1. Name Of The Medicinal Product
Temozolomide Hospira 180 mg hard capsules.
2. Qualitative And Quantitative Composition
Each hard capsule contains 180 mg temozolomide.
Excipients :
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180 mg capsule contains 131.4 mg of anhydrous lactose.
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For a full list of excipients, see section 6.1.
3. Pharmaceutical Form
Hard capsule.
The 180 mg capsules are maroon/white, hard gelatin capsules, imprinted with 'TMZ' on cap & '180' on body.
4. Clinical Particulars
4.1 Therapeutic Indications
Temozolomide Hospira is indicated for the treatment of:
- adult patients with newly-diagnosed glioblastoma multiforme concomitantly with radiotherapy (RT) and subsequently as monotherapy treatment.
- children from the age of three years, adolescents and adult patients with malignant glioma, such as glioblastoma multiforme or anaplastic astrocytoma, showing recurrence or progression after standard therapy.
4.2 Posology And Method Of Administration
Temozolomide Hospira should only be prescribed by physicians experienced in the oncological treatment of brain tumours.
Anti-emetic therapy may be administered (see section 4.4).
Posology
Adult patients with newly diagnosed glioblastoma multiforme
Temozolomide Hospira is administered in combination with focal radiotherapy (concomitant phase) followed by up to 6 cycles of temozolomide (TMZ) monotherapy (monotherapy phase).
Concomitant phase
TMZ is administered orally at a dose of 75 mg/m2 daily for 42 days concomitant with focal radiotherapy (60 Gy administered in 30 fractions). No dose reductions are recommended, but delay or discontinuation of temozolomide administration should be decided weekly according to haematological and non-haematological toxicity criteria. TMZ administration can be continued throughout the 42 day concomitant period (up to 49 days) if all of the following conditions are met:
- absolute neutrophil count (ANC) 9/l
- thrombocyte count 9/l
- common toxicity criteria (CTC) non-haematological toxicity
During treatment a complete blood count should be obtained weekly. TMZ administration should be temporarily interrupted or permanently discontinued during the concomitant phase according to the haematological and non-haematological toxicity criteria as noted in Table 1.
Table 1. TMZ dosing interruption or discontinuation during concomitant radiotherapy and TMZ
Toxicity
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TMZ interruptiona
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TMZ discontinuation
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Absolute neutrophil count
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9 /l
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< 0.5 x 109 /l
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Thrombocyte count
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9 /l
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< 10 x 109 /l
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CTC non-haematological toxicity (except for alopecia, nausea, vomiting)
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CTC Grade 2
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CTC Grade 3 or 4
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a : Treatment with concomitant TMZ can be continued when all of the following conditions are met: absolute neutrophil count 9 /l; thrombocyte count 9 /l; CTC non-haematological toxicity
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Monotherapy phase
Four weeks after completing the TMZ + RT phase, TMZ is administered for up to 6 cycles of monotherapy treatment. Dose in Cycle 1 (monotherapy) is 150 mg/m2 once daily for 5 days followed by 23 days without treatment. At the start of Cycle 2, the dose is escalated to 200 mg/m2 if the CTC non-haematological toxicity for Cycle 1 is Grade 9/l, and the thrombocyte count is 9/l. If the dose was not escalated at Cycle 2, escalation should not be done in subsequent cycles. Once escalated, the dose remains at 200 mg/m2 per day for the first 5 days of each subsequent cycle except if toxicity occurs. Dose reductions and discontinuations during the monotherapy phase should be applied according to Tables 2 and 3.
During treatment a complete blood count should be obtained on Day 22 (21 days after the first dose of TMZ). The dose should be reduced or administration discontinued according to Table 3.
