Side Effects of Sprycel (dasatinib)

Sprycel (dasatinib) is a kinase inhibitor used to treat chronic myeloid leukemia (CML) and acute lymphoblastic leukemia (ALL). 

Kinase inhibitors prevent the growth of tumors by reducing the action of proteins that control cell division, growth, and survival. These proteins are usually present in larger quantities or are more active in cancer cells. By reducing the activity of these proteins, growth and survival of cancer cells are reduced. 

Common side effects of Sprycel include

• fluid retention,
• headache,
• diarrhea,
• constipation,
• weakness,
• nausea and vomiting,
• abdominal distention,
• weight changes,
• rash,
• itching,
• chills,
• dizziness, and
• muscle pain.

Serious side effects of Sprycel include

• fever associated with reduced white blood cells,
• reduced platelets,
• reduced blood cell counts,
• infection,
• stomach or intestinal bleeding,
• bleeding in the brain,
• heart failure, and
• fluid in the lungs.

Drug interactions of Sprycel include ketoconazole, itraconazole, clarithromycin, atazanavir, indinavir, nelfinavir, ritonavir, saquinavir, telithromycin, voriconazole, and grapefruit juice, because these drugs reduce the breakdown of Sprycel by liver enzymes and increase the blood concentration of Sprycel.

• Dexamethasone, carbamazepine, phenobarbital, rifampin, phenobarbital, and St John's wort decrease the concentration of Sprycel resulting in decreased blood levels and possibly reduced effect.
• Drugs that reduce production of acid in the stomach such as proton pump inhibitors (PPIs) such as omeprazole and H2 blocking drugs such as famotidine reduce the absorption of Sprycel.
• Sprycel increases the blood concentration of simvastatin by reducing the activity of enzymes that break down simvastatin in the liver. This may increase the side effects of simvastatin.
• Sprycel may interact with other drugs that are broken down in a similar way as simvastatin. 

Sprycel is harmful to a fetus and should not be used during pregnancy. It is unknown if Sprycel is excreted in breast milk. Consult your doctor before breastfeeding. 

Common side effects are:

• fluid retention,
• headache,
• diarrhea,
• constipation,
• weakness,
• nausea and vomiting,
• abdominal distention,
• weight loss or gain,
• rash,
• itching,
• chills,
• dizziness, and
• muscle pain.

Other important and serious side effects of dasatinib include:

• fever associated with reduced white blood cells,
• reduced platelets,
• reduced blood cell counts,
• infection,
• stomach or intestinal bleeding,
• bleeding in the brain,
• heart failure, and
• fluid in the lungs.

The following adverse reactions are discussed in greater detail in other sections of the labeling:

• Myelosuppression
• Bleeding-related events 
• Fluid retention 
• Cardiovascular events 
• Pulmonary arterial hypertension
• QT prolongation 
• Severe dermatologic reactions
• Tumor lysis syndrome 
• Effects on growth and development in pediatric patients

Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

• The data described below reflect exposure to Sprycel at all doses tested in clinical studies (n=2809), including 324 adult patients with newly diagnosed chronic phase CML, 2388 adult patients with imatinib-resistant or -intolerant chronic or advanced phase CML or Ph+ ALL, and 97 pediatric patients with chronic phase CML.
• The median duration of therapy in a total of 2712 adult patients was 19.2 months (range 0 to 93.2 months).
• In a randomized trial in patients with newly diagnosed chronic phase CML, the median duration of therapy was approximately 60 months.
• The median duration of therapy in 1618 adult patients with chronic phase CML was 29 months (range 0 to 92.9 months).
• The median duration of therapy in 1094 adult patients with advanced phase CML or Ph+ ALL was 6.2 months (range 0 to 93.2 months).
• In two non-randomized trials in 97 pediatric patients with chronic phase CML (51 patients newly diagnosed and 46 patients resistant or intolerant to previous treatment with imatinib), the median duration of therapy was 51.1 months (range 1.9 to 99.6 months).
• In the overall population of 2712 adult patients, 88% of patients experienced adverse reactions at some time and 19% experienced adverse reactions leading to treatment discontinuation.
• In the randomized trial in adult patients with newly diagnosed chronic phase CML, the drug was discontinued for adverse reactions in 16% of patients with a minimum of 60 months of follow-up.
• After a minimum of 60 months of follow-up, the cumulative discontinuation rate was 39%.
• Among the 1618 patients with chronic phase CML, drug-related adverse reactions leading to discontinuation were reported in 329 (20.3%) patients; among the 1094 patients with advanced phase CML or Ph+ ALL, drug-related adverse reactions leading to discontinuation were reported in 191 (17.5%) patients.
• Among the 97 pediatric subjects, drug-related adverse reactions leading to discontinuation were reported in 1 patient (1%).
• Adverse reactions reported in ≥10% of adult patients, and other adverse reactions of interest, in a randomized trial in patients with newly diagnosed chronic phase CML at a median follow-up of approximately 60 months are presented in Table 5.
• Adverse reactions reported in ≥10% of adult patients treated at the recommended dose of 100 mg once daily (n=165), and other adverse reactions of interest, in a randomized dose-optimization trial of patients with chronic phase CML resistant or intolerant to prior imatinib therapy at a median follow-up of approximately 84 months are presented in Table 7.
• Adverse reactions reported in ≥10% of pediatric patients at a median follow-up of approximately 51.1 months are presented in Table 10.
• Drug-related serious adverse reactions (SARs) were reported for 16.7% of adult patients in the randomized trial of patients with newly diagnosed chronic phase CML.
• Serious adverse reactions reported in ≥5% of patients included pleural effusion (5%).
• Drug-related SARs were reported for 26.1% of patients treated at the recommended dose of 100 mg once daily in the randomized dose-optimization trial of adult patients with chronic phase CML resistant or intolerant to prior imatinib therapy. Serious adverse reactions reported in ≥5% of patients included pleural effusion (10%).
• Drug-related SARs were reported for 14.4% of pediatric patients.

