Bicalutamide 150 Mg Film-Coated Tablets
SUMMARY OF PRODUCT CHARACTERISTICS
1 NAME OF THE MEDICINAL PRODUCT
Bicalutamide 150 mg film-coated tablets
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
One tablet contains 150 mg of bicalutamide.
Excipients with known effect: Contains 193.2 mg lactose monohydrate For the full list of excipients, see section 6.1.
3 PHARMACEUTICAL FORM
Film-coated tablet.
White, or almost white, round, biconvex film-coated tablet, with engraved sign “XL” on one side and “RG” on other side.
4 CLINICAL PARTICULARS
4.1 Therapeutic indications
Bicalutamide 150 mg film-coated tablet is indicated either alone or as adjuvant to radical prostatectomy or radiotherapy in patients with locally advanced prostate cancer at high risk for disease progression (see section 5.1)
4.2 Posology and method of administration
Posology
Adult males including the elderly One 150 mg tablet once a day.
Bicalutamide 150 mg should be taken continuously for at least 2 years or until disease progression.
Paediatric population
Bicalutamide is not indicated in children and adolescents.
Renal impairment
No dose adjustment is necessary for patients with renal impairment. There is no experience with the use of bicalutamide in patients with severe renal impairment (creatinine clearance < 30 ml/min) (see section 4.4).
Hepatic impairment
No dose adjustment is necessary for patients with mild hepatic impairment.
The medicinal product may accumulate in patients with moderate to severe hepatic impairment (see section 4.4).
Method of administration Route: oral
The tablets should be swallowed whole with liquid.
4.3 Contraindications
Hypersensitivity to bicalutamide or any of the excipients listed in section 6.1.
Bicalutamide is contra-indicated in women and children (see section 4.6).
Co-administration of terfenadine, astemizole or cisapride with bicalutamide is contraindicated (see section 4.5).
4.4 Special warnings and precautions for use
Initiation of treatment should be under the direct supervision of a specialist and subsequently patients should be kept under regular surveillance.
Bicalutamide is extensively metabolised in the liver. Data suggest that its elimination may be slower in patients with severe hepatic impairment and that this could lead to increased accumulation of bicalutamide. Therefore, bicalutamide should be used with caution in patients with moderate to severe hepatic impairment.
Periodic liver function testing should be considered due to the possibility of hepatic changes. The majority of changes are expected to occur within the first 6 months of bicalutamide therapy.
Severe hepatic changes and hepatic failure have been rarely observed with bicalutamide and fatal outcomes have been reported (see section 4.8). Bicalutamide therapy should be discontinued if changes are severe.
As there is no experience with the use of bicalutamide in patients with severe renal impairment (creatinine clearance < 30 ml/min), bicalutamide should only be used with caution in these patients.
Androgen deprivation therapy may prolong the QT interval. In patients with a history of or risk factors for QT prolongation and in patients receiving concomitant medicinal products that might prolong the QT interval (see section 4.5) physicians should assess the benefit risk ratio including the potential for Torsade de pointes prior to initiating bicalutamide.
Periodical monitoring of cardiac function is advisable in patients with heart disease.
For patients who have an objective progression of disease together with elevated PSA, cessation of bicalutamide therapy should be considered.
Bicalutamide has been shown to inhibit cytochrome P450 (CYP 3A4), as such caution should be exercised when co-administered with drugs metabolised predominantly by CYP 3A4 (see sections 4.3 and 4.5).
The 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
In vitro studies have shown that R- bicalutamide is an inhibitor of CYP 3A4, with lesser inhibitory effects on CYP 2C9, 2C19 and 2D6 activity.
Although clinical studies using antipyrine as a marker of cytochrome P450 (CYP) activity showed no evidence of a drug interaction potential with bicalutamide, mean midazolam exposure (AUC) was increased by up to 80%, after co-administration of bicalutamide for 28 days. For drugs with a narrow therapeutic index such an increase could be of relevance. As such, concomitant use of terfenadine, astemizole and cisapride is contraindicated (see section 4.3) and caution should be exercised with the co-administration of bicalutamide with compounds such as ciclosporin and calcium channel blockers. Dosage reduction may be required for these drugs particularly if there is evidence of enhanced or adverse drug effect. For ciclosporin, it is recommended that plasma concentrations and clinical condition are closely monitored following initiation or cessation of bicalutamide therapy.
