Etoposide Injection USP 1000mg/50ml Taj Pharm

1. Name of the medicinal product

Etoposide Injection USP 20mg/ml Taj Pharma
Etoposide Injection USP 100mg/5ml Taj Pharma
Etoposide Injection USP 500mg/25ml Taj Pharma
Etoposide Injection USP 1000mg/50ml Taj Pharm

2. Composition 

a) Etoposide Injection USP 20mg/ml
Each ml contains:
Etoposide USP                     20mg
b) Etoposide Injection  100mg/5ml
Each ml contains:
Etoposide USP                    20mg
c) Etoposide Injection  500mg/25ml
Each ml contains:
Etoposide USP                    20mg
d) Etoposide Injection  1000mg/50ml
Each ml contains:
Etoposide USP                   20mg

For the full list of excipients, see section 6.1.

3. Pharmaceutical form

Powder for solution for injection.

4. Clinical particulars

4.1 Therapeutic indications

Testicular cancer

ETOPOSIDE is indicated in combination with other approved chemotherapeutic agents for the treatment of first line, recurrent or refractory testicular cancer in adults.

Small cell lung cancer

ETOPOSIDE is indicated in combination with other approved chemotherapeutic agents for the treatment of small-cell lung cancer in adults.

Hodgkin’s lymphoma

ETOPOSIDE is indicated in combination with other approved chemotherapeutic agents for the treatment of Hodgkin’s lymphoma in adult and paediatric patients.

Non-Hodgkin’s lymphoma

ETOPOSIDE is indicated in combination with other approved chemotherapeutic agents for the treatment of non-Hodgkin’s lymphoma in adult and paediatric patients.

Acute myeloid leukaemia

ETOPOSIDE is indicated in combination with other approved chemotherapeutic agents for the treatment of acute myeloid leukaemia in adult and paediatric patients.

Gestational trophoblastic neoplasia

ETOPOSIDE is indicated for first line and second line therapy in combination with other approved chemotherapeutic agents for the treatment of high risk gestational trophoblastic neoplasia in adults.

Ovarian cancer

ETOPOSIDE is indicated in combination with other approved chemotherapeutic agents for the treatment of non-epithelial ovarian cancer in adults.

ETOPOSIDE is indicated for the treatment of platinum-resistant/refractory epithelial ovarian cancer in adults.

4.2 Posology and method of administration

ETOPOSIDE should only be administered and monitored under the supervision of a qualified physician experienced in the use of anti-neoplastic medicinal products (see section 4.4).

Adult population

The recommended dose of ETOPOSIDE in adult patients is 50 to 100 mg/m²/day (etoposide equivalent) on days 1 to 5 or 100 to 120 mg/m² on days 1, 3, and 5 every 3 to 4 weeks in combination with other drugs indicated in the disease to be treated. Dosage should be modified to take into account the myelosuppressive effects of other drugs in the combination or the effects of prior radiotherapy or chemotherapy (see section 4.4) which may have compromised bone marrow reserve. The doses after the initial dose should be adjusted if neutrophil count is below 500 cells/mm³ for more than 5 days. In addition the dose should be adjusted in case of occurrence of fever, infections, or at a thrombocyte count below 25,000 cells/mm³, which is not caused by the disease. Follow up doses should be adjusted in case of occurrence of grade 3 or 4 toxicities or if renal creatinine clearance is below 50 ml/min. At decreased creatinine clearance of 15 to 50 mL/min a dose reduction by 25% is recommended.

Administration Precautions: As with other potentially toxic compounds, caution should be exercised in handling and preparing the solution of ETOPOSIDE. Skin reactions associated with accidental exposure to ETOPOSIDE may occur. The use of gloves is recommended. If ETOPOSIDE solution contacts the skin or mucosa, immediately wash the skin with soap and water and flush the mucosa with water (see section 6.6).

Elderly population

No dosage adjustment is necessary in elderly patients (age > 65 years old), other than based on renal function (see section 5.2).

Paediatric population

Hodgkin’s lymphoma; non-Hodgkin’s lymphoma; acute myeloid leukaemia

ETOPOSIDE in paediatric patients has been used in the range of 75 to 150 mg/m²/day (etoposide equivalent) for 2 to 5 days in combination with other antineoplastic agents. The treatment regimen should be chosen according to the local standard of care.

Ovarian cancer; small cell lung cancer; gestational trophoblastic neoplasia; testicular cancer

The safety and efficacy of ETOPOSIDE below 18 years of age have not been established. Currently available data are described in section 5.2 but no recommendation on a posology can be made.

