Линпарза

Линпарза is indicated as monotherapy for the maintenance treatment of adult patients with platinum-sensitive relapsed high-grade epithelial ovarian, fallopian tube, or primary peritoneal cancer who are in response (complete or partial) to platinum-based chemotherapy.

Treatment with Линпарза should be initiated and supervised by a physician experienced in the use of anticancer medicinal products.

Posology

Линпарза is available as 100 mg and 150 mg tablets.

The recommended dose of Линпарза is 300 mg (two 150 mg tablets) taken twice daily, equivalent to a total daily dose of 600 mg. The 100 mg tablet is available for dose reduction.

Patients should start treatment with Линпарза no later than 8 weeks after completion of their final dose of the platinum-containing regimen.

It is recommended that treatment be continued until progression of the underlying disease. There are no data on retreatment with Линпарза following subsequent relapse.

Important differences in posology between Линпарза tablets and capsules

Линпарза tablets (100 mg and 150 mg) should not be substituted for Линпарза capsules (50 mg) on a milligram-to-milligram basis due to differences in the dosing and bioavailability of each formulation. Therefore, the specific dose recommendations for each formulation should be followed.

Missing dose

If a patient misses a dose of Линпарза, they should take their next normal dose at its scheduled time.

Dose adjustments for adverse reactions

Treatment may be interrupted to manage adverse reactions such as nausea, vomiting, diarrhoea, and anaemia and dose reduction can be considered.

The recommended dose reduction is to 250 mg (one 150 mg tablet and one 100 mg tablet) twice daily (equivalent to a total daily dose of 500 mg).

If a further dose reduction is required, then reduction to 200 mg (two 100 mg tablets) twice daily (equivalent to a total daily dose of 400 mg) is recommended.

Dose adjustments for co-administration with CYP3A inhibitors

Concomitant use of strong or moderate CYP3A inhibitors is not recommended and alternative agents should be considered. If a strong CYP3A inhibitor must be co-administered, the recommended Линпарза dose reduction is to 100 mg (one 100 mg tablet) taken twice daily (equivalent to a total daily dose of 200 mg). If a moderate CYP3A inhibitor must be co-administered, the recommended Линпарза dose reduction is to 150 mg (one 150 mg tablet) taken twice daily (equivalent to a total daily dose of 300 mg).

Special populations

Elderly

No adjustment in starting dose is required for elderly patients. There are limited clinical data in patients aged 75 years and over.

Renal impairment

For patients with moderate renal impairment (creatinine clearance 31 to 50 ml/min) the recommended dose of Линпарза is 200 mg (two 100 mg tablets) twice daily (equivalent to a total daily dose of 400 mg).

Линпарза can be administered in patients with mild renal impairment (creatinine clearance 51 to 80 ml/min) with no dose adjustment.

Линпарза is not recommended for use in patients with severe renal impairment or end-stage renal disease (creatinine clearance ≤ 30 ml/min), as safety and pharmacokinetics have not been studied in these patients. Линпарза may only be used in patients with severe renal impairment if the benefit outweighs the potential risk, and the patient should be carefully monitored for renal function and adverse events.

Hepatic impairment

Линпарза can be administered to patients with mild or moderate hepatic impairment (Child-Pugh classification A or B) with no dose adjustment. Линпарза is not recommended for use in patients with severe hepatic impairment (Child-Pugh classification C), as safety and pharmacokinetics have not been studied in these patients.

Non-Caucasian patients

There are limited clinical data available in non-Caucasian patients. However, no dose adjustment is required on the basis of ethnicity.

Patients with performance status 2 to 4

There are very limited clinical data available in patients with performance status 2 to 4.

Paediatric population

The safety and efficacy of Линпарза in children and adolescents have not been established.

No data are available.

Method of administration

Линпарза is for oral use.

Линпарза tablets should be swallowed whole and not chewed, crushed, dissolved or divided. Линпарза tablets may be taken without regard to meals.

Breast-feeding during treatment and for 1 month after the last dose.

