituximab product (1.5).. oLenalidomide capsules are not indicated and are not recommended for the treatment of patients with chronic lymphocytic leukemia (CLL) outside of controlled clinical trials (1.6).. 1.1Multiple Myeloma Lenalidomide capsules in combination with dexamethasone are indicated for the treatment of adult patients with multiple myeloma (MM).Lenalidomide capsules are indicated as maintenance therapy in adult patients with MM following autologous hematopoietic stem cell transplantation (auto-HSCT).. 1.2Myelodysplastic Syndromes Lenalidomide capsules are indicated for the treatment of adult patients with transfusion-dependent anemia due to low- or intermediate-1-risk myelodysplastic syndromes (MDS) associated with deletion 5q cytogenetic abnormality with or without additional cytogenetic abnormalities.. 1.3Mantle Cell Lymphoma Lenalidomide capsules are indicated for the treatment of adult patients with mantle cell lymphoma (MCL) whose disease has relapsed or progressed after two prior therapies, one of which included bortezomib.. 1.4 Follicular Lymphoma Lenalidomide capsules in combination with rituximab product, are indicated for the treatment of adult patients with previously treated follicular lymphoma (FL).. 1.5 Marginal Zone Lymphoma Lenalidomide capsules in combination with rituximab product, are indicated for the treatment of adult patients with previously treated marginal zone lymphoma (MZL).. 1.6Limitations of Use Lenalidomide capsules are not indicated and are not recommended for the treatment of patients with CLL outside of controlled clinical trials [see Warnings and Precautions (5.5)].

INFORMATION FOR PATIENTS SECTION.

17 PATIENT COUNSELING INFORMATION Advise the patient to read the FDA-approved Patient labeling (Medication Guide)Embryo-Fetal Toxicity: Advise patients that lenalidomide capsules are contraindicated in pregnancy [see Boxed Warning and Contraindications (4.1)]. Lenalidomide capsules are thalidomide analogue and can cause serious birth defects or death to developing baby [see Warnings and Precautions (5.1) and Use in Specific Populations (8.1)].oAdvise females of reproductive potential that they must avoid pregnancy while taking lenalidomide capsules and for at least weeks after completing therapy.oInitiate lenalidomide capsule treatment in females of reproductive potential only following negative pregnancy test.oAdvise females of reproductive potential of the importance of monthly pregnancy tests and the need to use different forms of contraception including at least highly effective form, simultaneously during lenalidomide capsule therapy, during dose interruption and for weeks after she has completely finished taking lenalidomide capsules. Highly effective forms of contraception other than tubal ligation include IUD and hormonal (birth control pills, injections, patch or implants) and partners vasectomy. Additional effective contraceptive methods include latex or synthetic condom, diaphragm and cervical cap.oInstruct patient to immediately stop taking lenalidomide capsules and contact her healthcare provider if she becomes pregnant while taking this drug, if she misses her menstrual period, or experiences unusual menstrual bleeding, if she stops taking birth control, or if she thinks FOR ANY REASON that she may be pregnant.oAdvise patient that if her healthcare provider is not available, she should call the REMS Call Center at 1-888-423-5436 [see Warnings and Precautions (5.1) and Use in Specific Populations (8.3)].oAdvise males to always use latex or synthetic condom during any sexual contact with females of reproductive potential while taking lenalidomide capsules and for up to weeks after discontinuing lenalidomide capsules, even if they have undergone successful vasectomy.oAdvise male patients taking lenalidomide capsules that they must not donate sperm and for up to weeks after discontinuation of lenalidomide capsules [see Warnings and Precautions (5.1) and Use in Specific Populations (8.3)].oAll patients must be instructed to not donate blood while taking lenalidomide capsules, during dose interruptions and for weeks following discontinuation of lenalidomide capsules [see Warnings and Precautions (5.1)].Lenalidomide REMS Program: Because of the risk of embryo-fetal toxicity, lenalidomide capsules are only available through restricted program called the Lenalidomide REMS program [see Warnings and Precautions (5.2)].oPatients must sign Patient-Physician agreement form and comply with the requirements to receive lenalidomide capsules. In particular, females of reproductive potential must comply with the pregnancy testing, contraception requirements and participate in monthly telephone surveys. Males must comply with the contraception requirements [see Use in Specific Populations (8.3)].oLenalidomide capsules are available only from pharmacies that are certified in Lenalidomide REMS program. Provide patients with the telephone number and website for information on how to obtain the product.Pregnancy Exposure Registry: Inform females there is Pregnancy Exposure Registry that monitors pregnancy outcomes in females exposed to lenalidomide capsules during pregnancy and that they can contact the Pregnancy Exposure Registry by calling 1-888-423-5436 [see Use in Specific Populations (8.1)].Hematologic Toxicity: Inform patients that lenalidomide capsules are associated with significant neutropenia and thrombocytopenia [see Boxed Warning and Warnings and Precautions (5.3)].Venous and Arterial Thromboembolism: Inform patients of the risk of thrombosis including DVT, PE, MI, and stroke and to report immediately any signs and symptoms suggestive of these events for evaluation [see Boxed Warning and Warnings and Precautions (5.4)].Increased Mortality in Patients with CLL: Inform patients that lenalidomide capsules had increased mortality in patients with CLL and serious adverse cardiovascular reactions, including atrial fibrillation, myocardial infarction, and cardiac failure [see Warnings and Precautions (5.5)]. Second Primary Malignancies: Inform patients of the potential risk of developing second primary malignancies during treatment with lenalidomide capsules [see Warnings and Precautions (5.6)]. Hepatotoxicity: Inform patients of the risk of hepatotoxicity, including hepatic failure and death, and to report any signs and symptoms associated with this event to their healthcare provider for evaluation [see Warnings and Precautions (5.8)]. Severe Cutaneous Reactions: Inform patients of the potential risk for severe skin reactions such as SJS, TEN, and DRESS and report any signs and symptoms associated with these reactions to their healthcare provider for evaluation. Patients with prior history of Grade rash associated with thalidomide treatment should not receive lenalidomide capsules [see Warnings and Precautions (5.9)].Tumor Lysis Syndrome: Inform patients of the potential risk of tumor lysis syndrome and to report any signs and symptoms associated with this event to their healthcare provider for evaluation [see Warnings and Precautions (5.10)].Tumor Flare Reaction: Inform patients of the potential risk of tumor flare reaction and to report any signs and symptoms associated with this event to their healthcare provider for evaluation [see Warnings and Precautions (5.11)].Early Mortality in Patients with MCL: Inform patients with MCL of the potential for early death [see Warnings and Precautions (5.14)].Hypersensitivity: Inform patients of the potential for severe hypersensitivity reactions such as angioedema and anaphylaxis to lenalidomide capsules. Instruct patients to contact their healthcare provider right away for signs and symptoms of these reactions. Advise patients to seek emergency medical attention for signs or symptoms of severe hypersensitivity reactions [see Warnings and Precautions (5.15)].Dosing Instructions: Inform patients how to take lenalidomide capsules [see Dosage and Administration (2)]: oLenalidomide capsules should be taken once daily at about the same time each day.oLenalidomide capsules may be taken either with or without food. oThe capsules should not be opened, broken, or chewed. Lenalidomide capsules should be swallowed whole with water. oInstruct patients that if they miss dose of lenalidomide capsules, they may still take it up to 12 hours after the time they would normally take it. If more than 12 hours have elapsed, they should be instructed to skip the dose for that day. The next day, they should take lenalidomide capsules at the usual time. Warn patients to not take doses to make up for the one that they missed.. oAdvise females of reproductive potential that they must avoid pregnancy while taking lenalidomide capsules and for at least weeks after completing therapy.. oInitiate lenalidomide capsule treatment in females of reproductive potential only following negative pregnancy test.. oAdvise females of reproductive potential of the importance of monthly pregnancy tests and the need to use different forms of contraception including at least highly effective form, simultaneously during lenalidomide capsule therapy, during dose interruption and for weeks after she has completely finished taking lenalidomide capsules. Highly effective forms of contraception other than tubal ligation include IUD and hormonal (birth control pills, injections, patch or implants) and partners vasectomy. Additional effective contraceptive methods include latex or synthetic condom, diaphragm and cervical cap.. oInstruct patient to immediately stop taking lenalidomide capsules and contact her healthcare provider if she becomes pregnant while taking this drug, if she misses her menstrual period, or experiences unusual menstrual bleeding, if she stops taking birth control, or if she thinks FOR ANY REASON that she may be pregnant.. oAdvise patient that if her healthcare provider is not available, she should call the REMS Call Center at 1-888-423-5436 [see Warnings and Precautions (5.1) and Use in Specific Populations (8.3)].. oAdvise males to always use latex or synthetic condom during any sexual contact with females of reproductive potential while taking lenalidomide capsules and for up to weeks after discontinuing lenalidomide capsules, even if they have undergone successful vasectomy.. oAdvise male patients taking lenalidomide capsules that they must not donate sperm and for up to weeks after discontinuation of lenalidomide capsules [see Warnings and Precautions (5.1) and Use in Specific Populations (8.3)].. oAll patients must be instructed to not donate blood while taking lenalidomide capsules, during dose interruptions and for weeks following discontinuation of lenalidomide capsules [see Warnings and Precautions (5.1)].. oPatients must sign Patient-Physician agreement form and comply with the requirements to receive lenalidomide capsules. In particular, females of reproductive potential must comply with the pregnancy testing, contraception requirements and participate in monthly telephone surveys. Males must comply with the contraception requirements [see Use in Specific Populations (8.3)].. oLenalidomide capsules are available only from pharmacies that are certified in Lenalidomide REMS program. Provide patients with the telephone number and website for information on how to obtain the product.. oLenalidomide capsules should be taken once daily at about the same time each day.. oLenalidomide capsules may be taken either with or without food. oThe capsules should not be opened, broken, or chewed. Lenalidomide capsules should be swallowed whole with water. oInstruct patients that if they miss dose of lenalidomide capsules, they may still take it up to 12 hours after the time they would normally take it. If more than 12 hours have elapsed, they should be instructed to skip the dose for that day. The next day, they should take lenalidomide capsules at the usual time. Warn patients to not take doses to make up for the one that they missed.