Renal Impairment

In patients with impaired renal function, the following initial dose modification should be considered based on measured creatinine clearance.

In patients with creatinine clearance less than 15 mL/min and on dialysis further dose reduction is likely to be required as etoposide clearance is further reduced in these patients (see section 4.4). Subsequent dosing in moderate and severe renal impairment should be based on patient tolerance and clinical effect (see section 4.4). Since etoposide and its metabolites are not dialyzable, it can be administered pre- and post-haemodialysis (see section 4.9).

Method of administration

Etoposide phosphate is administered by slow intravenous infusion (usually over a 30 to 60 minute period) (see section 4.4).

For instructions on reconstitution and dilution of the medicinal product before administration, see section 6.6.

4.3 Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

Concomitant use of yellow fever vaccine or other live vaccines is contraindicated in immunosuppressed patients (see section 4.5).

Lactation (see section 4.6)

4.4 Special warnings and precautions for use

ETOPOSIDE should only be administered and monitored under the supervision of a qualified physician experienced in the use of anti-neoplastic medicinal products. In all instances where the use of ETOPOSIDE is considered for chemotherapy, the physician must evaluate the need and usefulness of the drug against the risk of adverse reactions. Most such adverse reactions are reversible if detected early. If severe reactions occur, the drug should be reduced in dosage or discontinued and appropriate corrective measures should be taken according to the clinical judgment of the physician. Reinstitution of ETOPOSIDE therapy should be carried out with caution, and with adequate consideration of the further need for the drug and close attention to possible recurrence of toxicity.

Myelosuppression

Dose limiting bone marrow suppression is the most significant toxicity associated with ETOPOSIDE therapy. Fatal myelosuppression has been reported following etoposide phosphate administration. Patients being treated with ETOPOSIDE must be observed for myelosuppression carefully and frequently both during and after therapy. The following haematological parameters should be measured at the start of therapy and prior to each subsequent dose of ETOPOSIDE: platelet count, haemoglobin, white blood cell count and differential. If radiotherapy or chemotherapy has been given prior to starting etoposide treatment, an adequate interval should be allowed to enable the bone marrow to recover. ETOPOSIDE should not be administered to patients with neutrophil counts less than 1,500 cells/mm³ or platelet counts less than 100,000 cells/mm³, unless caused by malignant disease. Doses subsequent to initial dose should be adjusted if neutrophil count less than 500 cells/mm³ occurs for more than 5 days or is associated with fever or infection, if platelet count less than 25,000 cells/mm³ occurs, if any grade 3 or 4 toxicity develops or if renal clearance is less than 50 ml/min.

Severe myelosuppression with resulting infection or haemorrhage may occur. Bacterial infections should be brought under control before treatment with ETOPOSIDE.

Secondary leukaemia

The occurrence of acute leukaemia, which can occur with or without myelodysplastic syndrome, has been described in patients that were treated with etoposide containing chemotherapeutic regimens. Neither the cumulative risk, nor the predisposing factors related to the development of secondary leukaemia are known. The roles of both administration schedules and cumulative doses of etoposide have been suggested, but have not been clearly defined.

An 11q23 chromosome abnormality has been observed in some cases of secondary leukaemia in patients who have received epipodophyllotoxins. This abnormality has also been seen in patients developing secondary leukaemia after being treated with chemotherapy regimens not containing epipodophyllotoxins and in leukaemia occurring de novo. Another characteristic that has been associated with secondary leukaemia in patients who have received epipodophyllotoxins appears to be a short latency period, with average median time to development of leukaemia being approximately 32 months.

Hypersensitivity

Physicians should be aware of the possible occurrence of an anaphylactic reaction with ETOPOSIDE, manifested by chills, pyrexia, tachycardia, bronchospasm, dyspnoea and hypotension, which can be fatal. Treatment is symptomatic. ETOPOSIDE should be terminated immediately, followed by the administration of pressor agents, corticosteroids, antihistamines, or volume expanders at the discretion of the physician.

Hypotension

ETOPOSIDE should be given only by slow intravenous infusion (usually over a 30 to 60 minute period) since hypotension has been reported as a possible side effect of rapid intravenous injection.

Injection site reaction

Injection site reactions may occur during administration of ETOPOSIDE. Given the possibility of extravasation, it is recommended to closely monitor the infusion site for possible infiltration during drug administration.