Caution should be exercised when prescribing bicalutamide to patients taking medicinal products that inhibit the oxidation processes in the liver, e.g. cimetidine and ketoconazole. This could result in increased plasma concentrations of bicalutamide, which theoretically could lead to an increase in side effects.
In vitro studies have shown that bicalutamide can displace the coumarin anticoagulant, warfarin, from its protein binding site. It is therefore recommended that prothrombin time is closely monitored if bicalutamide is started in patients who are already receiving coumarin anticoagulants.
Since androgen deprivation treatment may prolong the QT interval, the concomitant use of bicalutamide with medicinal products known to prolong the QT interval or medicinal products able to induce Torsade de pointes such as class IA (e.g. quinidine, disopyramide) or class III (e.g. amiodarone, sotalol, dofetilide, ibutilide) antiarrhythmic medicinal products, methadone, moxifloxacin, antipsychotics, etc. should be carefully evaluated (see section 4.4).
4.6 Fertility, pregnancy and lactation
Bicalutamide is contraindicated in females and must not be given to pregnant women or nursing mothers.
4.7 Effects on ability to drive and use machines
Bicalutamide is unlikely to impair the ability of patients to drive or operate machinery. However, it should be noted that occasionally dizziness or somnolence may occur (see section 4.8). Any affected patients should exercise caution.
4.8 Undesirable effects
Very common (>1/10); common (>1/100 to <1/10); uncommon (>1/1,000 to <1/100); rare (>1/10,000 to <1/1,000); very rare (<1/10,000), not known (cannot be estimated from the available data).
Table 1 Frequency of Adverse Reactions
|
System Organ Class |
Frequency |
Undesirable effect |
|
Blood and Lymphatic system disorder |
Common |
Anaemia |
|
Very rare |
Thromb ocytop eni a | |
|
Nervous System Disorders |
Common |
Dizziness, insomnia, somnolence |
|
Vascular disorders |
Common |
Hot flush |
|
Gastrointestinal |
Common |
Abdominal pain, constipation, diarrhoea, |
|
disorders |
dyspepsia, flatulence, nausea | |
|
Uncommon |
Dry mouth, | |
|
Rare |
Vomiting | |
|
Skin and subcutaneous tissue disorders |
Very common |
Rash |
|
Common |
Alopecia, dry skina, hirsutism/ hair re-growth, pruritus, sweating | |
|
Renal and urinary disorders |
Common |
Haematuria |
|
Uncommon |
Nocturia | |
|
Reproductive system |
Very common |
Gynaecomastia and breast tendernessb |
|
and breast disorders |
impotence |
|
Common |
Erectile dysfunction | |
|
General disorders and administration site conditions |
Very common |
Asthenia |
|
Common |
Chest pain, chills, general pain, oedema, pelvic pain, | |
|
Metabolism and nutrition disorders |
Common |
Decreased appetite, diabetes mellitus, weight gain |
|
Uncommon |
Hyperglycaemia, weight loss | |
|
Psychiatric disorders |
Common |
Decreased libido, depression |
|
Cardiac disorders |
Very rare |
Heart failure, angina, conduction defects including PR and QT interval prolongation, arrhythmias and non specific ECG changes |
|
Hepatobiliary disorders |
Common |
Hepatotoxicity, jaundice, hypertransaminasaemiac |
|
Rare |
Hepatic failured (fatal outcomes have been reported) | |
|
Investigations |
Common Not known |
Weight increased QT prolongation (see sections 4.4 and 4.5) |
|
Immune system disorders |
Uncommon |
Hypersensitivity, angioedema, urticaria |
|
Respiratory, thoracic and mediastinal disorders |
Uncommon |
Interstitial lung diseasee (fatal outcomes have been reported), dyspnoea |
a. Due to the coding conventions used in the EPC studies, adverse events of ‘dry skin’ were coded under the COSTART term of ‘rash’. No separate frequency descriptor can therefore be determined for the 150 mg bicalutamide dose however the same frequency as the 50 mg dose is assumed.
b. The majority of patients receiving bicalutamide 150 mg as monotherapy experience gynaecomastia and/or breast pain. In studies, these symptoms were considered to be severe in up to 5% of the patients. Gynaecomastia may not resolve spontaneously following cessation of therapy, particularly after prolonged treatment.
c. Hepatic changes are rarely severe and were frequently transient, resolving or improving with continued therapy or following cessation of therapy
d. Listed as an adverse drug reaction following review of post-marketed data. Frequency has been determined from the incidence of reported adverse events of hepatic failure in patients receiving treatment in the open-label bicalutamide arm of the 150 mg EPC studies.
e. Listed as an adverse drug reaction following review of post-marketed data. Frequency has been determined from the incidence of reported adverse events of interstitial pneumonia in the randomised treatment period of the 150 mg EPC studies.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme; website: www.mhra.gov.uk/yellowcard
4.9 Overdose
There is no human experience of over dosage. There is no specific antidote; treatment should be symptomatic. Dialysis may not be helpful, since bicalutamide is highly protein bound and is not recovered unchanged in the urine. General supportive care, including frequent monitoring of vital signs, is indicated.
