Topotecan Concentrate for solution for infusion IP (1ml Multiple Dose Vial) 1mg/ml Taj Pharma
Topotecan 1mg Injection is used in the treatment of ovarian cancer. It shows its working by stopping or slowing down the growth of cancer cells.
Topotecan 1mg Injection is given as an IV infusion into vein by a qualified medical professional. Your doctor will decide what dose is necessary and how often you need to take it. This will depend on what you are being treated for and may change from time to time. You should take it exactly as your doctor has advised. Taking it in the wrong way or taking too much can cause very serious side effects. It may take several weeks or months for you to see or feel the benefits but do not stop taking it unless your doctor tells you to.
The most common side effects of this medicine include tiredness, vomiting, weakness, nausea, and abdominal pain. This medicine may reduce the number of blood cells (decrease red blood and white blood cells) in your blood, thereby, increasing the susceptibility to infections. Inform your doctor if you notice fever, chills, sore throat, and severe diarrhea. Regular blood tests are required to check your blood cells along with heart, liver, and blood uric acid levels.
Before taking it, tell your doctor if you have heart disease, liver, or kidney problems or are taking any medicines to treat infections. Many other medicines can affect, or be affected by, this medicine so let your healthcare team know all medications you are using. This medicine is not recommended during pregnancy or while breastfeeding. The use of effective contraception by both males and females during treatment is important to avoid pregnancy.
USES OF TOPOTECAN INJECTION
- Ovarian cancer
SIDE EFFECTS OF TOPOTECAN INJECTION
- Abdominal pain
- Decreased white blood cell count
- Decreased blood cells (red cells, white cells, and platelets)
- Injection site reactions (pain, swelling, redness)
HOW TO USE TOPOTECAN INJECTION
Your doctor or nurse will give you this medicine. Kindly do not self administer.
HOW TOPOTECAN INJECTION WORKS
Topotecan 1mg Injection is an anti-cancer medication. It works by suppressing the activity of an enzyme (topoisomerase I) involved in DNA multiplication of the cancer cells. This slows the growth of cancer cells and eventually kills them.
Consuming alcohol with Topotecan 1mg Injection does not cause any harmful side effects.
CONSULT YOUR DOCTOR
Topotecan 1mg Injection is unsafe to use during pregnancy as there is definite evidence of risk to the developing baby. However, the doctor may rarely prescribe it in some life-threatening situations if the benefits are more than the potential risks. Please consult your doctor.
Topotecan 2.5mg Injection is unsafe to use during breastfeeding. Data suggests that the drug may cause toxicity to the baby.
Topotecan 1mg Injection may cause side effects which could affect your ability to drive.
Topotecan 1mg Injection can make you feel tired and this may affect your ability to drive.
Topotecan 1mg Injection should be used with caution in patients with kidney disease. Dose adjustment of Topotecan 1mg Injection may be needed. Please consult your doctor.
Use of Topotecan 1mg Injection is not recommended in patients with end-stage kidney disease.
SAFE IF PRESCRIBED
Topotecan 1mg Injection is safe to use in patients with liver disease. No dose adjustment of Topotecan 1mg Injection is recommended.
WHAT IF YOU FORGET TO TAKE TOPOTECAN INJECTION?
If you miss a dose of Topotecan 2.5mg Injection, please consult your doctor.
Topotecan Concentrate for solution for infusion IP 1mg/ml Taj Pharma (1ml Multiple Dose Vial)
1. NAME OF THE MEDICINAL PRODUCT
Topotecan 1mg/ml concentrate for solution for infusion
2. QUALITATIVE AND QUANTITATIVE COMPOSITION
a) Each ml multiple dose vial contains:?
Topotecan (as hydrochloride)????? 1mg
Each 1 ml vial of concentrate contains 1 mg topotecan (as hydrochloride)
b) Each Single Dose Vial contains:
Topotecan Hydrochloride equivalent to
4mg of topotecan as free base.
Each 4 ml vial of concentrate contains 4 mg topotecan (as hydrochloride)
For a full list of excipients see section 6.1.
3. PHARMACEUTICAL FORM
Concentrate for solution for infusion.
A clear yellow colour solution free from visible foreign particles. pH in the range of 1.5 to 2.5 and Osmolarity in the range of approximately 100 to 40 mOsm/Litre.
4. CLINICAL PARTICULARS
4.1 Therapeutic indications
Topotecan monotherapy is indicated for the treatment of:
- Patients with metastatic carcinoma of the ovary after failure of first-line or subsequent therapy.
- Patients with relapsed small cell lung cancer [SCLC] for whom re-treatment with the first- line regimen is not considered appropriate (see section 5.1).
Topotecan in combination with cisplatin is indicated for patients with carcinoma of the cervix recurrent after radiotherapy and for patients with Stage IVB disease. Patients with prior exposure to cisplatin require a sustained treatment free interval to justify treatment with the combination (see section 5.1).
4.2? Posology and method of administration
The use of topotecan should be confined to units specialised in the administration of cytotoxic chemotherapy. Topotecan should only be administered under the supervision of a physician experienced in the use of chemotherapy (see section 6.6).
When topotecan is used in combination with cisplatin, the full prescribing information for cisplatin should be consulted.
Prior to administration of the first course of topotecan, patients must have a baseline neutrophil count of ?1.5 x 109/l, a platelet count of ?100 x 109/l and a haemoglobin level of ? 9 g/dl (after transfusion if necessary).
Ovarian and Small Cell Lung Carcinoma
The recommended dose of topotecan is 1.5 mg/m2?body surface area/day administered by intravenous infusion over 30 minutes daily for 5 consecutive days with a 3 week interval between the start of each course. If well tolerated, treatment may continue until disease progression (see sections 4.8 and 5.1).
