Temozolomide capsules, USP is an alkylating drug indicated for the treatment of adult patients with:
Newly diagnosed glioblastoma concomitantly with radiotherapy and then as maintenance treatment. (1.1)
Refractory anaplastic astrocytoma who have experienced disease progression on a drug regimen containing nitrosourea and procarbazine. (1.2)
1.1Newly Diagnosed Glioblastoma
Temozolomide capsules, USP is indicated for the treatment of adult patients with newly diagnosed glioblastoma concomitantly with radiotherapy and then as maintenance treatment.
1.2Refractory Anaplastic Astrocytoma
Temozolomide capsules, USP is indicated for the treatment of adult patients with refractory anaplastic astrocytoma who have experienced disease progression on a drug regimen containing nitrosourea and procarbazine.
Contraindications
Temozolomide capsules, USP is contraindicated in patients with a history of hypersensitivity reactions to: temozolomide or any other ingredients in Temozolomide capsules, USP; and dacarbazine, since both temozolomide and dacarbazine are metabolized to the same active metabolite 5-(3-methyltriazen-1-yl)-imidazole-4-carboxamide. Reactions to Temozolomide have included anaphylaxis [see Adverse Reactions (6.2) ]. History of hypersensitivity to temozolomide or any other ingredients in Temozolomide capsules, USP and dacarbazine.
( 4.1 )
Warnings and precautions
Myelosuppression : Monitor absolute neutrophil count (ANC) and platelet count prior to each cycle and during treatment. Geriatric patients and women have a higher risk of developing myelosuppression. ( 5.1 ) Myelodysplastic Syndrome and Secondary Malignancies , including myeloid leukemia, have been observed. ( 5.2 ) Pneumocystis P neumonia (PCP): Closely monitor all patients, particularly those receiving steroids, for the development of lymphopenia and PCP.
( 5.3 ) Hepatotoxicity: Fatal and severe hepatotoxicity have been reported. Perform liver tests at baseline, midway through the first cycle, prior to each subsequent cycle, and approximately 2 to 4 weeks after the last dose of Temozolomide capsules, USP. ( 5.4 ) Embryo-Fetal Toxicity : Can cause fetal harm. Advise females of reproductive potential of the potential risk to a fetus and to use effective contraception. Advise male patients with pregnant partners or female partners of reproductive potential to use condoms.
Myelosuppression, including pancytopenia, leukopenia and anemia, some with fatal outcomes, have occurred with Temozolomide [see Adverse Reactions ( 6.1 , 6.2 )]. Geriatric patients and women have been shown in clinical trials to have a higher risk of developing myelosuppression. Prior to dosing, patients must have an ANC of 1.5 x 10 9 /L or greater and a platelet count of 100 x 10 9 /L or greater. For the concomitant phase with radiotherapy, obtain a complete blood count prior to initiation of treatment and weekly during treatment [see Dosage and Administration (2.1) ].
For the 28-day treatment cycles, obtain a complete blood count prior to treatment on Day 1 and on Day 22 of each cycle. Perform complete blood counts weekly until recovery if the ANC falls below 1.5 x 10 9 /L and the platelet count falls below 100 x 10 9 /L [see Dosage and Administration ( 2.1 , 2.2 )].
5.2Myelodysplastic Syndrome and Secondary Malignancies Cases
of myelodysplastic syndrome and secondary malignancies, including myeloid leukemia, have been observed following Temozolomide administration.
5.3Pneumocystis Pneumonia
Pneumocystis pneumonia (PCP) can occur in patients receiving Temozolomide. The risk of PCP is increased in patients receiving steroids or with longer treatment regimens. For patients with newly diagnosed glioblastoma, provide PCP prophylaxis for all patients during the concomitant phase. Continue in patients who experience lymphopenia until resolution to Grade 1 or less [see Dosage and Administration (2.1) ]. Monitor all patients receiving Temozolomide capsules, USP for the development of lymphopenia and PCP.
5.4Hepatotoxicity Fatal
and severe hepatotoxicity have been reported in patients receiving Temozolomide. Perform liver tests at baseline, midway through the first cycle, prior to each subsequent cycle, and approximately two to four weeks after the last dose of Temozolomide.
5.5Embryo-Fetal Toxicity Based
on findings from animal studies and its mechanism of action, Temozolomide can cause fetal harm when administered to a pregnant woman. Adverse developmental outcomes have been reported in both pregnant patients and pregnant partners of male patients. Oral administration of temozolomide to rats and rabbits during the period of organogenesis resulted in embryolethality and polymalformations at doses less than the maximum human dose based on body surface area.