Haematological toxicity

Haematological toxicity has been reported in patients treated with Линпарза, including clinical diagnoses and/or laboratory findings of generally mild or moderate (CTCAE grade 1 or 2) anaemia, neutropenia, thrombocytopenia and lymphopenia. Patients should not start treatment with Линпарза until they have recovered from haematological toxicity caused by previous anticancer therapy (haemoglobin, platelet and neutrophil levels should be ≤CTCAE grade 1). Baseline testing, followed by monthly monitoring, of complete blood counts is recommended for the first 12 months of treatment and periodically after this time to monitor for clinically significant changes in any parameter during treatment.

If a patient develops severe haematological toxicity or blood transfusion dependence, treatment with Линпарза should be interrupted and appropriate haematological testing should be initiated. If the blood parameters remain clinically abnormal after 4 weeks of Линпарза dose interruption, bone marrow analysis and/or blood cytogenetic analysis are recommended.

Myelodysplastic syndrome/Acute myeloid leukaemia

The incidence of myelodysplastic syndrome/acute myeloid leukaemia (MDS/AML) in patients treated in clinical trials with Линпарза monotherapy, including long-term survival follow-up, was <1.5% and the majority of events had a fatal outcome. The duration of therapy with olaparib in patients who developed MDS/AML varied from <6 months to >2 years; data with longer durations of exposure are limited. All patients had potential contributing factors for the development of MDS/AML, having received previous chemotherapy with platinum agents. Many had also received other DNA damaging agents and radiotherapy. The majority of reports were in germline breast cancer susceptibility gene 1 or 2 (gBRCA1/2) mutation carriers. Some of the patients had a history of previous cancer or of bone marrow dysplasia. If MDS and/or AML are confirmed while on treatment with Линпарза, it is recommended that Линпарза should be discontinued and the patient be treated appropriately.

Pneumonitis

Pneumonitis, including events with a fatal outcome, has been reported in <1.0% of patients treated with Линпарза in clinical studies. Reports of pneumonitis had no consistent clinical pattern and were confounded by a number of pre-disposing factors (cancer and/or metastases in lungs, underlying pulmonary disease, smoking history, and/or previous chemotherapy and radiotherapy). If patients present with new or worsening respiratory symptoms such as dyspnoea, cough and fever, or an abnormal chest radiologic finding is observed, Линпарза treatment should be interrupted and prompt investigation initiated. If pneumonitis is confirmed, Линпарза treatment should be discontinued and the patient treated appropriately.

Embryofoetal toxicity

Based on its mechanism of action (PARP inhibition), Линпарза could cause foetal harm when administered to a pregnant woman. Nonclinical studies in rats have shown that olaparib causes adverse effects on embryofoetal survival and induces major foetal malformations at exposures below those expected at the recommended human dose of 300 mg twice daily.

Pregnancy/contraception

Линпарза should not be used during pregnancy and in women of childbearing potential not using reliable contraception during therapy and for 1 month after receiving the last dose of Линпарза.

Interactions

Линпарза co-administration with strong or moderate CYP3A inhibitors is not recommended. If a strong or moderate CYP3A inhibitor must be co-administered, the dose of Линпарза should be reduced.

Линпарза co-administration with strong or moderate CYP3A inducers is not recommended. In the event that a patient already receiving Линпарза requires treatment with a strong or moderate CYP3A inducer, the prescriber should be aware that the efficacy of Линпарза may be substantially reduced.

Линпарза has moderate influence on the ability to drive and use machines. Patients who take Линпарза may experience fatigue, asthenia or dizziness. Patients who experience these symptoms should observe caution when driving or using machines.

Summary of the safety profile

Линпарза monotherapy has been associated with adverse reactions generally of mild or moderate severity (CTCAE 1 or 2) and generally not requiring treatment discontinuation. The most frequently observed adverse reactions across clinical trials in patients receiving Линпарза monotherapy (> 10%) were nausea, vomiting, diarrhoea, dyspepsia, fatigue, headache, dysgeusia, decreased appetite, dizziness, and anaemia.

Tabulated list of adverse reactions

The safety profile is based on pooled data from 1,248 patients treated with Линпарза monotherapy in clinical trials in the therapeutic indication at the recommended dose.

The following adverse reactions have been identified in clinical trials with patients receiving Линпарза monotherapy where patient exposure is known. Adverse drug reactions are listed by MedDRA System Organ Class (SOC) and then by MedDRA preferred term in Table 1. Within each SOC, preferred terms are arranged by decreasing frequency and then by decreasing seriousness. Frequencies of occurrence of adverse reactions 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 < 1/1000); very rare (< 1/10,000); not known (cannot be estimated from available data).