Topotecan should not be re-administered unless the neutrophil count is ?1 x 109/l, the platelet count is ?100 x 109/l, and the haemoglobin level is ?9 g/dl (after transfusion if necessary).
Standard oncology practice for the management of neutropenia is either to administer topotecan with other medicinal products (e.g. G-CSF) or to dose reduce the dose to maintain neutrophil counts.
If dose reduction is chosen for patients who experience severe neutropenia (neutrophil count < 0.5 x 109/l) for 7 days or more, or severe neutropenia associated with fever or infection, or who have had treatment delayed due to neutropenia, the dose should be reduced by 0.25 mg/m2/day to 1.25 mg/m2/day (or subsequently down to 1.0 mg/m2/day if necessary)
Doses should be similarly reduced if the platelet count falls below 25 x 109/l. In clinical studies, topotecan was discontinued if the dose had been reduced to 1.0 mg/m2?and a further dose reduction was required to manage adverse effects.
The recommended dose of topotecan is 0.75 mg/m2/day administered as 30 minute intravenous infusion on days 1, 2 and 3. Cisplatin is administered as an intravenous infusion on day 1 at a dose of 50 mg/m2/day and following the topotecan dose. This treatment schedule is repeated every 21 days for 6 courses or until progressive disease.
Topotecan should not be re-administered unless the neutrophil count is ? 1.5 x 109/l, the platelet count is ? 100 x 109/l, and the haemoglobin level is ?9 g/dl (after transfusion if necessary).
Standard oncology practice for the management of neutropenia is either to administer topotecan with other medicinal products (e.g. G-CSF) or to reduce the dose to maintain neutrophil counts.
If dose reduction is chosen for patients who experience severe neutropenia (neutrophil count < 0.5 x 109/l) for 7 days or more, or severe neutropenia associated with fever or infection or who have had treatment delayed due to neutropenia, the dose should be reduced by 20% to 0.60 mg/m2/day for subsequent courses (or subsequently down to 0.45 mg/m2/day if necessary).
Doses should be similarly reduced if the platelet count falls below 25 x 109/l.
Patients with renal impairment
Monotherapy (Ovarian and Small cell lung carcinoma)
There is insufficient experience with the use of topotecan in patients with severely impaired renal function (creatinine clearance < 20 ml/min). Use of topotecan in this group of patients is not recommended (see section 4.4).
Limited data indicate that the dose should be reduced in patients with moderate renal impairment. The recommended monotherapy dose of topotecan in patients with ovarian or small cell lung carcinoma and a creatinine clearance between 20 and 39 ml/min is 0.75 mg/m2?/day for 5 consecutive days.
Combination therapy (Cervical carcinoma)
In clinical studies with topotecan in combination with cisplatin for the treatment of cervical cancer, therapy was only initiated in patients with serum creatinine less than or equal to 1.5 mg/dL. If, during topotecan/cisplatin combination therapy serum creatinine exceeds 1.5 mg/dL, it is recommended that the full prescribing information be consulted for any advice on cisplatin dose reduction/continuation. If cisplatin is discontinued, there are insufficient data regarding continuing monotherapy with topotecan in patients with cervical cancer.
Patients with hepatic impairment
A small number of hepatically impaired patients (serum bilirubin between 1.5 and 10 mg/dl) were given intravenous topotecan at 1.5 mg/m2/day for five days every three weeks. A reduction in topotecan clearance was observed.However, there are insufficient data available to make a dose recommendation for this patient group (see section 4.4).
There is insufficient experience with the use of topotecan in patients with severely impaired hepatic function (serum bilirubin ?10 mg/dl) due to cirrhosis. Topotecan is not recommended to be used in this patient group (see section 4.4).
Currently available data are described in sections 5.1 and 5.2 but no recommendation on a posology can be made.
Method of Administration
Topotecan must be further diluted before use (see section 6.6).
Severe hypersensitivity to the active substance or to any of the excipients
Breast feeding (see section 4.6)
Severe bone marrow depression prior to starting first course, as evidenced by baseline neutrophils < 1.5 x 109/l and/or a platelet count of?<100 x 109/l.
4.4 Special Warnings and precautions for use
Haematological toxicity is dose-related and full blood count including platelets should be determined regularly (see section 4.2).
As with other cytotoxic medicinal products, topotecan can cause severe myelosuppression. Myelosuppression leading to sepsis and fatalities due to sepsis have been reported in patients treated with topotecan (see section 4.8).
Topotecan-induced neutropenia can cause neutropenic colitis. Fatalities due to neutropenic colitis have been reported in clinical studies with topotecan. In patients presenting with fever, neutropenia, and a compatible pattern of abdominal pain, the possibility of neutropenic colitis should be considered.
Topotecan has been associated with reports of interstitial lung disease (ILD), some of which have been fatal (see section 4.8). Underlying risk factors include history of ILD, pulmonary fibrosis, lung cancer, thoracic exposure to radiation and use of pneumotoxic substances and/or colony stimulating factors. Patients should be monitored for pulmonary symptoms indicative of ILD (e.g. cough, fever, dyspnoea and/or hypoxia), and topotecan should be discontinued if a new diagnosis of ILD is confirmed.
Topotecan monotherapy and topotecan in combination with cisplatin are commonly associated with clinically relevant thrombocytopenia. This should be taken into account when prescribing topotecan, e.g. if patients at increased risk of tumour bleeds are considered for therapy.
As would be expected, patients with poor performance status (PS>1) have a lower response rate and an increased incidence of complications such as fever, infection and sepsis (see section 4.8). Accurate assessment of performance status at the time therapy is given is important, to ensure that patients have not deteriorated to PS 3.
