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SUMMARY OF PRODUCT CHARACTERISTICS

1 NAME OF THE MEDICINAL PRODUCT

Etoposide 20mg/ml Concentrate for Solution for Infusion

2 QUALITATIVE AND QUANTITATIVE COMPOSITION

1 ml of concentrate for solution for infusion contains 20 mg of etoposide.

One vial of 5 ml concentrate for solution for infusion contains 100 mg of etoposide.

Excipients with known effect:

1 ml of concentrate for solution for infusion contains 158 mg ethanol.

One vial of 5 ml concentrate for solution for infusion contains 790 mg ethanol.

For the full list of excipients, see section 6.1.

3 PHARMACEUTICAL FORM

Concentrate for solution for infusion.

Clear, pale yellow solution, slightly viscous, free from visible particles

The pH is between 3,0 and 4,0

The osmoloarity is > 2000 mOsmol/L.

4    CLINICAL PARTICULARS

4.1    Therapeutic indications

Etoposide is indicated in combination with other chemotherapeutic agents for the treatment of:

-    testicular tumours

-    small cell lung cancer

-    monoblastic leukaemia (AML M5) and acute myelomonoblastic leukaemia (AML M4) when standard therapy has failed

4.2 Posology and method of administration

Administration precautions

Etoposide should only be administered under strict observation by a doctor specialised in oncology, preferable in institutions specialised in such therapies.

Etoposide 20 mg/ml concentrate for solution for infusion is to be diluted before administration. For instructions on dilution of the product before administration see section 6.6.

Etoposide is intended for slow intravenous infusion only. Etoposide must not be given by rapid intravenous injection.

Hypotension following rapid intravenous administration has been reported. Hence it is recommended that the etoposide solution be administered over a 30- to 60-minute period. Longer infusion times may be required based on patient tolerance.

Posology

The usual dose of etoposide, in combination with other approved chemotherapeutic agents, ranges from 60 - 120 mg/m²/day for 3-5 days. Chemotherapy courses are repeated at 2- to 4-week intervals after adequate recovery from any toxicity.

Overall, a dosage schedule of 100 mg/m²/day on days 1 through 5 or 120 mg/m²/day on days 1, 3, and 5 is used most frequently.

Generally 3 to 4 chemotherapy cycles are administered. Dose and amount of cycles should be adjusted to the level of bone marrow suppression and the reaction of the tumour.

Dose adjustments

Dosage of etoposide should be modified to take into account the myelosuppressive effects of other drugs in the combination or the effects of prior x-ray therapy or chemotherapy which may have compromised bone marrow reserve.

Patients should not begin a new cycle of treatment with etoposide if the neutrophil count is less than 1,500 cells/mm³ or the platelet count is less than 100,000 cells/mm³, unless caused by malignant disease.

Doses subsequent to the initial dose should be adjusted if neutrophil count less than 500 cells/mm³ occurs for more than 5 days or is associated with fever or infection, if platelet count less than 25,000 cells/mm³ occurs, if any other grade 3 or 4 toxicity develops or if renal clearance is less than 50 ml/min.

Special populations

Patients with renal impairment

In patients with impaired renal function, the following initial dose modification should be considered based on measured creatinine clearance.

Measured creatinine clearance	Dose of etoposide
>50 ml/min	100% of dose
15-50 ml/min	75% of dose

Subsequent dosing should be based on patient tolerance and clinical effect. Data are not available in patients with creatinine clearance <15 ml/min and further dose reductions should be considered in these patients.

Patients with hepatic impairment

Patients with impaired hepatic function should regularly have their hepatic function monitored due to the risk of accumulation (see section 4.4).

Elderly

Dose adjustment is not necessary.

Paediatric population

Safety and efficacy in children and adolescents have not been established. Therefore etoposide is not recommended for use in this age group.

Method of administration

Etoposide concentrate for solution for infusion 20 mg/ml must be diluted immediately prior to use with either 5% glucose or 0.9% sodium chloride solution to give a concentration range from 0.2 to 0.4 mg/ml, usually not more than 0.25 mg/ml for the final concentration. At higher concentrations precipitation of etoposide may occur.

Etoposide is intended for slow intravenous infusion only. Etoposide should not be given by rapid intravenous injection. To prevent the occurrence of hypotension, the infusion should be given over at least 30 minutes.