LACTATION SECTION.

8.2 Lactation Risk Summary. There is no information regarding the presence of lenalidomide in human milk, the effects of lenalidomide on the breastfed child, or the effects of lenalidomide on milk production. Because many drugs are excreted in human milk and because of the potential for adverse reactions in breastfed children from lenalidomide capsules, advise women not to breastfeed during treatment with lenalidomide capsules.

MECHANISM OF ACTION SECTION.

12.1 Mechanism of Action Lenalidomide is an analogue of thalidomide with immunomodulatory, antiangiogenic, and antineoplastic properties. Cellular activities of lenalidomide are mediated through its target cereblon, component of cullin ring E3 ubiquitin ligase enzyme complex. In vitro, in the presence of drug, substrate proteins (including Aiolos, Ikaros, and CK1) are targeted for ubiquitination and subsequent degradation leading to direct cytotoxic and immunomodulatory effects. Lenalidomide inhibits proliferation and induces apoptosis of certain hematopoietic tumor cells including MM, mantle cell lymphoma, and del (5q) myelodysplastic syndromes, follicular lymphoma and marginal zone lymphoma in vitro. Lenalidomide causes delay in tumor growth in some in vivo nonclinical hematopoietic tumor models including MM. Immunomodulatory properties of lenalidomide include increased number and activation of cells and natural killer (NK) cells leading to direct and enhanced antibody-dependent cell-mediated cytotoxicity (ADCC) via increased secretion of interleukin-2 and interferon-gamma, increased numbers of NKT cells, and inhibition of pro-inflammatory cytokines (e.g., TNF- and IL-6) by monocytes. In MM cells, the combination of lenalidomide and dexamethasone synergizes the inhibition of cell proliferation and the induction of apoptosis. The combination of lenalidomide and rituximab increases ADCC and direct tumor apoptosis in follicular lymphoma cells and increases ADCC in marginal zone lymphoma cells compared to rituximab alone in vitro.

NONCLINICAL TOXICOLOGY SECTION.

13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenicity studies with lenalidomide have not been conducted.Lenalidomide was not mutagenic in the bacterial reverse mutation assay (Ames test) and did not induce chromosome aberrations in cultured human peripheral blood lymphocytes, or mutations at the thymidine kinase (tk) locus of mouse lymphoma L5178Y cells. Lenalidomide did not increase morphological transformation in Syrian Hamster Embryo assay or induce micronuclei in the polychromatic erythrocytes of the bone marrow of male rats.A fertility and early embryonic development study in rats, with administration of lenalidomide up to 500 mg/kg (approximately 200 times the human dose of 25 mg, based on body surface area) produced no parental toxicity and no adverse effects on fertility.

OVERDOSAGE SECTION.

10 OVERDOSAGE There is no specific experience in the management of lenalidomide capsule overdose in patients with MM, MDS, MCL, FL, or MZL. In dose-ranging studies in healthy subjects, some were exposed to up to 200 mg (administered 100 mg BID) and in single-dose studies, some subjects were exposed to up to 400 mg. Pruritus, urticaria, rash, and elevated liver transaminases were the primary reported AEs. In clinical trials, the dose-limiting toxicity was neutropenia and thrombocytopenia.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.

PRINCIPAL DISPLAY PANEL 5 mg NDC 0378-1936-28LenalidomideCapsules5 mgWARNING: POTENTIAL FORHUMAN BIRTH DEFECTSPHARMACIST: Dispense the accompanying Medication Guide to each patient.Rx only 28 CapsulesEach capsule contains:Lenalidomide mgUsual Dosage: See prescribinginformation for dosing and administration. Keep this and all medicationout of the reach of children.Store at 20 to 25C (68 to 77F).[See USP Controlled RoomTemperature.]Manufactured for: Mylan Pharmaceuticals Inc. Morgantown, WV 26505 U.S.A.Made in IndiaMylan.comRMXI1936BD1Dispense in tight, light-resistant container asdefined in the USP using child-resistant closure.Keep container tightly closed.Code No.: MP/DRUGS/25/1/2014. Lenalidomide Capsules mg Bottle Label.

PEDIATRIC USE SECTION.

8.4 Pediatric Use Safety and effectiveness have not been established in pediatric patients.

PHARMACODYNAMICS SECTION.

12.2 Pharmacodynamics Cardiac Electrophysiology. The effect of lenalidomide on the QTc interval was evaluated in 60 healthy male subjects in thorough QT study. At dose two times the maximum recommended dose, lenalidomide did not prolong the QTc interval. The largest upper bound of the two-sided 90% CI for the mean differences between lenalidomide and placebo was below 10 ms.

