Fludarabine

Fludarabine Actavis 50mg Lyophilisate For Solution For Injection Or Infusion

Powder for solution for injection or infusion.

White or almost white lyophilisate.

Treatment of B-cell chronic lymphocytic leukaemia (CLL) in patients with sufficient bone marrow reserves.

First line treatment with Fludarabine Actavis should only be initiated in patients with advanced disease, Rai stages III/IV (Binet stage C), or Rai stages I/II (Binet stage A/B) where the patient has disease related symptoms or evidence of progressive disease.

Fludarabine Actavis should be administered under the supervision of a qualified physician experienced in the use of antineoplastic therapy.

It is strongly recommended that Fludarabine Actavis should be only administered intravenously. No cases have been reported in which paravenously administered fludarabine led to severe local adverse reactions. However, the unintentional paravenous administration must be avoided.

Adults

The recommended dose is 25 mg fludarabine phosphate/m² body surface given daily for 5 consecutive days every 28 days by the intravenous route.).

The optimal duration of treatment has not been clearly established. The duration of treatment depends on the treatment success and the tolerability of the drug.

It is recommended that Fludarabine Actavis be administered up to the achievement of response (usually 6 cycles) and then the drug should be discontinued.

Hepatic impairment

No data are available concerning the use of fludarabine phosphate in patients with hepatic impairment. In this group of patients, Fludarabine Actavis should be used with caution and administered if the perceived benefit outweighs any potential risk.

Renal impairment

Doses should be adjusted for patients with reduced renal function.

Fludarabine Actavis treatment is contraindicated, if creatinine clearance is < 30 ml/min.

Paediatric population

Fludarabine is not recommended for use in children and adolescents below age 18, due to a lack of data on safety and efficacy.

Geriatric population

Fludarabine Actavis is contraindicated

- in those patients who are hypersensitive to the active substance or any of the excipients

- in renally impaired patients with creatinine clearance < 30 ml/min

- in patients with decompensated haemolytic anaemia

- during pregnancy and lactation.

Neurotoxicity

When used at high doses in dose-ranging studies in patients with acute leukaemia, fludarabine phosphate was associated with severe neurological effects, including blindness, coma and death. Symptoms appeared from 21 to 60 days from last dose. This severe central nervous system toxicity occurred in 36 % of patients treated with doses approximately four times greater (96 mg/m²/day for 5 7 days) than the dose recommended for treatment of CLL. In patients treated at doses in the range of the dose recommended for CLL, severe central nervous system toxicity occurred rarely (coma, seizures and agitation) or uncommonly (confusion).

In postmarketing experience neurotoxicity has been reported to occur earlier or later than in clinical trials.

The effect of chronic administration of fludarabine phosphate on the central nervous system is unknown. However, patients tolerated the recommended dose, in some studies for relatively long term treatment times, whereby up to 26 courses of therapy were administered.

Patients should be closely observed for signs of neurological side effects.

Impaired state of health

In patients with impaired state of health, Fludarabine Actavis should be given with caution and after careful risk/benefit consideration. This applies especially for patients with severe impairment of bone marrow function (thrombocytopenia, anaemia, and/or granulocytopenia), immunodeficiency or with a history of opportunistic infection.

Myelosuppression

Severe bone marrow suppression, notably anaemia, thrombocytopenia and neutropenia, has been reported in patients treated with fludarabine phosphate. In a Phase I study in solid tumour patients, the median time to nadir counts was 13 days (range, 3 25 days) for granulocytes and 16 days (range, 2 32) for platelets. Most patients had haematological impairment at baseline either as a result of disease or as a result of prior myelosuppressive therapy. Cumulative myelosuppression may be seen. While chemotherapy-induced myelosuppression is often reversible, administration of fludarabine phosphate requires careful haematological monitoring.

Fludarabine Actavis is a potent antineoplastic agent with potentially significant toxic side effects. Patients undergoing therapy should be closely observed for signs of haematological and non-haematological toxicity. Periodic assessment of peripheral blood counts is recommended to detect the development of anaemia, neutropenia and thrombocytopenia.

