Cytogem

Overdose

There is no known antidote for overdose of Cytogem. Doses as high as 5700 mg/m2 have been administered by intravenous infusion over 30-minutes every 2 weeks with clinically acceptable toxicity. In the event of suspected overdose, the patient should be monitored with appropriate blood counts and receive supportive therapy, as necessary.

Contraindications

Breast-feeding.

Incompatibilities

This medicinal product is ready to use and must not be mixed with other medicinal products.

Pharmaceutical form

Undesirable effects

The most commonly reported adverse drug reactions associated with Cytogem treatment include: nausea with or without vomiting, raised liver transaminases (AST/ALT) and alkaline phosphatase, reported in approximately 60% of patients; proteinuria and haematuria reported in approximately 50% patients; dyspnoea reported in 10-40% of patients (highest incidence in lung cancer patients); allergic skin rashes occur in approximately 25% of patients and are associated with itching in 10% of patients.

The frequency and severity of the adverse reactions are affected by the dose, infusion rate and intervals between doses. Dose-limiting adverse reactions are reductions in thrombocyte, leucocyte and granulocyte counts.

Clinical trial data

Frequencies are defined as: Very common (> l/10), Common (> l/100 to <1/10), Uncommon (> l/1000 to <1/100), Rare (> l/10,000 to <1/1000), Very rare (<1/10,000).

The following table of undesirable effects and frequencies is based on data from clinical trials. Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.

Combination use in breast cancer

The frequency of grade 3 and 4 haematological toxicities, particularly neutropaenia, increases when Cytogem is used in combination with paclitaxel. However, the increase in these adverse reactions is not associated with an increased incidence of infections or haemorrhagic events. Fatigue and febrile neutropaenia occur more frequently when Cytogem is used in combination with paclitaxel. Fatigue, which is not associated with anaemia, usually resolves after the first cycle.

*Grade 4 neutropaenia lasting for more than 7 days occurred in 12.6% of patients in the combination arm and 5.0% of patients in the paclitaxel arm.

Combination use in bladder cancer

Combination use in ovarian cancer

Sensory neuropathy was also more frequent in the combination arm than with single agent carboplatin

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 the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.

Preclinical safety data

In repeat-dose studies of up to 6 months in duration in mice and dogs, the principal finding was schedule and dose-dependent haematopoietic suppression which was reversible.

Cytogem is mutagenic in an in vitro mutation test and an in vivo bone marrow micronucleus test. Long term animal studies evaluating the carcinogenic potential have not been performed.

In fertility studies, Cytogem caused reversible hypospermatogenesis in male mice. No effect on the fertility of females has been detected.

Evaluation of experimental animal studies has shown reproductive toxicity e.g. birth defects and other effects on the development of the embryo or foetus, the course of gestation or peri- and postnatal development.

Therapeutic indications

Cytogem is indicated for the treatment of locally advanced or metastatic bladder cancer in combination with cisplatin.

Cytogem is indicated for treatment of patients with locally advanced or metastatic adenocarcinoma of the pancreas.

Cytogem, in combination with cisplatin is indicated as first line treatment of patients with locally advanced or metastatic non-small cell lung cancer (NSCLC). Cytogem monotherapy can be considered in elderly patients or those with performance status 2.

Cytogem is indicated for the treatment of patients with locally advanced or metastatic epithelial ovarian carcinoma, in combination with carboplatin, in patients with relapsed disease following a recurrence-free interval of at least 6 months after platinum-based, first-line therapy.

Cytogem, in combination with paclitaxel, is indicated for the treatment of patients with unresectable, locally recurrent or metastatic breast cancer who have relapsed following adjuvant/neoadjuvant chemotherapy. Prior chemotherapy should have included an anthracycline unless clinically contraindicated.

