Paclitaxelpaclitaxel

Overdose

There is no known antidote for paclitaxel overdose. In the event of an overdose, the patient should be closely monitored. Treatment should be directed at the major anticipated toxicities, which are bone marrow suppression, mucositis and peripheral neuropathy.

Contraindications

Lactation.

Patients who have baseline neutrophil counts <1500 cells/mm3.

Pharmaceutical form

Undesirable effects

Summary of the safety profile

The most common clinically significant adverse reactions associated with the use of Paclitaxelpaclitaxel have been neutropenia, peripheral neuropathy, arthralgia/myalgia and gastrointestinal disorders.

The frequencies of adverse reactions associated with the administration of Paclitaxelpaclitaxel are listed in Table 6 (Paclitaxelpaclitaxel as monotherapy) and Table 7 (Paclitaxelpaclitaxel in combination with gemcitabine), and Table 9 (Paclitaxelpaclitaxel in combination with carboplatin).

Frequencies are defined as: very common (>1/10), common (>1/100 to <1/10), uncommon (>1/1000 to <1/100), rare (>1/10,000 to <1/1000), very rare (<1/10,000). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.

Breast cancer (Paclitaxelpaclitaxel administered as monotherapy)

Tabulated list of adverse reactions

Table 6 lists adverse reactions associated with the administration of Paclitaxelpaclitaxel to patients from studies in which Paclitaxelpaclitaxel has been administered as monotherapy at any dose in any indication (N = 789).

Table 6: Adverse reactions reported with Paclitaxelpaclitaxel monotherapy at any dose in clinical studies

MedDRA = Medical Dictionary for Regulatory Activities.

SMQ = Standardized MedDRA Query; SMQ is a grouping of several MedDRA preferred terms to capture a medical concept.

1 The frequency of hypersensitivity reactions is calculated based on one definitely related case in a population of 789 patients.

2 As reported in the post-marketing surveillance of Paclitaxelpaclitaxel.

3 The frequency of pneumonitis is calculated based on pooled data in 1310 patients in clinical trials receiving Paclitaxelpaclitaxel monotherapy for breast cancer and for other indications using MedDRA SMQ Interstitial lung disease.

Description of selected adverse reactions

The following are the most common and clinically relevant adverse reactions related to 229 patients with metastatic breast cancer who were treated with 260 mg/m2 Paclitaxelpaclitaxel once every three weeks in the pivotal phase III clinical study.

Blood and lymphatic system disorders

Neutropenia was the most notable important haematological toxicity (reported in 79% of patients), and was rapidly reversible and dose dependent; leukopenia was reported in 71% of patients. Grade 4 neutropenia (< 500 cells/mm3) occurred in 9% of patients treated with Paclitaxelpaclitaxel. Febrile neutropenia occurred in four patients on Paclitaxelpaclitaxel. Anaemia (Hb < 10 g/dl) was observed in 46% of patients on Paclitaxelpaclitaxel, and was severe (Hb < 8 g/dl) in three cases. Lymphopenia was observed in 45% of the patients.

Nervous system disorders

In general, the frequency and severity of neurotoxicity was dose-dependent in patients receiving Paclitaxelpaclitaxel. Peripheral neuropathy (mostly Grade 1 or 2 sensory neuropathy) was observed in 68% of patients on Paclitaxelpaclitaxel with 10% being Grade 3, and no cases of Grade 4.

Gastrointestinal disorders

Nausea occurred in 29% of the patients and diarrhoea in 25% of the patients.

Skin and subcutaneous tissue disorders

Alopecia was observed in >80% of the patients treated with Paclitaxelpaclitaxel. The majority of alopecia events occurred less than one month after initiation of Paclitaxelpaclitaxel. Pronounced hair loss >50% is expected for the majority of patients who experience alopecia.

Musculoskeletal and connective tissue disorders

Arthralgia occurred in 32% of patients on Paclitaxelpaclitaxel and was severe in 6% of cases. Myalgia occurred in 24% of patients on Paclitaxelpaclitaxel and was severe in 7% of cases. The symptoms were usually transient, typically occurred three days after Paclitaxelpaclitaxel administration and resolved within a week.

General disorders and administration site conditions

Asthenia/Fatigue was reported in 40% of the patients.

Pancreatic adenocarcinoma (Paclitaxelpaclitaxel administered in combination with gemcitabine)

Tabulated list of adverse reactions

Adverse reactions were assessed in 421 patients treated with Paclitaxelpaclitaxel in combination with gemcitabine and 402 gemcitabine monotherapy-treated patients receiving first-line systemic treatment for metastatic adenocarcinoma of the pancreas in a phase III randomized, controlled, open-label trial. Table 7 lists adverse reactions assessed in patients with pancreatic adenocarcinoma treated with Paclitaxelpaclitaxel in combination with gemcitabine.

Table 7: Adverse reactions reported with Paclitaxelpaclitaxel in combination with gemcitabine (N =421)

MedDRA = Medical Dictionary for Regulatory Activities; SMQ = Standardized MedDRA Query (a grouping of several MedDRA preferred terms to capture a medical concept).

1 Peripheral neuropathy evaluated using the SMQ (broad scope).

2 Pneumonitis is evaluated using the SMQ interstitial lung disease (broad scope)

In this phase III randomized, controlled, open-label trial, adverse reactions resulting in death within 30 days of the last dose of study drug were reported for 4% of patients receiving Paclitaxelpaclitaxel in combination with gemcitabine and for 4% of patients receiving gemcitabine monotherapy.

Description of selected adverse reactions

The following are the most common and important incidences of adverse reactions related to 421 patients with metastatic adenocarcinoma of the pancreas who were treated with 125 mg/m2 Paclitaxelpaclitaxel in combination with gemcitabine at a dose of 1000 mg/m2 given on Days 1, 8 and 15 of each 28-day cycle in the phase III clinical study.

Blood and lymphatic system disorders

Table 8 provides the frequency and severity of haematologic laboratory-detected abnormalities for patients treated with Paclitaxelpaclitaxel in combination with gemcitabine or with gemcitabine.