Table 2. TMZ dose levels for monotherapy treatment
Dose Level
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Dose (mg/m2 /day)
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Remarks
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–1
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100
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Reduction for prior toxicity
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0
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150
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Dose during Cycle 1
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1
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200
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Dose during Cycles 2-6 in absence of toxicity
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Table 3. TMZ dose reduction or discontinuation during monotherapy treatment
Toxicity
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Reduce TMZ by 1 dose levela
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Discontinue TMZ
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Absolute neutrophil count
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< 1.0 x 109 /l
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See footnote b
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Thrombocyte count
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< 50 x 109 /l
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See footnote b
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CTC non-haematological Toxicity (except for alopecia, nausea, vomiting)
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CTC Grade 3
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CTC Grade 4b
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a : TMZ dose levels are listed in Table 2.
b : TMZ is to be discontinued if:
• dose level -1 (100 mg/m2 ) still results in unacceptable toxicity
• the same Grade 3 non-haematological toxicity (except for alopecia, nausea, vomiting) recurs after dose reduction.
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Adult and paediatric patients 3 years of age or older with recurrent or progressive malignant glioma :
A treatment cycle comprises 28 days. In patients previously untreated with chemotherapy, TMZ is administered orally at a dose of 200 mg/m2 once daily for the first 5 days followed by a 23 day treatment interruption (total of 28 days). In patients previously treated with chemotherapy, the initial dose is 150 mg/m2 once daily, to be increased in the second cycle to 200 mg/m2 once daily, for 5 days if there is no haematological toxicity (see section 4.4)
Special populations
Paediatric patients
In patients 3 years of age or older, TMZ is only to be used in recurrent or progressive malignant glioma. There is no clinical experience with the use of TMZ in children under the age of 3 years. Experience in older children is very limited (see sections 4.4 and 5.1).
Patients with hepatic or renal impairment
The pharmacokinetics of TMZ were comparable in patients with normal hepatic function and in those with mild or moderate hepatic impairment. No data are available on the administration of TMZ in patients with severe hepatic impairment (Child's Class C) or with renal impairment. Based on the pharmacokinetic properties of TMZ, it is unlikely that dose reductions are required in patients with severe hepatic impairment or any degree of renal impairment. However, caution should be exercised when TMZ is administered in these patients.
Elderly patients
Based on a population pharmacokinetic analysis in patients 19-78 years of age, clearance of TMZ is not affected by age. However, elderly patients (>70 years of age) appear to be at increased risk of neutropenia and thrombocytopenia (see section 4.4).
Method of administration
Temozolomide Hospira should be administered in the fasting state.
The capsules must be swallowed whole with a glass of water and must not be opened or chewed.
If vomiting occurs after the dose is administered, a second dose should not be administered that day.
4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients.
Hypersensitivity to dacarbazine (DTIC).
Severe myelosuppression (see section 4.4).
4.4 Special Warnings And Precautions For Use
Pneumocystis carinii pneumonia
Patients who received concomitant TMZ and RT in a pilot trial for the prolonged 42 day schedule were shown to be at particular risk for developing Pneumocystis carinii pneumonia (PCP). Thus, prophylaxis against PCP is required for all patients receiving concomitant TMZ and RT for the 42 day regimen (with a maximum of 49 days) regardless of lymphocyte count. If lymphopenia occurs, they are to continue the prophylaxis until recovery of lymphopenia to grade
There may be a higher occurrence of PCP when TMZ is administered during a longer dosing regimen. However, all patients receiving TMZ, particularly patients receiving steroids, should be observed closely for the development of PCP, regardless of the regimen.
Malignancies
Cases of myelodysplastic syndrome and secondary malignancies, including myeloid leukaemia, have also been reported very rarely (see section 4.8).
Anti-emetic therapy:
Nausea and vomiting are very commonly associated with TMZ.
Anti-emetic therapy may be administered prior to or following administration of TMZ.
Patients with newly-diagnosed glioblastoma multiforme:
Anti-emetic prophylaxis is recommended prior to the initial dose of concomitant phase and it is strongly recommended during the monotherapy phase.
Patients with recurrent or progressive malignant glioma:
Patients who have experienced severe (Grade 3 or 4) vomiting in previous treatment cycles may require anti-emetic therapy.