Several instances of trilineage bone marrow hypoplasia or aplasia resulting in pancyopenia, sometimes resulting in death, have been reported in adult patients. The duration of clinically significan cytopenia in the reported cases has ranged fronm approximately 2 months to approximately 1 year. These episodes have occurred both in previously treated or untreated patients.

As with other cytotoxics, caution should be exercised with fludarabine phosphate, when further haematopoietic stem sampling is considered.

Transfusion-associated graft-versus-host disease

Transfusion-associated graft-versus-host disease (reaction by the transfused immunocompetent lymphocytes to the host) has been observed after transfusion of non-irradiated blood in patients treated with fludarabine phosphate. Fatal outcome as a consequence of this disease has been reported with a high frequency. Therefore, to minimize the risk, patients who require blood transfusion and who are undergoing, or who have received, treatment with Fludarabine Actavis should receive irradiated blood only.

Skin cancer

Reversible worsening or flare up of pre-existing skin cancer lesions as well as new onset of skin cancer have been reported in some patients to occur during or after fludarabine phosphate therapy.

Tumour lysis syndrome

Tumour lysis syndrome associated with fludarabine phosphate treatment has been reported in CLL patients with large tumour burdens. Since fludarabine phosphate can induce a response as early as the first week of treatment, precautions should be taken in those patients at risk of developing this complication.

Autoimmune impairment

Irrespective of any previous history of autoimmune processes or Coombs test status, life-threatening and sometimes fatal autoimmune phenomena (e.g. autoimmune haemolytic anaemia, autoimmune thrombocytopenia, thrombocytopenic purpura, pemphigus, Evans' syndrome) have been reported to occur during or after treatment with fludarabine phosphate. The majority of patients experiencing haemolytic anaemia developed a recurrence in the haemolytic process after rechallenge with fludarabine phosphate. Patients treated with Fludarabine Actavis should be closely monitored for signs of haemolysis.

Discontinuation of therapy with Fludarabine Actavis is recommended in case of haemolysis. Blood transfusion (irradiated, see above) and adrenocorticoid preparations are the most common treatment measures for autoimmune haemolytic anaemia.

Renal impairment

The total body clearance of the principle plasma metabolite 2-F-ara-A shows a correlation with creatinine clearance, indicating the importance of the renal excretion pathway for the elimination of the compound. Patients with reduced renal function demonstrated an increased total body exposure (AUC of 2F-ara-A). There are limited clinical data available in patients with impairment of renal function (creatinine clearance <70 ml/min).

Fludarabine must be administered cautiously in patients with renal insufficiency. In patients with moderate impairment of renal function (creatinine clearance between 30 and 70 ml/min.) the dose should be reduced by up to 50% and the patient should be monitored closely. Fludarabine treatment is contraindicated if creatinine clearance is <30 ml/min..

Geriatric population

Paediatric population

No data are available concerning the use of fludarabine phosphate in the paediatric population. Therefore, treatment with Fludarabine Actavis in children and adolescents below age 18 is not recommended.

Pregnancy

Fludarabine Actavis should not be used during pregnancy unless clearly necessary (e.g. life-threatening situation, no alternative safer treatment available without compromising the therapeutic benefit, treatment cannot be avoided). It has the potential to cause fetal harm. Prescribers may only consider the use of fludarabine, if the potential benefits justify the potential risks to the foetus.

Women should avaoid becoming pregnant while on fludarabine therapy.

Women of childbearing potential must be apprised of the potential hazard to the foetus.

Contraception

Females of child-bearing potential or fertile males must take effective contraceptive measures during and at least for 6 months after cessation of therapy.

Vaccination

During and after treatment with Fludarabine Actavis vaccination with live vaccines should be avoided.

Retreatment options after initial fludarabine treatment

A crossover from initial treatment with fludarbine phoshpate to chlorambucil for non responders to fludarabine phosphate should be avoided because most patients who have been resistant to fludarabine phoshpate have shown resistance to chlorambucil.

Excipients

This medicinal product contains less than 1 mmol sodium (23 mg) per ml after reconstitution, i.e. essentially sodium free.

No studies on the effects on the ability to drive and use machines have been performed.

Fludarabine Actavis may influence the ability to drive and use machines since fatigue, weakness, agitation, seizures and visual disturbances has been observed.