For instructions on dilution of the medicinal product before administration, see section 6.6.

Precautions to be taken before handling or administering the medicinal product

As with other potentially toxic compounds, caution should be exercised in handling and preparing the solution of etoposide. Skin reactions associated with accidental exposure to etoposide may occur. The use of gloves is recommended. If etoposide solution contacts the skin or mucosa, immediately wash the skin or mucosa thoroughly with soap and water.

Pregnant personnel should not handle chemotherapeutic agents.

4.3 Contraindications

Hypersensitivity to the active substance, podophyllotoxins or podophyllotoxin-derivatives or to any of the excipients listed in section 6.1.

Concomitant use of yellow fever vaccine or other live vaccines is contraindicated in immunosuppressed patients (see section 4.5). Intra-arterial and intracavitary injection.

4.4 Special warnings and precautions for use

Etoposide should be administered under the supervision of a qualified physician experienced in the use of cancer chemotherapeutic agents. Injection site reactions may occur during the administration of etoposide. Given the possibility of extravasation, it is recommended to closely monitor the infusion site for possible infiltration during drug administration. A specific treatment for extravasation reactions is unknown at this time.

Severe myelosuppression with resulting infection or bleeding may occur. Fatal myelosuppression has been reported following etoposide administration. Patients being treated with etoposide must be observed for myelosuppression carefully and frequently both during and after therapy. Dose limiting bone marrow suppression is the most significant toxicity associated with etoposide therapy. The following studies should be obtained at the start of therapy and prior to each subsequent dose of etoposide: platelet count, haemoglobin, white blood cell count and differential. If radiotherapy or chemotherapy has been given prior to starting etoposide treatment, an adequate interval should be allowed to enable the bone marrow to recover.

Etoposide should not be administered to patients with neutrophil counts less than 1,500 cell/mm³ or platelet counts less than 100,000 cells/mm³, unless caused by malignant disease.

Doses subsequent to the initial dose should be adjusted if neutrophil count less than 500 cells/mm³ occurs for more than 5 days or is associated with fever or infection, if platelet count less than 25,000 cells/mm³ occurs, if any other grade 3 or 4 toxicity develops or if renal clearance is less than 50 ml/min. Dosage should be modified to take into account the myelosuppressive effects of other drugs in the combination or the effects of prior radiation therapy or chemotherapy which may have compromised bone marrow reserve.

The occurrence of acute leukaemia, which can occur with or without myelodysplastic syndrome, has been described in patients that were treated with etoposide containing chemotherapeutic regimens.

Neither the cumulative risk, nor the predisposing factors related to the development of secondary leukaemia are known. The roles of both administration schedules and cumulative doses of etoposide have been suggested, but have not been clearly defined.

An 11q23 chromosome abnormality has been observed in some cases of secondary leukaemia in patients who have received epipodophyllotoxins. This abnormality has also been seen in patients developing secondary leukaemia after being treated with chemotherapy regimens not containing epipodophyllotoxins and in leukaemia occurring de novo. Another characteristic that has been associated with secondary leukaemia in patients who have received epipodophyllotoxins appears to be a short latency period, with average median time to development of leukaemia being approximately 32 months.

Physicians should be aware of the possible occurrence of an anaphylactic reaction with etoposide, manifested by chills, fever, tachycardia, bronchospasm, dyspnoea and hypotension, which can be fatal. Treatment is symptomatic. The infusion should be terminated immediately, followed by the administration of pressor agents, corticosteroids, antihistamines, or volume expanders at the discretion of the physician.

Etoposide should be given only by slow intravenous infusion (usually over a 30 to 60 minute period) since hypotension has been reported as a possible side effect of rapid intravenous injection.

In all instances where the use of etoposide is considered for chemotherapy, the physician must evaluate the need and usefulness of the drug against the risk of adverse reactions (see section 4.8). Most such adverse reactions are reversible if detected early. If severe reactions occur, the drug should be reduced in dosage or discontinued and appropriate corrective measures should be taken according to the clinical judgment of the physician. Reinstitution of etoposide therapy should be carried out with caution, and with adequate consideration of the further need for the drug and close attention to possible recurrence of toxicity.