There is insufficient experience of the use of topotecan in patients with severely impaired renal function (creatinine clearance < 20 ml/min) or severely impaired hepatic function (serum bilirubin ?10 mg/dl) due to cirrhosis. Use of topotecan in these patient groups is not recommended (see section 4.2).
A small number of hepatically impaired patients (serum bilirubin between 1.5 and 10 mg/dl) were given intravenous topotecan at 1.5 mg/m2?/day for five days every three weeks. A reduction in topotecan clearance was observed. However, there are insufficient data available to make a dose recommendation for this patient group (see section 4.2).
4.5 Interaction with other medicinal products and other forms of interaction
No?in vivo?human pharmacokinetic interaction studies have been performed.
Topotecan does not inhibit human P450 enzymes (see Section 5.2). In a population study using the intravenous route, the co-administration of granisetron, ondansetron, morphine or corticosteroids did not appear to have a significant effect on the pharmacokinetics of total topotecan (active and inactive form).
When combining topotecan with other chemotherapy agents, reduction of the doses of each medicinal product may be required to improve tolerability. However, when combining with platinum agents, there is a distinct sequence-dependent interaction depending on whether the platinum agent is given on day 1 or 5 of the topotecan dosing. If either cisplatin or carboplatin is given on day 1 of the topotecan dosing, a lower dose of each agent must be given to improve tolerability compared to the dose of each agent which can be given if the platinum agent is given on day 5 of the topotecan dosing.
When topotecan (0.75 mg/m2/day for 5 consecutive days) and cisplatin (60 mg/m2/day on Day 1) were administered in 13 patients with ovarian cancer, a slight increase in AUC (12%, n=9) and Cmax?(23%, n=11) was noted on day 5. This increase is considered unlikely to be of clinical relevance.
4.6 Fertility, pregnancy and lactation
Women of childbearing potential / Contraception in males and females
Topotecan has been shown to cause embryo-foetal lethality and malformations in preclinical studies (see section 5.3). As with other cytotoxic medicinal products, topotecan may cause foetal harm and therefore women of child bearing potential should be advised to avoid becoming pregnant during and for at least six months after cessation of therapy with topotecan.
As with all cytotoxic chemotherapy, patients being treated with topotecan must be advised that they or their partner must use an effective method of contraception.
If topotecan is used during pregnancy, or if the patient becomes pregnant during therapy with topotecan, the patient must be warned of the potential hazards to the foetus.
Topotecan is contra-indicated during breast-feeding (see section 4.3). Although it is not known whether topotecan is excreted in human breast milk, breast-feeding should be discontinued at the start of therapy.
No effects on male or female fertility have been observed in reproductive toxicity studies in rats (see section 5.3). However, as with other cytotoxic medicinal products topotecan is genotoxic and effects on fertility, including male fertility, cannot be excluded
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. However, caution should be observed when driving or operating machines if fatigue and asthenia persist.
4.8 Undesirable Effects
In dose-finding studies involving 523 patients with relapsed ovarian cancer and 631 patients with relapsed small cell lung cancer, the dose limiting toxicity of topotecan monotherapy was found to be haematological. Toxicity was predictable and reversible. There were no signs of cumulative haematological or non-haematological toxicity.
The safety profile of topotecan when given in combination with cisplatin in the cervical cancer clinical studies is consistent with that seen with topotecan monotherapy. The overall haematological toxicity is lower in patients treated with topotecan in combination with cisplatin compared to topotecan monotherapy, but higher than with cisplatin alone.
Additional adverse events were seen when topotecan was given in combination with cisplatin, however, these events were seen with cisplatin monotherapy and were not attributable to topotecan. The prescribing information for cisplatin should be consulted for a full list of adverse events associated with cisplatin use.
The integrated safety data for topotecan monotherapy are presented below.
Adverse reactions are listed below, by system organ class and absolute frequency (all reported events). Frequencies are defined as: 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) and not known (cannot be estimated from the available data).
Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.
|Infections and infestations|
|Blood and lymphatic system disorders|
|Very common||Febrile neutropenia, neutropenia (see ?Gastrointestinal disorders?), thrombocytopenia, anaemia, leucopenia|
|Not known||Severe bleeding (associated with thrombocytopenia)|
|Immune system disorders|
|Common||Hypersensitivity reaction including rash|
|Rare||Anaphylactic reaction, angioedema, urticaria|
|Metabolism and nutrition disorders|
|Very common||Anorexia (which may be severe)|
|Respiratory, thoracic and mediastinal disorders|
|Rare||Interstitial lung disease (some cases have been fatal)|
|Very common||Nausea, vomiting and diarrhoea (all of which may be severe), constipation, abdominal pain2, mucositis|
|Not known||Gastrointestinal perforation|
|Skin and subcutaneous tissue disorders|
|General disorders and administration site conditions|
|Very common||Pyrexia, asthenia, fatigue|
|Not known||Mucosal inflammation|
|1?Fatalities due to sepsis have been reported in patients treated with topotecan (see section 4.4).|
2?Neutropenic colitis, including fatal neutropenic colitis, has been reported to occur as a complication of topotecan- induced neutropenia (see section 4.4).
3?Reactions have been mild and have not generally required specific therapy.
The adverse events listed above have the potential to occur with a higher frequency in patients who have a poor performance status (see section 4.4).
The frequencies associated with the haematological and non-haematological adverse events listed below represent the adverse event reports considered to be related/possibly related to topotecan therapy.