The most common adverse events include myelosuppression (neutropenia, thrombocytopenia and anaemia), infection including pneumonia, cough, fever, fatigue, weakness, nausea, vomiting and diarrhoea. Other commonly reported events include stomatitis, mucositis, malaise, anorexia, oedema, chills, peripheral neuropathy, visual disturbances and skin rashes. Serious opportunistic infections have occurred in patients treated with fludarabine phosphate. Fatalities as a consequence of serious adverse events have been reported.

The table below reports adverse events by MedDRA system organ classes (MedDRA SOCs). The frequencies are based on clinical trial data regardless of the causal relationship with fludarabine. The rare adverse reactions were mainly identified from the post-marketing experience.

The most appropriate MedDRA term to describe a certain adverse event is listed. Synonyms or related conditions are not listed, but should be taken into account as well.

Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.

High doses of fludarabine phosphate have been associated with an irreversible central nervous system toxicity characterised by delayed blindness, coma, and death. High doses are also associated with severe thrombocytopenia and neutropenia due to bone marrow suppression. There is no known specific antidote for fludarabine phosphate overdosage. Treatment consists of drug discontinuation and supportive therapy.

Pharmacotherapeutic group: Antineoplastic agents ATC-code L01B B05

Fludarabine Actavis contains fludarabine phosphate, a water-soluble fluorinated nucleotide analogue of the antiviral agent vidarabine, 9ß-D-arabinofuranosyladenine (ara-A) that is relatively resistant to deamination by adenosine deaminase.

Fludarabine phosphate is rapidly dephosphorylated to 2F-ara-A which is taken up by cells and then phosphorylated intracellularly by deoxycytidine kinase to the active triphosphate, 2F-ara-ATP. This metabolite has been shown to inhibit ribonucleotide reductase, DNA polymerase α/δ and ε, DNA primase and DNA ligase thereby inhibiting DNA synthesis. Furthermore, partial inhibition of RNA polymerase II and consequent reduction in protein synthesis occur.

While some aspects of the mechanism of action of 2F-ara-ATP are as yet unclear, it is assumed that effects on DNA, RNA and protein synthesis all contribute to inhibition of cell growth with inhibition of DNA synthesis being the dominant factor. In addition, in vitro studies have shown that exposure of CLL lymphocytes to 2F-ara-A triggers extensive DNA fragmentation and cell death characteristic of apoptosis.

A phase III trial in patients with previously untreated B-chronic lymphocytic leukaemia comparing treatment with fludarabine phosphate vs. chlorambucil (40mg / m² q4 weeks) in 195 and 199 patients respectively showed the following outcome: statistically significant higher overall response rates and complete response rates after 1^st line treatment with fludarabine phosphate compared to chlorambucil (61.1% vs. 37.6% and 14.9% vs. 3.4%, respectively); statistically significant longer duration of response (19 vs. 12.2 months) and time to progression (17 vs. 13.2 months) for the patients in the fludarabine phosphate group. The median survival of the two patient groups was 56.1 months for fludarabine phsophate and 55.1 months for chlorambucil, a non-significant difference was also shown with performance status. The proportion of patients reported to have toxicities were comparable between fludarabine phosphate patients (89.7%) and chlorambucil patients (89.9%). While the difference in the overall incidence of haematological toxicities was not significant between the two treatment groups, significantly greater proportions of fludarabine phosphate patients experienced white blood cell (p=0.0054) and lymphocyte (p=0.0240) toxicities than chlorambucil patients. The proportions of patients who experienced nausea, vomiting, and diarrhoea were significantly lower for fludarabine phosphate patients (p<0.0001, p<0.0001, and p=0.0489, respectively) than chlorambucil patients. Toxicities of the liver were also reported for significantly (p=0.0487) less proportions of patients in the fludarabine phosphate group than in the chlorambucil group.

Patients who initially respond to fludarabine phosphate have a chance of responding again to fludarabine phosphate monotherapy.

A randomised trial of fludarabine phosphate vs. cyclophosphamide, adriamycin and prednisone (CAP) in 208 patients with CLL Binet stage B or C revealed the following results in the subgroup of 103 previously treated patients: the overall response rate and the complete response rate were higher with fludarabine phosphate compared to CAP (45% vs. 26% and 13% vs. 6%, respectively); response duration and overall survival were similar with fludarabine phosphate and CAP. Within the stipulated treatment period of 6 months the number of deaths was 9 (fludarabine phosphate) vs. 4 (CAP).