PHARMACOKINETICS SECTION.

12.3 Pharmacokinetics Absorption. Following single and multiple doses of lenalidomide capsules in patients with MM or MDS, the maximum plasma concentrations occurred between 0.5 and hours post-dose. The single and multiple dose pharmacokinetic disposition of lenalidomide is linear with AUC and Cmax values increasing proportionally with dose. Multiple doses of lenalidomide capsules at the recommended dosage does not result in drug accumulation.Administration of single 25 mg dose of lenalidomide capsules with high-fat meal in healthy subjects reduces the extent of absorption, with an approximate 20% decrease in AUC and 50% decrease in Cmax. In the trials where the efficacy and safety were established for lenalidomide capsules, the drug was administered without regard to food intake. Lenalidomide capsules can be administered with or without food.The oral absorption rate of lenalidomide in patients with MCL is similar to that observed in patients with MM or MDS.. Distribution. In vitro [14C]-lenalidomide binding to plasma proteins is approximately 30%.Lenalidomide is present in semen at hours (1379 ng/ejaculate) and 24 hours (35 ng/ejaculate) after the administration of lenalidomide capsules 25 mg daily.. Elimination. The mean half-life of lenalidomide is hours in healthy subjects and to hours in patients with MM, MDS or MCL.. Metabolism. Lenalidomide undergoes limited metabolism. Unchanged lenalidomide is the predominant circulating component in humans. Two identified metabolites are 5-hydroxy-lenalidomide and N-acetyl-lenalidomide; each constitutes less than 5% of parent levels in circulation.. Excretion. Elimination is primarily renal. Following single oral administration of [14C]-lenalidomide 25 mg to healthy subjects, approximately 90% and 4% of the radioactive dose was eliminated within ten days in urine and feces, respectively. Approximately 82% of the radioactive dose was excreted as lenalidomide in the urine within 24 hours. Hydroxy-lenalidomide and N-acetyl-lenalidomide represented 4.6% and 1.8% of the excreted dose, respectively. The renal clearance of lenalidomide exceeds the glomerular filtration rate.. Specific Populations. Renal Impairment Eight subjects with mild renal impairment (creatinine clearance (CLcr) 50 to 79 mL/min calculated using Cockcroft-Gault), subjects with moderate renal impairment (CLcr 30 to 49 mL/min), subjects with severe renal impairment (CLcr 30 mL/min), and patients with end stage renal disease (ESRD) requiring dialysis were administered single 25 mg dose of lenalidomide capsules. Three healthy subjects of similar age with normal renal function (CLcr 80 mL/min) were also administered single 25 mg dose of lenalidomide capsules. As CLcr decreased, half-life increased and drug clearance decreased linearly. Patients with moderate and severe impairment had 3-fold increase in half-life and 66% to 75% decrease in drug clearance compared to healthy subjects. Patients on hemodialysis (n 6) had an approximate 4.5-fold increase in half-life and an 80% decrease in drug clearance compared to healthy subjects. Approximately 30% of the drug in body was removed during 4-hour hemodialysis session.Adjust the starting dose of lenalidomide capsules in patients with renal impairment based on the CLcr value [see Dosage and Administration (2.6) ].. Hepatic Impairment Mild hepatic impairment (defined as total bilirubin 1 to 1.5 times upper limit of normal (ULN) or any aspartate transaminase greater than ULN) did not influence the disposition of lenalidomide. No pharmacokinetic data is available for patients with moderate to severe hepatic impairment.. Other Intrinsic Factors Age (39 to 85 years), body weight (33 to 135 kg), sex, race, and type of hematological malignancies (MM, MDS or MCL) did not have clinically relevant effect on lenalidomide clearance in adult patients.. Drug Interactions. Co-administration of single dose or multiple doses of dexamethasone (40 mg) had no clinically relevant effect on the multiple dose pharmacokinetics of lenalidomide capsules (25 mg).Co-administration of lenalidomide capsules (25 mg) after multiple doses of P-gp inhibitor such as quinidine (600 mg twice daily) did not significantly increase the Cmax or AUC of lenalidomide.Co-administration of the P-gp inhibitor and substrate temsirolimus (25 mg) with lenalidomide capsules (25 mg) did not significantly alter the pharmacokinetics of lenalidomide, temsirolimus, or sirolimus (metabolite of temsirolimus).In vitro studies demonstrated that lenalidomide capsules are substrate of P-glycoprotein (P-gp). Lenalidomide capsules are not substrate of human breast cancer resistance protein (BCRP), multidrug resistance protein (MRP) transporters MRP1, MRP2, or MRP3, organic anion transporters (OAT) OAT1 and OAT3, organic anion transporting polypeptide 1B1 (OATP1B1), organic cation transporters (OCT) OCT1 and OCT2, multidrug and toxin extrusion protein (MATE) MATE1, and organic cation transporters novel (OCTN) OCTN1 and OCTN2. Lenalidomide is not an inhibitor of P-gp, bile salt export pump (BSEP), BCRP, MRP2, OAT1, OAT3, OATP1B1, OATP1B3, or OCT2. Lenalidomide does not inhibit or induce CYP450 isoenzymes. Also, lenalidomide does not inhibit bilirubin glucuronidation formation in human liver microsomes with UGT1A1 genotyped as UGT1A11/1, UGT1A11/28, and UGT1A128/28.

PREGNANCY SECTION.

8.1 Pregnancy Pregnancy Exposure Registry. There is pregnancy exposure registry that monitors pregnancy outcomes in females exposed to lenalidomide capsules during pregnancy as well as female partners of male patients who are exposed to lenalidomide capsules. This registry is also used to understand the root cause for the pregnancy. Report any suspected fetal exposure to lenalidomide to the FDA via the MedWatch program at 1-800-FDA-1088 and also to REMS Call Center at 1-888-423-5436.. Risk Summary. Based on the mechanism of action [see Clinical Pharmacology (12.1)] and findings from animal studies [see Data], lenalidomide capsules can cause embryo-fetal harm when administered to pregnant female and are contraindicated during pregnancy [see Boxed Warning, Contraindications (4.1), and Use in Specific Populations (5.1)].Lenalidomide capsules are thalidomide analogue. Thalidomide is human teratogen, inducing high frequency of severe and life-threatening birth defects such as amelia (absence of limbs), phocomelia (short limbs), hypoplasticity of the bones, absence of bones, external ear abnormalities (including anotia, micropinna, small or absent external auditory canals), facial palsy, eye abnormalities (anophthalmos, microphthalmos), and congenital heart defects. Alimentary tract, urinary tract, and genital malformations have also been documented and mortality at or shortly after birth has been reported in about 40% of infants.Lenalidomide caused thalidomide-type limb defects in monkey offspring. Lenalidomide crossed the placenta after administration to pregnant rabbits and pregnant rats [see Data]. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential risk to fetus.If pregnancy does occur during treatment, immediately discontinue the drug. Under these conditions, refer patient to an obstetrician/gynecologist experienced in reproductive toxicity for further evaluation and counseling. Report any suspected fetal exposure to lenalidomide to the FDA via the MedWatch program at 1-800-FDA-1088 and also to REMS Call Center at 1-888-423-5436.The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have background risk of birth defect, loss, or other adverse outcomes. The estimated background risk in the U.S. general population of major birth defects is 2%-4% and of miscarriage is 15%-20% of clinically recognized pregnancies.. Data. Animal Data In an embryo-fetal developmental toxicity study in monkeys, teratogenicity, including thalidomide-like limb defects, occurred in offspring when pregnant monkeys received oral lenalidomide during organogenesis. Exposure (AUC) in monkeys at the lowest dose was 0.17 times the human exposure at the maximum recommended human dose (MRHD) of 25 mg. Similar studies in pregnant rabbits and rats at 20 times and 200 times the MRHD respectively, produced embryo lethality in rabbits and no adverse reproductive effects in rats.In pre- and post-natal development study in rats, animals received lenalidomide from organogenesis through lactation. The study revealed few adverse effects on the offspring of female rats treated with lenalidomide at doses up to 500 mg/kg (approximately 200 times the human dose of 25 mg based on body surface area). The male offspring exhibited slightly delayed sexual maturation and the female offspring had slightly lower body weight gains during gestation when bred to male offspring. As with thalidomide, the rat model may not adequately address the full spectrum of potential human embryo-fetal developmental effects for lenalidomide.Following daily oral administration of lenalidomide from Gestation Day through Gestation Day 20 in pregnant rabbits, fetal plasma lenalidomide concentrations were approximately 20-40% of the maternal Cmax. Following single oral dose to pregnant rats, lenalidomide was detected in fetal plasma and tissues; concentrations of radioactivity in fetal tissues were generally lower than those in maternal tissues. These data indicated that lenalidomide crossed the placenta.