5 PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Hormone antagonists and related agents, anti-androgens ATC code: L02BB03.
Bicalutamide is a non-steroidal antiandrogen, devoid of other endocrine activity. It binds to the wild type or normal androgen receptor without activating gene expression, and thus inhibits the androgen stimulus. Regression of prostatic tumours results from this inhibition. Clinically, discontinuation of bicalutamide can result in antiandrogen withdrawal syndrome in a subset of patients.
Bicalutamide 150mg was studied as a treatment for patients with localised (T1-T2, N0 or NX, M0) or locally advanced (T3-T4, any N, M0; T1-T2, N+, M0) non-metastatic prostate cancer in a combined analysis of 3 placebo controlled double-blind studies in 8113 patients, where bicalutamide was given as immediate hormonal therapy or as adjuvant to radical prostatectomy or radiotherapy, (primarily external beam radiation). At 9.7 years median follow up, 36.6% and 38.17% of all bicalutamide and placebo-treated patients, respectively, had experienced objective disease progression.
A reduction in risk of objective disease progression was seen across most patient groups but was most evident in those at highest risk of disease progression. Therefore, clinicians may decide that the optimum medical strategy for a patient at low risk of disease progression, particularly in the adjuvant setting following radical prostatectomy, may be to defer hormonal therapy until signs that the disease is progressing.
No overall survival difference was seen at 9.7 years median follow up with 31.4% mortality (HR=1.01; 95% CI 0.94 to1.09). However, some trends were apparent in exploratory subgroup analyses.
Data on progression-free survival and overall survival over time based on Kaplan-Meier estimates for patients with locally advanced disease are summarised in the following tables:
Table 1 Proportion of locally advanced disease patients with disease progression over time by therapy sub-group
|
Analysis population |
Treatment Arm |
Events (%) at 3 years |
Events (%) at 5 years |
Events (%) at 7 years |
Events (%) at 10 years |
|
Watchful waiting (n=657) |
Bicalutamide 150 mg |
19.7% |
36.3% |
52.1% |
73.2% |
|
placebo |
39.8% |
59.7% |
70.7% |
79.1% | |
|
Radiotherapy (n=305) |
Bicalutamide 150 mg |
13.9% |
33.0% |
42.1% |
62.7% |
|
placebo |
30.7% |
49.4% |
58.6% |
72.2% | |
|
Radical prostatectomy (n=1719) |
Bicalutamide 150 mg |
7.5% |
14.4% |
19.8% |
29.9% |
|
placebo |
11.7% |
19.4% |
23.2% |
30.9% |
Table 2 Overall survival in locally advanced disease by therapy sub-group
|
Analysis population |
Treatment Arm |
Events (%) at 3 years |
Events (%) at 5 years |
Events (%) at 7 years |
Events (%) at 10 years |
|
Watchful waiting (n=657) |
Bicalutamide 150 mg |
14.2% |
29.4% |
42.2% |
65.0% |
|
placebo |
17.0% |
36.4% |
53.7% |
67.5% | |
|
Radiotherapy (n=305) |
Bicalutamide 150 mg |
8.2% |
20.9% |
30.0% |
48.5% |
|
placebo |
12.6% |
23.1% |
38.1% |
53.3% | |
|
Radical prostatectomy (n=1719) |
Bicalutamide 150 mg |
4.6% |
10.0% |
14.6% |
22.4% |
|
placebo |
4.2% |
8.7% |
12.6% |
20.2% |
For patients with localised disease receiving bicalutamide alone, there was no significant difference in progression free survival. There was no significant difference in overall survival in patients with localised disease who received bicalutamide as adjuvant therapy, following radiotherapy (HR=0.98; 95% CI 0.80 to 1.20) or radical prostatectomy (HR=1.03; 95% CI 0.85 to 1.25). In patients with localised disease, who would otherwise have been managed by watchful waiting, there was also a trend toward decreased survival compared with placebo patients (HR=1.15; 95% CI 1.00 to 1.32). In view of this, the benefit-risk profile for the use of bicalutamide is not considered favourable in patients with localised disease.