Table 1 Tabulated list of adverse reactions

^a Anaemia includes preferred terms (PTs) of anaemia, haemoglobin decreased, red blood cell count decreased, erythropenia and haematocrit decreased; Neutropenia includes PTs of neutropenia, granulocytopenia, granulocyte count decreased and neutrophil count decreased, febrile neutropenia, neutropenic infection and neutropenic sepsis; Thrombocytopenia includes PTs of thrombocytopenia, platelet count decreased, platelet production decreased and plateletcrit decreased; Leukopenia includes PTs of leukopenia and white blood cell count decreased; Cough includes PTs of cough and productive cough; Rash includes PTs of rash, rash erythematous, rash generalised, rash macular, rash maculo-papular, rash papular, rash pruritic, exfoliative rash and generalised erythema; Hypersensitivity includes PTs of hypersensitivity and drug hypersensitivity; Dermatitis includes PTs of dermatitis, dermatitis allergic and dermatitis exfoliative.

^b Represents the incidence of laboratory findings of elevations in mean corpuscular volume from baseline to above the upper limit of normal (ULN), not of reported adverse reactions.

Description of selected adverse reactions

Haematological toxicity

Anaemia and other haematological toxicities were generally low grade (CTCAE grade 1 or 2), however, there were reports of CTCAE grade 3 and higher events. Anaemia was the most common CTCAE grade >3 adverse reaction reported in clinical studies. Median time to first onset of anaemia was approximately 4 weeks (approximately 7 weeks for CTCAE grade >3 events). Anaemia was managed with dose interruptions and dose reductions , and where appropriate with blood transfusions. In SOLO2, the incidence of anaemia adverse reactions was 43.6% (CTCAE grade >3 19.5%) and the incidences of dose interruptions, reductions and discontinuations for anaemia were 16.9%, 8.2% and 3.1%, respectively; 17.9% of patients treated with olaparib needed one or more blood transfusions. An exposure-response relationship between olaparib and decreases in haemoglobin has been demonstrated. In clinical studies with Линпарза the incidence of CTCAE grade > 2 shifts (decreases) from baseline in haemoglobin was 20%, absolute neutrophils 15%, platelets 5%, lymphocytes 30% and leucocytes 20% (all % approximate).

The incidence of elevations in mean corpuscular volume from low or normal at baseline to above the ULN was approximately 55%. Levels appeared to return to normal after treatment discontinuation and did not appear to have any clinical consequences.

Baseline testing, followed by monthly monitoring of complete blood counts is recommended for the first 12 months of treatment and periodically after this time to monitor for clinically significant changes in any parameter during treatment which may require dose interruption or reduction and/or further treatment.

Other laboratory findings

In clinical studies with Линпарза the incidence of CTCAE grade > 2 shifts (elevations) from baseline in blood creatinine was approximately 15%. Data from a double-blind placebo-controlled study showed median increase up to 23% from baseline remaining consistent over time and returning to baseline after treatment discontinuation, with no apparent clinical sequelae. 90% of patients had creatinine values of CTCAE grade 0 at baseline and 10% were CTCAE grade 1 at baseline.

Nausea and vomiting

Nausea was generally reported very early, with first onset within the first month of Линпарза treatment in the majority of patients. Vomiting was reported early, with first onset within the first two months of Линпарза treatment in the majority of patients. Both nausea and vomiting were reported to be intermittent for the majority of patients and can be managed by dose interruption, dose reduction and/or antiemetic therapy. Antiemetic prophylaxis is not required.

Paediatric population

No studies have been conducted in paediatric patients.

Other special populations

Limited safety data are available in elderly (age > 75 years) and non-Caucasian 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. Healthcare professionals are asked to report any suspected adverse reactions via

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Ireland

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e-mail: medsafety@hpra.ie

Malta

ADR Reporting

Website: www.medicinesauthority.gov.mt/adrportal

There is limited experience of overdose with olaparib. No unexpected adverse reactions were reported in a small number of patients who took a daily dose of up to 900 mg of olaparib tablets over two days. Symptoms of overdose are not established and there is no specific treatment in the event of Линпарза overdose. In the event of an overdose, physicians should follow general supportive measures and should treat the patient symptomatically.