Advise pregnant women of the potential risk to the fetus. Advise females of reproductive potential to use effective contraception during treatment with Temozolomide and for at least 6 months after the final dose. Because of potential risk of genotoxic effects on sperm, advise male patients with female partners of reproductive potential to use condoms during treatment with Temozolomide and for at least 3 months after the final dose.
Advise male patients not to donate semen during treatment with Temozolomide and for at least 3 months after the final dose [see Use in Specific Populations ( 8.1 , 8.3 )].
Pregnancy and breastfeeding
8.1Pregnancy Risk Summary Based
on its mechanism of action [see Clinical Pharmacology (12.1) ] and findings from animal studies, Temozolomide can cause fetal harm when administered to a pregnant woman. Available postmarketing reports describe cases of spontaneous abortions and congenital malformations, including polymalformations with central nervous system, facial, cardiac, skeletal, and genitourinary system anomalies with exposure to Temozolomide during pregnancy.
These cases report similar adverse developmental outcomes to those observed in animal studies. Administration of Temozolomide to rats and rabbits during the period of organogenesis caused numerous external, internal, and skeletal malformations at doses less than the maximum human dose based on body surface area (see Data). Advise pregnant women of the potential risk to a fetus. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.
Data Animal Data Five consecutive days of oral administration of temozolomide at doses of 75 and 150 mg/m 2 (0.38 and 0.75 times the human dose of 200 mg/m 2 ) in rats and rabbits, respectively, during the period of organogenesis (Gestation Days 8-12) caused numerous malformations of the external and internal organs and skeleton in both species. In rabbits, temozolomide at the 150 mg/m 2 dose (0.75 times the human dose of 200 mg/m 2 ) caused embryolethality as indicated by increased resorptions.
Adverse reactions
The following clinically significant adverse reactions are described elsewhere in the labeling: Myelosuppression [see Warnings and Precautions (5.1) ]. Myelodysplastic Syndrome and Secondary Malignancies [see Warnings and Precautions (5.2) ]. Pneumocystis Pneumonia [see Warnings and Precautions (5.3) ]. Hepatotoxicity [see Warnings and Precautions (5.4) ]. The most common adverse reactions (≥20% incidence) are: alopecia, fatigue, nausea, vomiting, headache, constipation, anorexia, and convulsions.
( 6.1 ) The most common Grade 3 to 4 hematologic laboratory abnormalities (≥10% incidence) in patients with anaplastic astrocytoma are: decreased lymphocytes, decreased platelets, decreased neutrophils, and decreased leukocytes. ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact Nivagen Pharmaceutical, Inc., at 1-877-977-0687 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
6.1Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. Newly Diagnosed Glioblastoma The safety of Temozolomide was evaluated in Study MK-7365-051 [see Clinical Studies (14.1) ]. Forty-nine percent (49%) of patients treated with Temozolomide reported one or more severe or life-threatening reactions, most commonly fatigue (13%), convulsions (6%), headache (5%), and thrombocytopenia (5%).
The most common adverse reactions (≥20%) across the cumulative Temozolomide experience were alopecia, fatigue, nausea, and vomiting. Table 3 s ummarizes the adverse reactions in Newly Diagnosed Glioblastoma Trial. Overall, the pattern of reactions during the maintenance phase was consistent with the known safety profile of Temozolomide. TABLE 3 : Adverse Reactions (≥5%) in Patients Receiving Temozolomide in Newly Diagnosed Glioblastoma Trial Adverse Reactions Concomitant Phase Maintenance Phase Radiation Therapy and Temozolomide N=288 One patient who was randomized to radiation therapy only arm received radiation therapy and Temozolomide.
Not e : Grade 5 (fatal) adverse reactions are included in the Grade ≥3 column. When laboratory abnormalities and adverse reactions were combined, Grade 3 or Grade 4 neutrophil abnormalities including neutropenic reactions were observed in 8% of patients, and Grade 3 or Grade 4 platelet abnormalities including thrombocytopenic reactions, were observed in 14% of patients. Refractory Anaplastic Astrocytoma The safety of Temozolomide was evaluated in Study MK-7365-006 [see Clinical Studies (14.2) ].