Table 8: Haematologic laboratory-detected abnormalities in pancreatic adenocarcinoma trial

a 405 patients assessed in Paclitaxelpaclitaxel/gemcitabine-treated group

b 388 patients assessed in gemcitabine-treated group

c 404 patients assessed in Paclitaxelpaclitaxel/gemcitabine-treated group

Peripheral neuropathy

For patients treated with Paclitaxelpaclitaxel in combination with gemcitabine, the median time to first occurrence of Grade 3 peripheral neuropathy was 140 days. The median time to improvement by at least 1 grade was 21 days, and the median time to improvement from Grade 3 peripheral neuropathy to Grade 0 or 1 was 29 days. Of the patients with treatment interrupted due to peripheral neuropathy, 44% (31/70 patients) were able to resume Paclitaxelpaclitaxel at a reduced dose. No patients treated with Paclitaxelpaclitaxel in combination with gemcitabine had Grade 4 peripheral neuropathy.

Sepsis

Sepsis was reported at a rate of 5% in patients with or without neutropenia who received Paclitaxelpaclitaxel in combination with gemcitabine during the conduct of a trial in pancreatic adenocarcinoma. Complications due to the underlying pancreatic cancer, especially biliary obstruction or presence of biliary stent, were identified as significant contributing factors. If a patient becomes febrile (regardless of neutrophil count), initiate treatment with broad spectrum antibiotics. For febrile neutropenia, withhold Paclitaxelpaclitaxel and gemcitabine until fever resolves and ANC > 1500 cells/mm3, then resume treatment at reduced dose levels.

Pneumonitis

Pneumonitis has been reported at a rate of 4% with the use of Paclitaxelpaclitaxel in combination with gemcitabine. Of the 17 cases of pneumonitis reported in patients treated with Paclitaxelpaclitaxel in combination with gemcitabine, 2 had a fatal outcome. Monitor patients closely for signs and symptoms of pneumonitis. After ruling out infectious etiology and upon making a diagnosis of pneumonitis, permanently discontinue treatment with Paclitaxelpaclitaxel and gemcitabine and promptly initiate appropriate treatment and supportive measures.

Non-small cell lung cancer (Paclitaxelpaclitaxel administered in combination with carboplatin)

Tabulated list of adverse reactions

Table 9 lists adverse reactions associated with the administration of Paclitaxelpaclitaxel in combination with carboplatin.

Table 9: Adverse reactions reported with Paclitaxelpaclitaxel in combination with carboplatin (N = 514)

MedDRA = Medical Dictionary for Regulatory Activities: SMQ = Standardized MedDRA Query

1 Based on laboratory assessments: maximal degree of myelosuppression (treated population)

2 Peripheral neuropathy is evaluated using the SMQ neuropathy (broad scope)

3 Pneumonitis is evaluated using the SMQ interstitial lung disease (broad scope)

For non-small cell lung cancer patients treated with Paclitaxelpaclitaxel and carboplatin, the median time to first occurrence of Grade 3 treatment related peripheral neuropathy was 121 days, and the median time to improvement from Grade 3 treatment related peripheral neuropathy to Grade 1 was 38 days. No patients treated with Paclitaxelpaclitaxel and carboplatin experienced Grade 4 peripheral neuropathy.

Anemia and thrombocytopenia were more commonly reported in the Paclitaxelpaclitaxel arm than in the Taxol arm (54% versus 28% and 45% versus 27% respectively).

Patient-reported taxane toxicity was assessed using the 4 subscales of the Functional Assessment of Cancer Therapy (FACT)-Taxane questionnaire. Using repeated measure analysis, 3 of the 4 subscales (peripheral neuropathy, pain hands/feet, and hearing) favored Paclitaxelpaclitaxel and carboplatin (p ≤ 0.002). For the other subscale (oedema), there was no difference in the treatment arms.

Post-marketing experience

Cranial nerve palsies, vocal cord paresis, and rare reports of severe hypersensitivity reactions have been reported during post-marketing surveillance of Paclitaxelpaclitaxel.

There have been rare reports of reduced visual acuity due to cystoid macular oedema during treatment with Paclitaxelpaclitaxel. Upon diagnosis of cystoid macular oedema, treatment with Paclitaxelpaclitaxel should be discontinued.

There have been reports of tumour lysis syndrome during treatment with Paclitaxelpaclitaxel.

In some patients previously exposed to capecitabine, reports of palmar-plantar erythrodysaesthesiae have been reported as part of the continuing surveillance of Paclitaxelpaclitaxel. Because these events have been reported voluntarily during clinical practice, true estimates of frequency cannot be made and a causal relationship to the events has not been established.

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 (Freephone 0808 100 3352).

Preclinical safety data

The carcinogenic potential of paclitaxel has not been studied. However, based on the published literature, paclitaxel is a potentially carcinogenic and genotoxic agent at clinical doses, based upon its pharmacodynamic mechanism of action. Paclitaxel has been shown to be clastogenic in vitro (chromosome aberrations in human lymphocytes) and in vivo (micronucleus test in mice). Paclitaxel has been shown to be genotoxic in vivo (micronucleus test in mice), but it did not induce mutagenicity in the Ames test or the Chinese hamster ovary/hypoxanthine-guanine phosphoribosyl transferase (CHO/HGPRT) gene mutation assay.

Paclitaxel at doses below the human therapeutic dose was associated with low fertility and foetal toxicity in rats. Animal studies with Paclitaxelpaclitaxel showed non-reversible, toxic effects on the male reproductive organs at clinically relevant exposure levels.

Therapeutic indications

Paclitaxelpaclitaxel monotherapy is indicated for the treatment of metastatic breast cancer in adult patients who have failed first-line treatment for metastatic disease and for whom standard, anthracycline containing therapy is not indicated.

Paclitaxelpaclitaxel in combination with gemcitabine is indicated for the first-line treatment of adult patients with metastatic adenocarcinoma of the pancreas.