RECENT MAJOR CHANGES SECTION.

Warnings and Precautions (5.1, 5.2) 8/2021Warnings and Precautions (5.1, 5.11) 5/2022.

REFERENCES SECTION.

15 REFERENCES 1.OSHA Hazardous Drugs. OSHA [Accessed on 29 January 2013, from http://www.osha.gov/SLTC/hazardousdrugs/index.html]. 1.OSHA Hazardous Drugs. OSHA [Accessed on 29 January 2013, from http://www.osha.gov/SLTC/hazardousdrugs/index.html].

RENAL IMPAIRMENT SUBSECTION.

Renal Impairment Eight subjects with mild renal impairment (creatinine clearance (CLcr) 50 to 79 mL/min calculated using Cockcroft-Gault), subjects with moderate renal impairment (CLcr 30 to 49 mL/min), subjects with severe renal impairment (CLcr 30 mL/min), and patients with end stage renal disease (ESRD) requiring dialysis were administered single 25 mg dose of lenalidomide capsules. Three healthy subjects of similar age with normal renal function (CLcr 80 mL/min) were also administered single 25 mg dose of lenalidomide capsules. As CLcr decreased, half-life increased and drug clearance decreased linearly. Patients with moderate and severe impairment had 3-fold increase in half-life and 66% to 75% decrease in drug clearance compared to healthy subjects. Patients on hemodialysis (n 6) had an approximate 4.5-fold increase in half-life and an 80% decrease in drug clearance compared to healthy subjects. Approximately 30% of the drug in body was removed during 4-hour hemodialysis session.Adjust the starting dose of lenalidomide capsules in patients with renal impairment based on the CLcr value [see Dosage and Administration (2.6) ].

RISKS.

Risk Summary. Based on the mechanism of action [see Clinical Pharmacology (12.1)] and findings from animal studies [see Data], lenalidomide capsules can cause embryo-fetal harm when administered to pregnant female and are contraindicated during pregnancy [see Boxed Warning, Contraindications (4.1), and Use in Specific Populations (5.1)].Lenalidomide capsules are thalidomide analogue. Thalidomide is human teratogen, inducing high frequency of severe and life-threatening birth defects such as amelia (absence of limbs), phocomelia (short limbs), hypoplasticity of the bones, absence of bones, external ear abnormalities (including anotia, micropinna, small or absent external auditory canals), facial palsy, eye abnormalities (anophthalmos, microphthalmos), and congenital heart defects. Alimentary tract, urinary tract, and genital malformations have also been documented and mortality at or shortly after birth has been reported in about 40% of infants.Lenalidomide caused thalidomide-type limb defects in monkey offspring. Lenalidomide crossed the placenta after administration to pregnant rabbits and pregnant rats [see Data]. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential risk to fetus.If pregnancy does occur during treatment, immediately discontinue the drug. Under these conditions, refer patient to an obstetrician/gynecologist experienced in reproductive toxicity for further evaluation and counseling. Report any suspected fetal exposure to lenalidomide to the FDA via the MedWatch program at 1-800-FDA-1088 and also to REMS Call Center at 1-888-423-5436.The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have background risk of birth defect, loss, or other adverse outcomes. The estimated background risk in the U.S. general population of major birth defects is 2%-4% and of miscarriage is 15%-20% of clinically recognized pregnancies.

SPL UNCLASSIFIED SECTION.

1.1Multiple Myeloma Lenalidomide capsules in combination with dexamethasone are indicated for the treatment of adult patients with multiple myeloma (MM).Lenalidomide capsules are indicated as maintenance therapy in adult patients with MM following autologous hematopoietic stem cell transplantation (auto-HSCT).