Pharmacotherapeutic group

Pharmacodynamic properties

Pharmacotherapeutic group: pyrimidine analogues ATC code: L01BC05

Cytotoxic activity in cell cultures

Cytogem shows significant cytotoxic effects against a variety of cultured murine and human tumour cells. Its action is phase-specific such that Cytogem primarily kills cells that are undergoing DNA synthesis (S-phase) and, under certain circumstances, blocks the progression of cells at the junction of the G1/S phase boundary. In vitro, the cytotoxic effect of Cytogem is dependent on both concentration and time.

Antitumoral activity in preclinical models

In animal tumour models, antitumoural activity of Cytogem is schedule-dependent. When Cytogem is administered daily, high mortality among the animals but minimal antitumoural activity is observed. If, however, Cytogem is given every third or fourth day, it can be administered in non-lethal doses with substantial antitumoural activity against a broad spectrum of mouse tumours.

Mechanism of action

Cellular metabolism and mechanism of action: Cytogem (dFdC), which is a pyrimidine antimetabolite, is metabolised intracellularly by nucleoside kinase to the active diphosphate (dFdCDP) and triphosphate (dFdCTP) nucleosides. The cytotoxic effect of Cytogem is due to inhibition of DNA synthesis by two mechanisms of action by dFdCDP and dFdCTP. First, dFdCDP inhibits ribonucleotide reductase, which is uniquely responsible for catalysing the reactions that produce deoxynucleoside triphosphates (dCTP) for DNA synthesis. Inhibition of this enzyme by dFdCDP reduces the concentration of deoxynucleosides in general and, in particular, dCTP. Second, dFdCTP competes with dCTP for incorporation into DNA (self-potentiation).

Likewise, a small amount of Cytogem may also be incorporated into RNA. Thus, the reduced intracellular concentration of dCTP potentiates the incorporation of dFdCTP into DNA. DNA polymerase epsilon lacks the ability to eliminate Cytogem and to repair the growing DNA strands. After Cytogem is incorporated into DNA, one additional nucleotide is added to the growing DNA strands. After this addition there is essentially a complete inhibition in further DNA synthesis (masked chain termination). After incorporation into DNA, Cytogem appears to induce the programmed cell death process known as apoptosis.

Clinical data

Bladder cancer

A randomised phase III study of 405 patients with advanced or metastatic urothelial transitional cell carcinoma showed no difference between the two treatment arms, Cytogem/cisplatin versus methotrexate/vinblastine/adriamycin/cisplatin (MVAC), in terms of median survival (12.8 and 14.8 months respectively, p=0.547), time to disease progression (7.4 and 7.6 months respectively, p=0.842) and response rate (49.4% and 45.7% respectively, p=0.512). However, the combination of Cytogem and cisplatin had a better toxicity profile than MVAC.

Pancreatic cancer

In a randomised phase III study of 126 patients with advanced or metastatic pancreatic cancer, Cytogem showed a statistically significant higher clinical benefit response rate than 5-fluorouracil (23.8% and 4.8% respectively, p=0.0022). Also, a statistically significant prolongation of the time to progression from 0.9 to 2.3 months (log-rank p<0.0002) and a statistically significant prolongation of median survival from 4.4 to 5.7 months (log-rank p<0.0024) was observed in patients treated with Cytogem compared to patients treated with 5-fluorouracil.

Non small cell lung cancer

In a randomised phase III study of 522 patients with inoperable, locally advanced or metastatic NSCLC, Cytogem in combination with cisplatin showed a statistically significant higher response rate than cisplatin alone (31.0% and 12.0%, respectively, p<0.0001). A statistically significant prolongation of the time to progression, from 3.7 to 5.6 months (log-rank p<0.0012) and a statistically significant prolongation of median survival from 7.6 months to 9.1 months (log-rank p<0.004) was observed in patients treated with Cytogem/cisplatin compared to patients treated with cisplatin.