Paclitaxelpaclitaxel in combination with carboplatin is indicated for the first-line treatment of non-small cell lung cancer in adult patients who are not candidates for potentially curative surgery and/or radiation therapy.

Pharmacotherapeutic group

Pharmacodynamic properties

Pharmacotherapeutic group: Antineoplastic agents, plant alkaloids and other natural products, taxanes, ATC Code: L01CD01

Mechanism of action

Paclitaxel is an antimicrotubule agent that promotes the assembly of microtubules from tubulin dimers and stabilises microtubules by preventing depolymerisation. This stability results in the inhibition of the normal dynamic reorganisation of the microtubule network that is essential for vital interphase and mitotic cellular functions. In addition, paclitaxel induces abnormal arrays or “bundles” of microtubules throughout the cell cycle and multiple asters of microtubules during mitosis.

Paclitaxelpaclitaxel contains human serum albumin-paclitaxel nanoparticles of approximately 130 nm in size, where the paclitaxel is present in a non-crystalline, amorphous state. Upon intravenous administration, the nanoparticles dissociate rapidly into soluble, albumin bound paclitaxel complexes of approximately 10 nm in size. Albumin is known to mediate endothelial caveolar transcytosis of plasma constituents, and in vitro studies demonstrated that the presence of albumin in Paclitaxelpaclitaxel enhances transport of paclitaxel across endothelial cells. It is hypothesised that this enhanced transendothelial caveolar transport is mediated by the gp-60 albumin receptor, and that there is enhanced accumulation of paclitaxel in the area of tumour due to the albumin-binding protein Secreted Protein Acidic Rich in Cysteine (SPARC).

Clinical efficacy and safety

Breast cancer

Data from 106 patients accrued in two single-arm open-label studies and from 454 patients treated in a randomised Phase III comparative study are available to support the use of Paclitaxelpaclitaxel in metastatic breast cancer. This information is presented below.

Single-arm open-label studies

In one study, Paclitaxelpaclitaxel was administered as a 30-minute infusion at a dose of 175 mg/m2 to 43 patients with metastatic breast cancer. The second trial utilised a dose of 300 mg/m2 as a 30 minute infusion in 63 patients with metastatic breast cancer. Patients were treated without steroid pre-treatment or planned G-CSF support. Cycles were administered at 3 week intervals. The response rates in all patients were 39.5% (95% CI: 24.9%-54.2%) and 47.6% (95% CI: 35.3%-60.0%), respectively. The median time to disease progression was 5.3 months (175 mg/m2; 95% CI: 4.6-6.2 months) and 6.1 months (300 mg/m2; 95% CI: 4.2-9.8 months).

Randomised comparative study

This multi-centre trial was conducted in patients with metastatic breast cancer, who were treated every 3 weeks with single-agent paclitaxel, either as solvent-based paclitaxel 175 mg/m2 given as a 3-hour infusion with premedication to prevent hypersensitivity (N = 225), or as Paclitaxelpaclitaxel 260 mg/m2 given as a 30 minute infusion without premedication (N = 229).

Sixty-four percent of patients had impaired performance status (ECOG 1 or 2) at study entry; 79% had visceral metastases; and 76% had > 3 sites of metastases. Fourteen percent of the patients had not received prior chemotherapy; 27% had received chemotherapy in the adjuvant setting only, 40% in the metastatic setting only, and 19% in both metastatic and adjuvant settings. Fifty-nine percent received study medicinal product as second or greater than second-line therapy. Seventy-seven percent of the patients had been previously exposed to anthracyclines.

Results for overall response rate and time to disease progression, and progression-free survival and survival for patients receiving > 1st-line therapy, are shown below.

*This data is based on Clinical Study Report: CA012-0 Addendum dated Final (23 March-2005)

a Chi-squared test

b Log-rank test

Two hundred and twenty nine patients treated with Paclitaxelpaclitaxel in the randomized, controlled clinical trial were evaluated for safety. Neurotoxicity to paclitaxel was evaluated through improvement by one grade for patients experiencing Grade 3 peripheral neuropathy at any time during therapy. The natural course of peripheral neuropathy to resolution to baseline due to cumulative toxicity of Paclitaxelpaclitaxel after > 6 courses of treatment was not evaluated and remains unknown.

Pancreatic adenocarcinoma

A multicenter, multinational, randomized, open-label study was conducted in 861 patients to compare Paclitaxelpaclitaxel/gemcitabine versus gemcitabine monotherapy as first-line treatment in patients with metastatic adenocarcinoma of the pancreas. Paclitaxelpaclitaxel was administered to patients (N = 431) as an intravenous infusion over 30-40 minutes at a dose of 125 mg/m2 followed by gemcitabine as an intravenous infusion over 30-40 minutes at a dose of 1000 mg/m2 given on Days 1, 8 and 15 of each 28-day cycle. In the comparator treatment arm, gemcitabine monotherapy was administered to patients (N = 430) in accordance with the recommended dose and regimen. Treatment was administered until disease progression or development of an unacceptable toxicity. Of the 431 patients with pancreatic adenocarcinoma who were randomized to receive Paclitaxelpaclitaxel in combination with gemcitabine, the majority (93%) were white, 4% were black and 2% were Asian. 16% had a Karnofsky Performance Status of 100; 42% had a KPS of 90; 35% had a KPS of 80; 7% had a KPS of 70; and <1% of patients had a KPS of below 70. Patients with high cardiovascular risk, history of peripheral artery disease and/or of connective tissue disorders and/or interstitial lung disease were excluded from the study.

Patients received a median treatment duration of 3.9 months in the Paclitaxelpaclitaxel/gemcitabine arm and 2.8 months in the gemcitabine arm. 32% of patients in the Paclitaxelpaclitaxel/gemcitabine arm compared with 15% of patients in the gemcitabine arm received 6 or more months of treatment. For the treated population, the median relative dose intensity for gemcitabine was 75% in the Paclitaxelpaclitaxel/gemcitabine arm and 85% in the gemcitabine arm. The median relative dose intensity of Paclitaxelpaclitaxel was 81%. A higher median cumulative dose of gemcitabine was delivered in the Paclitaxelpaclitaxel/gemcitabine arm (11400 mg/m2) when compared with the gemcitabine arm (9000 mg/m2).