Low serum albumin

Low serum albumin is associated with increased exposure to etoposide. Therefore patients with low serum albumin may be at increased risk for etoposide-associated toxicities.

Impaired renal function

In patients with moderate (CrCl =15 to 50 mL/min), or severe (CrCl <15ml/min) renal impairment undergoing haemodialysis, etoposide should be administered at a reduced dose (see section 4.2). Haematological parameters should be measured and dose adjustments in subsequent cycles considered based on haematological toxicity and clinical effect in moderate and severe renal impaired patients.

Impaired hepatic function

Patients with impaired hepatic function should regularly have their hepatic function monitored due to the risk of accumulation.

Tumour lysis syndrome

Tumour lysis syndrome (sometimes fatal) has been reported following the use of etoposide in association with other chemotherapeutic drugs. Close monitoring of patients is needed to detect early signs of tumour lysis syndrome, especially in patients with risk factors such as bulky treatment-sensitive tumours, and renal insufficiency. Appropriate preventive measures should also be considered in patients at risk of this complication of therapy.

Mutagenic potential

Given the mutagenic potential of etoposide, an effective contraception is required for both male and female patients during treatment and up to 6 months after ending treatment. Genetic consultation is recommended if the patient wishes to have children after ending the treatment. As etoposide may decrease male fertility, preservation of sperm may be considered for the purpose of later fatherhood (see section 4.6).

4.5 Interaction with other medicinal products and other forms of interaction

Effects of other drugs on the pharmacokinetics of etoposide phosphate

High dose ciclosporin, resulting in plasma concentrations above 2000 ng/mL, administered with oral etoposide has led to an 80% increase in etoposide exposure (AUC) with a 38% decrease in total body clearance of etoposide compared to etoposide alone.

Concomitant cisplatin therapy is associated with reduced total body clearance of etoposide.

Concomitant phenytoin therapy is associated with increased etoposide clearance and reduced efficacy, and other enzyme-inducing antiepileptic therapy may be associated with increased ETOPOSIDE clearance and reduced efficacy.

As etoposide phosphate is converted in vivo to etoposide by phosphorylation, caution should be exercised when administering etoposide phosphate with drugs that are known to inhibit phosphatase activity as such combination may reduce efficacy of etoposide phosphate.

In vitro plasma protein binding is 97%. Phenylbutazone, sodium salicylate, and aspirin may displace etoposide from plasma protein binding.

Effect of etoposide phosphate on the pharmacokinetics of other drugs

Co-administration of antiepileptic drugs and ETOPOSIDE can lead to decreased seizure control due to pharmacokinetic interactions between the drugs.

Co-administration of warfarin and etoposide may result in elevated international normalized ratio (INR). Close monitoring of INR is recommended.

Pharmacodynamic interactions

There is increased risk of fatal systemic vaccinal disease with the use of yellow fever vaccine. Live vaccines are contraindicated in immunosuppressed patients (see section 4.3).

Prior or concurrent use of other drugs with similar myelosuppressant action as etoposide may be expected to have additive or synergetic effects (see section 4.4).

Cross resistance between anthracyclines and etoposide has been reported in preclinical experiments.

Paediatric population

Interaction studies have only been performed in adults.

4.6 Fertility, pregnancy and lactation

Women of childbearing potential/Contraception in males and females

Women of childbearing potential should use appropriate contraceptive measures to avoid pregnancy during etoposide therapy. Etoposide has been shown to be teratogenic in mice and rats (see section 5.3). Given the mutagenic potential of etoposide, an effective contraceptive is required for both male and female patients during treatment and up to 6 months after ending treatment (see section 4.4). Genetic consultation is recommended if the patient wishes to have children after ending treatment.

Pregnancy

There are no or limited amount of data from the use of etoposide phosphate in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3). In general etoposide can cause fetal harm when administered to pregnant women. ETOPOSIDE should not be used during pregnancy unless the clinical condition of the woman requires treatment with etoposide. Women of childbearing potential should be advised to avoid becoming pregnant. Women of childbearing potential have to use effective contraception during and up to 6 months after treatment. If this drug is used during pregnancy, or if the patient becomes pregnant while receiving this drug, the patient should be informed of the potential hazard to the fetus.

Breastfeeding

Etoposide is excreted in human milk. There is the potential for serious adverse reactions in nursing infants from ETOPOSIDE. A decision must be made whether to discontinue breast-feeding or to discontinue ETOPOSIDE, taking into account the benefit of breast feeding for the child and the benefit of therapy for the woman (see section 4.3).