Chronic Myeloid Leukemia (CML)

Adverse reactions (excluding laboratory abnormalities) that were reported in at least 10% of adult patients are shown in Table 5 for newly diagnosed patients with chronic phase CML and Tables 7 and 10 for CML patients with resistance or intolerance to prior imatinib therapy.

Table 5: Adverse Reactions Reported in ≥10% of Adult Patients with Newly Diagnosed Chronic Phase CML (minimum of 60 months follow-up)

A comparison of cumulative rates of adverse reactions reported in ≥10% of patients with minimum follow-up of 1 and 5 years in a randomized trial of newly diagnosed patients with chronic phase CML treated with Sprycel are shown in Table 6.

Table 6: Adverse Reactions Reported in ≥10% of Adult Patients with Newly Diagnosed Chronic Phase CML in the Sprycel-Treated Arm (n=258)

At 60 months, there were 26 deaths in dasatinib-treated patients (10.1%) and 26 deaths in imatinib-treated patients (10.1%); 1 death in each group was assessed by the investigator as related to study therapy.

Table 7: Adverse Reactions Reported in ≥10% of Adult Patients with Chronic Phase CML Resistant or Intolerant to Prior Imatinib Therapy (minimum of 84 months follow-up)

Cumulative rates of selected adverse reactions that were reported over time in patients treated with the 100 mg once daily recommended starting dose in a randomized dose-optimization trial of imatinib-resistant or -intolerant patients with chronic phase CML are shown in Table 8.

Table 8: Selected Adverse Reactions Reported in Adult Dose Optimization Trial (Imatinib-Intolerant or -Resistant Chronic Phase CML)^a

Table 9: Adverse Reactions Reported in ≥10% of Adult Patients with Advanced Phase CML Resistant or Intolerant to Prior Imatinib Therapy

Table 10: Adverse Reactions Reported in ≥10% of Dasatinib-Treated Pediatric Patients (n=97)

Laboratory Abnormalities

• Myelosuppression was commonly reported in all patient populations. The frequency of Grade 3 or 4 neutropenia, thrombocytopenia, and anemia was higher in patients with advanced phase CML than in chronic phase CML (Tables 11 and 12).
• Myelosuppression was reported in patients with normal baseline laboratory values as well as in patients with pre-existing laboratory abnormalities.
• In patients who experienced severe myelosuppression, recovery generally occurred following dose interruption or reduction; permanent discontinuation of treatment occurred in 2% of adult patients with newly diagnosed chronic phase CML and 5% of adult patients with resistance or intolerance to prior imatinib therapy.
• Grade 3 or 4 elevations of transaminases or bilirubin and Grade 3 or 4 hypocalcemia, hypokalemia, and hypophosphatemia were reported in patients with all phases of CML but were reported with an increased frequency in patients with myeloid or lymphoid blast phase CML. Elevations in transaminases or bilirubin were usually managed with dose reduction or interruption. Patients developing Grade 3 or 4 hypocalcemia during Sprycel therapy often had recovery with oral calcium supplementation.
• Laboratory abnormalities reported in adult patients with newly diagnosed chronic phase CML are shown in Table 11. There were no discontinuations of Sprycel therapy in this patient population due to biochemical laboratory parameters.