In another randomised phase III study of 135 patients with stage IIIB or IV NSCLC, a combination of Cytogem and cisplatin showed a statistically significant higher response rate than a combination of cisplatin and etoposide (40.6% and 21.2%, respectively, p=0.025). A statistically significant prolongation of the time to progression, from 4.3 to 6.9 months (p=0.014) was observed in patients treated with Cytogem/cisplatin compared to patients treated with etoposide/cisplatin.

In both studies it was found that tolerability was similar in the two treatment arms.

Ovarian carcinoma

In a randomised phase III study, 356 patients with advanced epithelial ovarian carcinoma who had relapsed at least 6 months after completing platinum based therapy were randomised to therapy with Cytogem and carboplatin (GCb), or carboplatin (Cb). A statistically significant prolongation of the time to progression of disease, from 5.8 to 8.6 months (log-rank p= 0.0038) was observed in the patients treated with GCb compared to patients treated with Cb. Differences in response rate of 47.2% in the GCb arm versus 30.9% in the Cb arm (p=0.0016) and median survival 18 months (GCb) versus 17.3 (Cb) (p=0.73) favoured the GCb arm.

Breast cancer

In a randomised phase III study of 529 patients with inoperable, locally recurrent or metastatic breast cancer with relapse after adjuvant/neoadjuvant chemotherapy, Cytogem in combination with paclitaxel showed a statistically significant prolongation of time to documented disease progression from 3.98 to 6.14 months (log-rank p=0.0002) in patients treated with Cytogem/paclitaxel compared to patients treated with paclitaxel. After 377 deaths, the overall survival was 18.6 months versus 15.8 months (log rank p=0.0489, HR 0.82) in patients treated with Cytogem/paclitaxel compared to patients treated with paclitaxel and the overall response rate was 41.4% and 26.2% respectively (p= 0.0002).

Pharmacokinetic properties

The pharmacokinetics of Cytogem have been examined in 353 patients in seven studies. The 121 women and 232 men ranged in age from 29 to 79 years. Of these patients, approximately 45% had non-small cell lung cancer and 35% were diagnosed with pancreatic cancer. The following pharmacokinetic parameters were obtained for doses ranging from 500 to 2,592 mg/m2 that were infused from 0.4 to 1.2 hours.

Peak plasma concentrations (obtained within 5 minutes of the end of the infusion) were 3.2 to 45.5 µg/ml. Plasma concentrations of the parent compound following a dose of 1,000 mg/m2/30-minutes are greater than 5 µg/ml for approximately 30-minutes after the end of the infusion, and greater than 0.4 µg/ml for an additional hour.

Distribution

The volume of distribution of the central compartment was 12.4 l/m2 for women and 17.5 l/m2 for men (inter-individual variability was 91.9%). The volume of distribution of the peripheral compartment was 47.4 l/m2. The volume of the peripheral compartment was not sensitive to gender.

The plasma protein binding was considered to be negligible.

Half-life: This ranged from 42 to 94 minutes depending on age and gender. For the recommended dosing schedule, Cytogem elimination should be virtually complete within 5 to 11 hours of the start of the infusion. Cytogem does not accumulate when administered once weekly.

Metabolism

Cytogem is rapidly metabolised by cytidine deaminase in the liver, kidney, blood and other tissues. Intracellular metabolism of Cytogem produces the Cytogem mono, di and triphosphates (dFdCMP, dFdCDP and dFdCTP) of which dFdCDP and dFdCTP are considered active. These intracellular metabolites have not been detected in plasma or urine. The primary metabolite, 2'-deoxy-2', 2'-difluorouridine (dFdU), is not active and is found in plasma and urine.

Excretion

Systemic clearance ranged from 29.2 l/hr/m2 to 92.2 /hr/m2 depending on gender and age (inter-individual variability was 52.2%). Clearance for women is approximately 25% lower than the values for men. Although rapid, clearance for both men and women appears to decrease with age. For the recommended Cytogem dose of 1000 mg/m2 given as a 30-minute infusion, lower clearance values for women and men should not necessitate a decrease in the Cytogem dose. Urinary excretion: Less than 10% is excreted as unchanged drug. Renal clearance was 2 to 7 l/hr/m2.