Neutropenia: Severe (neutrophil count <0.5 x 109/l) during course 1 in 55 % of the patients with duration ?7 days in 20 % and overall in 77 % of patients (39 % of courses). In association with severe neutropenia, fever or infection occurred in 16 % of patients during course 1 and overall in 23 % of patients (6 % of courses). Median time to onset of severe neutropenia was 9 days and the median duration was 7 days. Severe neutropenia lasted beyond 7 days in 11 % of courses overall. Among all patients treated in clinical studies (including both those with severe neutropenia and those who did not develop severe neutropenia), 11 % (4 % of courses) developed fever and 26 % (9 % of courses) developed infection. In addition, 5 % of all patients treated (1 % of courses) developed sepsis (see section 4.4).
Thrombocytopenia:?Severe (platelets 25 x 109/l) in 25 % of patients (8 % of courses); moderate (platelets between 25.0 and 50.0 x 109/l) in 25 % of patients (15 % of courses). Median time to onset of severe thrombocytopenia was Day 15 and the median duration was 5 days. Platelet transfusions were given in 4 % of courses. Reports of significant sequelae associated with thrombocytopenia including fatalities due to tumour bleeds have been infrequent.
Anaemia:?Moderate to severe (Hb ?8.0 g/dl) in 37 % of patients (14 % of courses). Red cell transfusions were given in 52 % of patients (21 % of courses).
Frequently reported non-haematological effects were gastrointestinal such as nausea (52 %), vomiting (32 %), and diarrhoea (18 %), constipation (9 %) and mucositis (14 %). The incidence of severe (Grade 3 or 4) nausea, vomiting, diarrhoea and mucositis was 4, 3, 2 and 1 % respectively.
Mild abdominal pain was reported in 4 % of patients.
Fatigue was observed in approximately 25 % and asthenia in 16 % of patients receiving topotecan. Severe (grade 3 or 4) fatigue and asthenia both occurred with an incidence of 3 % respectively.
Total or pronounced alopecia was observed in 30 % of patients and partial alopecia in 15 % of patients.
Other severe events that were recorded as related or possibly related to topotecan treatment were anorexia (12 %), malaise (3 %) and hyperbilirubinaemia (1 %).
Hypersensitivity reactions including rash, urticaria, angioedema and anaphylactic reactions have been reported rarely. In clinical studies, rash was reported in 4 % of patients and pruritus in 1.5 % of patients.
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.
Overdoses have been reported in patients being treated with intravenous topotecan (up to 10 fold of the recommended dose) and topotecan capsules (up to 5 fold of the recommended dose). The signs and symptoms observed following overdose were consistent with the known undesirable events associated with topotecan (see section 4.8). The primary complications of overdose are bone marrow suppression and mucositis. In addition, elevated hepatic enzymes have been reported with intravenous topotecan overdose.
There is no known antidote for topotecan overdose. Further management should be as clinically indicated or as recommended by the national poisons center, where available.
5. PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmaco-therapeutic group: antineoplastic agents, other antineoplastic agents.
Mechanism of action
The anti-tumour activity of topotecan involves the inhibition of topoisomerase-I, an enzyme intimately involved in DNA replication as it relieves the torsional strain introduced ahead of the moving replication fork. Topotecan inhibits topoisomerase-I by stabilising the covalent complex of enzyme and strand-cleaved DNA, which is an intermediate of the catalytic mechanism. The cellular sequela of inhibition of topoisomerase-I by topotecan is the induction of protein-associated DNA single-strand breaks.
Clinical efficacy and safety
Relapsed Ovarian Cancer
In a comparative study of topotecan and paclitaxel in patients previously treated for ovarian carcinoma with platinum based chemotherapy (n = 112 and 114, respectively), the response rate (95 % CI) was 20.5 % (13 %, 28 %) versus 14 % (8 %, 20 %) and median time to progression 19 weeks versus 15 weeks (hazard ratio 0.7 [0.6, 1.0]), for topotecan and paclitaxel, respectively. Median overall survival was 62 weeks for topotecan versus 53 weeks for paclitaxel (hazard ratio 0.9 [0.6, 1.3]).
The response rate in the whole ovarian carcinoma programme (n = 392, all previously treated with cisplatin or cisplatin and paclitaxel) was 16 %. The median time to response in clinical studies was 7.6-11.6 weeks. In patients refractory to, or relapsing within 3 months after cisplatin therapy (n = 186), the response rate was 10 %.
These data should be evaluated in the context of the overall safety profile of the medicinal product, in particular of the significant haematological toxicity (see section 4.8).
A supplementary retrospective analysis was conducted on data from 523 patients with relapsed ovarian cancer. Overall, 87 complete and partial responses were observed, with 13 of these occurring during cycles 5 and 6 and 3 occurring thereafter. Of the patients who received more than 6 cycles of therapy, 91 % completed the study as planned or were treated until disease progression with only 3 % withdrawn for adverse events.
A phase III study (Study 478) compared oral topotecan plus Best Supportive Care [BSC] [n=71] with BSC alone [n=70] in patients who had relapsed following first line therapy [median time to progression [TTP] from first-line therapy: 84 days for oral topotecan + BSC, 90 days for BSC alone] and for whom retreatment with i.v. chemotherapy was not considered appropriate. In the oral topotecan plus BSC group there was a statistically significant improvement in overall survival compared with the BSC alone group (Logrank p=0.0104). The unadjusted hazard ratio for the oral topotecan plus BSC group relative to BSC alone group was 0.64 (95% CI: 0.45, 0.90). Median survival in patients treated with oral topotecan + BSC was 25.9 weeks [95 % C.I. 18.3, 31.6] compared to 13.9 weeks [95 % C.I. 11.1, 18.6] for patients receiving BSC alone [p=0.0104].
Patient self-reports of symptoms using an unblinded assessment showed a consistent trend for symptom benefit for oral topotecan + BSC.