Pharmacotherapeutic group: antineoplastic agents, other antineoplastic agents, ATC code: L01XX46

Mechanism of action and pharmacodynamic effects

Olaparib is a potent inhibitor of human poly (ADP-ribose) polymerase enzymes (PARP-1, PARP-2, and PARP-3), and has been shown to inhibit the growth of selected tumour cell lines in vitro and tumour growth in vivo either as a standalone treatment or in combination with established chemotherapies.

PARPs are required for the efficient repair of DNA single strand breaks and an important aspect of PARP-induced repair requires that after chromatin modification, PARP auto-modifies itself and dissociates from the DNA to facilitate access for base excision repair (BER) enzymes. When olaparib is bound to the active site of DNA-associated PARP it prevents the dissociation of PARP and traps it on the DNA, thus blocking repair. In replicating cells this also leads to the formation of DNA double-strand breaks (DSBs) when replication forks meet the PARP-DNA adducts. In normal cells, homologous recombination repair (HRR) pathway is effective at repairing these DNA DSBs. In cancers that lack functional components of HRR such as BRCA1 or 2, DNA DSBs cannot be repaired accurately or effectively. Instead, alternative and error-prone pathways are activated, such as the classical non-homologous end joining (NHEJ) pathway, leading to increased genomic instability. After a number of rounds of replication, genomic instability can reach insupportable levels and result in cancer cell death, as cancer cells already have a high DNA damage load relative to normal cells. In the absence of BRCA1 or BRCA2 mutations, HRR pathway may be compromised by other mechanisms, although the causative aberrancy and penetrance are not fully elucidated. Absence of fully functional HRR pathway is one of the key determinants of platinum sensitivity in ovarian and other cancers.

In BRCA1/2-deficient in vivo models, olaparib given after platinum treatment resulted in a delay in tumour progression and an increase in overall survival compared to platinum treatment alone that correlated with the period of olaparib maintenance treatment.

Detection of BRCA1/2 mutation

If BRCA1/2 mutation status is determined, it should be conducted by an experienced laboratory using a validated test method.

Genetic counselling for patients tested for mutations in breast cancer susceptibility genes 1/2 (BRCA1/2) should be performed according to local regulations.

Clinical efficacy and safety

SOLO2 study (D0816C00002)

The safety and efficacy of olaparib as maintenance therapy were studied in a Phase III randomised, double-blind, placebo-controlled trial in patients with germline BRCA1/2-mutated platinum-sensitive relapsed (PSR) ovarian, fallopian tube or primary peritoneal cancer. The study compared the efficacy of Линпарза maintenance treatment (300 mg [2 x 150 mg tablets] twice daily) taken until progression with placebo treatment in 295 patients with high-grade serous or endometrioid PSR ovarian cancer (2:1 randomisation: 196 olaparib and 99 placebo) who were in response (CR [complete response] or PR [partial response]) following completion of platinum-containing chemotherapy.

Patients who have received two or more platinum-containing regimens and whose disease had recurred > 6 months after completion of penultimate platinum-based chemotherapy were enrolled. Patients could not have received prior olaparib or other PARP inhibitor treatment. Patients could have received prior bevacizumab, except in the regimen immediately prior to randomisation.

All patients had evidence of germline BRCA1/2 mutation (gBRCA1/2m) at baseline. Patients with BRCA1/2 mutations were identified either from germline testing in blood via a local test or the Myriad CLIA Integrated BRACAnalysis^® test or from testing a tumour sample using a local test. Large rearrangements in the BRCA1/2 genes were detected in 4.7% (14/295) of the randomised patients.

Demographic and baseline characteristics were generally well balanced between the olaparib and placebo arms. Median age was 56 years in both arms. Ovarian cancer was the primary tumour in > 80% of the patients. The most common histological type was serous (> 90%), endometrioid histology was reported in 6% of the patients. In the olaparib arm 55% of the patients had only 2 prior lines of treatment with 45% receiving 3 or more prior lines of treatment. In the placebo arm 61% of patients had received only 2 prior lines with 39% receiving 3 or more prior lines of treatment. Most patients were ECOG performance status 0 (81%). Platinum free interval was > 12 months in 60% and > 6-12 months in 40% of the patients. Response to prior platinum chemotherapy was complete in 47% and partial in 53% of the patients. In the olaparib and placebo arms, 17% and 20% of patients had prior bevacizumab, respectively.