Post-hoc analyses using only data of up to 6 months after start of treatment revealed a difference between survival curves of fludarabine phosphate and CAP in favour of CAP in the subgroup of pretreated Binet stage C patients.

Plasma and urinary pharmacokinetics of fludarabine (2F-ara-A)

The pharmacokinetics of fludarabine (2F-ara-A) have been studied after intravenous administration by rapid bolus injection and short-term infusion as well as following continuous infusion of fludarabine phosphate (fludarabine phosphate, 2F-ara-AMP).

2F-ara-AMP is a water-soluble prodrug, which is rapidly and quantitatively dephosphorylated in the human organism to the nucleoside fludarabine (2Fara-A). After single dose infusion of 25 mg 2F-ara-AMP per m² to cancer patients for 30 minutes 2F-ara-A reached mean maximum concentrations in the plasma of 3.5 - 3.7 μM at the end of the infusion. Corresponding 2FaraA levels after the fifth dose showed a moderate accumulation with mean maximum levels of 4.4 - 4.8 µM at the end of infusion. During a 5day treatment schedule 2FaraA plasma trough levels increased by a factor of about 2. An accumulation of 2F-ara-A over several treatment cycles can be excluded. Postmaximum levels decayed in three disposition phases with an initial half-life of approx. 5 minutes, an intermediate half-life of 1 - 2 hours and a terminal half-life of approx. 20 hours.

An interstudy comparison of 2F-ara-A pharmacokinetics resulted in a mean total plasma clearance (CL) of 79 ± 40 ml/min/m² (2.2 ± 1.2 ml/min/kg) and a mean volume of distribution (Vss) of 83 ± 55 l/m² (2.4 ± 1.6 l/kg). Data showed a high interindividual variability. Plasma levels of 2Fara-A and areas under the plasma level time curves increased linearly with the dose, whereas half-lives, plasma clearance and volumes of distribution remained constant independent of the dose indicating a dose linear behaviour.

Occurrence of neutropenia and haematocrit changes indicated that the cytotoxicity of fludarabine phosphate depresses the haematopoiesis in a dose dependent manner.

2F-ara-A elimination is largely by renal excretion. 40 to 60 % of the administered i.v. dose was excreted in the urine. Mass balance studies in laboratory animals with ³H-2F-ara-AMP showed a complete recovery of radio-labelled substances in the urine. Another metabolite, 2F-ara-hypoxanthine, which represents the major metabolite in the dog, was observed in humans only to a minor extent. Individuals with impaired renal function exhibit a reduced total body clearance, indicating the need for a dose reduction. In vitro investigations with human plasma proteins revealed no pronounced tendency of 2F-ara-A protein binding.

Cellular pharmacokinetics of fludarabine triphosphate

2F-ara-A is actively transported into leukaemic cells, whereupon it is rephosphorylated to the monophosphate and subsequently to the di- and triphosphate. The triphosphate 2F-ara-ATP is the major intracellular metabolite and the only metabolite known to have cytotoxic activity. Maximum 2F-ara-ATP levels in leukaemic lymphocytes of CLL patients were observed at a median of 4 hours and exhibited a considerable variation with a median peak concentration of approx. 20 µM. 2F-ara-ATP levels in leukaemic cells were always considerably higher than maximum 2F-ara-A levels in the plasma indicating an accumulation at the target sites. In vitro incubation of leukaemic lymphocytes showed a linear relationship between extracellular 2F-ara-A exposure (product of 2F-ara-A concentration and duration of incubation) and intracellular 2FaraATP enrichment. 2F-araATP elimination from target cells showed median halflife values of 15 and 23 hours.

No clear correlation was found between 2FaraA pharmacokinetics and treatment efficacy in cancer patients.

In acute toxicity studies, single doses of fludarabine phosphate produced severe intoxication symptoms or death at dosages about two orders of magnitude above the therapeutic dose. As expected for a cytotoxic compound, the bone marrow, lymphoid organs, gastrointestinal mucosa, kidneys and male gonads were affected.