The primary efficacy endpoint was overall survival (OS). The key secondary endpoints were progression-free survival (PFS) and overall response rate (ORR), both assessed by independent, central, blinded radiological review using RECIST guidelines (Version 1.0).

Table 11: Efficacy results from randomized study in patients with pancreatic adenocarcinoma (Intent-to-treat population)

CI = confidence interval, HRA+G/G = hazard ratio of Paclitaxelpaclitaxel+gemcitabine/gemcitabine, pA+G/pG=response rate ratio of Paclitaxelpaclitaxel+gemcitabine/gemcitabine

a stratified Cox proportional hazard model

b stratified log-rank test, stratified by geographic region (North America versus others), KPS (70 to 80 versus 90 to 100), and presence of liver metastasis (yes versus no).

There was a statistically significant improvement in OS for patients treated with Paclitaxelpaclitaxel/gemcitabine versus gemcitabine alone, with 1.8 months increase in median OS, 28% overall reduction in risk of death, 59% improvement in 1-year survival, and 125% improvement in 2-year survival rates.

Figure 1: Kaplan-Meier curve of overall survival (intent-to-treat population)

Treatment effects on OS favoured the Paclitaxelpaclitaxel/gemcitabine arm across the majority of pre-specified subgroups (including gender, KPS, geographic region, primary location of pancreatic cancer, stage at diagnosis, presence of liver metastases, presence of peritoneal carcinomatosis, prior Whipple procedure, presence of biliary stent at baseline, presence of pulmonary metastases, and number of metastatic sites). For patients > 75 years of age in the Paclitaxelpaclitaxel/gemcitabine and gemcitabine arms the survival Hazard Ratio (HR) was 1.08 (95% CI 0.653, 1. 797). For patients with normal baseline CA 19-9 levels the survival HR was 1.07 (95% CI 0.692, 1.661).

There was a statistically significant improvement in PFS for patients treated with Paclitaxelpaclitaxel/gemcitabine versus gemcitabine alone, with 1.8 months increase in median PFS.

Non-small cell lung cancer

A multicenter, randomized, open-label study was conducted in 1052 chemotherapy-naive patients with Stage IIIb/IV non-small cell lung cancer. The study compared Paclitaxelpaclitaxel in combination with carboplatin versus solvent-based paclitaxel in combination with carboplatin as first-line treatment in patients with advanced non-small cell lung cancer. Over 99% of patients had an ECOG (Eastern Cooperative Oncology Group) performance status of 0 or 1. Patients with pre-existing neuropathy of Grade > 2 or serious medical risk factors involving any of the major organ systems were excluded. Paclitaxelpaclitaxel was administered to patients (N=521) as an intravenous infusion over 30 minutes at a dose of 100 mg/m2 on Days 1, 8 and 15 of each 21-day cycle without any steroid premedication and without granulocyte colony stimulating factor prophylaxis. Beginning immediately after the end of Paclitaxelpaclitaxel administration, carboplatin at a dose of AUC = 6 mg-min/mL was administered intravenously on Day 1 only of each 21-day cycle. Solvent-based paclitaxel was administered to patients (N=531) at a dose of 200 mg/m2 as an intravenous infusion over 3 hours with standard premedication, immediately followed by carboplatin administered intravenously at AUC = 6 mg-min/mL. Each drug was administered on Day 1 of each 21-day cycle. In both study arms treatment was administered until disease progression or development of an unacceptable toxicity. Patients received a median of 6 cycles of treatment in both study arms.

The primary efficacy endpoint was overall response rate defined as the percentage of patients who achieved an objective confirmed complete response or partial response based on an independent, central, blinded radiological review using RECIST (Version 1.0). Patients in the Paclitaxelpaclitaxel/carboplatin arm had a significantly higher overall response rate compared with patients in the control arm: 33% versus 25%, p = 0.005 (Table 12). There was a significant difference in overall response rate in the Paclitaxelpaclitaxel/carboplatin arm compared to the control arm in patients with non-small cell lung cancer of squamous histology (N=450, 41% vs. 24%, p<0.001), however this difference did not translate into a difference in PFS or OS. There was no difference in ORR between the treatment arms in patients with non-squamous histology (N=602, 26% vs 25%, p=0.808).

Table 12: Overall response rate in randomized non-small cell lung cancer trial (intent-to-treat population)

CI = confidence interval; HRA/T = hazard ratio of Paclitaxelpaclitaxel/carboplatin to solvent-based paclitaxel/carboplatin; pA/pT = response rate ratio of Paclitaxelpaclitaxel/carboplatin to solvent-based paclitaxel/carboplatin.

a P-value is based on a chi-square test.

There was no statistically significant difference in progression-free survival (by blinded radiologist assessment) and overall survival between the two treatment arms. A non-inferiority analysis was conducted for PFS and OS, with a pre-specified non-inferiority margin of 15%. The non-inferiority criterion was met for both PFS and OS with the upper bound of the 95% confidence interval for the associated hazard ratios being less than 1.176 (Table 13).

Table 13: Non-inferiority analyses on progression-free survival and overall survival in randomized non-small cell lung cancer trial (intent-to-treat population)

CI = confidence interval; HRA/T = hazard ratio of Paclitaxelpaclitaxel/carboplatin to solvent-based paclitaxel/carboplatin; pA/pT = response rate ratio of Paclitaxelpaclitaxel/carboplatin to solvent-based paclitaxel/carboplatin.

a Per EMA methodological considerations for PFS endpoint, missing observations or initiation of subsequent new therapy were not used for censoring.