The primary endpoint was progression free survival (PFS) determined by investigator assessment using Response Evaluation Criteria in Solid Tumors (RECIST) 1.1. Secondary efficacy endpoints included time from randomisation to second progression or death (PFS2); OS (overall survival), time from randomisation to discontinuation of treatment or death (TDT), time from randomisation to first subsequent anti-cancer therapy or death (TFST), time from randomisation to start of second subsequent anti-cancer therapy or death (TSST); and health related quality of life (HRQoL).

The study met its primary objective demonstrating a statistically significant improvement in investigator assessed PFS for olaparib compared with placebo with a hazard ratio (HR) of 0.30 (95% CI 0.22-0.41; p<0.0001; median 19.1 months olaparib vs 5.5 months placebo). The investigator assessment of PFS was supported with a blinded independent central radiological review of PFS (HR 0.25; 95% CI 0.18-0.35; p<0.0001; median 30.2 months for olaparib and 5.5 months placebo). At 2 years, 43% olaparib-treated patients remained progression free compared with only 15% placebo-treated patients.

A summary of the primary objective outcome for patients with gBRCA1/2m PSR ovarian cancer in SOLO2 is presented in Table 2 and Figure 1.

Table 2 Summary of primary objective outcome for patients with gBRCA1/2m PSR ovarian cancer in SOLO2

^a HR= Hazard Ratio. A value <1 favours olaparib. The analysis was performed using a log-rank test stratified by response to previous platinum chemotherapy (CR or PR), and time to disease progression (>6-12 months and >12 months) in the penultimate platinum-based chemotherapy.

bd Twice daily; PFS progression-free survival; CI confidence interval;

Figure 1 SOLO2: Kaplan-Meier plot of PFS in patients with gBRCA1/2m PSR ovarian cancer (63% maturity - investigator assessment)

The secondary endpoints TFST and PFS2 demonstrated a persistent and statistically significant improvement for olaparib compared with placebo (Table 3).

Table 3 Summary of key secondary objective outcomes for patients with gBRCA1/2m PSR ovarian cancer in SOLO2

* Not controlled for multiplicity

^a HR= Hazard Ratio. A value <1 favours olaparib. The analysis was performed using a log-rank test stratified by response to previous platinum chemotherapy (CR or PR), and time to disease progression (>6-12 months and >12 months) in the penultimate platinum-based chemotherapy.

bd Twice daily; NR not reached; CI confidence interval; PFS2 time from randomisation to second progression or death; TFST Time from randomisation to start of first subsequent therapy or death.

Among the patients entering the trial with measurable disease (target lesions at baseline), an objective response rate of 41% was achieved in the Линпарза arm versus 17% on placebo. Of patients treated with Линпарза, who entered the study with evidence of disease (target or non-target lesions at baseline), 15.0% experienced complete response compared with 9.1% of patients on placebo.

At the time of the analysis of PFS the median duration of treatment was 19.4 months for olaparib and 5.6 months for placebo. The majority of patients remained on the 300 mg bd starting dose of olaparib. The incidence of dose interruptions, reductions, discontinuations due to an adverse event was 45.1%, 25.1% and 10.8%, respectively. Dose interruptions occurred most frequently in the first 3 months and dose reductions in the first 3-6 months of treatment. The most frequent adverse reactions leading to dose interruption or dose reduction were anaemia, nausea and vomiting.

Patient-reported outcome (PRO) data indicate no difference for the olaparib-treated patients as compared to placebo as assessed by the change from baseline in the Trial Outcome Index (TOI) of the Functional Assessment of Cancer Therapy - Ovarian (FACT-O).