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS oLactation: Advise not to breastfeed (8.2).. oLactation: Advise not to breastfeed (8.2).. 8.1 Pregnancy Pregnancy Exposure Registry. There is pregnancy exposure registry that monitors pregnancy outcomes in females exposed to lenalidomide capsules during pregnancy as well as female partners of male patients who are exposed to lenalidomide capsules. This registry is also used to understand the root cause for the pregnancy. Report any suspected fetal exposure to lenalidomide to the FDA via the MedWatch program at 1-800-FDA-1088 and also to REMS Call Center at 1-888-423-5436.. Risk Summary. Based on the mechanism of action [see Clinical Pharmacology (12.1)] and findings from animal studies [see Data], lenalidomide capsules can cause embryo-fetal harm when administered to pregnant female and are contraindicated during pregnancy [see Boxed Warning, Contraindications (4.1), and Use in Specific Populations (5.1)].Lenalidomide capsules are thalidomide analogue. Thalidomide is human teratogen, inducing high frequency of severe and life-threatening birth defects such as amelia (absence of limbs), phocomelia (short limbs), hypoplasticity of the bones, absence of bones, external ear abnormalities (including anotia, micropinna, small or absent external auditory canals), facial palsy, eye abnormalities (anophthalmos, microphthalmos), and congenital heart defects. Alimentary tract, urinary tract, and genital malformations have also been documented and mortality at or shortly after birth has been reported in about 40% of infants.Lenalidomide caused thalidomide-type limb defects in monkey offspring. Lenalidomide crossed the placenta after administration to pregnant rabbits and pregnant rats [see Data]. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential risk to fetus.If pregnancy does occur during treatment, immediately discontinue the drug. Under these conditions, refer patient to an obstetrician/gynecologist experienced in reproductive toxicity for further evaluation and counseling. Report any suspected fetal exposure to lenalidomide to the FDA via the MedWatch program at 1-800-FDA-1088 and also to REMS Call Center at 1-888-423-5436.The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have background risk of birth defect, loss, or other adverse outcomes. The estimated background risk in the U.S. general population of major birth defects is 2%-4% and of miscarriage is 15%-20% of clinically recognized pregnancies.. Data. Animal Data In an embryo-fetal developmental toxicity study in monkeys, teratogenicity, including thalidomide-like limb defects, occurred in offspring when pregnant monkeys received oral lenalidomide during organogenesis. Exposure (AUC) in monkeys at the lowest dose was 0.17 times the human exposure at the maximum recommended human dose (MRHD) of 25 mg. Similar studies in pregnant rabbits and rats at 20 times and 200 times the MRHD respectively, produced embryo lethality in rabbits and no adverse reproductive effects in rats.In pre- and post-natal development study in rats, animals received lenalidomide from organogenesis through lactation. The study revealed few adverse effects on the offspring of female rats treated with lenalidomide at doses up to 500 mg/kg (approximately 200 times the human dose of 25 mg based on body surface area). The male offspring exhibited slightly delayed sexual maturation and the female offspring had slightly lower body weight gains during gestation when bred to male offspring. As with thalidomide, the rat model may not adequately address the full spectrum of potential human embryo-fetal developmental effects for lenalidomide.Following daily oral administration of lenalidomide from Gestation Day through Gestation Day 20 in pregnant rabbits, fetal plasma lenalidomide concentrations were approximately 20-40% of the maternal Cmax. Following single oral dose to pregnant rats, lenalidomide was detected in fetal plasma and tissues; concentrations of radioactivity in fetal tissues were generally lower than those in maternal tissues. These data indicated that lenalidomide crossed the placenta. 8.2 Lactation Risk Summary. There is no information regarding the presence of lenalidomide in human milk, the effects of lenalidomide on the breastfed child, or the effects of lenalidomide on milk production. Because many drugs are excreted in human milk and because of the potential for adverse reactions in breastfed children from lenalidomide capsules, advise women not to breastfeed during treatment with lenalidomide capsules. 8.3 Females and Males of Reproductive Potential Pregnancy Testing. Lenalidomide capsules can cause fetal harm when administered during pregnancy [see Use in Specific Populations (8.1)]. Verify the pregnancy status of females of reproductive potential prior to initiating lenalidomide capsule therapy and during therapy. Advise females of reproductive potential that they must avoid pregnancy weeks before therapy, while taking lenalidomide capsules, during dose interruptions and for at least weeks after completing therapy.Females of reproductive potential must have negative pregnancy tests before initiating lenalidomide capsules. The first test should be performed within 10-14 days, and the second test within 24 hours prior to prescribing lenalidomide capsules. Once treatment has started and during dose interruptions, pregnancy testing for females of reproductive potential should occur weekly during the first weeks of use, then pregnancy testing should be repeated every weeks in females with regular menstrual cycles. If menstrual cycles are irregular, the pregnancy testing should occur every weeks. Pregnancy testing and counseling should be performed if patient misses her period or if there is any abnormality in her menstrual bleeding. Lenalidomide capsule treatment must be discontinued during this evaluation.. Contraception. Females Females of reproductive potential must commit either to abstain continuously from heterosexual sexual intercourse or to use methods of reliable birth control simultaneously: one highly effective form of contraception tubal ligation, IUD, hormonal (birth control pills, injections, hormonal patches, vaginal rings, or implants), or partners vasectomy, and additional effective contraceptive method male latex or synthetic condom, diaphragm, or cervical cap. Contraception must begin weeks prior to initiating treatment with lenalidomide capsules, during therapy, during dose interruptions, and continuing for weeks following discontinuation of lenalidomide capsule therapy. Reliable contraception is indicated even where there has been history of infertility, unless due to hysterectomy. Females of reproductive potential should be referred to qualified provider of contraceptive methods, if needed.. Males Lenalidomide is present in the semen of males who take lenalidomide capsules. Therefore, males must always use latex or synthetic condom during any sexual contact with females of reproductive potential while taking lenalidomide capsules and for up to weeks after discontinuing lenalidomide capsules, even if they have undergone successful vasectomy. Male patients taking lenalidomide capsules must not donate sperm and for up to weeks after discontinuing lenalidomide capsules. 8.4 Pediatric Use Safety and effectiveness have not been established in pediatric patients.. 8.5 Geriatric Use MM In Combination. Overall, of the 1613 patients in the NDMM study who received study treatment, 94% (1521/1613) were 65 years of age or older, while 35% (561/1613) were over 75 years of age. The percentage of patients over age 75 was similar between study arms (Rd Continuous: 33%; Rd18: 34%; MPT: 33%). Overall, across all treatment arms, the frequency in most of the adverse reaction categories (e.g., all adverse reactions, grade 3/4 adverse reactions, serious adverse reactions) was higher in older (> 75 years of age) than in younger (<= 75 years of age) subjects. Grade or adverse reactions in the General Disorders and Administration Site Conditions body system were consistently reported at higher frequency (with difference of at least 5%) in older subjects than in younger subjects across all treatment arms. Grade or adverse reactions in the Infections and Infestations, Cardiac Disorders (including cardiac failure and congestive cardiac failure), Skin and Subcutaneous Tissue Disorders, and Renal and Urinary Disorders (including renal failure) body systems were also reported slightly, but consistently, more frequently (< 5% difference), in older subjects than in younger subjects across all treatment arms. For other body systems (e.g., Blood and Lymphatic System Disorders, Infections and Infestations, Cardiac Disorders, Vascular Disorders), there was less consistent trend for increased frequency of grade 3/4 adverse reactions in older vs younger subjects across all treatment arms. Serious adverse reactions were generally reported at higher frequency in the older subjects than in the younger subjects across all treatment arms.. MM Maintenance Therapy. Overall, 10% (106/1018) of patients were 65 years of age or older, while no patients were over 75 years of age. Grade or adverse reactions were higher in the lenalidomide capsules arm (more than 5% higher) in the patients 65 years of age or older versus younger patients. The frequency of Grade or adverse reactions in the Blood and Lymphatic System Disorders were higher in the lenalidomide capsules arm (more than 5% higher) in the patients 65 years of age or older versus younger patients. There were not sufficient number of patients 65 years of age or older in lenalidomide capsule maintenance studies who experienced either serious adverse reaction, or discontinued therapy due to an adverse reaction to determine whether elderly patients respond relative to safety differently from younger patients. MM After At Least One Prior Therapy. Of the 703 MM patients who received study treatment in Studies and 2, 45% were age 65 or over while 12% of patients were age 75 and over. The percentage of patients age 65 or over was not significantly different between the lenalidomide capsules/dexamethasone and placebo/dexamethasone groups. Of the 353 patients who received lenalidomide capsules/dexamethasone, 46% were age 65 and over. In both studies, patients 65 years of age were more likely than patients <= 65 years of age to experience DVT, pulmonary embolism, atrial fibrillation, and renal failure following use of lenalidomide capsules. No differences in efficacy were observed between patients over 65 years of age and younger patients.Of the 148 patients with del 5q MDS enrolled in the major study, 38% were age 65 and over, while 33% were age 75 and over. Although the overall frequency of adverse reactions (100%) was the same in patients over 65 years of age as in younger patients, the frequency of serious adverse reactions was higher in patients over 65 years of age than in younger patients (54% vs 33%). greater proportion of patients over 65 years of age discontinued from the clinical studies because of adverse reactions than the proportion of younger patients (27% vs 16%). No differences in efficacy were observed between patients over 65 years of age and younger patients.Of the 134 patients with MCL enrolled in the MCL trial, 63% were age 65 and over, while 22% of patients were age 75 and over. The overall frequency of adverse reactions was similar in patients over 65 years of age and in younger patients (98% vs 100%). The overall incidence of grade and adverse reactions was also similar in these patient groups (79% vs 78%, respectively). The frequency of serious adverse reactions was higher in patients over 65 years of age than in younger patients (55% vs 41%). No differences in efficacy were observed between patients over 65 years of age and younger patients.. FL or MZL in Combination. Overall, 48% (282/590) of patients were 65 years of age or older, while 14% (82/590) of patients were over 75 years of age. The overall frequency of adverse reactions was similar in patients 65 years of age or older and younger patients for both studies pooled (98%). Grade or adverse reactions were higher in the lenalidomide capsules arm (more than 5% higher) in the patients 65 years of age or older versus younger patients (71% versus 59%). The frequency of Grade or adverse reactions were higher in the lenalidomide capsules arm (more than 5% higher) in the patients 65 years of age or older versus younger patients in the Blood and Lymphatic System Disorders (47% versus 40%) and Infections and Infestations (16% versus 11%). Serious adverse reactions were higher in the lenalidomide capsules arm (more than 5% higher) in the patients 65 years of age or older versus younger patients (37% versus 18%). The frequency of serious adverse reactions were higher in the lenalidomide capsules arm (more than 5% higher) in the patients 65 years of age or older versus younger patients in Infections and Infestations (15% versus 6%).Since elderly patients are more likely to have decreased renal function, care should be taken in dose selection. Monitor renal function.. 8.6Renal Impairment Adjust the starting dose of lenalidomide capsules based on the creatinine clearance value and for patients on dialysis [see Dosage and Administration (2.6) ].