During the week following administration, 92 to 98% of the dose of Cytogem administered is recovered, 99% in the urine, mainly in the form of dFdU and 1% of the dose is excreted in faeces.

dFdCTP kinetics

This metabolite can be found in peripheral blood mononuclear cells and the information below refers to these cells. Intracellular concentrations increase in proportion to Cytogem doses of 35-350 mg/m2/30-minutes, which give steady state concentrations of 0.4-5 µg/ml. At Cytogem plasma concentrations above 5 µg/ml, dFdCTP levels do not increase, suggesting that the formation is saturable in these cells.

Half-life of terminal elimination: 0.7-12 hours.

dFdU kinetics

Peak plasma concentrations (3-15 minutes after end of 30-minute infusion, 1000 mg/m2): 28-52 µg/ml.

Trough concentration following once weekly dosing: 0.07-1.12 µg/ml, with no apparent accumulation.

Triphasic plasma concentration versus time curve, mean half-life of terminal phase - 65 hours (range 33-84 hr).

Formation of dFdU from parent compound: 91%-98%.

Mean volume of distribution of central compartment: 18 l/m2 (range 11-22 l/m2).

Mean steady state volume of distribution (Vss): 150 l/m2 (range 96-228 l/m2).

Tissue distribution: Extensive.

Mean apparent clearance: 2.5 l/hr/m2 (range 1-4 l/hr/m2).

Urinary excretion: All.

Cytogem and paclitaxel combination therapy

Combination therapy did not alter the pharmacokinetics of either Cytogem or paclitaxel.

Cytogem and carboplatin combination therapy

When given in combination with carboplatin the pharmacokinetics of Cytogem were not altered.

Renal impairment

Mild to moderate renal insufficiency (GFR from 30 ml/min to 80 ml/min) has no consistent, significant effect on Cytogem pharmacokinetics.

Name of the medicinal product

Qualitative and quantitative composition

Special warnings and precautions for use

Prolongation of the infusion time and increased dosing frequency have been shown to increase toxicity.

Haematological toxicity

Cytogem can suppress bone marrow function as manifested by leucopoenia, thrombocytopenia and anaemia.

Patients receiving Cytogem should be monitored prior to each dose for platelet, leucocyte and granulocyte counts. Suspension or modification of therapy should be considered when drug-induced bone marrow depression is detected. However, myelosuppression is short lived and usually does not result in dose reduction and rarely in discontinuation.

Peripheral blood counts may continue to deteriorate after Cytogem administration has been stopped. In patients with impaired bone marrow function, the treatment should be started with caution.

As with other cytotoxic treatments, the risk of cumulative bone-marrow suppression must be considered when Cytogem treatment is given together with other chemotherapy.

Hepatic and renal impairment

Cytogem should be used with caution in patients with hepatic insufficiency or with impaired renal function as there is insufficient information from clinical studies to allow clear dose recommendation for this patient population.

Administration of Cytogem in patients with concurrent liver metastases or a pre-existing medical history of hepatitis, alcoholism or liver cirrhosis may lead to exacerbation of the underlying hepatic impairment.

Laboratory evaluation of renal and hepatic function (including virological tests) should be performed periodically.

Concomitant radiotherapy

Concomitant radiotherapy (given together or ≤ 7 days apart): Toxicity has been reported.

Live vaccinations

Yellow fever vaccine and other live attenuated vaccines are not recommended in patients treated with Cytogem.

Posterior reversible encephalopathy syndrome

Reports of posterior reversible encephalopathy syndrome (PRES) with potentially severe consequences have been reported in patients receiving Cytogem as single agent or in combination with other chemotherapeutic agents. Acute hypertension and seizure activity were reported in most Cytogem patients experiencing PRES, but other symptoms such as headache, lethargy, confusion and blindness could also be present. Diagnosis is optimally confirmed by magnetic resonance imaging (MRI). PRES was typically reversible with appropriate supportive measures. Cytogem should be permanently discontinued and supportive measures implemented, including blood pressure control and anti-seizure therapy, if PRES develops during therapy.