Patients with a low serum albumin concentration may have an increased risk of etoposide toxicity. Patients with impaired hepatic and renal function should regularly have their renal and hepatic function monitored due to the risk of accumulation.

Bacterial infections should be treated before the start of the therapy with etoposide. Great care should be taken on giving etoposide to patients who have, or have been exposed to infection with herpes zoster.

Given the mutagenic potential of etoposide, an effective contraception is required for both male and female patients during treatment and up to 6 months after ending treatment. Genetic consultation is recommended if the patient wishes to have children after ending the treatment. As etoposide may decrease male fertility, preservation of sperm may be considered for the purpose of later fatherhood (see section 4.6).

This medicinal product contains 19.5%v/v ethanol. Each 5 ml vial contains up to 0.79 g of ethanol. This can be harmful for those suffering from liver disease, alcoholism, epilepsy, brain injury or disease as well as for children and pregnant women. Alcohol also may modify or increase the effect of other medicines.

Paediatric population

Safety and effectiveness of etoposide in paediatric patients have not been systematically studied.

4.5 Interaction with other medicinal products and other forms of interaction

High dose ciclosporin, resulting in concentrations above 2000 ng/ml, administered with oral etoposide has led to an 80% increase in etoposide exposure (AUC) with a 38% decrease in total body clearance of etoposide compared to etoposide alone.

Concomitant cisplatin therapy is associated with reduced total body clearance of etoposide.

Concomitant phenytoin therapy is associated with increased etoposide clearance and reduced efficacy.

Concomitant warfarin therapy may result in elevated international normalized ratio (INR). Close monitoring of INR is recommended.

There is increased risk of fatal systemic vaccinal disease with the use of yellow fever vaccine. Live vaccines are contraindicated in immunosuppressed patients (see section 4.3).

Prior or concurrent use of other drugs with similar myelosuppressant action as etoposide/etoposide phosphate may be expected to have additive or synergetic effects (see section 4.4).

In vitro plasma protein binding is 97%. Phenylbutazone, sodium salicylate, and aspirin may displace etoposide from plasma protein binding.

Cross-resistance between anthracyclines and etoposide has been reported in preclinical experiments.

4.6 Fertility, pregnancy and lactation

Pregnancy

Etoposide can cause fetal harm when administered to pregnant women. Etoposide has been shown to be teratogenic in mice and rats (see section 5.3). There are no adequate and well-controlled studies in pregnant women. Women of childbearing potential should be advised to avoid becoming pregnant and to take effective contraceptive measures during treatment with etoposide. If etoposide is used during pregnancy, or if the patient becomes pregnant while receiving the medicine, the patient should be informed of the potential hazard to the fetus.

Breastfeeding

It is not known whether etoposide is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from etoposide, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

Fertility

Given the mutagenic potential of etoposide, an effective contraception is required for both male and female patients during treatment and up to 6 months after ending treatment. Genetic consultation is recommended if the patient wishes to have children after ending the treatment. As etoposide may decrease male fertility, preservation of sperm may be considered for the purpose of later fatherhood.

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 with etoposide. If the patient experiences side effects such as fatigue and somnolence they should avoid driving or operating machines.

disorders
Gastrointestinal disorders	Very common	Abdominal pain, constipation, nausea and vomiting, anorexia
	Common	Mucositis (including stomatitis and esophagitis), diarrhoea
	Rare	Dysphagia, dysgeusia
Hepato-biliary disorders	Very common	Hepatotoxicity
Skin and subcutaneous tissue disorders	Very common	Alopecia, pigmentation
	Common	Rash, urticaria, pruritus
	Rare	Stevens-Johnson syndrome, toxic epidermal necrolysis, radiation recall dermatitis
General disorders and administration site conditions	Very common	Asthenia, malaise
	Common	Extravasation****, phlebitis
* Myelosuppression with fatal outcome has been reported. ** Anaphylactic-type reactions can be fatal. *** Seizure is occasionally associated with allergic reactions. **** Postmarketing complications reported for extravasation included local soft tissue toxicity, swelling, pain, cellulitis, and necrosis including skin necrosis.

Description of selected adverse reactions

In the paragraphs below the incidences of adverse events, given as the mean percent, are derived from studies that utilized single agent etoposide therapy.