Systemic toxicity studies following repeated administration of fludarabine phosphate showed also the expected effects on rapidly proliferating tissues above a threshold dose. The severity of morphological manifestations increased with dose levels and duration of dosing and the observed changes were generally considered to be reversible. In principle, the available experience from the therapeutic use of fludarabine phosphate points to a comparable toxicological profile in humans, although additional undesirable effects such as neurotoxicity were observed in patients.

The results from animal embryotoxicity studies indicated a teratogenic potential of fludarabine phosphate. In view of the small safety margin between the teratogenic doses in animals and the human therapeutic dose as well as in analogy to other antimetabolites which are assumed to interfere with the process of differentiation, the therapeutic use of fludarabine phosphate is associated with a relevant risk of teratogenic effects in humans.

Fludarabine phosphate has been shown to induce chromosomal aberrations in an in vitro cytogenetic assay, to cause DNA-damage in a sister chromatid exchange test and to increase the rate of micronuclei in the mouse micronucleus test in vivo, but was negative in gene mutation assays and in the dominant lethal test in male mice. Thus, the mutagenic potential was demonstrated in somatic cells but could not be shown in germ cells.

The known activity of fludarabine phosphate at the DNA-level and the mutagenicity test results form the basis for the suspicion of a tumorigenic potential. No animal studies which directly address the question of tumorigenicity have been conducted, because the suspicion of an increased risk of second tumours due to fludarabine phosphate therapy can exclusively be verified by epidemiological data.

According to the results from animal experiments following intravenous administration of fludarabine phosphate, no remarkable local irritation has to be expected at the injection site. Even in case of misplaced injections, no relevant local irritation was observed after paravenous, intraarterial, and intramuscular administration of an aqueous solution containing 7.5 mg fludarabine phosphate/ml.

Mannitol

Sodium hydroxide (for pH adjustment).

Vial before opening:

4 years.

After reconstitution:

The physicochemical stability of the drug product after reconstitution in water for injections has been demonstrated for 8 hours at 25°C ± 2°C/ 60% ± 5 %RH and for 7 days at 5°C ± 3°C. 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.

Colourless glass vial (type I) with bromobutylic rubber stopper and metallic cap (aluminium) with polypropylene disk. Vial will be packed with or without a protective plastic overwrap.

Pack sizes

1 x 50mg vial

5 x 50mg vial

Not all pack sizes may be marketed.

Reconstitution

Fludarabine Actavis should be prepared for parenteral use by aseptically adding sterile water for injection. When reconstituted with 2 ml of sterile water for injection, the powder should fully dissolve in 15 seconds or less. Each ml of the resulting solution will contain 25 mg of fludarabine phosphate, 25 mg of mannitol, and sodium hydroxide to adjust the pH to 7.7. The pH range for the final product is 7.2 - 8.2.

Dilution

The required dose (calculated on the basis of the patient's body surface) is drawn up into a syringe.

For intravenous bolus injection this dose is further diluted in 10 ml of 0.9 % sodium chloride. Alternatively, for infusion, the required dose may be diluted in 100 ml of 0.9 % sodium chloride.

Inspection prior to use

The reconstituted solution is clear and colourless. It should be visually inspected before use.

Only clear and colourless solutions without particles should be used. Fludarabine Actavis should not be used in case of a defective container.

Handling and disposal

Fludarabine Actavis should not be handled by pregnant staff.

Procedures for proper handling should be followed according to local requirements for cytotoxic drugs. Caution should be exercised in the handling and preparation of the Fludarabine Actavis solution. The use of latex gloves and safety glasses is recommended to avoid exposure in case of breakage of the vial or other accidental spillage.

If the solution comes into contact with the skin or mucous membranes, the area should be washed thoroughly with soap and water. In the event of contact with the eyes, rinse them thoroughly with copious amounts of water. Exposure by inhalation should be avoided.

The medicinal product is for single use only. Any unused product or waste material should be disposed of in accordance with local requirements for cytotoxic agents.

Actavis Group PTC ehf

Reykjavíkurvegur 76-78

IS-220 Hafnarfjörður

Iceland

PL 30306/0006

13/03/2008

18/11/2010