Oxaliplatin Hospira 5 Mg/Ml Concentrate For Solution For Infusion
SUMMARY OF PRODUCT CHARACTERISTICS
1
NAME OF THE MEDICINAL PRODUCT
Oxaliplatin Hospira 5 mg/ml Concentrate for Solution for Infusion
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
One ml of concentrate for solution for infusion contains 5 mg oxaliplatin.
10 ml of concentrate for solution for infusion contains 50 mg of oxaliplatin. 20 ml of concentrate for solution for infusion contains 100 mg of oxaliplatin. 40 ml of concentrate for solution for infusion contains 200 mg of oxaliplatin.
For the full list of excipients, see section 6.1.
3 PHARMACEUTICAL FORM
Concentrate for solution for infusion. Clear, colourless solution.
4 CLINICAL PARTICULARS
4.1 Therapeutic indications
Oxaliplatin in combination with 5-fluorouracil (5-FU) and folinic acid (FA) is indicated for:
• Adjuvant treatment of stage III (Duke’s C) colon cancer after complete resection of primary tumour
• Treatment of metastatic colorectal cancer.
Oxaliplatin is indicated in adults only.
4.2 Posology and method of administration
The preparation of injectable solutions of cytotoxic agents must be carried out by trained specialist personnel with knowledge of the medicinal product used, in conditions that guarantee the integrity of the medicinal product, the protection of the environment and in particular the protection of the personnel handling the medicinal products, in accordance with hospital policy. It requires a preparation area reserved for this purpose. It is forbidden to smoke, eat or drink in this area (see section 6.6).
Posology
FOR ADULTS ONLY
The recommended dose for oxaliplatin in adjuvant setting is 85 mg/m2 intravenously repeated every 2 weeks for 12 cycles (6 months).
The recommended dose for oxaliplatin in treatment of metastatic colorectal cancer is 85 mg/m2 intravenously repeated every 2 weeks.
Dosage given should be adjusted according to tolerability (see section 4.4).
Oxaliplatin should always be administered before fluoropyrimidines - i.e. 5-fluorouracil.
Oxaliplatin is administered as a 2- to 6-hour intravenous infusion in 250 to 500 ml of glucose 5% solution (50 mg/ml) to give a concentration between 0.2 mg/ml and 0.70 mg/ml; 0.70 mg/ml is the highest concentration in clinical practice for an oxaliplatin dose of 85 mg/m2.
Oxaliplatin was mainly used in combination with continuous infusion 5-fluorouracil based regimens. For the two-weekly treatment schedule 5-fluorouracil regimens combining bolus and continuous infusion were used.
Special Populations
- Renal impairment:
Oxaliplatin has not been studied in patients with severe renal impairment (See section 4.3).
In patients with moderate renal impairment, treatment may be initiated at the normally recommended dose (see section 4.4). There is no need for dose adjustment in patients with mild renal dysfunction.
- Hepatic impairment:
In a phase I study including patients with several levels of hepatic impairment, frequency and severity of hepatobiliary disorders appeared to be related to progressive disease and impaired liver function tests at baseline. No specific dose adjustment for patients with abnormal liver function tests was performed during clinical development.
- Elderly patients:
No increase in severe toxicities was observed when oxaliplatin was used as a single agent or in combination with 5-fluorouracil in patients over the age of 65. In consequence no specific dose adaptation is required for elderly patients.
- Paediatric Population:
There is no relevant indication of Oxaliplatin in children. The effectiveness of oxaliplatin as single agent in the paediatric populations with solid tumors has not been established (see section 5.1).
Method of administration
Oxaliplatin is administered by intravenous infusion.
The administration of oxaliplatin does not require hyperhydration.
Oxaliplatin diluted in 250 to 500 ml of glucose 5% solution (50 mg/ml) to give a concentration not less than 0.2 mg/ml must be infused either via a peripheral vein or central venous line over 2 to 6 hours. Oxaliplatin infusion must always precede that of 5-fluorouracil.
In the event of extravasation, administration must be discontinued immediately. Instructions for use:
Oxaliplatin must be diluted before use. Only 5% glucose diluent is to be used to dilute the concentrate for solution for infusion product. (See section 6.6).
4.3 Contraindications
Oxaliplatin is contraindicated in patients who
- have hypersensitivity to oxaliplatin or to any of the excipient listed in section 6.1.
- are breast feeding.
- have myelosuppression prior to starting first course, as evidenced by baseline neutrophils <2x109/l and/or platelet count of <100x109l.
- have a peripheral sensory neuropathy with functional impairment prior to first course.
- have a severely impaired renal function (creatinine clearance less than 30 ml/min).
4.4
Special warnings and precautions for use
Oxaliplatin should only be used in specialised departments of oncology and should be administered under the supervision of an experienced oncologist.
Renal function
Due to limited information on safety in patients with moderately impaired renal function, administration should only be considered after suitable appraisal of the benefit/risk for the patient. In this situation, renal function should be closely monitored and dose adjusted according to toxicity.
History of allergic reaction
Patients with a history of allergic reaction to platinum compounds should be monitored for allergic symptoms. In case of an anaphylactic-like reaction to oxaliplatin, the infusion should be immediately discontinued and appropriate symptomatic treatment initiated. Oxaliplatin rechallenge is contra-indicated.
Extravasation
In case of oxaliplatin extravasation, the infusion must be stopped immediately and usual local symptomatic treatment initiated.
Neurological toxicity
Neurological toxicity of oxaliplatin should be carefully monitored, especially if coadministered with other medicinal products with specific neurological toxicity. A neurological examination should be performed before each administration and periodically thereafter.