Fertility

As etoposide may decrease male fertility, preservation of sperm may be considered for the purpose of later fatherhood.

4.7 Effects on ability to drive and use machines

No studies on the effects on the ability to drive and use machines have been performed. Etoposide phosphate may cause adverse reactions that affect the ability to drive or use machines such as fatigue, somnolence, nausea, vomiting, cortical blindness, hypersensitivity reactions with hypotension. Patients who experience such adverse reactions should be advised to avoid driving or using machines.

4.8 Undesirable effects

Summary of the safety profile

Dose limiting bone marrow suppression is the most significant toxicity associated with ETOPOSIDE therapy. In clinical studies in which ETOPOSIDE was administered as a single agent at a total dose of ≥450 mg/m² the most frequent adverse reactions of any severity were leucopenia (91%), neutropenia (88%), anaemia (72%) thrombocytopenia (23%), asthenia (39%), nausea and/or vomiting (37%), alopecia (33%) and chills and/or fever (24%).

Tabulated summary of adverse reactions

The following adverse reactions were reported from ETOPOSIDE clinical studies and post-marketing experience. These adverse reactions are presented by system organ class and frequency, which is defined by the following categories: very common (≥1/10), common (≥1/100, <1/10), uncommon (≥1/1, 000, <1/100), rare (≥1/10, 000, <1/1,000), not known (cannot be estimated from the available data).

Description of selected adverse reactions

In the paragraphs below the incidences of adverse events, given as the mean percent, are derived from studies that utilized single agent ETOPOSIDE therapy.

Haematological Toxicity

Myelosuppression (see section 4.4) with fatal outcome has been reported following administration of etoposide phosphate. Myelosuppression is most often dose-limiting. Bone marrow recovery is usually complete by day 20, and no cumulative toxicity has been reported. Granulocyte and platelet nadirs tend to occur about 10 to14 days after administration of etoposide phosphate depending on the way of administration and treatment scheme. Nadirs tend to occur earlier with intravenous administration compared to oral administration. Leucopenia and severe leucopenia (less than 1,000 cells/mm³) were observed in 91% and 17%, respectively, for etoposide phosphate. Thrombocytopenia and severe thrombocytopenia (less than 50,000 platelets/mm³) were seen in 23% and 9% respectively, for etoposide phosphate. Reports of fever and infection were also very common in patients with neutropenia treated with etoposide phosphate. Bleeding has been reported.

Gastrointestinal Toxicity

Nausea and vomiting are the major gastrointestinal toxicities of etoposide phosphate. The nausea and vomiting can usually be controlled by antiemetic therapy.

Alopecia

Reversible alopecia, sometimes progressing to total baldness, was observed in up to 44% of patients treated with etoposide phosphate.

Hypotension

Transient hypotension following rapid intravenous administration has been reported in patients treated with etoposide phosphate and has not been associated with cardiac toxicity or electrocardiographic changes. Hypotension usually responds to cessation of infusion of etoposide phosphate and/or other supportive therapy as appropriate. When restarting the infusion, a slower administration rate should be used. No delayed hypotension has been noted.

Hypertension

In clinical studies involving etoposide phosphate, episodes of hypertension have been reported. If clinically significant hypertension occurs in patients receiving etoposide phosphate, appropriate supportive therapy should be initiated.

Hypersensitivity

Anaphylactic reactions have been reported to occur during or immediately after intravenous administration of etoposide phosphate. The role that concentration or rate of infusion plays in the development of anaphylactic reactions is uncertain. Blood pressure usually normalizes within a few hours after cessation of the infusion. Anaphylactic reactions can occur with the initial dose of etoposide phosphate.

Anaphylactic reactions (see section 4.4), manifested by chills, tachycardia, bronchospasm, dyspnoea, diaphoresis, pyrexia, pruritus, hypertension or hypotension, syncope, nausea, and vomiting have been reported to occur in 3% (7 of 245 patients treated with ETOPOSIDE in 7 clinical studies) of patients treated with ETOPOSIDE. Facial flushing was reported in 2% of patients and skin rashes in 3%. These reactions have usually responded promptly to the cessation of the infusion and administration of pressor agents, corticosteroids, antihistamines, or volume expanders as appropriate.

Acute fatal reactions associated with bronchospasm have also been reported with etoposide phosphate. Apnoea with spontaneous resumption of breathing following cessation of infusion have also been reported.

Metabolic Complications

Tumour lysis syndrome (sometimes fatal) has been reported following the use of etoposide phosphate in association with other chemotherapeutic drugs (see section 4.4).