Table 11: CTC Grade ¾ Laboratory Abnormalities in Adult Patients with Newly Diagnosed Chronic Phase CML (minimum of 60 months follow-up)

Laboratory abnormalities reported in patients with CML resistant or intolerant to imatinib who received the recommended starting doses of Sprycel are shown by disease phase in Table 12.

Table 12: CTC Grade 3/4 Laboratory Abnormalities in Clinical Studies of CML in Adults: Resistance or Intolerance to Prior Imatinib Therapy

Among adult patients with chronic phase CML with resistance or intolerance to prior imatinib therapy, cumulative Grade 3 or 4 cytopenias were similar at 2 and 5 years including:

• neutropenia (36% vs 36%),
• thrombocytopenia (23% vs 24%), and
• anemia (13% vs 13%).

In the pediatric studies, the rates of laboratory abnormalities were consistent with the known profile for laboratory parameters in adults.

Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia (Ph+ ALL) In Adults

• A total of 135 patients with Ph+ ALL were treated with Sprycel in clinical studies.
• The median duration of treatment was 3 months (range 0.03 - 31 months).
• The safety profile of patients with Ph+ ALL was similar to those with lymphoid blast phase CML.
• The most frequently reported adverse reactions included fluid retention events, such as
  • pleural effusion (24%) and superficial edema (19%), and
  • gastrointestinal disorders, such as diarrhea (31%), nausea (24%), and vomiting (16%).
• Hemorrhage (19%), pyrexia (17%), rash (16%), and dyspnea (16%) were also frequently reported.
• Serious adverse reactions reported in ≥5% of patients included
  • pleural effusion (11%),
  • gastrointestinal bleeding (7%),
  • febrile neutropenia (6%), and
  • infection (5%).

Additional Pooled Data From Clinical Trials

The following additional adverse reactions were reported in adult and pediatric patients (n=2809) in Sprycel CML and Ph+ ALL clinical studies at a frequency of ≥10%, 1% - <10%, 0.1% - <1%, or <0.1%.

These adverse reactions are included based on clinical relevance.