One Phase 2 study (Study 065) and one Phase 3 study (Study 396) were conducted to evaluate the efficacy of oral topotecan versus intravenous topotecan in patients who had relapsed ? 90 days after completion of one prior regimen of chemotherapy.(see Table 1). Oral and intravenous topotecan were associated with similar symptom palliation in patients with relapsed sensitive SCLC in patient selfreports on an unblinded symptom scale assessment in each of these two studies.
Table 1. Summary of survival, response rate, and time to progression in SCLC patients treated with oral topotecan or intravenous topotecan
|Study 065||Study 396|
|Oral topotecan||Intravenous topotecan||Oral topotecan||Intravenous topotecan|
|(N = 52)||(N = 54)||(N = 153)||?||(N = 151)|
|Median survival (weeks)||32.3||25.1||33.0||35.0|
|(95% CI)||(26.3, 40.9)||(21.1, 33.0)||(29.1, 42.4)||(31.0, 37.1)|
|Hazard ratio (95% CI)||0.88 (0.59, 1.31)||0.88 (0.7, 1.11)|
|Response rate (%)||23.1||14.8||18.3||21.9|
|(95% CI)||(11.6, 34.5)||(5.3, 24.3)||(12.2, 24.4)||(15.3, 28.5)|
|Difference in response rate|
|8.3 (-6.6, 23.1)||-3.6 (-12.6, 5.5)|
|Median time to progression (weeks)||14.9||13.1||11.9||14.6|
|(95% CI)||(8.3, 21.3)||(11.6, 18.3)||(9.7, 14.1)||(13.3, 18.9)|
|Hazard ratio (95% CI)||0.90 (0.60, 1.35)||1.21 (0.96, 1.53)|
N = total number of patients treated.
CI = Confidence interval.
In another randomised phase III study which compared IV topotecan to cyclophosphamide, doxorubicin and vincristine (CAV) in patients with relapsed, sensitive SCLC, the overall response rate was 24.3% for topotecan compared to 18.3% for the CAV group. Median time to progression was similar in the two groups (13.3 weeks and 12.3 weeks respectively). Median survivals for the two groups were 25.0 and 24.7 weeks respectively. The hazard ratio for survival with IV topotecan relative to CAV was 1.04 (95% CI 0.78 ? 1.40).
The response rate to topotecan in the combined small cell lung cancer programme [n = 480] for patients with relapsed disease sensitive to first-line therapy, was 20.2 %. The median survival was 30.3 weeks (95 % CI: 27.6, 33.4).
In a population of patients with refractory SCLC (those not responding to first line therapy), the response rate to topotecan was 4.0%.
In a randomised, comparative phase III trial conducted by the Gynaecological Oncology Group (GOG 0179), topotecan plus cisplatin (n=147) was compared with cisplatin alone (n=146) for the treatment of histologically confirmed persistent, recurrent or Stage IVB carcinoma of the cervix where curative treatment with surgery and/or radiation was not considered appropriate. Topotecan plus cisplatin had a statistically significant benefit in overall survival relative to cisplatin monotherapy after adjusting for interim analyses (Log-rank p =0.033).
Table 2: Study results Study GOG-0179
|Cisplatin 50mg/m2?on day 1, every 21 days||Cisplatin 50mg/m2?on day 1 + Topotecan 0.75mg/m2?on days 1-3, every 21 days|
|Survival (months)||(n= 146)||(n = 147)|
|Median (95% C.I.)||6.5 (5.8, 8.8)||9.4 (7.9, 11.9)|
|Hazard ratio (95% C.I.)||0.76 (0.59-0.98)|
|Log rank p-value||0.033|
|Patients without Prior Cisplatin Chemoradiotherapy|
|Survival (months)||(n= 46)||(n = 44)|
|Median (95% C.I.)||8.8 (6.4, 11.5)||15.7 (11.9, 17.7)|
|Hazard ratio (95% C.I.)||0.51 (0.31, 0.82)|
|Patients with Prior Cisplatin Chemoradiotherapy|
|Survival (months)||(n= 72)||(n = 69)|
|Median (95% C.I)||5.9 (4.7, 8.8)||7.9 (5.5, 10.9)|
|Hazard ratio (95% C.I.)||0.85 (0.59, 1.21)|
In patients (n=39) with recurrence within 180 days after chemoradiotherapy with cisplatin, the median survival in the topotecan plus cisplatin arm was 4.6 months (95% C.I.: 2.6, 6.1) versus 4.5 months (95%C.I.: 2.9, 9.6) for the cisplatin arm with a hazard ratio of 1.15 (0.59, 2.23). In those patients (n=102) with recurrence after 180 days, the median survival in the topotecan plus cisplatin arm was 9.9 months (95% C.I.: 7, 12.6) versus 6.3 months (95%C.I.: 4.9, 9.5) for the cisplatin arm with a hazard ratio of 0.75 (0.49, 1.16).
Topotecan was also evaluated in the paediatric population; however, only limited data on efficacy and safety are available.
In an open-label study involving children (n = 108, age range: infant to 16 years) with recurrent or progressive solid tumours, topotecan was administered at a starting dose of 2.0 mg/m2?given as a 30-minute infusion for 5 days repeated every 3 weeks for up to one year depending on response to therapy. Tumour types included were Ewing’s Sarcoma/primitive neuroectodermal tumour, neuroblastoma, osteoblastoma, and rhabdomyosarcoma. Antitumour activity was demonstrated primarily in patients with neuroblastoma. Toxicities of topotecan in paediatric patients with recurrent and refractory solid tumours were similar to those historically seen in adult patients. In this study, forty-six (43%) patients received G-CSF over 192 (42.1%) courses; sixty-five (60%) received transfusions of Packed Red Blood Cells and fifty (46%) of platelets over 139 and 159 courses (30.5% and 34.9%) respectively. Based on the dose-limiting toxicity of myelosuppression, the maximum tolerated dose (MTD) was established at 2.0 mg/m2/day with G-CSF and 1.4 mg/m2/day without G-CSF in a pharmacokinetic study in paediatric patients with refractory solid tumours (see section 5.2).