Paediatric population

The European Medicines Agency has waived the obligation to submit the results of studies with Paclitaxelpaclitaxel in all subsets of the paediatric population in the treatment of metastatic breast cancer, pancreatic adenocarcinoma and non-small cell lung cancer (see section 4.2 for information on paediatric use).

Pharmacokinetic properties

The pharmacokinetics of total paclitaxel following 30- and 180-minute infusions of Paclitaxelpaclitaxel at dose levels of 80 to 375 mg/m2 were determined in clinical studies. The paclitaxel exposure (AUC) increased linearly from 2653 to 16736 ng.hr/ml following dosing from 80 to 300 mg/m2.

In a study in patients with advanced solid tumours, the pharmacokinetic characteristics of paclitaxel following Paclitaxelpaclitaxel administered intravenously at 260 mg/m2 over 30 minutes were compared with those following 175 mg/m2 of the solvent-based paclitaxel injection administered over 3 hours. Based on non-compartmental PK analysis, the plasma clearance of paclitaxel with Paclitaxelpaclitaxel was larger (43%) than that following a solvent-based paclitaxel injection and its volume of distribution was also higher (53%). There were no differences in terminal half-lives.

In a repeat dose study with 12 patients receiving Paclitaxelpaclitaxel administered intravenously at 260 mg/m2, intrapatient variability in AUC was 19% (range = 3.21%-37.70%). There was no evidence for accumulation of paclitaxel with multiple treatment courses.

Distribution

Following Paclitaxelpaclitaxel administration to patients with solid tumours, paclitaxel is evenly distributed into blood cells and plasma and is highly bound to plasma proteins (94%).

The protein binding of paclitaxel following Paclitaxelpaclitaxel was evaluated by ultrafiltration in a within-patient comparison study. The fraction of free paclitaxel was significantly higher with Paclitaxelpaclitaxel (6.2%) than with solvent-based paclitaxel (2.3%). This resulted in significantly higher exposure to unbound paclitaxel with Paclitaxelpaclitaxel compared with solvent-based paclitaxel, even though the total exposure is comparable. This is possibly due to paclitaxel not being trapped in Cremophor EL micelles as with solvent-based paclitaxel. Based on the published literature, in vitro studies of binding to human serum proteins, (using paclitaxel at concentrations ranging from 0.1 to 50 µg/ml), indicate that the presence of cimetidine, ranitidine, dexamethasone, or diphenhydramine did not affect protein binding of paclitaxel.

Based on population pharmacokinetic analysis, the total volume of distribution is approximately 1741 L; the large volume of distribution indicates extensive extravascular distribution and/or tissue binding of paclitaxel.

Biotransformation and elimination

Based on the published literature, in vitro studies with human liver microsomes and tissue slices show that paclitaxel is metabolised primarily to 6α-hydroxypaclitaxel; and to two minor metabolites, 3'-p-hydroxypaclitaxel and 6α-3'-p-dihydroxypaclitaxel. The formation of these hydroxylated metabolites is catalysed by CYP2C8, CYP3A4, and both CYP2C8 and CYP3A4 isoenzymes, respectively.

In patients with metastatic breast cancer, after a 30-minute infusion of Paclitaxelpaclitaxel at 260 mg/m2, the mean value for cumulative urinary excretion of unchanged active substance accounted for 4% of the total administered dose with less than 1% as the metabolites 6α-hydroxypaclitaxel and 3'-p-hydroxypaclitaxel, indicating extensive non-renal clearance. Paclitaxel is principally eliminated by hepatic metabolism and biliary excretion.

At the clinical dose range of 80 to 300 mg/m2, the mean plasma clearance of paclitaxel ranges from 13 to 30 L/h/m2, and the mean terminal half-life ranges from 13 to 27 hours.

Hepatic impairment

The effect of hepatic impairment on population pharmacokinetics of Paclitaxelpaclitaxel was studied in patients with advanced solid tumours. This analysis included patients with normal hepatic function (n=130), and pre-existing mild (n=8), moderate (n=7), or severe (n=5) hepatic impairment (according to NCI Organ Dysfunction Working Group criteria). The results show that mild hepatic impairment (total bilirubin >1 to ≤1.5 x ULN) has no clinically important effect on pharmacokinetics of paclitaxel. Patients with moderate (total bilirubin >1.5 to ≤3 x ULN) or severe (total bilirubin >3 to ≤5 x ULN) hepatic impairment have a 22% to 26% decrease in the maximum elimination rate of paclitaxel and approximately 20% increase in mean paclitaxel AUC compared with patients with normal hepatic function. Hepatic impairment has no effect on mean paclitaxel Cmax. In addition, elimination of paclitaxel shows an inverse correlation with total bilirubin and a positive correlation with serum albumin.

Pharmacokinetic/pharmacodynamic modeling indicates that there is no correlation between hepatic function (as indicated by the baseline albumin or total bilirubin level) and neutropenia after adjusting for Paclitaxelpaclitaxel exposure.

Pharmacokinetic data are not available for patients with total bilirubin >5 x ULN or for patients with metastatic adenocarcinoma of the pancreas.

Renal impairment

Population pharmacokinetic analysis included patients with normal renal function (n=65), and pre-existing mild (n=61), moderate (n=23), or severe (n=l) renal impairment (according to draft FDA guidance criteria 2010). Mild to moderate renal impairment (creatinine clearance >30 to <90 ml/min) has no clinically important effect on the maximum elimination rate and systemic exposure (AUC and Cmax) of paclitaxel. Pharmacokinetic data are insufficient for patients with severe renal impairment and not available for patients with end stage kidney disease.

Older people

Population pharmacokinetic analysis for Paclitaxelpaclitaxel included patients with ages ranging from 24 to 85 years old and shows that age does not significantly influence the maximum elimination rate and systemic exposure (AUC and Cmax) of paclitaxel.

Pharmacokinetic/pharmacodynamic modelling using data from 125 patients with advanced solid tumours indicates that patients > 65 years of age may be more susceptible to development of neutropenia within the first treatment cycle, although the plasma paclitaxel exposure is not affected by age.