Laryngopharyngeal dysaesthesia
For patients who develop acute laryngopharyngeal dysaesthesia (see section 4.8), during or within the hours following the 2-hour infusion, the next oxaliplatin infusion should be administered over 6 hours.
Neurological symptoms
If neurological symptoms (paraesthesia, dysaesthesia) occur, the following recommended oxaliplatin dosage adjustment should be based on the duration and severity of these symptoms:
- If symptoms last longer than seven days and are troublesome, the subsequent oxaliplatin dose should be reduced from 85 to 65 mg/m2 (metastatic setting) or 75 mg/m (adjuvant setting).
- If paraesthesia without functional impairment persists until the next cycle, the subsequent oxaliplatin dose should be reduced from 85 to 65 mg/m2(metastatic setting) or 75 mg/m (adjuvant setting).
- If paraesthesia with functional impairment persists until the next cycle, oxaliplatin should be discontinued.
- If these symptoms improve following discontinuation of oxaliplatin therapy, resumption of therapy may be considered.
Peripheral sensory neuropathy
Patients should be informed of the possibilities of persistent symptoms of peripheral sensory neuropathy after the end of the treatment. Localised moderate parasthesias or parasthesias that may interfere with functional activities can persist after up to 3 years following treatment cessation in the adjuvant setting.
Reversible Posterior Leukoencephalopathy Syndrome (RPLS)
Cases of Reversible Posterior Leukoencephalopathy Syndrome (RPLS also known as PRES, Posterior Reversible Encephalopathy Syndrome) have been reported in patients receiving oxaliplatin in combination chemotherapy. RPLS is a rare, reversible, rapidly evolving neurological condition, which can include seizure, hypertension, headache, confusion, blindness, and other visual and neurological disturbances (see section 4.8). Diagnosis of RPLS is based upon confirmation by brain imaging, preferably MRI (Magnetic Resonance Imaging).
Gastrointestinal toxicity
Gastrointestinal toxicity, which manifests as nausea and vomiting, warrants prophylactic and/or therapeutic anti-emetic therapy (see section 4.8).
Dehydration, paralytic ileus, intestinal obstruction, hypokalemia, metabolic acidosis and renal impairment may be caused by severe diarrhoea/emesis particularly when combining oxaliplatin with 5-fluorouracil.
Haemtological toxicity
If haematological toxicity occurs (neutrophils < 1.5x109/l or platelets < 50x109/l), administration of the next course of therapy should be postponed until haematological values return to acceptable levels. A full blood count with white cell differential should be performed prior to start of therapy and before each subsequent course.
Patients must be adequately informed of the risk of diarrhoea/emesis, mucositis/stomatitis and neutropenia after oxaliplatin and /5-fluorouracil administration so that they can urgently contact their treating physician for appropriate management. If mucositis/stomatitis occurs with or without neutropenia, the next treatment should be delayed until recovery from mucositis/stomatitis to grade 1 or less and/or until the neutrophil count is > 1.5 x 109/l.
For oxaliplatin combined with 5-fluorouracil (with or without folinic acid), the usual dose adjustments for 5-fluorouracil associated toxicities should apply.
If grade 4 diarrhoea, grade 3-4 neutropenia (neutrophils < 1.0x109/l), grade 3-4 thrombocytopenia (platelets < 50x109/l) occur, the dose of oxaliplatin should be reduced from 85 to 65 mg/m2 (metastatic setting) or 75 mg/m2 (adjuvant setting), in addition to any 5-fluorouracil dose reductions required.
Respiratory symptoms
In the case of unexplained respiratory symptoms such as non-productive cough, dyspnoea, crackles or radiological pulmonary infiltrates, oxaliplatin should be discontinued until further pulmonary investigations exclude an interstitial lung disease or pulmonary fibrosis (see section 4.8).
Hepatic Toxicity
In cases of abnormal test results of liver function or portal hypertension, which does not obviously result from liver metastases, very rare cases of drug induced hepatic vascular disorder should be considered.
4.5 Interaction with other medicinal products and other forms of interaction
In patients who have received a single dose of 85 mg/m2 of oxaliplatin, immediately before administration of 5-fluorouracil, no change in the level of exposure to 5-fluorouracil has been observed.
In vitro, no significant displacement of oxaliplatin binding to plasma proteins has been observed with the following agents: erythromycin, salicylates, granisetron, paclitaxel, and sodium valproate.
4.6 Fertility, pregnancy and lactation
Pregnancy
To date there is no available information on safety of use in pregnant women. In animal studies, reproductive toxicity was observed. Consequently oxaliplatin is not recommended during pregnancy and in women of childbearing potential not using contraceptive measures.
The use of oxaliplatin should only be considered after suitably appraising the patient of the risk to the foetus and with the patient’s consent.
Women should not become pregnant during treatment with oxaliplatin and should use an effective method of contraception. Genotoxic effects were observed with oxaliplatin in the preclinical studies. Therefore male patients treated with oxaliplatin are advised not to father a child during and up to 6 months after treatment and to seek advice on conservation of sperm prior to treatment.
Women of childbearing potential/Contraception in males and females Appropriate contraceptive measures must be taken during and after cessation of therapy during 4 months for women and 6 months for men.
Breastfeeding
Excretion in breast milk has not been studied. Breast-feeding is contra-indicated during oxaliplatin therapy.
Fertility
Oxaliplatin may have an anti-fertility effect which could be irreversible.