• Gastrointestinal Disorders: 1% - <10% - mucosal inflammation (including mucositis/stomatitis), dyspepsia, abdominal distension, constipation, gastritis, colitis (including neutropenic colitis), oral soft tissue disorder; 0.1% - <1% - ascites, dysphagia, anal fissure, upper gastrointestinal ulcer, esophagitis, pancreatitis, gastroesophageal reflux disease; <0.1% - protein losing gastroenteropathy, ileus, acute pancreatitis, anal fistula.
• General Disorders and Administration-Site Conditions: ≥10% - peripheral edema, face edema; 1% - <10% - asthenia, chest pain, chills; 0.1% - <1% - malaise, other superficial edema, peripheral swelling; <0.1% - gait disturbance.
• Skin and Subcutaneous Tissue Disorders: 1% - <10% - alopecia, acne, dry skin, hyperhidrosis, urticaria, dermatitis (including eczema); 0.1% - <1% - pigmentation disorder, skin ulcer, bullous conditions, photosensitivity, nail disorder, neutrophilic dermatosis, panniculitis, palmar-plantar erythrodysesthesia syndrome, hair disorder; <0.1% - leukocytoclastic vasculitis, skin fibrosis.
• Respiratory, Thoracic, and Mediastinal Disorders: 1% - <10% - lung infiltration, pneumonitis, cough; 0.1% - <1% - asthma, bronchospasm, dysphonia, pulmonary arterial hypertension; <0.1% - acute respiratory distress syndrome, pulmonary embolism.
• Nervous System Disorders: 1% - <10% - neuropathy (including peripheral neuropathy), dizziness, dysgeusia, somnolence; 0.1% - <1% - amnesia, tremor, syncope, balance disorder; <0.1% - convulsion, cerebrovascular accident, transient ischemic attack, optic neuritis, VIIth nerve paralysis, dementia, ataxia.
• Blood and Lymphatic System Disorders: 0.1% - <1% - lymphadenopathy, lymphopenia; <0.1% - aplasia pure red cell.
• Musculoskeletal and Connective Tissue Disorders: 1% - <10% - muscular weakness, musculoskeletal stiffness; 0.1% - <1% - rhabdomyolysis, tendonitis, muscle inflammation, osteonecrosis, arthritis; <0.1% - epiphyses delayed fusion (reported at 1% - <10% in the pediatric studies), growth retardation (reported at 1% - <10% in the pediatric studies).
• Investigations: 1% - <10% - weight increased, weight decreased; 0.1% - <1% - blood creatine phosphokinase increased, gamma-glutamyltransferase increased.
• Infections and Infestations: 1% - <10% - pneumonia (including bacterial, viral, and fungal), upper respiratory tract infection/inflammation, herpes virus infection, enterocolitis infection, sepsis (including fatal outcomes [0.2%]).
• Metabolism and Nutrition Disorders: 1% - <10% - appetite disturbances, hyperuricemia; 0.1% - <1% - hypoalbuminemia, tumor lysis syndrome, dehydration, hypercholesterolemia; <0.1% - diabetes mellitus.
• Cardiac Disorders: 1% - <10% - arrhythmia (including tachycardia), palpitations; 0.1% - <1% - angina pectoris, cardiomegaly, pericarditis, ventricular arrhythmia (including ventricular tachycardia), electrocardiogram T-wave abnormal, troponin increased; <0.1% - cor pulmonale, myocarditis, acute coronary syndrome, cardiac arrest, electrocardiogram PR prolongation, coronary artery disease, pleuropericarditis.
• Eye Disorders: 1% - <10% - visual disorder (including visual disturbance, vision blurred, and visual acuity reduced), dry eye; 0.1% - <1% - conjunctivitis, visual impairment, lacrimation increased, <0.1% - photophobia.
• Vascular Disorders: 1% - <10% - flushing, hypertension; 0.1% - <1% - hypotension, thrombophlebitis, thrombosis; <0.1% - livedo reticularis, deep vein thrombosis, embolism.
• Psychiatric Disorders: 1% - <10% - insomnia, depression; 0.1% - <1% - anxiety, affect lability, confusional state, libido decreased.
• Pregnancy, Puerperium, and Perinatal Conditions: <0.1% - abortion.
• Reproductive System and Breast Disorders: 0.1% - <1% - gynecomastia, menstrual disorder.
• Injury, Poisoning, and Procedural Complications: 1% - <10% - contusion.
• Ear and Labyrinth Disorders: 1% - <10% - tinnitus; 0.1% - <1% - vertigo, hearing loss.
• Hepatobiliary Disorders: 0.1% - <1% - cholestasis, cholecystitis, hepatitis.
• Renal and Urinary Disorders: 0.1% - <1% - urinary frequency, renal failure, proteinuria; <0.1% - renal impairment.
• Immune System Disorders: 0.1% - <1% - hypersensitivity (including erythema nodosum).
• Endocrine Disorders: 0.1% - <1% - hypothyroidism; <0.1% - hyperthyroidism, thyroiditis.

Postmarketing Experience

The following additional adverse reactions have been identified during post-approval use of Sprycel. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

• Infections: hepatitis B virus reactivation
• Cardiac disorders: atrial fibrillation/atrial flutter
• Respiratory, thoracic, and mediastinal disorders: interstitial lung disease
• Skin and subcutaneous tissue disorders: Stevens-Johnson syndrome
• Renal and urinary disorders: nephrotic syndrome
• Blood and lymphatic system disorders: thrombotic microangiopathy

Effect Of Other Drugs On Dasatinib

Strong CYP3A4 Inhibitors

• The coadministration with strong CYP3A inhibitors may increase dasatinib concentrations.
• Increased dasatinib concentrations may increase the risk of toxicity.
• Avoid concomitant use of strong CYP3A4 inhibitors.
• If concomitant administration of a strong CYP3A4 inhibitor cannot be avoided, consider a Sprycel dose reduction.

Strong CYP3A4 Inducers

• The coadministration of Sprycel with strong CYP3A inducers may decrease dasatinib concentrations.
• Decreased dasatinib concentrations may reduce efficacy.
• Consider alternative drugs with less enzyme induction potential.
• If concomitant administration of a strong CYP3A4 inducer cannot be avoided, consider a Sprycel dose increase.

Gastric Acid Reducing Agents

• The coadministration of Sprycel with a gastric acid reducing agent may decrease the concentrations of dasatinib. Decreased dasatinib concentrations may reduce efficacy.
• Do not administer H2 antagonists or proton pump inhibitors with Sprycel.
• Consider the use of antacids in place of H2 antagonists or proton pump inhibitors.
• Administer the antacid at least 2 hours prior to or 2 hours after the dose of Sprycel.
• Avoid simultaneous administration of Sprycel with antacids.