Cardiovascular

Due to the risk of cardiac and/or vascular disorders with Cytogem, particular caution must be exercised with patients presenting a history of cardiovascular events.

Capillary leak syndrome

Capillary leak syndrome has been reported in patients receiving Cytogem as single agent or in combination with other chemotherapeutic agents. The condition is usually treatable if recognised early and managed appropriately, but fatal cases have been reported. The condition involves systemic capillary hyperpermeability during which fluid and proteins from the intravascular space leak into the interstitium. The clinical features include generalised oedema, weight gain, hypoalbuminaemia, severe hypotension, acute renal impairment and pulmonary oedema. Cytogem should be discontinued and supportive measures implemented if capillary leak syndrome develops during therapy. Capillary leak syndrome can occur in later cycles and has been associated in the literature with adult respiratory distress syndrome.

Pulmonary

Pulmonary effects, sometimes severe (such as pulmonary oedema, interstitial pneumonitis or adult respiratory distress syndrome (ARDS)) have been reported in association with Cytogem therapy.

If such effects develop, consideration should be made to discontinuing Cytogem therapy. Early use of supportive care measure may help ameliorate the condition.

Renal

Haemolytic uraemic syndrome

Clinical findings consistent with the haemolytic uraemic syndrome (HUS) were rarely reported (post- marketing data) in patients receiving Cytogem. HUS is a potentially life-threatening disorder. Cytogem should be discontinued at the first signs of any evidence of microangiopathic haemolytic anaemia, such as rapidly falling haemoglobin with concomitant thrombocytopaenia, elevation of serum bilirubin, serum creatinine, blood urea nitrogen, or LDH. Renal failure may not be reversible with discontinuation of therapy and dialysis may be required.

Fertility

In fertility studies Cytogem caused hypospermatogenesis in male mice. Therefore, men being treated with Cytogem are advised not to father a child during and up to 6 months after treatment and to seek further advice regarding cryoconservation of sperm prior to treatment because of the possibility of infertility due to therapy with Cytogem.

Sodium

Cytogem 10 mg/ml contains 549.00 mg (23.88 mmol) sodium per infusion bag of 120 ml. This should be taken into consideration by patients on a controlled sodium diet.

Cytogem SUN 10 mg/ml contains 640.50 mg (27.86 mmol) sodium per infusion bag of 140 ml. This should be taken into consideration by patients on a controlled sodium diet.

Cytogem 10 mg/ml contains 732.00 mg (31.84 mmol) sodium per infusion bag of 160 ml. This should be taken into consideration by patients on a controlled sodium diet.

Cytogem 10 mg/ml contains 777.75 mg (33.83 mmol) sodium per infusion bag of 170 ml. This should be taken into consideration by patients on a controlled sodium diet.

Cytogem 10 mg/ml contains 823.50 mg (35.82 mmol) sodium per infusion bag of 180 ml. This should be taken into consideration by patients on a controlled sodium diet.

Cytogem 10 mg/ml contains 915.00 mg (39.80 mmol) sodium per infusion bag of 200 ml. This should be taken into consideration by patients on a controlled sodium diet.

Cytogem 10 mg/ml contains 1006.50 mg (43.78 mmol) sodium per infusion bag of 220 ml. This should be taken into consideration by patients on a controlled sodium diet.

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, Cytogem has been reported to cause mild to moderate somnolence, especially in combination with alcohol consumption. Patients should be cautioned against driving or operating machinery until it is established that they do not become somnolent

Dosage (Posology) and method of administration

Cytogem should only be prescribed by a physician qualified in the use of anti-cancer chemotherapy.