Laboratory parameters
Prior to dosing, the following laboratory parameters must be met: ANC 9/l and platelet count 9/l. A complete blood count should be obtained on Day 22 (21 days after the first dose) or within 48 hours of that day, and weekly until ANC> 1.5 x 109/l and platelet count> 100 x 109/l. If ANC falls to < 1.0 x 109/l or the platelet count is < 50 x109/l during any cycle, the next cycle should be reduced one dose level (see section 4.2). Dose levels include 100 mg/m2, 150 mg/m2, and 200 mg/m2. The lowest recommended dose is 100 mg/m2.
Paediatric use
There is no clinical experience with use of TMZ in children under the age of 3 years. Experience in older children and adolescents is very limited (see sections 4.2 and 5.1).
Elderly patients (> 70 years of age)
Elderly patients appear to be at increased risk of neutropenia and thrombocytopenia, compared with younger patients. Therefore, special care should be taken when TMZ is administered in elderly patients.
Male patients
Men being treated with TMZ are advised not to father a child up to 6 months after receiving the last dose and to seek advice on cryoconservation of sperm prior to treatment (see section 4.6).
Lactose
This medicinal product contains lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
Interaction studies have only been performed in adults.
In a separate phase I study, administration of TMZ with ranitidine did not result in alterations in the extent of absorption of temozolomide or the exposure to its active metabolite monomethyl triazenoimidazole carboxamide (MTIC).
Administration of TMZ with food resulted in a 33 % decrease in Cmax and a 9% decrease in area under the curve (AUC).
As it cannot be excluded that the change in Cmax is clinically significant, Temozolomide Hospira should be administered without food.
Based on an analysis of population pharmacokinetics in Phase II trials, co-administration of dexamethasone, prochlorperazine, phenytoin, carbamazepine, ondansetron, H2 receptor antagonists, or phenobarbital did not alter the clearance of TMZ. Co-administration with valproic acid was associated with a small but statistically significant decrease in clearance of TMZ.
No studies have been conducted to determine the effect of TMZ on the metabolism or elimination of other medicinal products. However, since TMZ does not undergo hepatic metabolism and exhibits low protein binding, it is unlikely that it would affect the pharmacokinetics of other medicinal products (see section 5.2).
Use of TMZ in combination with other myelosuppressive agents may increase the likelihood of myelosuppression.
4.6 Pregnancy And Lactation
Pregnancy
There are no data in pregnant women. In preclinical studies in rats and rabbits receiving 150 mg/m2, teratogenicity and/or foetal toxicity were demonstrated (see section 5.3). Temozolomide Hospira should not be administered to pregnant women. If use during pregnancy must be considered, the patient should be apprised of the potential risk to the foetus. Women of childbearing potential should be advised to use effective contraception to avoid pregnancy while they are receiving TMZ.
Lactation
It is not known whether TMZ is excreted in human milk; thus, breast-feeding should be discontinued while receiving treatment with TMZ.
Male fertility
TMZ can have genotoxic effects. Therefore, men being treated with it should be advised not to father a child up to 6 months after receiving the last dose and to seek advice on cryoconservation of sperm prior to treatment because of the possibility of irreversible infertility due to therapy with TMZ.
4.7 Effects On Ability To Drive And Use Machines
No studies on the effects on the ability to drive and use machines have been performed. The ability to drive and use machines may be impaired in patients treated with TMZ due to fatigue and somnolence.
4.8 Undesirable Effects
Clinical trial experience
In patients treated with TMZ, whether used in combination with RT or as monotherapy following RT for newly-diagnosed glioblastoma multiforme, or as monotherapy in patients with recurrent or progressive glioma, the reported very common adverse reactions were similar: nausea, vomiting, constipation, anorexia, headache and fatigue.
Convulsions were reported very commonly in the newly-diagnosed glioblastoma multiforme patients receiving monotherapy, and rash was reported very commonly in newly-diagnosed glioblastoma multiforme patients receiving TMZ concurrent with RT and also as monotherapy, and commonly in recurrent glioma. Most haematologic adverse reactions were reported commonly or very commonly in both indications (Tables 4 and 5), with frequency of grade 3-4 laboratory findings is presented after each table.