Other intrinsic factors

Population pharmacokinetic analyses for Paclitaxelpaclitaxel indicate that gender, race (Asian vs. White), and type of solid tumours do not have a clinically important effect on systemic exposure (AUC and Cmax) of paclitaxel. Patients weighing 50 kg had paclitaxel AUC approximately 25% lower than those weighing 75 kg. The clinical relevance of this finding is uncertain.

Name of the medicinal product

Qualitative and quantitative composition

Special warnings and precautions for use

Paclitaxelpaclitaxel is an albumin-bound nanoparticle formulation of paclitaxel, which may have substantially different pharmacological properties compared to other formulations of paclitaxel. It should not be substituted for or with other paclitaxel formulations.

Hypersensitivity

Rare occurrences of severe hypersensitivity reactions, including very rare events of anaphylactic reactions with fatal outcome, have been reported. If a hypersensitivity reaction occurs, the medicinal product should be discontinued immediately, symptomatic treatment should be initiated, and the patient should not be rechallenged with paclitaxel.

Haematology

Bone marrow suppression (primarily neutropenia) occurs frequently with Paclitaxelpaclitaxel. Neutropenia is dose-dependent and a dose-limiting toxicity. Frequent monitoring of blood cell counts should be performed during Paclitaxelpaclitaxel therapy. Patients should not be retreated with subsequent cycles of Paclitaxelpaclitaxel until neutrophils recover to >1500 cells/mm3 and platelets recover to >100,000 cells/mm3.

Neuropathy

Sensory neuropathy occurs frequently with Paclitaxelpaclitaxel, although development of severe symptoms is less common. The occurrence of Grade 1 or 2 sensory neuropathy does not generally require dose reduction. When Paclitaxelpaclitaxel is used as monotherapy, if Grade 3 sensory neuropathy develops, treatment should be withheld until resolution to Grade 1 or 2 followed by a dose reduction for all subsequent courses of Paclitaxelpaclitaxel is recommended. For combination use of Paclitaxelpaclitaxel and gemcitabine, if Grade 3 or higher peripheral neuropathy develops, withhold Paclitaxelpaclitaxel; continue treatment with gemcitabine at the same dose. Resume Paclitaxelpaclitaxel at reduced dose when peripheral neuropathy improves to Grade 0 or 1. For combination use of Paclitaxelpaclitaxel and carboplatin, if Grade 3 or higher peripheral neuropathy develops, treatment should be withheld until improvement to Grade 0 or 1 followed by a dose reduction for all subsequent courses of Paclitaxelpaclitaxel and carboplatin.

Sepsis

Sepsis was reported at a rate of 5% in patients with or without neutropenia who received Paclitaxelpaclitaxel in combination with gemcitabine. Complications due to the underlying pancreatic cancer, especially biliary obstruction or presence of biliary stent, were identified as significant contributing factors. If a patient becomes febrile (regardless of neutrophil count), initiate treatment with broad spectrum antibiotics. For febrile neutropenia, withhold Paclitaxelpaclitaxel and gemcitabine until fever resolves and ANC > 1500 cells/mm3, then resume treatment at reduced dose levels.

Pneumonitis

Pneumonitis occurred in 1% of patients when Paclitaxelpaclitaxel was used as monotherapy and in 4% of patients when Paclitaxelpaclitaxel was used in combination with gemcitabine. Closely monitor all patients for signs and symptoms of pneumonitis. After ruling out infectious etiology and upon making a diagnosis of pneumonitis, permanently discontinue treatment with Paclitaxelpaclitaxel and gemcitabine and promptly initiate appropriate treatment and supportive measures.

Hepatic impairment

Because the toxicity of paclitaxel can be increased with hepatic impairment, administration of Paclitaxelpaclitaxel in patients with hepatic impairment should be performed with caution. Patients with hepatic impairment may be at increased risk of toxicity, particularly from myelosuppression; such patients should be closely monitored for development of profound myelosuppression.

Paclitaxelpaclitaxel is not recommended in patients that have total bilirubin > 5 x ULN or AST > 10 x ULN. In addition, Paclitaxelpaclitaxel is not recommended in patients with metastatic adenocarcinoma of the pancreas that have moderate to severe hepatic impairment (total bilirubin > 1.5 x ULN and AST ≤ 10 x ULN).

Cardiotoxicity

Rare reports of congestive heart failure and left ventricular dysfunction have been observed among individuals receiving Paclitaxelpaclitaxel. Most of the individuals were previously exposed to cardiotoxic medicinal products such as anthracyclines, or had underlying cardiac history. Thus patients receiving Paclitaxelpaclitaxel should be vigilantly monitored by physicians for the occurrence of cardiac events.

CNS metastases

The effectiveness and safety of Paclitaxelpaclitaxel in patients with central nervous system (CNS) metastases has not been established. CNS metastases are generally not well controlled by systemic chemotherapy.

Gastrointestinal symptoms

If patients experience nausea, vomiting and diarrhoea following the administration of Paclitaxelpaclitaxel, they may be treated with commonly used anti-emetics and constipating agents.

Patients 75 years and older

For patients of 75 years and older, no benefit for the combination treatment of Paclitaxelpaclitaxel and gemcitabine in comparison to gemcitabine monotherapy has been demonstrated. In the very elderly (>75 years) who received Paclitaxelpaclitaxel and gemcitabine, there was a higher incidence of serious adverse reactions and adverse reactions that led to treatment discontinuation including haematologic toxicities, peripheral neuropathy, decreased appetite and dehydration. Patients with pancreatic adenocarcinoma aged 75 years and older should be carefully assessed for their ability to tolerate Paclitaxelpaclitaxel in combination with gemcitabine with special consideration to performance status, co-morbidities and increased risk of infections.

Other

Although limited data is available, no clear benefit in terms of prolonged overall survival has been demonstrated in pancreatic adenocarcinoma patients with normal CA 19-9 levels prior to start of treatment with Paclitaxelpaclitaxel and gemcitabine.