Infusion bags of Cytogem SUN 10 mg/ml solution for infusion allow delivery of 120 ml/ 140 ml/ 160 ml/ 170 ml/ 180 ml/ 200 ml/ 220 ml of solution (equivalent to 1200 mg/ 1400 mg/ 1600 mg/ 1700 mg/1800 mg/ 2000 mg/ 2200 mg, respectively).

If the required dose cannot be achieved with the available presentations, use of an alternative Cytogem product, including Cytogem as a concentrate or Cytogem as powder for solution for infusion, is recommended.

Posology

Bladder cancer

Combination use

The recommended dose for Cytogem is 1000 mg/m2, given by 30-minute infusion. The dose should be given on Days 1, 8 and 15 of each 28-day cycle in combination with cisplatin. Cisplatin is given at a recommended dose of 70 mg/m2 on Day 1 following Cytogem or day 2 of each 28-day cycle. This 4-week cycle is then repeated. Dosage reduction with each cycle or within a cycle may be applied based upon the grade of toxicity experienced by the patient.

Pancreatic cancer

The recommended dose of Cytogem is 1000 mg/m2, given by 30-minute intravenous infusion. This should be repeated once weekly for up to 7 weeks followed by a week of rest. Subsequent cycles should consist of injections once weekly for 3 consecutive weeks out of every 4 weeks. Dosage reduction with each cycle or within a cycle may be applied based upon the grade of toxicity experienced by the patient.

Non small Cell lung cancer

Monotherapy

The recommended dose of Cytogem is 1000 mg/m2, given by 30-minute intravenous infusion. This should be repeated once weekly for 3 weeks, followed by a 1-week rest period. This 4-week cycle is then repeated. Dosage reduction with each cycle or within a cycle may be applied based upon the grade of toxicity experienced by the patient.

Combination use

The recommended dose for Cytogem is 1,250 mg/m2 body surface area given as a 30-minute intravenous infusion on Days 1 and 8 of the treatment cycle (21 days). Dosage reduction with each cycle or within a cycle may be applied based upon the grade of toxicity experienced by the patient.

Cisplatin has been used at doses between 75-100 mg/m2 once every 3 weeks.

Breast cancer

Combination use

Cytogem in combination with paclitaxel is recommended using paclitaxel (175 mg/m2) administered on Day 1 over approximately 3-hours as an intravenous infusion, followed by Cytogem (1250 mg/m2) as a 30-minute intravenous infusion on Days 1 and 8 of each 21-day cycle. Dose reduction with each cycle or within a cycle may be applied based upon the grade of toxicity experienced by the patient. Patients should have an absolute granulocyte count of at least 1,500 (x 106/l) prior to initiation of Cytogem + paclitaxel combination.

Ovarian cancer

Combination use

Cytogem in combination with carboplatin is recommended using Cytogem 1000 mg/m2 administered on Days 1 and 8 of each 21-day cycle as a 30-minute intravenous infusion. After Cytogem, carboplatin will be given on Day 1 consistent with a target Area under curve (AUC) of 4.0 mg/ml-min. Dosage reduction with each cycle or within a cycle may be applied based upon the grade of toxicity experienced by the patient.

Monitoring for toxicity and dose modification due to toxicity

Dose modification due to non haematological toxicity

Periodic physical examination and checks of renal and hepatic function should be made to detect non-haematological toxicity. Dosage reduction with each cycle or within a cycle may be applied based upon the grade of toxicity experienced by the patient. In general, for severe (Grade 3 or 4) non-haematological toxicity, except nausea/vomiting, therapy with Cytogem should be withheld or decreased depending on the judgement of the treating physician. Doses should be withheld until toxicity has resolved in the opinion of the physician.

For cisplatin, carboplatin, and paclitaxel dosage adjustment in combination therapy, please refer to the corresponding Summary of Product Characteristics.

Dose modification due to haematological toxicity

Initiation of a cycle

For all indications, the patient must be monitored before each dose for platelet and granulocyte counts. Patients should have an absolute granulocyte count of at least 1,500 (x 106/l) and platelet account of 100,000 (x 106/l) prior to the initiation of a cycle.