In the tables, undesirable effects are classified according to System Organ Class and frequency. Frequency groupings are defined according to the following convention: Very Common (
Newly-diagnosed glioblastoma multiforme
Table 4 provides treatment-emergent adverse events in patients with newly-diagnosed glioblastoma multiforme during the concomitant and monotherapy phases of treatment.
Table 4. Treatment-emergent events during concomitant and monotherapy treatment phases in patients with newly diagnosed glioblastoma multiforme
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System Organ Class
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TMZ + concomitant RT
n=288*
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TMZ monotherapy
n=224
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Infections and infestations
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Common:
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Infection, Herpes simplex, wound infection, pharyngitis, candidiasis oral
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Infection, candidiasis oral
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Uncommon:
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Herpes simplex , Herpes zoster, influenza–like symptoms
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Blood and lymphatic system disorders
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Common:
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Neutropenia, thrombocytopenia, lymphopenia, leukopenia
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Febrile neutropenia, thrombocytopenia, anaemia, leukopenia
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Uncommon:
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Febrile neutropenia, anaemia
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Lymphopenia, petechiae
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Endocrine disorders
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Uncommon:
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Cushingoid
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Cushingoid
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Metabolism and nutrition disorders
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Very Common
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Anorexia
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Anorexia
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Common:
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Hyperglycaemia, weight decreased
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Weight decreased
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Uncommon:
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Hypokalemia, alkaline phosphatase increased, weight increased
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Hyperglycaemia, weight increased
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Psychiatric disorders
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Common:
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Anxiety, emotional lability, insomnia
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Anxiety, depression, emotional lability, insomnia
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Uncommon:
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Agitation, apathy, behaviour disorder, depression, hallucination
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Hallucination, amnesia
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Nervous system disorders
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Very Common:
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Headache
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Convulsions, headache
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Common:
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Convulsions, consciousness decreased, somnolence, aphasia, balance impaired, dizziness, confusion, memory impairment, concentration impaired, neuropathy, paresthesia, speech disorder, tremor
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Hemiparesis, aphasia, balance impaired, somnolence, confusion, dizziness, memory impairment, concentration impaired, dysphasia, neurological disorder (NOS), neuropathy, peripheral neuropathy, paresthesia, speech disorder, tremor
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Uncommon:
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Status epilepticus, extrapyramidal disorder, hemiparesis, ataxia, cognition impaired, dysphasia, gait abnormal, hyperesthesia, hypoesthesia, neurological disorder (NOS), peripheral neuropathy
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Hemiplegia, ataxia, coordination abnormal, gait abnormal, hyperesthesia, sensory disturbance
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Eye disorders
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Common:
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Vision blurred
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Visual field defect, vision blurred, diplopia
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Uncommon:
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Hemianopia, visual acuity reduced, vision disorder, visual field defect, eye pain
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Visual acuity reduced, eye pain, eyes dry
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Ear and labyrinth disorders
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Common:
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Hearing impairment
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Hearing impairment, tinnitus
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Uncommon:
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Otitis media, tinnitus, hyperacusis, earache
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Deafness, vertigo, earache
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Cardiac disorders
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Uncommon:
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Palpitation
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Vascular disorders
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Common:
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Haemorrhage, oedema, oedema leg
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Haemorrhage, deep venous thrombosis, oedema leg
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Uncommon:
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Cerebral haemorrhage, hypertension
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Embolism pulmonary, oedema, oedema peripheral
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Respiratory, thoracic and mediastinal disorders
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Common:
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Dyspnoea, coughing
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Dyspnoea, coughing
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Uncommon:
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Pneumonia, upper respiratory infection, nasal congestion
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Pneumonia, sinusitis, upper respiratory infection, bronchitis
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Gastrointestinal disorders
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Very Common:
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Constipation, nausea, vomiting
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Constipation, nausea, vomiting
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Common:
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Stomatitis, diarrhoea, abdominal pain, dyspepsia, dysphagia
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Stomatitis, diarrhoea, dyspepsia, dysphagia, mouth dry
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Uncommon:
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Abdominal distension, faecal incontinence, gastrointestinal disorder (NOS), gastroenteritis, haemorrhoids
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Skin and subcutaneous tissue disorders
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Very Common:
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Rash, alopecia