4.7 Effects on ability to drive and use machines
No studies on the effects on the ability to drive and use machinery have been performed. However, oxaliplatin treatment resulting in an increased risk of dizziness, nausea and vomiting, and other neurological symptoms that affect gait and balance may lead to a minor or moderate influence on the ability to drive and use machines.
4.8 Undesirable effects
The most frequent adverse events of oxaliplatin in combination with 5-fluorouracil/folinic acid (5-FU/FA) were gastrointestinal (diarrhoea, nausea, vomiting and mucositis), haematological (neutropenia, thrombocytopenia) and neurological (acute and dose cumulative peripheral sensory neuropathy). Overall these adverse events were more frequent and severe with oxaliplatin and 5-FU/FA combination than with 5-FU/FA alone.
The frequencies reported in the table below are derived from clinical trials in the metastatic and adjuvant settings (having included 416 and 1108 patients respectively in the oxaliplatin + 5-FU/FA treatment arms) and from post marketing experience.
Frequencies in this table are defined using the following convention: very common (>1/10), common (> 1/100 to < 1/10), uncommon (> 1/1000 to < 1/100), rare (> 1/10000 to < 1/1000), very rare (< 1/10000) not known (cannot be estimated from the available data).
Further details are given after the table.
|
MedDRA Organ System Class |
Very common |
Common |
Uncommon |
Rare |
Unknown |
|
Infections and infestations* |
- Infection |
- Rhinitis - Upper respiratory tract infection - Neutropenic sepsis. | |||
|
Blood and lymphatic system disorders* |
- Anaemia -Neutropenia -Thrombocytopenia - Leukopenia - Lymphopenia |
- Febrile neutropenia |
Autoimmune thrombocyto penia - Haemolytic anaemia |
Autoimmu ne pancytope nia | |
|
Immune system disorders* |
- Allergy/allergic reaction+ | ||||
|
Metabolism and nutrition disorders |
- Anorexia - Glycaemia alterations - Hypokalaemia - Natremia alterations |
- Dehydration |
- Metabolic acidosis | ||
|
Psychiatric disorders |
- Depression -Insomnia |
Nervousness | |||
|
Nervous system disorders* |
- Peripheral sensory neuropathy - Sensory disturbance - Dysgeusia - Headache |
- Dizziness - Motor neuritis - Meningism |
- Dysarthria - Reversible Posterior Leukoencep halopathy syndrome (RPLC or PRES)** (see section 4.4) | ||
|
Eye disorders |
Conjunctivitis - Visual disturbances |
-Transient vision loss (reversible, following therapy discontinuati on) |
- Visual acuity reduced transiently - Visual field disturbance - Optic neuritis | ||
|
Ear and labyrinth disorders |
- Ototoxicity |
- Deafness | |||
|
Vascular disorders |
- Epistaxis |
Haemorrhage - Flushing - Deep vein thrombosis - Pulmonary embolism | |||
|
Respiratory, thoracic and medistinal disorders |
- Dyspnoea - Coughing |
- Hiccups |
- Interstitial lung disease - Pulmonary fibrosis** | ||
|
Gastointestinal |
- Nausea |
- Dyspepsia |
- Ileus |
- Colitis |
|
disorders* |
- Diarrhoea - Vomiting - Stomatitis/ mucositis - Abdominal pain - Constipation |
Gastroesophag eal reflux - Rectal haemorrhage Gastrointestin al haemorrhage |
- Intestinal obstruction |
including Clostridium difficile diarrhoea -Pancreatitis | |
|
Hepato-biliary disorders |
-Hepatic enzyme increase - Blood bilirubin increase | ||||
|
Skin and subcutaneous tissue disorders |
- Skin disorder - Alopecia |
- Skin exfolation (i.e Hand and Foot syndrome) - Rash erythematous - Rash Hyperhidrosis - Nail disorder |
Hyper sensitivity vasculitis | ||
|
Musculo skeletal, connective tissue disorders |
- Back pain |
- Arthralgia - Bone pain | |||
|
Renal and urinary disorders |
- Dysuria - Micturition frequency abnormal - Haematuria - Blood Creatinine increase | ||||
|
General disorders and administration site conditions |
- Fatigue - Fever++ - Asthenia - Pain - Injection site reaction+++ Rigors | ||||
|
Investigations |
- Blood alkaline phosphatase increase - Blood lactate dehydrogenase increase - Weight increase (adjuvant setting) |
- Weight decrease (metastatic setting) |
* See detailed section below ** See section 4.4
+ Very common allergies/allergic reactions, occurring mainly during infusion, sometimes fatal. Common allergic reactions such as skin rash (particularly urticaria), conjunctivitis, rhinitis. Common anaphylactic reactions, including bronchospasm, sensation of chest pain, angioedema, hypotension and anaphylactic shock. Delayed hypersensitivity has also been reported with oxaliplatin hours or even days after the infusion.
++ Very common fever, rigors (tremors), either from infection (with or without febrile neutropenia) or possibly from immunological mechanism.
+++ Injection site reaction including local pain, redness, swelling and thrombosis have been reported. Extravasation may result in local pain and inflammation which may be severe and lead to complications, including necrosis, especially when oxaliplatin is infused through a peripheral vein (see 4.4)
Hepatobiliary disorders
Very rare (<1/10,000):
Liver sinusoidal obstruction syndrome, also known as veno-occlusive liver disease or pathological manifestations related to such liver disorders, including peliosis hepatis, nodular regenerative hyperplasia, perisinusoidal fibrosis. Clinical manifestations may be portal hypertension and/or elevation of transaminases.