Paediatric population

The safety profile between paediatric patients and adults is expected to be similar.

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.

4.9 Overdose

Total doses of 2.4 g/m² to 3.5 g/m² administered intravenously over three days have resulted in severe mucositis and myelotoxicity. Metabolic acidosis and cases of serious hepatic toxicity have been reported in patients receiving higher than recommended intravenous doses of etoposide. Similar toxicities can be expected with oral formulation. A specific antidote is not available. Treatment should therefore be symptomatic and supportive, and patients should be closely monitored. Etoposide and its metabolites are not dialyzable.

5. Pharmacological properties

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Cytostatics, plant alkaloids and other natural products, podophyllotoxin derivatives, ATC code: L01CB01

Mechanism of action

Etoposide phosphate is metabolised in vivo into the active substance etoposide by a process of dephosphorylation. The mechanism of action of etoposide phosphate is considered to be the same as that of etoposide.

The main effect of etoposide appears to be at the late S and early G₂ portion of the cell cycle in mammalian cells. Two dose-dependent responses are seen: At high concentrations (10 mcg/mL or more), cells entering mitosis are lysed; at low concentrations (0.3 to 10 mcg/mL), cells are inhibited from entering prophase. Microtubule assembly is not affected. The predominant macromolecular effect of etoposide seems to be the rupture of the double strand by an interaction with DNA-topoisomerase II or by the formation of free radicals. Etoposide has been shown to cause metaphase arrest in chick fibroblasts.

5.2 Pharmacokinetic properties

Absorption

After either intravenous infusion or oral capsule administration, the C_max and AUC values exhibit marked intra- and inter-subject variability.

Distribution

The mean volumes of distribution at steady state range from 18 to 29 liters . Etoposide shows low penetration into the CSF. In vitro, etoposide is highly protein bound (97%) to human plasma proteins.

Etoposide binding ratio correlates directly with serum albumin in cancer patients and normal volunteers (see section 4.4). Unbound fraction of etoposide correlates significantly with bilirubin in cancer patients.

Biotransformation

The hydroxyacid metabolite [4′ dimethyl-epipodophyllic acid-9-(4,6 0-ethylidene-β-D-glucopyranoside)], formed by opening of the lactone ring, is found in the urine of adults and children. It is also present in human plasma, presumably as the trans isomer. Glucuronide and/or sulfate conjugates of etoposide are also excreted in human urine. In addition, O-demethylation of the dimethoxyphenol ring occurs through the CYP450 3A4 isoenzyme pathway to produce the corresponding catechol.

Elimination

On intravenous administration, the disposition of etoposide is best described as a biphasic process with a distribution half-life of about 1.5 hours and terminal elimination half-life ranging from 4 to 11 hours. Total body clearance values range from 33 to 48 mL/min or 16 to 36 mL/min/m² and, like the terminal elimination half-life, are independent of dose over a range 100 to 600 mg/m². After intravenous administration of ¹⁴C etoposide (100 to 124 mg/m²), mean recovery of radioactivity in the urine was 56% (45% of the dose was excreted as etoposide) and faecal recovery of radioactivity was 44% of the adminitered dose at 120 hours.

Linearity/non-linearity

Total body clearance and the terminal elimination half-life are independent of dose over a range 100 to 600 mg/m². Over the same dose range, the areas under the plasma concentration vs. time curves (AUC) and the maximum plasma concentration (C_max) values increase linearly with dose.

Renal impairment

Patients with impaired renal function receiving etoposide have exhibited reduced total body clearance, increased AUC and higher steady state volume of distribution (see section 4.2).

Hepatic impairment

In adult cancer patients with liver dysfunction, total body clearance of etoposide is not reduced.

Elderly population

Although minor differences in pharmacokinetic parameters between patients ≤65 years and >65 years of age have been observed, these are not considered clinically significant.

Paediatric population

In children, approximately 55% of the dose is excreted in the urine as etoposide in 24 hours. The mean renal clearance of etoposide is 7 to 10 mL/min/m² or about 35% of the total body clearance over a dose range of 80 to 600 mg/m². Etoposide, therefore, is cleared by both renal and nonrenal processes, ie, metabolism and biliary excretion. The effect of renal disease on plasma etoposide clearance is not known in children. In children, elevated SGPT levels are associated with reduced drug total body clearance. Prior use of cisplatin may also result in a decrease of etoposide total body clearance in children.

An inverse relationship between plasma albumin levels and etoposide renal clearance is found in children.