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS oIncreased Mortality: Serious and fatal cardiac adverse reactions occurred in patients with CLL treated with lenalidomide capsules (5.5).oSecond Primary Malignancies (SPM): Higher incidences of SPM were observed in controlled trials of patients with MM receiving lenalidomide capsules (5.6).oIncreased Mortality: Observed in patients with MM when pembrolizumab was added to dexamethasone and thalidomide analogue (5.7).oHepatotoxicity: Hepatic failure including fatalities; monitor liver function. Stop lenalidomide capsules and evaluate if hepatotoxicity is suspected (5.8).oSevere Cutaneous Reactions: Discontinue lenalidomide capsules for severe reactions (5.9).oTumor Lysis Syndrome (TLS) Including Fatalities: Monitor patients at risk of TLS (i.e., those with high tumor burden) and take appropriate precautions (5.10).oTumor Flare Reaction: Serious tumor flare reactions, including fatal reactions, have occurred during investigational use of lenalidomide capsules for chronic lymphocytic leukemia and lymphoma (5.11).oImpaired Stem Cell Mobilization: decrease in the number of CD34+ cells collected after treatment (> cycles) with lenalidomide capsules has been reported. Consider early referral to transplant center (5.12).oEarly mortality in MCL: Higher rate of early deaths have occurred in patients with MCL (5.14).oHypersensitivity: Monitor patients for potential hypersensitivity. Discontinue lenalidomide capsules for angioedema and anaphylaxis (5.15).. oIncreased Mortality: Serious and fatal cardiac adverse reactions occurred in patients with CLL treated with lenalidomide capsules (5.5).. oSecond Primary Malignancies (SPM): Higher incidences of SPM were observed in controlled trials of patients with MM receiving lenalidomide capsules (5.6).. oIncreased Mortality: Observed in patients with MM when pembrolizumab was added to dexamethasone and thalidomide analogue (5.7).. oHepatotoxicity: Hepatic failure including fatalities; monitor liver function. Stop lenalidomide capsules and evaluate if hepatotoxicity is suspected (5.8).. oSevere Cutaneous Reactions: Discontinue lenalidomide capsules for severe reactions (5.9).. oTumor Lysis Syndrome (TLS) Including Fatalities: Monitor patients at risk of TLS (i.e., those with high tumor burden) and take appropriate precautions (5.10).. oTumor Flare Reaction: Serious tumor flare reactions, including fatal reactions, have occurred during investigational use of lenalidomide capsules for chronic lymphocytic leukemia and lymphoma (5.11).. oImpaired Stem Cell Mobilization: decrease in the number of CD34+ cells collected after treatment (> cycles) with lenalidomide capsules has been reported. Consider early referral to transplant center (5.12).. oEarly mortality in MCL: Higher rate of early deaths have occurred in patients with MCL (5.14).. oHypersensitivity: Monitor patients for potential hypersensitivity. Discontinue lenalidomide capsules for angioedema and anaphylaxis (5.15).. 5.1Embryo-Fetal Toxicity Lenalidomide capsules are thalidomide analogue and are contraindicated for use during pregnancy. Thalidomide is known human teratogen that causes life-threatening human birth defects or embryo-fetal death [see Use in Specific Populations (8.1)]. An embryo-fetal development study in monkeys indicates that lenalidomide produced malformations in the offspring of female monkeys who received the drug during pregnancy, similar to birth defects observed in humans following exposure to thalidomide during pregnancy.Lenalidomide capsules are only available through the Lenalidomide REMS program [see Warnings and Precautions (5.2)] .. Females of Reproductive Potential. Females of reproductive potential must avoid pregnancy for at least weeks before beginning lenalidomide capsule therapy, during therapy, during dose interruptions and for at least weeks after completing therapy.Females must commit either to abstain continuously from heterosexual sexual intercourse or to use two methods of reliable birth control, beginning weeks prior to initiating treatment with lenalidomide capsules, during therapy, during dose interruptions and continuing for weeks following discontinuation of lenalidomide capsule therapy.Two negative pregnancy tests must be obtained prior to initiating therapy. The first test should be performed within 10-14 days and the second test within 24 hours prior to prescribing lenalidomide capsule therapy and then weekly during the first month, then monthly thereafter in females with regular menstrual cycles or every weeks in females with irregular menstrual cycles [see Use in Specific Populations (8.3)].. Males. Lenalidomide is present in the semen of patients receiving the drug. Therefore, males must always use latex or synthetic condom during any sexual contact with females of reproductive potential while taking lenalidomide capsules and for up to weeks after discontinuing lenalidomide capsules, even if they have undergone successful vasectomy. Male patients taking lenalidomide capsules must not donate sperm and for up to weeks after discontinuing lenalidomide capsules [see Use in Specific Populations (8.3)].. Blood Donation. Patients must not donate blood during treatment with lenalidomide capsules and for weeks following discontinuation of the drug because the blood might be given to pregnant female patient whose fetus must not be exposed to lenalidomide.. 5.2Lenalidomide REMS Program Because of the embryo-fetal risk [see Warnings and Precautions (5.1)], lenalidomide capsules are available only through restricted program under Risk Evaluation and Mitigation Strategy (REMS), the Lenalidomide REMS program.Required components of the Lenalidomide REMS program include the following:oPrescribers must be certified with the Lenalidomide REMS program by enrolling and complying with the REMS requirements.oPatients must sign Patient-Physician agreement form and comply with the REMS requirements. In particular, female patients of reproductive potential who are not pregnant must comply with the pregnancy testing and contraception requirements [see Use in Specific Populations (8.3)] and males must comply with contraception requirements [see Use in Specific Populations (8.3)]. oPharmacies must be certified with the Lenalidomide REMS program, must only dispense to patients who are authorized to receive lenalidomide capsules and comply with REMS requirements.Further information about the Lenalidomide REMS program is available at www.lenalidomiderems.com or by telephone at 1-888-423-5436. oPrescribers must be certified with the Lenalidomide REMS program by enrolling and complying with the REMS requirements.. oPatients must sign Patient-Physician agreement form and comply with the REMS requirements. In particular, female patients of reproductive potential who are not pregnant must comply with the pregnancy testing and contraception requirements [see Use in Specific Populations (8.3)] and males must comply with contraception requirements [see Use in Specific Populations (8.3)]. oPharmacies must be certified with the Lenalidomide REMS program, must only dispense to patients who are authorized to receive lenalidomide capsules and comply with REMS requirements.. 