Renal and urinary disorders
Very rare (<1/10000):
Acute tubular necrosis, acute interstitial nephritis and acute renal failure. Haematological toxicity:
Incidence by patient (%), by grade
|
Oxaliplatin and 5FU/FA 85 mg/m2 every 2 weeks |
Metastatic Setting |
Adjuvant Setting | ||||
|
All grades |
Gr 3 |
Gr 4 |
All grades |
Gr 3 |
Gr 4 | |
|
Anaemia |
82.2 |
3 |
<1 |
75.6 |
0.7 |
0.1 |
|
Neutropenia |
71.4 |
28 |
14 |
78.9 |
28.8 |
12.3 |
|
Thrombocytopenia |
71.6 |
4 |
<1 |
77.4 |
1.5 |
0.2 |
|
Febrile neutropenia |
5.0 |
3.6 |
1.4 |
0.7 |
0.7 |
0.0 |
|
Neutropenic sepsis |
1.1 |
0.7 |
0.4 |
1.1 |
0.6 |
0.4 |
Postmarketing experience with frequency unknown Haemolytic uremic syndrome Digestive toxicity:
Incidence by patient (%), by grade
|
Oxaliplatin and 5FU/FA |
Metastatic Setting |
Adjuvant Setting | ||||
|
85 mg/m2 | ||||||
|
Every 2 weeks |
All grades |
Gr 3 |
Gr 4 |
All grades |
Gr 3 |
Gr 4 |
|
Nausea |
69.9 |
8 |
<1 |
73.7 |
4.8 |
0.3 |
|
Diarrhoea |
60.8 |
9 |
2 |
56.3 |
8.3 |
2.5 |
|
Vomiting |
49.0 |
6 |
1 |
47.2 |
5.3 |
0.5 |
|
Mucositis / Stomatitis |
39.9 |
4 |
<1 |
42.1 |
2.8 |
0.1 |
Prophylaxis and/or treatment with potent antiemetic agents is indicated.
Dehydration, paralytic ileus, intestinal obstruction, hypokalemia, metabolic acidosis and renal impairment may be caused by severe diarrhoea/emesis particularly when combining oxaliplatin with 5-fluorouracil (see section 4.4).
Nervous system:
The dose limiting toxicity of oxaliplatin is neurological. It involves a sensory peripheral neuropathy characterised by dysaesthesia and/or parasthesia of the extremities with or without cramps, often triggered by the cold. These symptoms occur in up to 95% of patients treated. The duration of these symptoms, which usually regress between courses of treatment, increases with the number of treatment cycles.
The onset of pain and/or a functional disorder are indications, depending on the duration of the symptoms, for dose adjustment, or even treatment discontinuation (see section 4.4).
This functional disorder includes difficulties in executing delicate movements and is a possible consequence of sensory impairment. The risk of occurrence of persistent symptoms for a cumulative dose of 850 mg/m2 (10 cycles) is approximately 10% and 20% for a cumulative dose of 1020 mg/m2 (12 cycles).
In the majority of cases, the neurological signs and symptoms improve or totally recover when treatment is discontinued. In the adjuvant setting of colon cancer, 6 months after treatment cessation, 87% of patients had no or mild symptoms. After up to 3 years of follow up, about 3% of patients presented either with persisting localised paraesthesias of moderate intesity (2.3%) or with paraesthesias that may interfere with functional activities (0.5%).
Acute neurosensory manifestations (see section 5.3) have been reported. They start within hours of administration and often occur on exposure to cold. They usuallypresent as transient paresthesia, dysesthesia and hypoesthesia. An acute syndrome of pharyngolaryngeal dysesthesia occurs in 1% and 2% of patients and is characterised by subjective sensations of dysphagia or dyspnoea/feeling of suffocation, without any objective evidence of respiratory distress (no cyanosis or hypoxia) or of laryngospasm or bronchospasm (no stridor or wheezing). Although antihistamines and bronchodilators have been administered in such cases, the symptoms are rapidly reversible even in the absence of treatment. Prolongation of the infusion helps to reduce the incidence of this syndrome (see section 4.4). Occasionally other symptoms that have been observed include jaw spasm/muscle spasm/muscle contractions-involuntary/muscle twitching/myoclonus, coordination abnormal/gait abnormal/ataxia/balance disorders, throat or chest tightness/pressure/discomfort /pain. In addition, cranial nerve dysfunction may be associated, or also occur as an isolated event such as ptosis, diplopia, aphonia/dysphonia, hoarseness, sometimes described as vocal cord paralysis, abnormal tongue sensation or dysarthria, sometimes described as aphasia, trigeminal neuralgia/facial pain/eye pain, decrease in visual acuity, visual field disorders.
Other neurological symptoms such as dysarthria, loss of deep tendon reflex and Lhermitte's sign were reported during treatment with oxaliplatin. Isolated cases of optic neuritis have been reported.
Allergic reactions:
Incidence by patient (%), by grade
|
Oxaliplatin and 5FU/FA 85 mg/m2 every 2 weeks |
Metastatic Setting |
Adjuvant Setting | ||||
|
All grades |
Gr 3 |
Gr 4 |
All grades |
Gr 3 |
Gr 4 | |
|
Allergic reactions / Allergy |
9.1 |
1 |
<1 |
10.3 |
2.3 |
0.6 |
4.9 Overdose
There is no known antidote to oxaliplatin.
Symptoms
In cases of overdose, exacerbation of adverse events can be expected. Management
Monitoring of haematological parameters should be initiated and symptomatic treatment given.