Within a cycle

Dose modifications of Cytogem within a cycle should be performed according to the following tables:

* Treatment omitted will not be re-instated within a cycle before the absolute granulocyte count reaches at least 500 (x106/l) and the platelet count reaches 50,000 (x106/l).

* Treatment omitted will not be re-instated within a cycle. Treatment will start on day 1 of the next cycle once the absolute granulocyte count reaches at least 1,500 (x106/l) and the platelet count reaches 100,000 (x106/l).

* Treatment omitted will not be re-instated within a cycle. Treatment will start on day 1 of the next cycle once the absolute granulocyte count reaches at least 1,500 (x106/l) and the platelet count reaches 100,000 (x106/l).

Dose modifications due to haematological toxicity in subsequent cycles, for all indications

The Cytogem dose should be reduced to 75% of the original cycle initiation dose, in the case of the following haematological toxicities:

- Absolute granulocyte count < 500 x 106/l for more than 5 days

- Absolute granulocyte count < 100 x 106/l for more than 3 days

- Febrile neutropaenia

- Platelets < 25,000 x106/l

- Cycle delay of more than 1 week due to toxicity

Method of administration

Cytogem solution for infusion is for intravenous use only. The solution may be administered directly to the patient without further preparation. Cytogem solution for infusion is compatible with IV infusion set when administered over a period of 30 minutes. For single use only.

Cytogem is tolerated well during infusion and may be administered ambulant. If extravasation occurs, generally the infusion must be stopped immediately and started again in another blood vessel. The patient should be monitored carefully after the administration.

Special populations

Patients with renal or hepatic impairment

Cytogem should be used with caution in patients with hepatic or renal insufficiency as there is insufficient information from clinical studies to allow for clear dose recommendations for these patient populations.

Elderly population (> 65 years)

Cytogem has been well tolerated in patients over the age of 65. There is no evidence to suggest that dose adjustments, other than those already recommended for all patients, are necessary in the elderly.

Paediatric population (< 18 years)

Cytogem is not recommended for use in children under 18 years of age due to insufficient data on safety and efficacy.

Special precautions for disposal and other handling

Handling

- Calculate the dose, and decide which size of the Cytogem infusion bags is needed.

- Inspect the product pack for any damage. Do not use if there are signs of tampering.

- Apply patient-specific label on the overwrap.

Removal of infusion bag from overwrap and infusion bag inspection

- Tear overwrap at notch. Do not use if overwrap has been previously opened or damaged.

- Remove infusion bag from overwrap.

- Use only if infusion bag and seal are intact. Prior to administration check for minute leaks by squeezing bag firmly. If leaks are found, discard the bag and solution as sterility may be impaired.

- Parenteral medicinal products should be inspected visually for particulate matter and discolouration prior to administration. If particulate matter is observed, do not administer.

Administration

- Break the Minitulipe stopper seal by applying pressure on one side with hand.

- Using aseptic technique, attach sterile administration set.

- Refer to directions for use accompanying the administration set.

Precautions

- Do not use in series connection.

- Do not introduce additives into the infusion bag.

- The solution for infusion is ready to use and and must not be mixed with other medicinal products.

- After opening the infusion bag:

From a microbiological point of view, the solution should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user.

- Cytogem solution for infusion is for single use only.

Personnel must be provided with appropriate handling materials, notably long sleeved gowns, protection masks, caps, protective goggles, sterile single-use gloves, protective covers for the work area and collection bags for waste.

Cytotoxic preparations should not be handled by pregnant staff.

If the product comes into contact with the eyes, severe irritation may result. In such an event, the eyes should be washed thoroughly and immediately. Consult a doctor if irritation persists. If the solution should come into contact with skin, rinse the affected area thoroughly with water. Excreta and vomit must be handled with care.

Disposal

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