Haematological toxicity

Myelosuppression with fatal outcome has been reported following administration of etoposide. Myelosuppression is most often dose-limiting. Bone marrow recovery is usually complete by day 20, and no cumulative toxicity has been reported.

Granulocyte and platelet nadirs tend to occur about 10-14 days after administration of etoposide or etoposide phosphate depending on the way of administration and treatment scheme. Nadirs tend to occur earlier with intravenous administration compared to oral administration.

Leukopenia and severe leukopenia (less than 1,000 cells/mm ) were observed in 60 - 91% and 7 - 17%, respectively, for etoposide/etoposide phosphate. Thrombocytopenia and severe thrombocytopenia (less than 50,000 platelets/mm³) were seen in 28 - 41% and 4 - 20%, respectively, for etoposide/etoposide phosphate. Reports of fever and infection were also very common in patients with neutropenia treated with etoposide/etoposide phosphate.

Gastrointestinal toxicity

Nausea and vomiting are the major gastrointestinal toxi cities of etoposide. The nausea and vomiting can usually be controlled by antiemetic therapy. They have been noted in 31 - 43% of patients given intravenous etoposide.

Anorexia was seen in 10 - 13% of patients and stomatitis in 1 - 6% of those patients given intravenous etoposide. Diarrhoea was noted in 1 - 13% of these patients.

Alopecia

Reversible alopecia, sometimes progressing to total baldness, has been observed in up to 66% of patients treated with etoposide and 44% of patients treated with etoposide phosphate.

Blood_pressure changes Hypotension

Transient hypotension following rapid intravenous administration has been reported in patients treated with etoposide and has not been associated with cardiac toxicity or electrocardiographic changes. Hypotension usually responds to cessation of infusion of etoposide and/or other supportive therapy as appropriate. When restarting the infusion, a slower administration rate should be used.

No delayed hypotension has been noted.

Hypertension

In clinical studies involving etoposide, episodes of hypertension have been reported. If clinically significant hypertension occurs in patients receiving etoposide, appropriate supportive therapy should be initiated.

Allergic reactions

Anaphylactic-type reactions have also been reported to occur during or immediately after intravenous administration of etoposide. The role that concentration or rate of infusion plays in the development of anaphylactic-type reactions is uncertain. Blood pressure usually normalizes within a few hours after cessation of the infusion. Anaphylactic-type reactions can occur with the initial dose of etoposide.

Acute fatal reactions associated with bronchospasm have been reported with etoposide. Facial flushing was reported in 2% of patients and skin rashes in 3% treated with etoposide phosphate.

Metabolic complications

Tumour lysis syndrome (sometimes fatal) has been reported following the use of etoposide in association with other chemotherapeutic drugs.

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 Yellow Card Scheme Website: www.mhra.gov.uk/yellowcard

4.9 Overdose

2 2

Total doses of 2.4 g/m to 3.5 g/m administered intravenously over three days have resulted in severe mucositis and myelotoxicity. Metabolic acidosis and cases of serious hepatic toxicity have been reported in patients receiving higher than recommended intravenous doses of etoposide.

A specific antidote is not available. Treatment should therefore be symptomatic and supportive, and patients should be closely monitored.

5 PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Podophyllotoxin derivatives, ATC code: L01CB01

Etoposide is a semisynthetic derivative of podophyllotoxin used in the treatment of certain neoplastic diseases. Podophyllotoxins inhibit mitosis by blocking microtubular assembly. Etoposide inhibits cell cycle progression at a premitotic phase (late S and G₂).

It does not interfere with the synthesis of nucleonic acids.

5.2 Pharmacokinetic properties

The concentration of etoposide in blood and organs is low with maximum values in the liver and the kidneys. Protein binding could be as high as 98%.

On intravenous administration, the disposition of etoposide is best described as a biphasic process with an initial half-life of about 1.5 hours. After distribution, halflife is about 40 hours. The terminal half-life is 6 - 8 hours.

Following a single intravenous dose etoposide is excreted in the urine for about 63% and in the faeces for about 31% after 80 hours.