5 PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Other antineoplastic agents, platinum compounds.
ATC code : L01XA 03
Oxaliplatin is an antineoplastic drug belonging to a new class of platinum-based compounds in which the platinum atom is complexed with 1,2-diaminocyclohexane (“DACH” ) and an oxalate group.
Oxaliplatin is a single enantiomer, the Cis -[oxalato ( trans-l-1,2- DACH ) platinum].
Oxaliplatin exhibits a wide spectrum of both in vitro cytotoxicity and in vivo antitumour activity in a variety of tumour model systems including human colorectal cancer models. Oxaliplatin also demonstrates in vitro and in vivo activity in various cisplatin resistant models.
A synergistic cytotoxic action has been observed in combination with 5-fluorouracil both in vitro and in vivo.
Mechanism of action
Studies on the mechanism of action of oxaliplatin, although not completely elucidated, show that the aqua-derivatives resulting from the biotransformation of oxaliplatin, interact with DNA to form both inter and intra-strand cross-links, resulting in the disruption of DNA synthesis leading to cytotoxic and antitumour effects.
2
In patients with metastatic colorectal cancer, the efficacy of oxaliplatin (85mg/m repeated every two weeks) combined with 5-fluorouracil/folinic acid is reported in three clinical studies:
- In front-line treatment, the 2-arm comparative phase III (EFC2962) study randomized patients either to 5-fluorouracil/folinic acid alone (LV5FU2, N=210) or the combination of oxaliplatin with 5-fluorouracil/folinic (FOLFOX4, N=210)
- In pretreated patients the comparative 3-arm (EFC4584) study randomized patients refractory to an irinotecan (CPT-11) + 5-fluorouracil/folinic combination either to 5-fluorouracil/folinic acid alone (LV5FU2, N=275), oxaliplatin single agent (N=275), or combination of oxaliplatin with 5-fluorouracil/folinic (FOLFOX4, N=271)
- Finally, the uncontrolled phase II (EFC2964) study included patients refractory to 5-fluorouracil/folinic acid alone, that were treated with the oxaliplatin and 5-fluorouracil/folinic acid combination (FOLFOX4, N=57)
Clinical efficacy and safety
The two randomized clinical trials, EFC2962 in front-line therapy and EFC4584 in pretreated patients, demonstrated a significantly higher response rate and a prolonged progression free survival (PFS)/time to progression (TTP) as compared to treatment
with 5-fluorouracil/folinic acid alone. IN EFC 4584 performed in refractory pretreated patients, the difference in median overall survival (OS) between the combination of oxaliplatin and 5-FU/FA did not reach statistical significance.
Response rate under FOLFOX4 versus LV5FU2
|
Response rate % (95% CI) Independent radiological review ITT analysis |
LV5FU2 |
FOLFOX4 |
Oxaliplatin Single agent |
|
Front-line treatment EFC2962 Response assessment every 8 weeks |
22 (16-27) |
49 (42-46) |
NA* |
|
P value = 0.0001 | |||
|
Pretreated patients EFC4584 (refractory to CPT-11 + 5FU/FA) Response assessment every 6 weeks |
0.7 (0.0-2.7) |
11.1 (7.6-15.5) |
1.1 (0.2-3.2) |
|
P value < 0.0001 | |||
|
Pretreated patients EFC2964 (refractory to 5-FU/FA) Response assessment every 12 weeks |
NA* |
23 (13-36) |
NA* |
|
NA: Not Applicable Median Progression Free Survival (PFS) / Median FOLFOX4 versus LV5F1 |
Time to Progression (TTP) U2 | ||
|
Median PFS/TTP, Months (95% CI) ITT analysis with independent radiological examination |
LV5FU2 |
FOLFOX4 |
Oxaliplatin Single agent |
|
Front-line treatment EFC2962 (PFS) |
6.0 (5.5-6.5) |
8.2 (7.2-8.8) |
NA* |
|
Log-rank P value = 0.0003 | |||
|
Pretreated patients EFC4584 (TTP) (refractory to CPT-11 + 5FU/FA) |
2.6 (1.8-2.9) |
5.3 (4.7-6.1) |
2.1 (1.6-2.7) |
|
Log-rank P value < 0.0001 | |||
|
Pretreated patients EFC2964 (refractory to 5-FU/FA) |
NA* |
5.1 (3.1-5.7) |
NA* |
NA: Not Applicable
Median Overall Survival (OS) under FOLFOX4 versus LV5FU2
|
Median OS, Months (95% CI) ITT analysis |
LV5FU2 |
FOLFOX4 |
Oxaliplatin Single agent |
|
Front-line treatment EFC2962 |
14.7 (13.0-18.2) |
16.2 (14.7-18.2) |
NA* |
|
Log-rank P value = 0.12 | |||
|
Pretreated patients EFC4584 (refractory to CPT-11 + 5FU/FA) |
8.8 (7.3-9.3) |
9.9 (9.1-10.5) |
8.1 (7.2-8.7) |
|
Log-rank P value = 0.09 | |||
|
Pretreated patients EFC2964 |
NA* |
10.8 |
NA* |
|
(refractory to 5-FU/FA) |
(9.3-12.8) |
NA : Not Applicable
In pretreated patients (EFC4584), who were symptomatic at baseline, a higher proportion of those treated with oxaliplatin/5-fluorouracil/folinic acid experienced a significant improvement of their disease-related symptoms compared to those treated with 5-fluorouracil/folinic acid alone (27.7% vs 14.6% p= 0.0033).