In a separate programme, the efficacy of bicalutamide 150 mg for the treatment of patients with locally advanced non-metastatic prostate cancer for whom immediate castration was indicated, was demonstrated in a combined analysis of 2 studies with 480 previously untreated patients with non-metastatic (M0) prostate cancer. At 56% mortality and a median follow-up of 6.3 years, there was no significant difference between bicalutamide and castration in survival (hazard ratio = 1.05 [CI 0.81 to 1.36]); however, equivalence of the two treatments could not be concluded statistically.
In a combined analysis of 2 studies with 805 previously untreated patients with metastatic (M1) disease at 43% mortality, bicalutamide 150 mg was demonstrated to be less effective than castration in survival time (hazard ratio = 1.30 [CI 1.04 to 1.65]), with a numerical difference in estimated time to death of 42 days (6 weeks) over a median survival time of 2 years.
Bicalutamide is a racemate with its antiandrogen activity being almost exclusively in the R-enantiomer.
5.2 Pharmacokinetic properties
Bicalutamide is well absorbed following oral administration. There is no evidence of any clinically relevant effect of food on bioavailability.
The (S)-enantiomer is rapidly cleared relative to the (R)-enantiomer, the latter having a plasma elimination half-life of about 1 week.
On daily administration of bicalutamide 150 mg, the (R)-enantiomer accumulates about 10fold in plasma as a consequence of its long half-life.
Steady state plasma concentrations of the (R)-enantiomer, of approximately 22 microgram/ml are observed during daily administration of bicalutamide 150 mg. At steady state, the predominantly active (R)-enantiomer accounts for 99% of the total circulating enantiomers.
The pharmacokinetics of the (R)-enantiomer are unaffected by age, renal impairment or mild to moderate hepatic impairment. There is evidence that for subjects with severe hepatic impairment, the (R)-enantiomer is more slowly eliminated from plasma.
Bicalutamide is highly protein bound (racemate to 96%, (R)-enantiomer > 99%) and extensively metabolised (by oxidation and glucuronidation); its metabolites are eliminated via the kidneys and bile in approximately equal proportions.
In clinical study the mean concentration of R-bicalutamide in semen of men receiving bicalutamide 150 mg was 4.9 pg/ml. The amount of bicalutamide potentially delivered to a female partner during intercourse is low and equates to approximately 0.3 pg/kg. This is below that required to induce changes in offspring of laboratory animals.
5.3 Preclinical safety data
Bicalutamide is a potent antiandrogen and a mixed oxidaze enzyme inducer in animals. Target organ changes, including tumor induction(Leydig cells, thyroid, liver) in animals are related to these activities. Enyzme induction has not been observed in man and none of these findings is considered to have relevance to the treatment of pacients with prostate cancer. Atrophy of seminiferous tubules is a predicted class effect with antiandrogens and has been observed for all species examined. Full reversal of testicular atrophy was 24 weeks after a 12 month repeated dose toxicity study in rats, although functional reversal was evident in reproduction 7
week after the end of an 11 week dosing period. A period of subfertility or infertility should be assumed in man.
6 PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Tablet core:
Lactose monohydrate,
Sodium starch glycolate (type A),
Povidone K-30,
Silica, colloidal anhydrous,
Magnesium stearate Film-coating:
Opadry II. White 33G28523 (Hypromellose, Titanium dioxide (E171), Lactose monohydrate, Macrogol 3350, Triacetin)
6.2 Incompatibilities
Not applicable.
6.3. Shelf life
5 years.
6.4 Special precautions for storage
This medicinal product does not require any special storage conditions.
6.5 Nature and contents of container
10, 14, 20, 28, 30, 40, 50, 56, 80, 84, 90, 100, 140, 200, 280film-coated tablets in blister packs (PVC/PVDC/ aluminium foil)
Not all pack sizes may be marketed.
6.6 Special precautions for disposal
No special requirements.
7
MARKETING AUTHORISATION HOLDER
Arrow Generics Limited Whiddon Valley, Barnstaple,
Devon,
EX32 8NS United Kingdom
8 MARKETING AUTHORISATION NUMBER(S)
PL: 18909/0230
9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
16/07/2008
10 DATE OF REVISION OF THE TEXT
25/02/2015