Gender

Although minor differences in pharmacokinetic parameters between genders have been observed, these are not considered clinically significant.

Drug interactions

In a study of the effects of other therapeutic agents on in vitro binding of ¹⁴C etoposide to human serum proteins, only phenylbutazone, sodium salicylate, and aspirin displaced protein-bound etoposide at concentrations generally achieved in vivo (see section 4.5).

5.3 Preclinical safety data

Chronic toxicity

Anaemia, leucopenia, and thrombocytopenia were observed in rats and mice, while dogs had mild reversible deterioration of liver and kidney functions. The dose multiple (based on mg/m² doses) for these findings at the no-observed adverse-effect-level in the preclinical studies were ≥ approximately 0.05 times compared to the highest clinical dose. Historically, preclinical species have been more sensitive compared to humans towards cytotoxic agents. Testicular atrophy, spermatogenesis arrest, and growth retardation were reported in rats and mice.

Mutagenicity

Etoposide is mutagenic in mammalian cells.

Reproductive toxicity

In animal studies etoposide was associated with dose-related embryotoxicity and teratogenicity.

Carcinogenic potential

Given its mechanism of action, etoposide phosphate should be considered a possible carcinogen in humans.

6. Pharmaceutical particulars

6.1 List of excipients

Dextran 40, Sodium citrate.

6.2 Incompatibilities

ETOPOSIDE should not be physically mixed with any other drug.

6.3 Shelf life

3 Years.

Storage conditions after reconstitution of the medicinal product

After reconstitution: chemical and physical in-use stability has been demonstrated for 24 hours at 15 to 30°C and for 7 days at 2 to 8°C. From a microbiological point of view, the reconstituted solution should immediately be used undiluted or should be diluted. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 7 days at 2 to 8°C, unless dilution has taken place in controlled and validated aseptic conditions.

After dilution: when the reconstituted solution is diluted immediately, the chemical and physical in-use stability of the diluted infusion solution has been demonstrated for 24 hours at 15 to 30°C and for 7 days at 2° to 8°C. From a microbiological point of view, the product should be used immediately.

6.4 Special precautions for storage

Store in a refrigerator (2 to 8°C)

Store in the original package in order to protect from light.

6.5 Nature and contents of container

Type I glass vial with a butyl rubber stopper and flip-off aluminium seal. Packs of 1, 5, 10, 20, 25 vials.

Not all pack sizes may be marketed

6.6 Special precautions for disposal and other handling

Procedures for proper handling and disposal of anti-cancer drugs should be followed.

Care must be taken whenever handling cytostatic products. Always take steps to prevent exposure. As with other potentially toxic compounds, caution should be exercised in handling and preparing ETOPOSIDE solutions. Skin reactions associated with accidental exposure to ETOPOSIDE may occur. The use of gloves is recommended. If etoposide phosphate should contact the skin or mucosa, immediately wash the skin with soap and water and flush the mucosa with water.

ETOPOSIDE solutions must be prepared under aseptic conditions.

Preparation of ETOPOSIDE 100 mg powder for solution for infusion

Before use the content of each vial must be reconstituted with 5 ml or 10 ml of:

• water for injections or,
• 5% glucose solution or,
• 0.9 % sodium chloride solution.

This will yield a reconstituted stock solution containing 20 mg/ml or 10 mg/ml etoposide.

After reconstitution, the solution can be administered without further dilution or it can be further diluted with 5% glucose solution or 0.9% sodium chloride solution to obtain concentrations as low as 0.1 mg/ml etoposide.

The products administered by parenteral route must be visually examined to check for any particulates or discoloration prior to administration. If any discolouration or particulate matter is observed, the reconstituted solution must be discarded.

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

7. Marketing authorisation holder

Manufactured in India By:
TAJ PHARMACEUTICALS LIMITED
at SURVEY NO.188/1 TO 189/1,190/1 TO 4,
ATHIYAWAD, DABHEL, DAMAN- 396210 (INDIA)

Etoposide Injection USP 100mg/5ml Taj Pharma

Package leaflet: Information for the patient

Read all of this leaflet carefully before you start taking this medicine because it contains important information for you.

– Keep this leaflet. You may need to read it again.

– If you have any further questions, ask your doctor or pharmacist.

– This medicine has been prescribed for you only. Do not pass it on to others. It may harm them,

even if their signs of illness are the same as yours.

– If you get any side effects, talk to your doctor or pharmacist. This includes any possible side

effects not listed in this leaflet. See section 4.