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Rash, alopecia
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Common:
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Dermatitis, dry skin, erythema, pruritus
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Dry skin, pruritus
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Uncommon:
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Skin exfoliation, photosensitivity reaction, pigmentation abnormal
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Erythema, pigmentation abnormal, sweating increased
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Musculoskeletal and connective tissue disorders
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Common:
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Muscle weakness, arthralgia
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Muscle weakness, arthralgia, musculoskeletal pain, myalgia
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Uncommon:
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Myopathy, back pain, musculoskeletal pain, myalgia
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Myopathy, back pain
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Renal and urinary disorders
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Common:
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Micturition frequency, urinary incontinence
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Urinary incontinence
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Uncommon:
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Dysuria
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Reproductive system and breast disorders
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Uncommon:
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Impotence
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Vaginal haemorrhage, menorrhagia, amenorrhea, vaginitis, breast pain
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General disorders and administration site conditions
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Very Common:
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Fatigue
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Fatigue
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Common:
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Allergic reaction, fever, radiation injury, face oedema, pain, taste perversion
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Allergic reaction, fever, radiation injury, pain, taste perversion
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Uncommon:
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Asthenia, flushing, hot flushes, condition aggravated, rigors, tongue discolouration, parosmia, thirst
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Asthenia, face oedema, pain, condition aggravated, rigors, tooth disorder, taste perversion
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Investigations
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Common:
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ALT increased
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ALT increased
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Uncommon:
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Hepatic enzymes increased, Gamma GT increased, AST increased
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*A patient who was randomised to the RT arm only, received TMZ + RT.
Laboratory results
Myelosuppression (neutropenia and thrombocytopenia), which is known dose limiting toxicity for most cytotoxic agents, including TMZ, was observed. When laboratory abnormalities and adverse events were combined across concomitant and monotherapy treatment phases, Grade 3 or Grade 4 neutrophil abnormalities including neutropenic events were observed in 8% of the patients. Grade 3 or Grade 4 thrombocyte abnormalities, including thrombocytopenic events were observed in 14% of the patients who received TMZ.
Recurrent or progressive malignant glioma
In clinical trials, the most frequently occurring treatment-related undesirable effects were gastrointestinal disorders, specifically nausea (43%) and vomiting (36%). These effects were usually Grade 1 or 2 (0 – 5 episodes of vomiting in 24 hours) and were either self-limiting or readily controlled with standard anti-emetic therapy. The incidence of severe nausea and vomiting was 4%.
Table 5 includes adverse reactions reported during clinical trials for recurrent or progressive malignant glioma and following the marketing of Temodal (temozolomide).
Table 5. Adverse reactions in patients with recurrent or progressive malignant glioma
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Infections and infestations
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Rare:
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Opportunistic infections, including PCP
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Blood and lymphatic system disorders
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Very common:
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Neutropenia or lymphopenia (grade 3-4), thrombocytopenia (grade 3-4)
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Uncommon:
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Pancytopenia, anaemia (grade 3-4), leukopenia
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Metabolism and nutrition disorders
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Very common:
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Anorexia
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Common:
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Weight decrease
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Nervous system disorders
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Very common:
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Headache
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Common:
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Somnolence, dizziness, paresthesia
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Respiratory, thoracic and mediastinal disorders
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Common:
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Dyspnoea
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Gastrointestinal disorders
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Very common:
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Vomiting, nausea, constipation
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Common:
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Diarrhoea, abdominal pain, dyspepsia
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Skin and subcutaneous tissue disorders
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Common:
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Rash, pruritus, alopecia
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Very rare:
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Erythema multiforme, erythroderma, urticaria, exanthema
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General disorders and administration site conditions
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Very common:
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Fatigue
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Common:
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Fever, asthenia, rigors, malaise, pain, taste perversion
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Very rare:
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Allergic reactions, including anaphylaxis, angioedema
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Laboratory results:
Grade 3 or 4 thrombocytopenia and neutropenia occurred in 19% and 17% respectively, of patients treated for malignant glioma. This led to hospitalisation and/or discontinuation of TMZ in 8% and 4%, respectively. Myelosuppression was predictable (usually within the first few cycles, with the nadir between Day 21 and Day 28), and recovery was rapid, usually within 1-2 weeks. No evidence of cumulative myelosuppression was observed. The presence of thrombocytopenia may increase the risk of bleeding, and the presence of neutropenia or leukopenia may increase the risk of infection.