5.2 Pharmacokinetic properties
Following intravenous administration of topotecan at doses of 0.5 to 1.5 mg/m2?as a 30 minute infusion daily for five days, topotecan demonstrated a high plasma clearance of 62 l/h (SD 22), corresponding to approximately 2/3 of liver blood flow. Topotecan also had a high volume of distribution, about 132 l, (SD 57) and a relatively short half-life of 2-3 hours. Comparison of pharmacokinetic parameters did not suggest any change in pharmacokinetics over the 5 days of dosing. Area under the curve increased approximately in proportion to the increase in dose. There is little or no accumulation of topotecan with repeated daily dosing and there is no evidence of a change in the pharmacokinetics after multiple doses. Preclinical studies indicate plasma protein binding of topotecan is low (35%) and distribution between blood cells and plasma was fairly homogeneous.
The elimination of topotecan has only been partly investigated in man. A major route of clearance of topotecan was by hydrolysis of the lactone ring to form the ring-opened carboxylate.
Metabolism accounts for <10% of the elimination of topotecan. An N-desmethyl metabolite, which was shown to have similar or less activity than the parent in a cell-based assay, was found in urine, plasma, and faeces. The mean metabolite:parent AUC ratio was < 10 % for both total topotecan and topotecan lactone. An O-glucuronidation metabolite of topotecan and N-desmethyl topotecan has been identified in the urine.
Overall recovery of topotecan related material following five daily doses of topotecan was 71 to 76 % of the administered IV dose. Approximately 51% was excreted as total topotecan and 3 % was excreted as N-desmethyl topotecan in the urine. Faecal elimination of total topotecan accounted for 18 % while faecal elimination of N-desmethyl topotecan was 1.7%. Overall, the N-desmethyl metabolite contributed a mean of less than 7 % (range 4-9 %) of the total topotecan related material accounted for in the urine and faeces. The topotecan-O-glucuronide and N-desmethyl topotecan-O-glucuronide in the urine were less than 2.0 %.
In vitro?data using human liver microsomes indicate the formation of small amounts of N-demethylated topotecan. In vitro, topotecan did not inhibit human P450 enzymes CYP1A2, CYP2A6, CYP2C8/9, CYP2C19, CYP2D6, CYP2E, CYP3A, or CYP4A nor did it inhibit the human cytosolic enzymes dihydropyrimidine or xanthine oxidase.
When given in combination with cisplatin (cisplatin day 1, topotecan days 1 to 5), the clearance of topotecan was reduced on day 5 compared to day 1 (19.1 L/h/m2?compared to 21.3 L/h/m2?[n=9]) (see section 4.5).
Plasma clearance in patients with hepatic impairment (serum bilirubin between 1.5 and 10 mg/dl) decreased to about 67 % when compared with a control group of patients. Topotecan half-life was increased by about 30 % but no clear change in volume of distribution was observed. Plasma clearance of total topotecan (active and inactive form) in patients with hepatic impairment only decreased by about 10 % compared with the control group of patients.
Plasma clearance in patients with renal impairment (creatinine clearance 41-60 ml/min.) decreased to about 67 % compared with control patients. Volume of distribution was slightly decreased and thus half-life only increased by 14 %. In patients with moderate renal impairment topotecan plasma clearance was reduced to 34 % of the value in control patients. Mean half-life increased from 1.9 hours to 4.9 hours.
In a population study, a number of factors including age, weight and ascites had no significant effect on clearance of total topotecan (active and inactive form).
The pharmacokinetics of topotecan given as a 30-minute infusion for 5 days were evaluated in two studies. One study included a dose range of 1.4 mg/m2?to 2.4 mg/m2?in children (aged 2 up to 12 years, n = 18), adolescents (aged 12 up to 16 years, n = 9), and young adults (aged 16 to 21 years, n = 9) with refractory solid tumours. The second study included a dose range of 2.0 mg/m2?to 5.2 mg/m2?in children (n = 8), adolescents (n = 3), and young adults (n = 3) with leukaemia. In these studies, there were no apparent differences in the pharmacokinetics of topotecan among children, adolescents, and young adult patients with solid tumours or leukaemia, but data are too limited to draw definite conclusions.
5.3 Preclinical safety data
Resulting from its mechanism of action, topotecan is genotoxic to mammalian cells (mouse lymphoma cells and human lymphocytes) in vitro and mouse bone marrow cells in vivo. Topotecan was also shown to cause embryo-foetal lethality when given to rats and rabbits.
In reproductive toxicity studies with topotecan in rats there was no effect on male or female fertility; however, in females super-ovulation and slightly increased pre-implantation loss were observed
The carcinogenic potential of topotecan has not been studied.
- PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Hydrochloric acid (for pH adjustment)
Sodium hydroxide (for pH adjustment)
Water for injections
In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.
6.3? Shelf life
Chemical and physical in-use stability has been demonstrated for 30 days at 25?C under normal light conditions and at 2-8?C when protected from light. From a microbiological point of view, the product 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 24 hours at 2 to 8?C, unless dilution has taken place in controlled and validated aseptic conditions.
6.4 Special precautions for storage
?Store below 25?C?. Keep the vial in the outer carton in order to protect from light.
For storage conditions after dilution of the medicinal product, see section 6.3.