What is in this Leaflet:

1. What ETOPOSIDE is and what it is used for
2. What you need to know before you are given ETOPOSIDE
3. How you will be given ETOPOSIDE
4. Possible Side Effects
5. How to store ETOPOSIDE
6. Contents of the pack and other information

1. What ETOPOSIDE is and what it is used for

The name of your medicine is ETOPOSIDE.

Each vial contains etoposide phosphate equivalent to etoposide 100 mg as the active ingredient.

Etoposide phosphate belongs to a group of medicines called cytostatics which are used in the treatment of cancer.

ETOPOSIDE is used in the treatment of certain types of cancer in adults:

– testicular cancer

– small cell lung cancer

– cancer of the blood (acute myeloid leukaemia)

– tumour in the lymphatic system (Hodgkin’s lymphoma, non-Hodgkin’s lymphoma)

– reproductive system cancers (gestational trophoblastic neoplasia and ovarian cancer)

ETOPOSIDE is used in the treatment of certain types of cancers in children:

– cancer of the blood (acute myeloid leukaemia)

– tumour in the lymphatic system (Hodgkin’s lymphoma, non-Hodgkin’s lymphoma)

The exact reason why you have been prescribed ETOPOSIDE is best discussed with your doctor.

2. What you need to know before you are given ETOPOSIDE

Do not take ETOPOSIDE:

– If you are allergic to etoposide or any of the other ingredients of this medicine (listed in section 6).

– If you have recently been given a live vaccine, including Yellow fever vaccine.

– If you are breast-feeding or planning to breast-feed.

If any of the above affects you, or if you are unsure if they do, tell your doctor who will be able to advise you.

Warnings and precautions

Talk to your doctor, pharmacist or nurse before receiving ETOPOSIDE:

– if you have any infections.

– if you have had radiotherapy or chemotherapy recently.

– if you have low levels of a protein called albumin in your blood.

– if you have liver or kidney problems.

Effective anti-cancer treatment can destroy cancer cells rapidly in large numbers. On very rare occasions this may cause harmful amounts of substances from these cancer cells to be released into the blood. If this happens it can cause problems with the liver, kidney, heart or blood, which may result in death if not treated.

In order to prevent this, your doctor will need to do regular blood tests to monitor the level of these substances during treatment with this medicine.

This medicine can cause a reduction in the level of some blood cells, which could cause you to suffer from infections, or may mean that your blood doesn’t clot as well as it should if you cut yourself. Blood tests will be taken at the start of your treatment, and before each dose you take, to make sure that this isn’t happening.

If you have reduced liver or kidney function, your doctor may also want you to take regular blood tests to monitor these levels.

Other medicines and ETOPOSIDE

Tell your doctor or pharmacist if you are taking, have recently taken or might take any other medicines.

This is especially important:

• If you are taking a medicine called ciclosporin (a drug used to reduce the activity of the immune system).
• If you are being treated with cisplatin (a medicine used to treat cancer)
• If you are taking phenytoin or any other medicines used to treat epilepsy
• If you are taking warfarin (a medicine used to prevent blood clots from forming)
• If you have recently been given any live vaccines
• If you are taking phenylbutazone, sodium salicylate, or aspirin
• If you are taking any anthracyclines (a group of medicines used to treat cancer)
• If you are taking any drugs with a similar mechanism of action as ETOPOSIDE

Pregnancy, breast-feeding and fertility

If you are pregnant or breast-feeding, think you may be pregnant or are planning to have a baby, ask your doctor or pharmacist for advice before taking this medicine.

ETOPOSIDE must not be used during pregnancy unless clearly indicated by your doctor.

You must not breastfeed while you are receiving ETOPOSIDE.

Both male patients and female patients of child-bearing age should use an effective contraceptive method (e.g., the barrier method or condoms) during treatment and for at least 6 months after the end of treatment with ETOPOSIDE.

Male patients treated with ETOPOSIDE are advised not to father a child during treatment and for up to 6 months after treatment. In addition, men are advised to seek counselling on sperm preservation before starting treatment.

Both male and female patients who are considering having a child after having treatment with

ETOPOSIDE should discuss this with their doctor or nurse.

Driving and using machines

No studies on the effects on the ability to drive and use machines have been performed. However, if you feel tired, sick to your stomach, dizzy or light-headed you should not do so until you have discussed it with your doctor.

3. How you will be given ETOPOSIDE

ETOPOSIDE will be given to you by a doctor or nurse. It will be given as a slow infusion into a vein. This may take between 30 to 60 minutes.