Erlotinib should not be coadministered with Paclitaxelpaclitaxel plus gemcitabine.

Excipients

When reconstituted, each ml of Paclitaxelpaclitaxel concentrate contains 0.183 mmol sodium, which is 4.2 mg of sodium. To be taken into consideration by patients on a controlled sodium diet.

Effects on ability to drive and use machines

Paclitaxelpaclitaxel has minor or moderate influence on the ability to drive and use machines. Paclitaxelpaclitaxel may cause adverse reactions such as tiredness (very common) and dizziness (common) that may affect the ability to drive and use machinery. Patients should be advised not to drive and use machines if they feel tired or dizzy.

Dosage (Posology) and method of administration

Paclitaxelpaclitaxel should only be administered under the supervision of a qualified oncologist in units specialised in the administration of cytotoxic agents. It should not be substituted for or with other paclitaxel formulations.

Posology

Breast cancer

The recommended dose of Paclitaxelpaclitaxel is 260 mg/m2 administered intravenously over 30 minutes every 3 weeks.

Dose adjustments during treatment of breast cancer

Patients who experience severe neutropenia (neutrophil count < 500 cells/mm3 for a week or longer) or severe sensory neuropathy during Paclitaxelpaclitaxel therapy should have the dose reduced to 220 mg/m2 for subsequent courses. Following recurrence of severe neutropenia or severe sensory neuropathy, additional dose reduction should be made to 180 mg/m2. Paclitaxelpaclitaxel should not be administered until neutrophil counts recover to >1500 cells/mm3. For Grade 3 sensory neuropathy, withhold treatment until resolution to Grade 1 or 2, followed by a dose reduction for all subsequent courses.

Pancreatic adenocarcinoma

The recommended dose of Paclitaxelpaclitaxel in combination with gemcitabine is 125 mg/m2 administered intravenously over 30 minutes on Days 1, 8 and 15 of each 28-day cycle. The concurrent recommended dose of gemcitabine is 1000 mg/m2 administered intravenously over 30 minutes immediately after the completion of Paclitaxelpaclitaxel administration on Days 1, 8 and 15 of each 28-day cycle.

Dose adjustments during treatment of pancreatic adenocarcinoma

Table 1: Dose level reductions for patients with pancreatic adenocarcinoma

Table 2: Dose modifications for neutropenia and/or thrombocytopenia at the start of a cycle or within a cycle for patients with pancreatic adenocarcinoma

Abbreviations: ANC=Absolute Neutrophil Count; WBC=white blood cell

Table 3: Dose modifications for other adverse drug reactions in patients with pancreatic adenocarcinoma

a. See Table 1 for dose level reductions

Non-small cell lung cancer:

The recommended dose of Paclitaxelpaclitaxel is 100 mg/m2 administered as an intravenous infusion over 30 minutes on Days 1, 8 and 15 of each 21-day cycle. The recommended dose of carboplatin is AUC = 6 mg-min/mL on Day 1 only of each 21-day cycle, beginning immediately after the end of Paclitaxelpaclitaxel administration.

Dose adjustments during treatment of non-small cell lung cancer:

Paclitaxelpaclitaxel should not be administered on Day 1 of a cycle until absolute neutrophil count (ANC) is >1500 cells/mm3 and platelet count is >100,000 cells/mm3. For each subsequent weekly dose of Paclitaxelpaclitaxel, patients must have an ANC >500 cells/mm3 and platelets >50,000 cells/mm3 or the dose is to be withheld until counts recover. When counts recover, resume dosing the following week according to the criteria in Table 4. Reduce subsequent dose only if criteria in Table 4 are met.

Table 4: Dose reductions for haematologic toxicities in patients with non-small cell lung cancer

1On Day 1 of the 21-day cycle reduce the dose of Paclitaxelpaclitaxel and carboplatin simultaneously. On Days 8 or 15 of the 21-day cycle reduce the dose of Paclitaxelpaclitaxel; reduce the dose of carboplatin in the subsequent cycle.

2Maximum of 7 days post scheduled Day 1 dose of next cycle.

For Grade 2 or 3 cutaneous toxicity, Grade 3 diarrhoea, or Grade 3 mucositis, interrupt treatment until the toxicity improves to ≤ Grade 1, then restart treatment according to the guidelines in Table 5. For > Grade 3 peripheral neuropathy, withhold treatment until resolution to ≤ Grade 1. Treatment may be resumed at the next lower dose level in subsequent cycles according to the guidelines in Table 5. For any other Grade 3 or 4 non-haematologic toxicity, interrupt treatment until the toxicity improves to ≤ Grade 2, then restart treatment according to the guidelines in Table 5.

Table 5: Dose reductions for non-haematologic toxicities in patients with non-small cell lung cancer

1On Day 1 of the 21-day cycle reduce the dose of Paclitaxelpaclitaxel and carboplatin simultaneously. On Days 8 or 15 of the 21-day cycle reduce the dose of Paclitaxelpaclitaxel; reduce the dose of carboplatin in the subsequent cycle.

Special populations

Patients with hepatic impairment

For patients with mild hepatic impairment (total bilirubin > 1 to ≤ 1.5 x ULN and aspartate aminotransferase [AST] ≤ 10 x ULN), no dose adjustments are required, regardless of indication. Treat with same doses as patients with normal hepatic function.

For metastatic breast cancer patients and non-small cell lung cancer patients with moderate to severe hepatic impairment (total bilirubin > 1.5 to ≤ 5 x ULN and AST ≤ 10 x ULN), a 20% reduction in dose is recommended. The reduced dose may be escalated to the dose for patients with normal hepatic function if the patient is tolerating the treatment for at least two cycles.

For patients with metastatic adenocarcinoma of the pancreas that have moderate to severe hepatic impairment, there are insufficient data to permit dosage recommendations.

For patients with total bilirubin > 5 x ULN or AST > 10 x ULN, there are insufficient data to permit dosage recommendations regardless of indication.