In non pretreated patients (EFC2962), no statistical difference between the two treatment groups was found for any of the quality of life dimensions. However, the quality of life scores were generally better in the control arm for measurement of global health status and pain and worse in the oxaliplatin arm for nausea and vomiting.
In the adjuvant setting, the MOSAIC comparative phase III study (EFC3313) randomised 2246 patients (899 stage II/Duke’s B2 and 1347 stage III/Duke’s C) further to complete resection of the primary tumour of colon cancer either to 5-FU/FA alone (LV5FU2) or to combination of oxaliplatin and 5-FU/FA (FOLFOX4).
|
EFC 3313 3-year disease free survival (ITT analysis)* |
for t |
he overall population | |
|
Treatment arm |
LV5FU2 |
FOLFOX4 | |
|
Percent 3-year disease free |
73.3 |
78.7 | |
|
survival (95% CI) |
(70.6-75.9) |
(76.2-81.1) | |
|
Hazard ratio (95% CI) |
0.76 (0.64-0.89) | ||
|
Stratified log rank test |
P = 0.0008 | ||
* median follow up 44.2 months (all patients followed for at least 3 years)
The study demonstrated an overall significant advantage in 3-year disease free survival for the oxaliplatin and 5-FU/FA combination (FOLFOX4) over 5-FU/FA alone (LV5FU2).
EFC 3313 3-year disease free survival (ITT analysis)* according to stage of
disease
|
Patient stage |
Stage II (Duke’s B2) |
Stage III Duke’s C | ||
|
Treatment arm |
LV5FU2 |
FOLFOX4 |
LV5FU2 |
FOLFOX4 |
|
Percent 3-year disease free |
84.3 |
87.4 |
65.8 |
72.8 |
|
survival |
(80.9-87.7) |
(84.3-90.5) |
(62.2-69.5 |
(69.4-76.2) |
|
(95% CI) | ||||
|
Hazard ratio (95% CI) |
0.79 |
0.75 | ||
|
(0.57-1.09) |
(0.62-0.90) | |||
|
Log-rank test |
P = 0.151 |
P = 0.002 | ||
* median follow up 44.2 months (all patients followed for at least 3 years)
Overall Survival (ITT analysis):
At time of the analysis of the 3-year disease free survival, which was the primary endpoint of the MOSAIC trial, 85.1% of the patients were still alive in the FOLFOX4 arm versus 83.8% in the LV5FU2 arm. This translated into an overall reduction in mortality risk of 10% in favour of the FOLFOX4 not reaching statistical significance (hazard ratio = 0.90). The figures were 92.2% versus 92.4% in the stage II (Duke’s B2) sub-population (hazard ratio = 1.01) and 80.4% versus 78.1% in the stage III (Duke’s C) sub-population (hazard ratio = 0.87), for FOLFOX4 and LV5FU2, respectively.
Oxaliplatin single agent has been evaluated in paediatric population in 2 Phase I (69 patients) and 2 Phase II (166 patients) studies. A total of 235 paediatric patients (7 months-22 years of age) with solid tumors have been treated. The effectiveness of oxaliplatin single agent in the paediatric populations treated has not been established. Accrual in both Phase II studies was stopped for lack of tumor response
5.2 Pharmacokinetic properties
Absorption
The pharmacokinetics of individual active compounds have not been determined. The pharmacokinetics of ultrafiltrable platinum, representing a mixture of all unbound, active and inactive platinum species, following a two-hour infusion of oxaliplatin at 130 mg /m2 every three weeks for 1 to 5 cycles and oxaliplatin at 85 mg/m2 every two weeks for 1 to 3 cycles are as follows:
Summary of Platinum Pharmacokinetic Parameter Estimates in Ultrafiltrate Following Multiple Doses of Oxaliplatin at 85 mg/m2 Every Two Weeks or at 130
|
Dose |
Cmax |
AUC0-48 |
AUC |
t1/2l |
t 1/2B |
t1/> |
Vss |
CL |
|
p g/ml |
pg.h/ml |
pg.h/ml |
h |
h |
h |
L |
L/h | |
|
85 mg/m2 | ||||||||
|
Mean |
0.814 |
4.19 |
4.68 |
0.43 |
16.8 |
391 |
440 |
17.4 |
|
SD |
0.193 |
0.647 |
1.40 |
0.35 |
5.74 |
406 |
199 |
6.35 |
|
130 mg/m2 | ||||||||
|
Mean |
1.21 |
8.20 |
11.9 |
0.28 |
16.3 |
273 |
582 |
10.1 |
|
SD |
0.10 |
2.40 |
4.60 |
0.06 |
2.90 |
19.0 |
261 |
3.07 |
Mean AUC0-48, and Cmax values were determined on Cycle 3 (85 mg/m ) or cycle 5 (130 mg/m ). Mean AUC, Vss, CL, and CLR0-48 values were determined on Cycle 1.
Cend, Cmax, AUC, AUC0-48, Vss and CL values were determined y non-compartmental analysis. t1/2o, t 1/2p, and t1/2y, were determined by compartmental analysis (Cycles 1-3 combined).
Distribution
At the end of a 2-hour infusion, 15% of the administered platinum is present in the systemic circulation, the remaining 85% being rapidly distributed into tissues or eliminated in the urine. Irreversible binding to red blood cells and plasma, results in half-lives in these matrices that are close to the natural turnover of red blood cells and serum albumin. No accumulation was observed in plasma ultrafiltrate following 85 mg/m2 every two weeks or 130mg/m2 every three weeks and steady state was attained by cycle one in this matrix. Inter- and intra-subject variability is generally low.