The dose you receive will be specific to you, which the doctor will calculate. The usual dose, based on etoposide, is 50 to100mg/m2 body surface area, daily for 5 days in a row or 100 to 120 mg/ m2 body surface area on days 1, 3 and 5. This course of treatment may then be repeated, depending on the results of blood tests, but this will not be for at least 21 days after the first course of treatment.

For children being treated for cancer of the blood or lymphatic system the dose used is 75 to 150 mg/m2 body surface area daily for 2 to 5 days.

The doctor may sometimes prescribe a different dose particularly if you are receiving, or have received, other treatments for your cancer or if you have kidney problems.

If you are given more ETOPOSIDE

As ETOPOSIDE is given to you by a doctor or nurse, overdose is unlikely. However, if this does occur your doctor will treat any symptoms that follow.

If you have any further questions on the use of this medicine, ask your doctor, pharmacist or nurse.

4. Possible side effects

Like all medicines, this medicine can cause side effects, although not everybody gets them.

Tell your doctor or nurse immediately if you get any of the following symptoms: swelling of your tongue or throat, breathing difficulties, fast heartbeat, flushing of the skin or a rash. These may be signs of a severe allergic reaction.

Severe liver, kidney or heart damage from a condition called tumour lysis syndrome, caused by harmful amounts of substances from the cancer cells getting into the blood stream, has been seen sometimes when ETOPOSIDE is taken along with other drugs used to treat cancer.

Possible side effects experienced with ETOPOSIDE that are;

Very common side effects (affecting more than 1 in 10 people)

• blood disorders (this is why you will be having blood tests between courses of treatment)
• changes in skin colour (pigmentation)
• constipation
• feeling weak (asthenia)
• temporary hair loss
• generally feeling unwell (malaise)
• nausea and vomiting
• damage to the liver (hepatotoxicity)
• abdominal pain
• increased liver enzymes
• loss of appetite
• jaundice (increased bilirubin)

Common side effects (affecting between 1 in 10 and 1 in 100 people)

• acute leukaemia • severe allergic reactions
• irregular heart beat (arrhythmia), or a heart attack (myocardial infarction)
• high blood pressure
• low blood pressure
• dizziness
• sore lips, mouth or throat ulcers
• diarrhea
• skin problems such as itching or rash
• reactions at the site of infusion
• inflammation of a vein
• infection

Uncommon side effects (affecting between 1 in 100 and 1 in 1000 people)

• tingling or numbness in hands and feet • bleeding

Rare side effects (affecting between 1 in 1,000 and 1 in 10,000 people)

• acid reflux
• temporary blindness
• flushing
• difficulty swallowing
• a change in the way things taste
• severe allergic reactions
• convulsions (seizure)
• serious reactions of the skin and/or mucous membranes which may include painful blisters and fever, including extensive detachment of the skin (Stevens-Johnson syndrome and toxic epidermal necrolysis)
• fever
• sleepiness or tiredness
• breathing problems
• a sunburn-like rash that may occur on skin that has previously been exposed to radiotherapy and can be severe (radiation recall dermatitis)

Not known (frequency cannot be estimated from the available data)

• tumour lysis syndrome (complications of substances released from treated cancer cells entering the blood)
• face and tongue swelling
• infertility
• difficulty breathing

Reporting of side effects

If you get any side effects, talk to your doctor or pharmacist.

5. How to store ETOPOSIDE

Store in a refrigerator (2 to 8°C).

Store in the original package in order to protect from light.

Keep this medicine out of the sight and reach of children.

Do not use this medicine after the expiry date which is stated on the carton and vial after EXP. The expiry

date refers to the last day of that month.

6. Contents of the pack and other information

What ETOPOSIDE contains

– The active substance is etoposide phophate. Each ml contains 20mg of etoposide phosphate.

– The other ingredients are Sodium citrate and Dextran 40.

What ETOPOSIDE looks like and contents of the pack

ETOPOSIDE is a white to off-white dry powder.

It is supplied in a glass vial with a butyl rubber stopper and flip-off aluminium seal.

100 mg powder for solution for infusion is supplied in packs of 1, 5, 10, 20 or 25 vials

Not all pack sizes may be marketed.

7. Manufactured in India By:
TAJ PHARMACEUTICALS LIMITED
at SURVEY NO.188/1 TO 189/1,190/1 TO 4,
ATHIYAWAD, DABHEL, DAMAN- 396210 (INDIA