6.5 Nature and contents of container
Topotecan 1 mg/ml, 1 ml is supplied in 2 ml Type I amber glass vial and are closed with 13 mm flurotec rubber stopper and sealed with 13 mm aluminium flip off royal blue seal.
Topotecan 1 mg/ml, 4 ml is supplied in 5 ml Type I amber glass vial and are closed with 13 mm flurotec rubber stopper and sealed with 13 mm aluminium flip off royal blue seal.
Topotecan Infusion is available in cartons containing 1 vial and 5 vials.
Not all pack sizes may be marketed.
6.6 Special precautions for disposal and other handling
Topotecan is provided as a sterile concentrate containing 1 mg Topotecan in 1 ml solution and 4 mg Topotecan in 4 ml solution.
Parenteral products should be visually inspected for particulate matter and discoloration prior to administration. This medicinal product is a clear yellow colour solution. If visible particles are observed, the product should not be administered. Further dilution with either sodium chloride 9 mg/ml (0.9%) solution for injection or glucose 50 mg/ml (5%) solution for injection is required, to obtain a final concentration of between 25 and 50 micrograms/ml prior to administration to the patient.
The normal procedures for proper handling and disposal of anticancer medicinal products should be adopted, namely:
? Personnel should be trained to reconstitute the medicinal product.
? Pregnant staff should be excluded from working with this medicinal product.
? Personnel handling this medicinal product during reconstitution should wear protective clothing including mask, goggles and gloves.
? All items for administration or cleaning, including gloves, should be placed in high-risk, waste disposal bags for high-temperature incineration.
? Accidental contact with the skin or eyes should be treated immediately with copious amounts of water. If there is lasting irritation, a doctor should be consulted.
? Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
7. Manufactured in India by:
TAJ PHARMACEUTICALS LTD.
Survey No.188/1 to 189/1,190/1 to 4,
Daman- 396210 (INDIA)
Topotecan Concentrate for solution for infusion IP 1mg/ml
(1ml Multiple Dose Vial) Taj Pharma
Package leaflet: Information for the patient
Read all of this leaflet carefully before you start taking this medicine because it contains important information for you.
- Keep this leaflet. You may need to read itagain.
- If you have any further questions, ask your doctor orpharmacist.
- This medicine has been prescribed for you only. Do not pass it on to others. It may harmthem, even if their signs of illness are the same asyours.
- If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. See section4.
What is in this leaflet:
- What Topotecan is and what it is usedfor
- What you need to know before you take Topotecan
- How to take Topotecan
- Possible sideeffects
- How to store Topotecan
- Contents of the pack and otherinformation
1 WHAT TOPOTECAN IS AND WHAT IT IS USEDFOR
Topotecan Injection helps to destroy tumours. A doctor or a nurse will give you the medicine as an infusion into a vein (a drip) in hospital.
Topotecan Injection is used to treat:
– ovarian cancer or small cell lung cancer that has come back after chemotherapy
– advanced cervical cancer if surgery or radiotherapy treatment is not possible. When treating cervical cancer, Topotecan Injection is combined with another medicine called cisplatin.
Your doctor will decide with you whether Topotecan Injection therapy is better than further treatment with your initial chemotherapy
2 WHAT YOU NEED TO KNOW BEFORE YOU TAKE TOPOTECAN
You should not receive Topotecan Injection:
– if you are allergic to topotecan or any of the other ingredients of this medicine (listed in section 6).
– if you are breast feeding
– if your blood cell counts are too low. Your doctor will tell you whether this is the case, based on the results of your last blood test.
Tell your doctor if any of these applies to you.
Warning and precautions
Talk to your doctor or pharmacist or nurse before you are given this medicine your doctor needs to know:
– if you have any kidney or liver problems. Your dose of Topotecan Injection may need to be adjusted.
– if you are pregnant or plan to become pregnant. See section ?Pregnancy and breast-feeding? below.
– if you plan to father a child. See section ?Pregnancy and breast-feeding? below.
Other medicines and Topotecan Injection
Tell your doctor or pharmacist if you are taking have recently taken or might take any other medicines, including any herbal products or medicines obtained without a prescription.
Remember to tell your doctor if you start to take any other medicines while you are on Topotecan Injection.
Topotecan Injection with food, drink and alcohol
There is no known interaction between Topotecan Injection and alcohol. However, you should check with your doctor whether drinking alcohol is advisable for you.
Pregnancy breast-feeding and fertility Topotecan Injection is not recommended for pregnant women. It may harm the baby if conceived before, during or at least six months after treatment. You should use an effective method of contraception. Ask your doctor for advice. Do not try to become pregnant until a doctor advises you it is safe to do so.
Male patients who wish to father a child, should ask their doctor for family planning advice or treatment. If your partner becomes pregnant during your treatment, tell your doctor immediately.
Do not breast-feed if you are being treated with Topotecan Injection. Do not restart breast-feeding until the doctor tells you it is safe to do so.
Driving and using machines
Topotecan Injection can make people feel tired.
If you feel tired or weak, do not drive or use machines.
3 HOW TO TAKE TOPOTECAN
The dose of Topotecan Injection you are given will be worked out by your doctor, based on:
– your body size (surface area measured in square meters)
– the results of blood tests carried out before treatment
– the disease being treated.
The recommended dose
? Ovarian and small cell lung cancer: 1.5 mg per square meters of body surface area per day. You will have treatment once a day for 5 days. This pattern of treatment will normally be repeated every 3 weeks.
- Cervical cancer: 0.75 mg per square meters of body surface area per day. You will havetreatment once a day for 3 days. This pattern of treatment will normally be repeated every 3 weeks.
When treating cervical cancer, Topotecan Injection is combined with another medicine, called cisplatin. Your doctor will determine the correct dose of cisplatin.