Patients with renal impairment

Adjustment of the starting Paclitaxelpaclitaxel dose is not required for patients with mild to moderate renal impairment (estimated creatinine clearance >30 to <90 ml/min). There are insufficient data available to recommend dose modifications of Paclitaxelpaclitaxel in patients with severe renal impairment or end stage renal disease (estimated creatinine clearance <30 ml/min).

Older people

No additional dosage reductions, other than those for all patients, are recommended for patients 65 years and older.

Of the 229 patients in the randomized study who received Paclitaxelpaclitaxel monotherapy for breast cancer, 13% were at least 65 years of age and < 2% were 75 years and older. No toxicities occurred notably more frequently among patients at least 65 years of age who received Paclitaxelpaclitaxel. However, a subsequent analysis in 981 patients receiving Paclitaxelpaclitaxel monotherapy for metastatic breast cancer, of which 15% were > 65 years old and 2% were > 75 years old, showed a higher incidence of epistaxis, diarrhoea, dehydration, fatigue and peripheral oedema in patients > 65 years.

Of the 421 patients with pancreatic adenocarcinoma in the randomized study who received Paclitaxelpaclitaxel in combination with gemcitabine, 41% were 65 years and older and 10% were 75 years and older. In patients aged 75 years and older who received Paclitaxelpaclitaxel and gemcitabine, there was a higher incidence of serious adverse reactions and adverse reactions that led to treatment discontinuation. Patients with pancreatic adenocarcinoma aged 75 years and older should be carefully assessed before treatment is considered.

Of the 514 patients with non-small cell lung cancer in the randomized study who received Paclitaxelpaclitaxel in combination with carboplatin, 31% were 65 years or older and 3.5% were 75 years or older. Myelosuppression events, peripheral neuropathy events, and arthralgia were more frequent in patients 65 years or older compared to patients younger than 65 years of age. There is limited experience of Paclitaxelpaclitaxel/carboplatin use in patients 75 years or older.

Pharmacokinetic/pharmacodynamic modelling using data from 125 patients with advanced solid tumours indicates that patients > 65 years of age may be more susceptible to development of neutropenia within the first treatment cycle.

Paediatric population

The safety and efficacy of Paclitaxelpaclitaxel in children and adolescents aged 0-17 years has not been established. There is no relevant use of Paclitaxelpaclitaxel in the paediatric population in the indication of metastatic breast cancer or pancreatic adenocarcinoma or non-small cell lung cancer.

Method of administration

Administer reconstituted Paclitaxelpaclitaxel suspension intravenously using an infusion set incorporating a 15 µm filter. Following administration, it is recommended that the intravenous line be flushed with sodium chloride 9 mg/ml (0.9%) solution for injection to ensure administration of the complete dose.

Special precautions for disposal and other handling

Preparation and administration precautions

Paclitaxel is a cytotoxic anticancer medicinal product and, as with other potentially toxic compounds, caution should be exercised in handling Paclitaxelpaclitaxel. The use of gloves, goggles and protective clothing is recommended. If the suspension contacts the skin, the skin should be washed immediately and thoroughly with soap and water. If it contacts mucous membranes, the membranes should be flushed thoroughly with water. Paclitaxelpaclitaxel should only be prepared and administered by personnel appropriately trained in the handling of cytotoxic agents. Pregnant staff should not handle Paclitaxelpaclitaxel.

Given the possibility of extravasation, it is advisable to closely monitor the infusion site for possible infiltration during administration of the medicinal product. Limiting the infusion of Paclitaxelpaclitaxel to 30 minutes, as directed, reduces the likelihood of infusion-related reactions.

Reconstitution and administration of the product

Paclitaxelpaclitaxel is supplied as a sterile lyophilised powder for reconstitution before use. After reconstitution, each ml of suspension contains 5 mg of paclitaxel formulated as albumin bound nanoparticles.

100 mg vial: Using a sterile syringe, 20 ml of sodium chloride 9 mg/ml (0.9%) solution for infusion should slowly be injected into a vial of Paclitaxelpaclitaxel over a minimum of 1 minute.

250 mg vial: Using a sterile syringe, 50 ml of sodium chloride 9 mg/ml (0.9%) solution for infusion should slowly be injected into a vial of Paclitaxelpaclitaxel over a minimum of 1 minute.

The solution should be directed onto the inside wall of the vial. The solution should not be injected directly onto the powder as this will result in foaming.

Once the addition is complete, the vial should be allowed to stand for a minimum of 5 minutes to ensure proper wetting of the solid. Then, the vial should gently and slowly be swirled and/or inverted for at least 2 minutes until complete resuspension of any powder occurs. The generation of foam must be avoided. If foaming or clumping occurs, the solution must stand for at least 15 minutes until foam subsides.

The reconstituted suspension should be milky and homogenous without visible precipitates. Some settling of the reconstituted suspension may occur. If precipitates or settling are visible, the vial should be gently inverted again to ensure complete resuspension prior to use.

Inspect the suspension in the vial for particulate matter. Do not administer the reconstituted suspension if particulate matter is observed in the vial.

The exact total dosing volume of 5 mg/ml suspension required for the patient should be calculated and the appropriate amount of reconstituted Paclitaxelpaclitaxel should be injected into an empty, sterile, PVC or non-PVC type intravenous bag.

The use of medical devices containing silicone oil as a lubricant (i.e. syringes and IV bags) to reconstitute and administer Paclitaxelpaclitaxel may result in the formation of proteinaceous strands. Administer Paclitaxelpaclitaxel using an infusion set incorporating a 15 µm filter to avoid administration of these strands. Use of a 15 µm filter removes strands and does not change the physical or chemical properties of the reconstituted product.

Use of filters with a pore size less than 15 µm may result in blockage of the filter.

The use of specialized di(2-ethylhexyl)phthalate (DEHP)-free solution containers or administration sets is not necessary to prepare or administer Paclitaxelpaclitaxel infusions.

Following administration, it is recommended that the intravenous line be flushed with sodium chloride 9 mg/ml (0.9%) solution for injection to ensure administration of the complete dose.

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