Gender
In a population pharmacokinetics analysis of clinical trial experience there were 101 female and 169 male subjects for whom nadir neutrophil counts were available and 110 female and 174 male subjects for whom nadir platelet counts were available. There were higher rates of Grade 4 neutropenia (ANC < 0.5 x 109/l), 12% vs 5%, and thrombocytopenia (< 20 x 109/l), 9% vs 3%, in women vs men in the first cycle of therapy. In a 400 subject recurrent glioma data set, Grade 4 neutropenia occurred in 8% of female vs 4% of male subjects and Grade 4 thrombocytopenia in 8% of female vs 3% of male subjects in the first cycle of therapy. In a study of 288 subjects with newly diagnosed glioblastoma multiforme, Grade 4 neutropenia occurred in 3% of female vs 0% of male subjects and Grade 4 thrombocytopenia in 1% of female vs 0% of male subjects in the first cycle of therapy.
Post-marketing experience:
Antineoplastic agents, and notably alkylating agents, have been associated with a potential risk of myelodysplastic syndrome (MDS) and secondary malignancies, including leukemia. Very rare cases of MDS and secondary malignancies, including myeloid leukemia have been reported in patients treated with regimens that included TMZ. Prolonged pancytopenia, which may result in aplastic anaemia has been reported very rarely. Cases of toxic epidermal necrolysis and Stevens-Johnson syndrome have been reported very rarely. Cases of interstitial pneumonitis/pneumonitis have been reported very rarely.
4.9 Overdose
Doses of 500, 750, 1,000, and 1,250 mg/m2 (total dose per cycle over 5 days) have been evaluated clinically in patients. Dose-limiting toxicity was haematological and was reported with any dose but is expected to be more severe at higher doses. An overdose of 10,000 mg (total dose in a single cycle, over 5 days) was taken by one patient and the adverse reactions reported were pancytopenia, pyrexia, multi-organ failure and death. There are reports of patients who have taken the recommended dose for more than 5 days of treatment (up to 64 days) with adverse events reported including bone marrow suppression, with or without infection, in some cases severe and prolonged and resulting in death. In the event of an overdose, haematological evaluation is needed. Supportive measures should be provided as necessary.
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
Pharmacotherapeutic group: Antineoplastic agents - Other alkylating agents, ATC code L01A X03
Temozolomide is a triazene, which undergoes rapid chemical conversion at physiologic pH to the active monomethyl triazenoimidazole carboxamide (MTIC). The cytotoxicity of MTIC is thought to be due primarily to alkylation at the O6 position of guanine with additional alkylation also occurring at the N7 position. Cytotoxic lesions that develop subsequently are thought to involve aberrant repair of the methyl adduct.
Newly diagnosed glioblastoma multiforme
A total of 573 patients were randomised to receive either TMZ + RT (n=287) or RT alone (n=286). Patients in the TMZ + RT arm received concomitant TMZ (75 mg/m2) once daily, starting the first day of RT until the last day of RT, for 42 days (with a maximum of 49 days). This was followed by monotherapy TMZ (150 – 200 mg/m2) on Days 1 - 5 of every 28-day cycle for up to 6 cycles, starting 4 weeks after the end of RT. Patients in the control arm received RT only. Pneumocystis carinii pneumonia (PCP) prophylaxis was required during RT and combined TMZ therapy.
TMZ was administered as salvage therapy in the follow-up phase in 161 patients of the 282 (57%) in the RT alone arm, and 62 patients of the 277 (22%) in the TMZ + RT arm.
The hazard ratio (HR) for overall survival was 1.59 (95% CI for HR=1.33 -1.91) with a log-ran