How Topotecan Injection is prepared
Topotecan is supplied as a concentrate for solution for infusion. The concentrate must be diluted before administration.
How Topotecan Injection is given
A doctor or nurse will give you a suitable dose of Topotecan Injection as an infusion (a drip). It is usually dripped into your arm over about 30 minutes.
The treatment may vary, depending on the results of your regular blood tests.
If you stop taking Topotecan Injection
Your doctor will decide when to stop the treatment.
4 POSSIBLE SIDE EFFECTS
Like all medicines, this medicine can cause side effects, although not everybody gets them.
Serious side effects: tell your doctor
Very common (may affect more than 1 in 10 people)
– Signs of infections: Topotecan Injection may reduce the number of white blood cells and lower your resistance to infection. This can even be life threatening. Signs include:
– serious deterioration of your general condition
– local symptoms such as sore throat or urinary problems (for example, a burning sensation when urinating, which may be a urinary infection)
– occasionally severe stomach pain, fever and possibly diarrhoea (rarely with blood) can be signs of bowel inflammation (colitis)
Rare (may affect up to 1 in 1,000 people)
– Severe allergic or anaphylactic reactions causing swelling of the lips, face or neck leading to severe difficulty in breathing, skin rash or hives, anaphylactic shock (a severe reduction in blood pressure, paleness, agitation, weak pulse, decreased consciousness.
– Lung inflammation (interstitial lung disease): You are most at risk if you have existing lung disease, have had radiation treatment to your lungs, or have previously taken medicines that caused lung damage. Signs include:
– difficulty breathing
Tell your doctor immediately if you get any symptoms of these conditions, as hospitalisation may be necessary.
Other side effects:
Very common (may affect more than 1 in 10 people)
– Feeling generally weak and tired (temporary anaemia). In some cases you may need a blood transfusion.
– Abnormally low white blood cell count (neutropenia) which may be accompanied with fever and signs of infections (febrile neutropenia)
– Unusual bruising or bleeding, caused by a decrease in the number of clotting cells in the blood. This can lead to severe bleeding from relatively small injuries such as a small cut. Rarely, it can lead to more severe bleeding (haemorrhage). Talk to your doctor for advice on how to minimize the risk of bleeding.
– Weight loss and loss of appetite (anorexia); tiredness; weakness.
– Feeling sick (nausea), being sick (vomiting); diarrhoea; stomach pain; constipation
– Inflammation and ulcers of the mouth tongue or gums
– High body temperature (fever)
– Hair loss.
Common (may affect up to 1 in 10 people)
– Allergic or hypersensitivity reactions (including rash)
– Yellow skin
– Itching sensation
– Feeling unwell (malaise)
– Deficiency of all three cellular components (red cells, white cells, and platelets) of the blood (pancytopenia).
Rare: (may affect up to 1 in 1,000 people)
– Swelling caused by fluid build up (angioedema)
– Mild pain and inflammation at the site of injection
– Itchy rash (or hives).
Not known (frequency cannot be estimated from the available data)
The frequency of some side effects is not known (events from spontaneous reports and the frequency cannot be estimated from the available data):
– Severe stomach pain, nausea, vomiting of blood, black or bloody stools (possible symptoms of gastrointestinal perforation).
– Mouth sores,
– Difficulty swallowing,
– Abdominal pain,
– Bloody stools (possible signs and symptoms of inflammation of the inner lining of the mouth, stomach and/or gut [mucosal inflammation]).
Very rare: (may affect up to 1 in 10,000 people)
– Discharge of blood into tissues (extravasation).
If you are being treated for cervical cancer, you may get side effects from the other medicine (cisplatin) that you will be given along with Topotecan Injection. Those effects are described in the cisplatin patient leaflet.
Reporting of side effects
If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any possible side effects not listed in this leaflet. By reporting side effects you can help provide more information on the safety of this medicine
5 HOW TO STORETOPOTECAN
Keep this medicine out of the sight and reach of children.
Do not use this medicine after the expiry date, which is stated on the vial and carton after EXP. The expiry date refers to the last day of that month.
?Store below 25?C?
Keep the container in the outer carton in order to protect from light.
This medicine is for single use only. After opening, the product should be used immediately for dilution.
Chemical and physical in-use stability after dilution has been demonstrated for 30 days at 25?C under normal light conditions and at 2-8?C when protected from light.
From a microbiological point of view, the product after dilution 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 24 hours at 2 to 8?C, unless dilution has taken place in controlled and validated aseptic conditions.
Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to throw away medicines you no longer used. These measures will help to protect the environment.
6 CONTENTS OF THE PACK AND OTHER INFORMATION
What Topotecan contains
The active substance is Topotecan.
a) Each ml multiple dose vial contains:?
Topotecan (as hydrochloride)????? 1mg
Each 1 ml vial of concentrate contains 1 mg topotecan (as hydrochloride)
b) Each Single Dose Vial contains:
Topotecan Hydrochloride equivalent to
4mg of topotecan as free base.
Each 4 ml vial of concentrate contains 4 mg topotecan (as hydrochloride)
– The other ingredients are: tartaric acid, water for injections and hydrochloric acid or sodium hydroxide (for pH adjustment).
Contents of the pack
This medicine is a concentrate for solution for infusion.
The concentrate is a clear yellow colour solution. It is filled in an amber colour glass vial sealed with flurotec rubber stoppers and aluminium flip-off seals.
This medicinal product is available in two pack sizes, containing either 1 vial or 5 vials.
Not all pack sizes may be marketed.
7. Manufactured in India By:
TAJ PHARMACEUTICALS LIMITED
Mumbai, India Survey No.188/1 to 189/1,190/1 to 4,
Daman- 396210 (INDIA)