5.3Hematologic Toxicity Lenalidomide capsules can cause significant neutropenia and thrombocytopenia. Monitor patients with neutropenia for signs of infection. Advise patients to observe for bleeding or bruising, especially with use of concomitant medication that may increase risk of bleeding. Patients taking lenalidomide capsules should have their complete blood counts assessed periodically as described below [see Dosage and Administration (2.1, 2.2, 2.3)].Monitor complete blood counts (CBC) in patients taking lenalidomide capsules in combination with dexamethasone or as lenalidomide capsule maintenance therapy for MM every days (weekly) for the first cycles, on Days and 15 of Cycle 3, and every 28 days (4 weeks) thereafter. dose interruption and/or dose reduction may be required [see Dosage and Administration (2.1)]. In the MM maintenance therapy trials, Grade or neutropenia was reported in up to 59% of lenalidomide capsule-treated patients and Grade or thrombocytopenia in up to 38% of lenalidomide capsule-treated patients [see Adverse Reactions (6.1)].Monitor complete blood counts (CBC) in patients taking lenalidomide capsules for MDS weekly for the first weeks and at least monthly thereafter. Grade or hematologic toxicity was seen in 80% of patients enrolled in the MDS study. In the 48% of patients who developed Grade or neutropenia, the median time to onset was 42 days (range, 14-411 days), and the median time to documented recovery was 17 days (range, 2-170 days). In the 54% of patients who developed Grade or thrombocytopenia, the median time to onset was 28 days (range, 8-290 days), and the median time to documented recovery was 22 days (range, 5-224 days) [see Boxed Warning and Dosage and Administration (2.2)].Monitor complete blood counts (CBC) in patients taking lenalidomide capsules for MCL weekly for the first cycle (28 days), every weeks during cycles 2-4, and then monthly thereafter. Patients may require dose interruption and/or dose reduction. In the MCL trial, Grade or neutropenia was reported in 43% of the patients. Grade or thrombocytopenia was reported in 28% of the patients.Monitor complete blood counts (CBC) in patients taking lenalidomide capsules for FL or MZL weekly for the first weeks of Cycle (28 days), every weeks during Cycles 2-4, and then monthly thereafter. Patients may require dose interruption and/or dose reduction. In the AUGMENT and MAGNIFY trials, Grade or neutropenia was reported in 50% and 33%, respectively, of patients in the lenalidomide capsules/rituximab arm. Grade or thrombocytopenia was reported in 2% and 8%, respectively, of patients in the lenalidomide capsules/rituximab arm [see Adverse Reactions (6.1)].. 5.4Venous and Arterial Thromboembolism Venous thromboembolic events (VTE [DVT and PE]) and arterial thromboembolic events (ATE, myocardial infarction and stroke) are increased in patients treated with lenalidomide capsules.A significantly increased risk of DVT (7.4%) and of PE (3.7%) occurred in patients with MM after at least one prior therapy who were treated with lenalidomide capsules and dexamethasone therapy compared to patients treated in the placebo and dexamethasone group (3.1% and 0.9%) in clinical trials with varying use of anticoagulant therapies. In the newly diagnosed multiple myeloma (NDMM) study in which nearly all patients received antithrombotic prophylaxis, DVT was reported as serious adverse reaction (3.6%, 2.0%, and 1.7%) in the Rd Continuous, Rd18, and MPT Arms, respectively. The frequency of serious adverse reactions of PE was similar between the Rd Continuous, Rd18, and MPT Arms (3.8%, 2.8%, and 3.7%, respectively) [see Boxed Warning and Adverse Reactions (6.1)].Myocardial infarction (1.7%) and stroke (CVA) (2.3%) are increased in patients with MM after at least one prior therapy who were treated with lenalidomide capsules and dexamethasone therapy compared to patients treated with placebo and dexamethasone (0.6%, and 0.9%) in clinical trials. In the NDMM study, myocardial infarction (including acute) was reported as serious adverse reaction (2.3%, 0.6%, and 1.1%) in the Rd Continuous, Rd18, and MPT Arms, respectively. The frequency of serious adverse reactions of CVA was similar between the Rd Continuous, Rd18, and MPT Arms (0.8%, 0.6 %, and 0.6%, respectively) [see Adverse Reactions (6.1)].Patients with known risk factors, including prior thrombosis, may be at greater risk and actions should be taken to try to minimize all modifiable factors (e.g., hyperlipidemia, hypertension, smoking).In controlled clinical trials that did not use concomitant thromboprophylaxis, 21.5% overall thrombotic events (Standardized MedDRA Query Embolic and Thrombotic events) occurred in patients with refractory and relapsed MM who were treated with lenalidomide capsules and dexamethasone compared to 8.3% thrombosis in patients treated with placebo and dexamethasone. The median time to first thrombosis event was 2.8 months. In the NDMM study in which nearly all patients received antithrombotic prophylaxis, the overall frequency of thrombotic events was 17.4% in patients in the combined Rd Continuous and Rd18 Arms, and was 11.6% in the MPT Arm. The median time to first thrombosis event was 4.3 months in the combined Rd Continuous and Rd18 Arms.In the AUGMENT trial, the incidence of VTE (including DVT and PE) in FL or MZL patients was 3.4% in the lenalidomide capsules/rituximab arm [see Adverse Reactions (6.1)]. In the AUGMENT trial, the incidence of ATE (including MI) in FL or MZL patients was 0.6% in the lenalidomide capsules/rituximab arm [see Adverse Reactions (6.1)].Thromboprophylaxis is recommended. The regimen of thromboprophylaxis should be based on an assessment of the patients underlying risks. Instruct patients to report immediately any signs and symptoms suggestive of thrombotic events. ESAs and estrogens may further increase the risk of thrombosis and their use should be based on benefit-risk decision in patients receiving lenalidomide capsules [see Drug Interactions (7.2)].. 5.5Increased Mortality in Patients with CLL In prospective randomized (1:1) clinical trial in the first line treatment of patients with chronic lymphocytic leukemia, single agent lenalidomide capsule therapy increased the risk of death as compared to single agent chlorambucil. In an interim analysis, there were 34 deaths among 210 patients on the lenalidomide capsules treatment arm compared to 18 deaths among 211 patients in the chlorambucil treatment arm, and hazard ratio for overall survival was 1.92 [95% CI: 1.08-3.41], consistent with 92% increase in the risk of death. The trial was halted for safety in July 2013.Serious adverse cardiovascular reactions, including atrial fibrillation, myocardial infarction, and cardiac failure occurred more frequently in the lenalidomide capsules treatment arm. Lenalidomide capsules are not indicated and not recommended for use in CLL outside of controlled clinical trials.. 