Biotransformation
Biotransformation in vitro is considered to be the result of non-enzymatic degradation and there is no evidence of cytochrome P450-mediated metabolism of the diaminocyclohexane (DACH) ring.
Oxaliplatin undergoes extensive biotransformation in patients, and no intact drug was detectable in plasma ultrafiltrate at the end of a 2h-infusion. Several cytotoxic biotransformation products including the monochloro-, dichloro- and diaquo-DACH platinum species have been identified in the systemic circulation together with a number of inactive conjugates at later time points.
Elimination
Platinum is predominantly excreted in urine, with clearance mainly in the 48 hours following administration.
By day 5, approximately 54% of the total dose was recovered in the urine and < 3% in the faeces.
The effect of renal impairment on the disposition of oxaliplatin was studied in patients
with varying
degrees of renal function.
Oxaliplatin was administered at a dose of 85 mg/m2 in the control group with a normal renal function (CLcr > 80 ml/min, n=12) and in patients with mild (CLcr = 50 to 80 ml/min, n=13) and moderate (CLcr = 30 to 49 ml/min, n=11) renal impairment, and at a dose of 65 mg/m2 in patients with severe renal impairment (CLcr < 30 ml/min, n=5). Median exposure was 9, 4, 6, and 3 cycles, respectively, and PK data at cycle 1 were obtained in 11, 13, 10, and 4 patients respectively.
There was an increase in plasma ultrafiltrate (PUF) platinum AUC, AUC/dose and a decrease in total and renal CL and Vss with increasing renal impairment especially in the (small) group of patients with severe renal impairment: point estimate (90% CI) of estimated mean ratios by renal status versus normal renal function for AUC/dose were 1.36 (1.08, 1.71), 2.34 (1.82, 3.01) and 4.81 (3.49, 6.64) for patients with mild and moderate and in severe renal failure respectively.
Elimination of oxaliplatin is significantly correlated with the creatinine clearance. Total PUF platinum CL was respectively 0.74 (0.59, 0.92), 0.43 (0.33, 0.55) and 0.21 (0.15, 0.29) and for Vss respectively 0.52 (0.41, 0.65), 0.73 (0.59, 0.91) and 0.27 (0.20, 0.36) for patients with mild, moderate and severe renal failure respectively. Total body clearance of PUF platinum was therefore reduced by respectively 26% in mild, 57% in moderate, and 79% in severe renal impairment compared to patients with normal function.
Renal clearance of PUF platinum was reduced in patients with impaired renal function by 30% in mild, 65% in moderate, and 84% in severe renal impairment compared to patients with normal function.
There was an increase in beta half life of PUF platinum with increasing degree of renal impairment mainly in the severe group.
Despite the small number of patients with severe renal dysfunction, these data are of
concern in patients in severe renal failure and should be taken into account when prescribing oxaliplatin in patients with renal impairment (see sections 4.2, 4.3 and 4.4).
5.3 Preclinical safety data
The target organs identified in preclinical species (mice, rats, dogs, and/or monkeys) in single- and multiple-dose studies included the bone marrow, the gastrointestinal system, the kidney, the testes, the nervous system, and the heart. The target organ toxicities observed in animals are consistent with those produced by other platinum-containing drugs and DNA-damaging, cytotoxic drugs used in the treatment of human cancers with the exception of the effects produced on the heart. Effects on the heart were observed only in the dog and included electrophysiological disturbances with lethal ventricular fibrillation. Cardiotoxicity is considered specific to the dog not only because it was observed in the dog alone but also because doses similar to those producing lethal cardiotoxicity in dogs (150 mg/m2) were well-tolerated by humans. Preclinical studies using rat sensory neurons suggest that the acute neurosensory symptoms related to Oxaliplatin may involve an interaction with voltage-gated Na+ channels.
Oxaliplatin was mutagenic and clastogenic in mammalian test systems and produced embryo-fetal toxicity in rats. Oxaliplatin is considered a probable carcinogen, although carcinogenic studies have not been conducted.
6 PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Water for Injections Tartaric acid
Sodium Hydroxide (for pH adjustment)
6.2 Incompatibilities
This medicinal product should not be mixed with other medicinal products except for those mentioned in section 6.6. Oxaliplatin can be co-administered with folinic acid via a Y-line.
- DO NOT mix with alkaline medicinal products or solutions, in particular 5-fluorouracil, folinic acid preparations containing trometamol as an excipients and trometamol salts of other medicinal products. Alkaline drugs or solutions will adversely affect the stability of oxaliplatin (see section 6.6).
- DO NOT dilute oxaliplatin with saline or other solutions containing chloride ions (including calcium, potassium or sodium chlorides).
- DO NOT use injection equipment containing aluminium.
- DO NOT mix with other medicinal products in the same infusion bag or line (see section 6.6 to check instructions related to co-administration with folinic acid)
6.3 Shelf life
Medicinal product as packaged for sale: 18 months
Inspect visually prior to use. Only clear solutions without particles should be used.
After dilution in 5% glucose, chemical and physical in-use stability has been demonstrated for 24 hours at +2°C - +8°C and for 6 hours at +25°C.
From a microbiological point of view, the solution for infusion should be used immediately.
If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2°C to 8°C unless dilution has taken place in controlled and validated aseptic conditions.
6.4 Special precautions for storage
Store below 25 °C.
Medicinal product as packaged for sale: Keep the vial in the outer carton in order to protect from light. Do not freeze.
For storage conditions of the diluted medicinal product see section 6.3.