Study 19 (D0810C00019)

The safety and efficacy of olaparib as a maintenance therapy in the treatment of PSR ovarian, including fallopian tube or primary peritoneal cancer patients, following treatment with two or more platinum containing regimens, were studied in a large Phase II randomised, double-blind, placebo-controlled trial (study 19). The study compared the efficacy of Линпарза capsule maintenance treatment (400 mg [8 x 50 mg capsules] twice daily) taken until progression with placebo treatment in 265 (136 olaparib and 129 placebo) PSR high grade serous ovarian cancer patients who were in response (CR or PR) following completion of platinum-containing chemotherapy. The primary endpoint was PFS based on investigator assessment using RECIST 1.0. Secondary efficacy endpoints included OS, disease control rate (DCR) defined as confirmed CR/PR + SD (stable disease), HRQoL and disease related symptoms. Exploratory analyses of TFST and TSST were also performed.

Patients whose disease had recurred >6 months after completion of penultimate platinum-based chemotherapy were enrolled. Enrolment did not require evidence of BRCA1/2 mutation (BRCA mutation status for some patients was determined retrospectively). Patients could not have received prior olaparib or other PARP inhibitor treatment. Patients could have received prior bevacizumab, except in the regimen immediately prior to randomisation. Retreatment with olaparib was not permitted following progression on olaparib.

Patients with BRCA1/2 mutations were identified either from germline testing in blood via a local test or the Myriad CLIA Integrated BRACAnalysis® test or from testing a tumour sample using a test performed by Foundation Medicine. Large rearrangements in the BRCA1/2 genes were detected in 7.4% (10/136) of the randomised patients.

Demographic and baseline characteristics were generally well balanced between the olaparib and placebo arms. Median age was 59 years in both arms. Ovarian cancer was the primary tumour in 86% of the patients. In the olaparib arm 44% of the patients had only 2 prior lines of treatment with 56% receiving 3 or more prior lines of treatment. In the placebo arm 49% of patients had received only 2 prior lines with 51% receiving 3 or more prior lines of treatment. Most patients were ECOG performance status 0 (77%). Platinum free interval was > 12 months in 60% and > 6-12 months in 40% of the patients. Response to prior platinum chemotherapy was complete in 45% and partial in 55% of the patients. In the olaparib and placebo arms, 6% and 5% of patients had prior bevacizumab, respectively.

The study met its primary objective demonstrating a statistically significant improvement in PFS for olaparib compared with placebo in the overall population with a HR of 0.35 (95% CI 0.25-0.49; p<0.00001; median 8.4 months olaparib vs 4.8 months placebo). At the final OS analysis (data cut off [DCO] 9 May 2016) at 79% maturity, the hazard ratio comparing olaparib with placebo was 0.73 (95% CI 0.55-0.95; p=0.02138 [did not meet pre-specified significance level of < 0.0095]; median 29.8 months olaparib versus 27.8 months placebo). In the olaparib-treated group, 23.5% (n=32/136) of patients remained on treatment for >2 years as compared with 3.9% (n=5/128) of the patients on placebo. Although patient numbers were limited, 13.2% (n=18/136) of the patients in the olaparib-treated group remained on treatment for >5 years as compared with 0.8% (n=1/128) in the placebo group.

Preplanned subgroup analysis identified patients with BRCA1/2-mutated ovarian cancer (n=136, 51.3%; including 20 patients identified with a somatic tumour BRCA1/2 mutation) as the subgroup that derived the greatest clinical benefit from olaparib maintenance monotherapy. A benefit was also observed in patients with BRCA1/2 wild-type/variants of uncertain significance (BRCA1/2 wt/VUS), although of a lesser magnitude. There was no strategy for multiple testing in place for the sub-group analyses.

A summary of the primary objective outcome for patients with BRCA1/2-mutated and BRCA1/2 wt/VUS PSR ovarian cancer in Study 19 is presented in Table 4 and for all patients in Study 19 in Table 4 and Figure 2.

Table 4 Summary of primary objective outcome for all patients and patients with BRCA1/2-mutated and BRCA1/2 wt/VUS PSR ovarian cancer in study 19

^a All patients comprises of the following subgroups: BRCA1/2-mutated, BRCA1/2 wt/VUS and BRCA1/2 status unknown (11 patients with status unknown, not shown as a separate subgroup in table).