Etoposide is cleared by both renal and non-renal processes i.e. metabolism and biliary excretion. In patients with renal dysfunction plasma etoposide clearance is decreased. In adults, the total body clearance of etoposide is correlated with creatinine clearance, serum albumin concentration and non-renal clearance. In children, elevated serum ALT levels are associated with reduced drug total body clearance. Prior use of cisplatin may result in a decrease of etoposide total body clearance.

5.3 Preclinical safety data

Etoposide was embryotoxic and teratogenic in animal experiments. Etoposide was genotoxic in in vitro and in vivo tests. No conventional carcinogenicity studies have been conducted, but based on its genotoxic properties, etoposide is considered to be a potential carcinogen.

6.1 List of excipients

Macrogol 400 Polysorbate 80 Ethanol, anhydrous

Citric acid, anhydrous (for pH adjustment)

6.2 Incompatibilities

Plastic devices made of acrylic or ABS polymers have been reported to crack when used with undiluted Etoposide 20 mg/ml concentrate for solution for infusion. This effect has not been reported with etoposide after dilution of the concentrate for solution for infusion according to instructions.

The intravenous solution is suitable for infusion only in glass and PVC containers.

Etoposide should not be physically mixed with any other medicinal product.

6.3 Shelf life

Before opening: 3 years

After dilution:

Chemical and physical in-use stability has been demonstrated for the diluted solution 0.2 mg etoposide/ml for 96 hours and for the diluted solution 0.4 mg etoposide/ml for 24 hours at 25°C, without any special protection from light.

From a microbiological point of view, the product should always be used immediately after dilution.

6.4 Special precautions for storage

Do not store above 25°C. Do not refrigerate or freeze. If the solution is not clear or an undissolvable precipitate is formed the solution must not be used.

Keep the vial in the outer carton in order to protect from light.

For the storage conditions after dilution of the medicinal product, see section 6.3. Do not store diluted solutions in the refrigerator or freezer.

Solutions showing any sign of precipitation should not be used.

6.5 Nature and contents of container

Each vial contains 5 ml concentrate for solution for infusion.

Etoposide is contained in 8 ml Type I colourless glass vial with bromobutyl rubber stop and sealed with aluminium metallic cap with flip off.

The vial is packed with a protective plastic overwrap.

Pack sizes: 1 or 10 vials per carton.

Not all pack sizes may be marketed.

6.6 Special precautions for disposal

Preparation and handling of the product

Etoposide should not be used without diluting.

Etoposide concentrate for solution for infusion 20 mg/ml must be diluted immediately prior to use with either 5% glucose or 0.9% sodium chloride solution to give a final concentration of 0.2 to 0.4 mg/ml, usually not more than 0.25 mg/ml. At higher concentrations precipitation of etoposide may occur.

Etoposide needs to be diluted with volumes ranging from 250-1,000 ml, based on the individual dosage. Care should be taken not to exceed the final concentration of 0.4 mg/ml.

Examples of approximate volumes of diluent needed for different dose ranges:

Amount of etoposide (mg)	Amount of solution needed to prepare the dilution (ml)
<100 mg	250 ml
101 mg to 200 mg	500 ml
>200 mg	750 - 1000 ml

Solutions showing any signs of precipitation should not be used.

Etoposide should not be physically mixed with any other medicinal product.

The intravenous solution is suitable for infusion only in glass and PVC containers.

Gloves should be worn during administration. Waste-disposal procedures should take into account the cytotoxic nature of this substance.

If Etoposide contacts skin, mucosae or eyes, immediately wash thoroughly with water. Soap may be used for skin cleansing.

Any contact with the fluid should be avoided. During preparation and reconstitution a strictly aseptic working technique should be used; protective measures should include the use of gloves, mask, safety goggles and protective clothing. Use of vertical laminar airflow (LAF) hood is recommended.

Pregnant personnel should not handle chemotherapeutic agents.

Disposal

For waste-disposal and safety information, guidelines on safe handling of antineoplastic drugs should be followed.

7 MARKETING AUTHORISATION HOLDER

Caduceus Pharma Ltd

6^th Floor 94 Wigmore Streeet

London

W1U3RF

United Kingdom

8    MARKETING AUTHORISATION NUMBER(S)

PL 24668/0127

9    DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

25/07/2014

10    DATE OF REVISION OF THE TEXT

25/07/2014