6.5 Nature and contents of container
1 vial with 10 ml concentrate (Type I clear glass vial with or without Onco-Tain sleeve) with elastomeric stopper and flip-off cap.
1 vial with 20 ml concentrate (Type I clear glass vial with or without Onco-Tain sleeve) with elastomeric stopper and flip-off cap.
1 vial with 40 ml concentrate (Type I clear glass vial with or without Onco-Tain sleeve) with elastomeric stopper and flip-off cap.
Pack size: 1 vial per box. Not all pack sizes may be marketed.
6.6 Special precautions for disposal
As with other potentially toxic compounds, caution should be exercised when handling and preparing oxaliplatin solutions.
Instructions for Handling
The handling of this cytotoxic agent by healthcare personnel requires every precaution to guarantee the protection of the handler and his surroundings.
The preparation of injectable solutions of cytotoxic agents must be carried out by trained specialist personnel with knowledge of the medicines used, in conditions that guarantee the integrity of the medicinal product, the protection of the environment and in particular the protection of the personnel handling the medicines, in accordance with the hospital policy. It requires a preparation area reserved for this purpose. It is forbidden to smoke, eat or drink in this area.
Personnel must be provided with appropriate handling materials, notably long sleeved gowns, protection masks, caps, protective goggles, sterile single-use gloves, protective covers for the work area, containers and collection bags for waste.
Excreta and vomit must be handled with care.
Pregnant women must be warned to avoid handling cytotoxic agents.
Any broken container must be treated with the same precautions and considered as contaminated waste. Contaminated waste should be incinerated in suitably labelled rigid containers. See below chapter “Disposal”.
If oxaliplatin concentrate or solution for infusion should come into contact with skin, wash immediately and thoroughly with water.
If oxaliplatin concentrate or solution for infusion should come into contact with mucous membranes, wash immediately and thoroughly with water.
Special precautions for administration
- DO NOT use injection material containing aluminium.
- DO NOT administer undiluted.
- Only glucose 5% infusion solution is to be used as a diluent. DO NOT dilute for infusion with sodium chloride or chloride containing solutions.
- DO NOT mix with any other medicinal products in the same infusion bag or administer simultaneously by the same infusion line
- DO NOT mix with alkaline drugs or solutions, in particular 5-fluorouracil, folinic acid preparations containing trometamol as an excipients and trometamol salts of other drugs. Alkaline drugs or solutions will adversely effect the stability of oxaliplatin.
Instruction for use with folinic acid (FA) (as calcium folinate or disodium folinate) Oxaliplatin 85 mg/m2 intravenous infusion in 250 to 500 ml of glucose 5 % solution is given at the same time as folinic acid (FA) intravenous infusion in glucose 5 % solution, over 2 to 6 hours, using a Y-line placed immediately before the site of infusion.
These two medical products should not be combined in the same infusion bag.
Folinic acid must not contain trometamol as an excipient and must only be diluted using isotonic glucose 5 % solution, never in alkaline solutions or sodium chloride or chloride containing solutions.
Intructions for use with 5-fluorouracil
Oxaliplatin should always be administered before fluoropyrimidines - i.e. 5-fluorouracil. After oxaliplatin administration, flush the line and then administer 5-fluorouracil.
For additional information on drugs combined with oxaliplatin, see the corresponding manufacturer’s summary of product characteristics.
Concentrate for solution for infusion
Inspect visually prior to use. Only clear solutions without particles should be used. The medicinal product is for single use only. Any unused concentrate should be discarded.
Dilution for intravenous infusion
Withdraw the required amount of concentrate from the vial(s) and then dilute with 250 ml to 500 ml of a glucose 5% solution to give an oxaliplatin concentration between 0.2 mg/ml and 0.7 mg/ml. The concentration range over which the physicochemical stability of oxaliplatin has been demonstrated is 0.2 mg/ml to 1.3 mg/ml.
Administer by intravenous infusion.
After dilution in 5% glucose, chemical and physical in-use stability has been demonstrated for 24 hours at 2°C to 8°C and for 6 hours at 25°C.
From a microbiological point of view, this infusion preparation should be used immediately.
If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2°C to 8°C unless dilution has taken place in controlled and validated aseptic conditions.
Inspect visually prior to use. Only clear solutions without particles should be used.
The medicinal product is for single use only. Any unused infusion solution should be discarded.
NEVER use sodium chloride or chloride containing solutions for dilution.
The compatibility of Oxaliplatin solution for infusion has been tested with representative, PVC-based, administration sets.
Infusion
The administration of oxaliplatin does not require prehydration.
Oxaliplatin diluted in 250 to 500 ml of a glucose 5% solution to give a concentration not less than 0.2 mg/ml must be infused either by peripheral vein or central venous line over 2 to 6 hours. When oxaliplatin is administered with 5-fluorouracil, the oxaliplatin infusion must precede the administration of 5-fluorouracil.
Disposal
Remnants of the medicinal product as well as all materials that have been used for dilution and administration must be destroyed according to hospital standard procedures applicable to cytotoxic agents in accordance with local requirements related to the disposal of hazardous waste.
7 MARKETING AUTHORISATION HOLDER
Hospira UK Limited
Horizon
Honey Lane
Hurley
Maidenhead
SL6 6RJ
UK
8 MARKETING AUTHORISATION NUMBER(S)
PL 04515/0215
9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
12th September 2007
DATE OF REVISION OF THE TEXT
10
20/10/2016
11 DOSIMETRY (IF APPLICABLE)
12 INSTRUCTIONS FOR PREPARATION OF RADIOPHARMACEUTICALS (IF APPLICABLE)