^b HR= Hazard Ratio. A value <1 favours olaparib. The analysis was performed using a Cox proportional hazards model with factors for treatment, ethnic descent, platinum sensitivity and response to final platinum therapy.

bd Twice daily; PFS progression-free survival; DCO data cut off; CI confidence interval; NR not reached.

Figure 2 Study 19: Kaplan-Meier plot of PFS in the FAS (58% maturity - investigator assessment) DCO 30 June 2010

A summary of key secondary objective outcomes for patients with BRCA1/2-mutated and BRCA1/2 wt/VUS PSR ovarian cancer in Study 19 is presented in Table 5 and for all patients in Study 19 in Table 5 and Figure 3.

Table 5 Summary of key secondary objective outcomes for all patients and patients with BRCA1/2-mutated and BRCA1/2 wt/VUS PSR ovarian cancer in study 19

^* There was no strategy for multiple testing in place for the sub-group analyses or for the all patients TFST.

^a All patients comprises of the following subgroups: BRCA1/2-mutated, BRCA1/2 wt/VUS and BRCA1/2 status unknown (11 patients with status unknown, not shown as a separate subgroup in table).

^b HR= Hazard Ratio. A value <1 favours olaparib. The analysis was performed using a Cox proportional hazards model with factors for treatment, ethnic descent, platinum sensitivity and response to final platinum therapy.

^c Approximately a quarter of placebo-treated patients in the BRCA-mutated subgroup (14/62; 22.6%) received a subsequent PARP inhibitor.

bd Twice daily; OS Overall survival; DCO data cut off; CI confidence interval; TFST time from randomisation to start of first subsequent therapy or death.

Figure 3 Study 19: Kaplan Meier plot of OS in the FAS (79% maturity) DCO 09 May 2016

At the time of the analysis of PFS the median duration of treatment was 8 months for olaparib and 4 months for placebo. The majority of patients remained on the 400 mg bd starting dose of olaparib. The incidence of dose interruptions, reductions, discontinuations due to an adverse event was 34.6%, 25.7% and 5.9%, respectively. Dose interruptions and reductions occurred most frequently in the first 3 months of treatment. The most frequent adverse reactions leading to dose interruption or dose reduction were nausea, anaemia, vomiting, neutropenia and fatigue. The incidence of anaemia adverse reactions was 22.8% (CTCAE grade >3 7.4%).

Patient-reported outcome (PRO) data indicate no difference for the olaparib-treated patients as compared to placebo as measured by improvement and worsening rates in the Trial Outcome Index (TOI) and Functional Analysis of Cancer Therapy-Ovarian total score (FACT-O total).

Paediatric population

The pharmacokinetics of olaparib at the 300 mg tablet dose are characterised by an apparent plasma clearance of ~7 L/h, an apparent volume of distribution of ~158 L and a terminal half-life of 15 hours. On multiple dosing, an AUC accumulation ratio of 1.8 was observed and PK appeared to be time-dependent to a small extent.

Absorption

Following oral administration of olaparib via the tablet formulation (2 x 150 mg), absorption is rapid with median peak plasma concentrations typically achieved 1.5 hours after dosing.

Co-administration with food slowed the rate (t_max delayed by 2.5 hours and C_max reduced by approximately 21%) but did not significantly affect the extent of absorption of olaparib (AUC increased 8%). Consequently, Линпарза may be taken without regard to food.

Distribution

The in vitro plasma protein binding is approximately 82% at 10 µg/mL which is approximately C_max.

In vitro, human plasma protein binding of olaparib was dose-dependent; the fraction bound was approximately 91% at 1 µg/mL, reducing to 82% at 10 µg/mL and to 70% at 40 µg/mL. In solutions of purified proteins, the olaparib fraction bound to albumin was approximately 56%, which was independent of olaparib concentrations. Using the same assay, the fraction bound to alpha-1 acid glycoprotein was 29% at 10 µg/mL with a trend of decreased binding at higher concentrations.

Biotransformation

In vitro, CYP3A4/5 were shown to be the enzymes primarily responsible for the metabolism of olaparib.