5.6Second Primary Malignancies In clinical trials in patients with MM receiving lenalidomide capsules, an increase of hematologic plus solid tumor second primary malignancies (SPM) notably AML and MDS have been observed. An increase in hematologic SPM including AML and MDS occurred in 5.3% of patients with NDMM receiving lenalidomide capsules in combination with oral melphalan compared with 1.3% of patients receiving melphalan without lenalidomide capsules. The frequency of AML and MDS cases in patients with NDMM treated with lenalidomide capsules in combination with dexamethasone without melphalan was 0.4%.In patients receiving lenalidomide capsule maintenance therapy following high dose intravenous melphalan and auto-HSCT, hematologic SPM occurred in 7.5% of patients compared to 3.3% in patients receiving placebo. The incidence of hematologic plus solid tumor (excluding squamous cell carcinoma and basal cell carcinoma) SPM was 14.9%, compared to 8.8% in patients receiving placebo with median follow-up of 91.5 months. Non-melanoma skin cancer SPM, including squamous cell carcinoma and basal cell carcinoma, occurred in 3.9% of patients receiving lenalidomide capsule maintenance, compared to 2.6% in the placebo arm.In patients with relapsed or refractory MM treated with lenalidomide capsules/dexamethasone, the incidence of hematologic plus solid tumor (excluding squamous cell carcinoma and basal cell carcinoma) SPM was 2.3% versus 0.6% in the dexamethasone alone arm. Non-melanoma skin cancer SPM, including squamous cell carcinoma and basal cell carcinoma, occurred in 3.1% of patients receiving lenalidomide capsules/dexamethasone, compared to 0.6% in the dexamethasone alone arm.Patients who received lenalidomide capsule-containing therapy until disease progression did not show higher incidence of invasive SPM than patients treated in the fixed duration lenalidomide capsule-containing arms. Monitor patients for the development of second primary malignancies. Take into account both the potential benefit of lenalidomide capsules and the risk of second primary malignancies when considering treatment with lenalidomide capsules.In the AUGMENT trial with FL or MZL patients receiving lenalidomide capsules/rituximab therapy, hematologic plus solid tumor SPMs, notably AML, have been observed. In the AUGMENT trial, hematologic SPM of AML occurred in 0.6% of patients with FL or MZL receiving lenalidomide capsules/rituximab therapy. The incidence of hematologic plus solid tumor SPMs (excluding nonmelanoma skin cancers) was 1.7% in the lenalidomide capsules/rituximab arm with median follow-up of 29.8 months (range 0.5 to 51.3 months) [see Adverse Reactions (6.1)]. Monitor patients for the development of second primary malignancies. Take into account both the potential benefit of lenalidomide capsules and the risk of second primary malignancies when considering treatment with lenalidomide capsules.. 5.7Increased Mortality in Patients with MM When Pembrolizumab Is Added to Thalidomide Analogue and Dexamethasone In two randomized clinical trials in patients with MM, the addition of pembrolizumab to thalidomide analogue plus dexamethasone, use for which no PD-1 or PD-L1 blocking antibody is indicated, resulted in increased mortality. Treatment of patients with MM with PD-1 or PD-L1 blocking antibody in combination with thalidomide analogue plus dexamethasone is not recommended outside of controlled clinical trials.. 5.8Hepatotoxicity Hepatic failure, including fatal cases, has occurred in patients treated with lenalidomide capsules in combination with dexamethasone. In clinical trials, 15% of patients experienced hepatotoxicity (with hepatocellular, cholestatic and mixed characteristics); 2% of patients with MM and 1% of patients with myelodysplasia had serious hepatotoxicity events. The mechanism of drug-induced hepatotoxicity is unknown. Pre-existing viral liver disease, elevated baseline liver enzymes, and concomitant medications may be risk factors. Monitor liver enzymes periodically. Stop lenalidomide capsules upon elevation of liver enzymes. After return to baseline values, treatment at lower dose may be considered.. 5.9Severe Cutaneous Reactions Severe cutaneous reactions including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS) have been reported. DRESS may present with 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. Patients with prior history of Grade rash associated with thalidomide treatment should not receive lenalidomide capsules. Consider lenalidomide capsule interruption or discontinuation for Grade 2-3 skin rash. Permanently discontinue lenalidomide capsules for Grade rash, exfoliative or bullous rash, or for other severe cutaneous reactions such as SJS, TEN or DRESS [see Dosage and Administration (2.5)].. 5.10Tumor Lysis Syndrome Fatal instances of tumor lysis syndrome (TLS) have been reported during treatment with lenalidomide capsules. The patients at risk of TLS are those with high tumor burden prior to treatment. Monitor patients at risk closely and take appropriate preventive approaches. In the AUGMENT trial in FL or MZL patients, TLS occurred in patients (1.1%) in the lenalidomide capsules/rituximab arm. TLS occurred in patient (0.5%) in the MAGNIFY trial during the lenalidomide capsules/rituximab induction period; the event was serious, Grade adverse reaction. 5.11Tumor Flare Reaction Tumor flare reaction (TFR), including fatal reactions, have occurred during investigational use of lenalidomide capsules for CLL and lymphoma, and is characterized by tender lymph node swelling, low grade fever, pain and rash. Lenalidomide capsules are not indicated and not recommended for use in CLL outside of controlled clinical trials.Monitoring and evaluation for TFR is recommended in patients with MCL, FL, or MZL. Tumor flare reaction may mimic progression of disease (PD).In the MCL trial, 13/134 (10%) of subjects experienced TFR; all reports were Grade or in severity. All of the events occurred in Cycle and one patient developed TFR again in Cycle 11. In the AUGMENT trial in FL or MZL patients, TFR was reported in 19/176 (10.8%) of patients in lenalidomide capsules with rituximab arm; one patient in the lenalidomide capsules/rituximab arm experienced Grade TFR. In the MAGNIFY trial, 9/222 (4.1%) of patients experienced TFR; all reports were Grade or in severity and event was considered as serious. In separate MCL phase trial, one case of TFR resulted in fatal outcome.Lenalidomide capsules may be continued in patients with Grade and TFR without interruption or modification, at the physicians discretion. Patients with Grade and TFR may also be treated with corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDs) and/or narcotic analgesics for management of TFR symptoms. In patients with Grade or TFR, it is recommended to withhold treatment with lenalidomide capsules until TFR resolves to <= Grade 1. Patients with Grade or TFR may be treated for management of symptoms per the guidance for treatment of Grade and TFR.. 5.12Impaired Stem Cell Mobilization A decrease in the number of CD34+ cells collected after treatment (> cycles) with lenalidomide capsules has been reported. In patients who are auto-HSCT candidates, referral to transplant center should occur early in treatment to optimize the timing of the stem cell collection. In patients who received more than cycles of lenalidomide capsule-containing treatment or for whom inadequate numbers of CD34+ cells have been collected with G-CSF alone, G-CSF with cyclophosphamide or the combination of G-CSF with CXCR4 inhibitor may be considered.. 5.13Thyroid Disorders Both hypothyroidism and hyperthyroidism have been reported [see Adverse Reactions (6.2)]. Measure thyroid function before start of lenalidomide capsule treatment and during therapy. 5.14Early Mortality in Patients with MCL In another MCL study, there was an increase in early deaths (within 20 weeks), 12.9% in the lenalidomide capsules arm versus 7.1% in the control arm. On exploratory multivariate analysis, risk factors for early deaths include high tumor burden, MIPI score at diagnosis, and high WBC at baseline (>= 10 109/L).. 5.15Hypersensitivity Hypersensitivity, including angioedema, anaphylaxis, and anaphylactic reactions to lenalidomide capsules has been reported. Permanently discontinue lenalidomide capsules for angioedema and anaphylaxis [see Dosage and Administration (2.2)].