Following oral dosing of ¹⁴C-olaparib to female patients, unchanged olaparib accounted for the majority of the circulating radioactivity in plasma (70%) and was the major component found in both urine and faeces (15% and 6% of the dose respectively). The metabolism of olaparib is extensive. The majority of the metabolism was attributable to oxidation reactions with a number of the components produced undergoing subsequent glucuronide or sulfate conjugation. Up to 20, 37 and 20 metabolites were detected in plasma, urine and faeces respectively, the majority of them representing < 1% of the dosed material. A ring-opened piperazin-3-ol moiety, and two mono-oxygenated metabolites (each ~10%) were the major circulating components, with one of the mono-oxygenated metabolites also being the major metabolite in the excreta (6% and 5% of the urinary and faecal radioactivity respectively).

In vitro, olaparib produced little/no inhibition of UGT2B7, or CYPs 1A2, 2A6, 2B6, 2C8, 2C9, 2C19, 2D6 or 2E1 and is not expected to be a clinically significant time dependent inhibitor of any of these CYP enzymes. Olaparib inhibited UGT1A1 in vitro, however, PBPK simulations suggest this is not of clinical importance. In vitro, olaparib is a substrate of the efflux transporter P-gp, however, this is unlikely to be of clinical significance.

In vitro, data also show that olaparib is not a substrate for OATP1B1, OATP1B3, OCT1, BCRP or MRP2 and is not an inhibitor of OATP1B3, OAT1 or MRP2.

Elimination

Following a single dose of ¹⁴C-olaparib, ~86% of the dosed radioactivity was recovered within a 7-day collection period, ~44% via the urine and ~42% via the faeces. Majority of the material was excreted as metabolites.

Special populations

In population based PK analyses, patient age, bodyweight, or race (including White and Japanese patients) were not significant covariates.

Renal impairment

In patients with mild renal impairment (creatinine clearance 51 to 80 ml/min), AUC increased by 24% and C_max by 15% compared with patients with normal renal function. No Линпарза dose adjustment is required for patients with mild renal impairment.

In patients with moderate renal impairment (creatinine clearance 31 to 50 ml/min), AUC increased by 44% and C_max by 26% compared with patients with normal renal function. Линпарза dose adjustment is recommended for patients with moderate renal impairment.

There are no data in patients with severe renal impairment or end-stage renal disease (creatinine clearance < 30 ml/min).

Hepatic impairment

In patients with mild hepatic impairment (Child-Pugh classification A), AUC increased by 15% and C_max by 13% and in patients with moderate hepatic impairment (Child-Pugh classification B), AUC increased by 8% and C_max decreased by 13% compared with patients with normal hepatic function. No Линпарза dose adjustment is required for patients with mild or moderate hepatic impairment. There are no data in patients with severe hepatic impairment (Child-Pugh classification C).

Paediatric population

No studies have been conducted to investigate the pharmacokinetics of olaparib in paediatric patients.

Genotoxicity

Olaparib showed no mutagenic potential, but was clastogenic in mammalian cells in vitro. When dosed orally to rats, olaparib induced micronuclei in bone marrow. This clastogenicity is consistent with the known pharmacology of olaparib and indicates potential for genotoxicity in man.

Repeat-dose toxicity

In repeat-dose toxicity studies of up to 6 months duration in rats and dogs, daily oral doses of olaparib were well-tolerated. The major primary target organ for toxicity in both species was the bone marrow, with associated changes in peripheral haematology parameters. These changes were reversible within 4 weeks of cessation of dosing. In rats, minimal degenerative effects on gastrointestinal tract were also noted. These findings occurred at exposures below those seen clinically. Studies using human bone marrow cells also showed that direct exposure to olaparib can result in toxicity to bone marrow cells in ex vivo assays.

Reproductive toxicology

In a female fertility study where rats were dosed until implantation, although extended oestrus was observed in some animals, mating performance and pregnancy rate was not affected. However, there was a slight reduction in embryofoetal survival.

In rat embryofoetal development studies, and at dose levels that did not induce significant maternal toxicity, olaparib caused reduced embryofoetal survival, reduced foetal weight and foetal developmental abnormalities, including major eye malformations (e.g. anophthalmia, microphthalmia), vertebral/rib malformation, and visceral and skeletal abnormalities.

Carcinogenicity

Carcinogenicity studies have not been conducted with olaparib.

Not applicable.

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.

• R52.1 – Chronic intractable pain
• R52.2 – Other chronic pain
• R52.9 – Unspecified pain