Myelosuppression (thrombocytopenia and neutropenia) was the dose-limiting adverse reaction. It usually occurred within the first few cycles of therapy and was not cumulative. Myelosuppression occurred late in the treatment cycle and returned to normal, on average, within 14 days of nadir counts. The median nadirs occurred at 26 days for platelets (range: 21-40 days) and 28 days for neutrophils (range: 1-44 days). Only 14% (22/158) of patients had a neutrophil nadir and 20% (32/158) of patients had a platelet nadir, which may have delayed the start of the next cycle.
Less than 10% of patients required hospitalization, blood transfusion, or discontinuation of therapy due to myelosuppression. The most common adverse reactions (≥20%) were nausea, vomiting, headache, fatigue, constipation, and convulsions. Tables 4 and 5 summarize the adverse reactions and hematological laboratory abnormalities in Refractory Anaplastic Astrocytoma Trial. TABLE 4: Adverse Reactions (≥5%) in Patients Receiving Temozolomide in Refractory Anaplastic Astrocytoma Trial Adverse Reactions Temozolomide N=158 All Reactions (%) Grades 3-4 (%) Gastrointestinal System Nausea 53 10 Vomiting 42 6 Constipation 33 1 Diarrhea 16 2 Abdominal pain 9 1 Anorexia 9 1 General Headache 41 6 Fatigue 34 4 Asthenia 13 6 Fever 13 2 Back pain 8 3 Central and Peripheral Nervous System Convulsions 23 5 Hemiparesis 18 6 Dizziness 12 1 Coordination abnormal 11 1 Amnesia 10 4 Insomnia 10 Paresthesia 9 1 Somnolence 9 3 Paresis 8 3 Urinary incontinence 8 2 Ataxia 8 2 Dysphasia 7 1 Convulsions local 6 Gait abnormal 6 1 Confusion 5 Cardiovascular Edema peripheral 11 1 Resistance Mechanism Infection viral 11 Endocrine Adrenal hypercorticism 8 Respiratory System Upper respiratory tract infection 8 Pharyngitis 8 Sinusitis 6 Coughing 5 Skin and Appendages Rash 8 Pruritus 8 1 Urinary System Urinary tract infection 8 Micturition increased frequency 6 Psychiatric Anxiety 7 1 Depression 6 Reproductive Disorders Breast pain, female 6 Metabolic Weight increase 5 Musculoskeletal System Myalgia 5 Vision Diplopia 5 Vision abnormal This term includes blurred vision; visual deficit; vision changes; and vision troubles. 5 TABLE 5: Grade 3 to 4 Adverse Hematologic Laboratory Abnormalities in Refractory Anaplastic Astrocytoma Trial Temozolomide Change from Grade 0 to 2 at baseline to Grade 3 or 4 during treatment. ' Denominator range= 142, 158 Decreased lymphocytes 55% Decreased platelets 19% Decreased neutrophils 14% Decreased leukocytes 11% Decreased hemoglobin 4% Hematological Toxicities for Advanced Gliomas: In clinical trial experience with 110 to 111 females and 169 to 174 males (depending on measurements), females experienced higher rates of Grade 4 neutropenia (ANC < 0.5 x 10 9 /L) and thrombocytopenia (< 20 x 10 9 /L) than males in the first cycle of therapy (12% vs. 5% and 9% vs. 3%, respectively).
In the entire safety database for which hematologic data exist (N=932), 7% (4/61) and 9.5% (6/63) of patients > 70 years experienced Grade 4 neutropenia or thrombocytopenia in the first cycle, respectively. For patients ≤ 70 years, 7% (62/871) and 5.5% (48/879) experienced Grade 4 neutropenia or thrombocytopenia in the first cycle, respectively. Pancytopenia, leukopenia, and anemia also occurred.
6.2Postmarketing Experience
The following adverse reactions have been identified during post-approval use of Temozolomide. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to the drug exposure. Dermatologic : Toxic epidermal necrolysis and Stevens-Johnson syndrome Immune System : Hypersensitivity reactions, including anaphylaxis.
Erythema multiforme, which resolved after discontinuation of Temozolomide and, in some cases, recurred upon rechallenge. Hematopoietic : Prolonged pancytopenia, which may result in aplastic anemia and fatal outcomes. Hepatobiliary : Fatal and severe hepatotoxicity, elevation of liver enzymes, hyperbilirubinemia, cholestasis, and hepatitis. Infections : Serious opportunistic infections, including some cases with fatal outcomes, with bacterial, viral (primary and reactivated), fungal, and protozoan organisms.
Pulmonary : Interstitial pneumonitis,
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Composition
Active ingredients
TEMOZOLOMIDE 20MG
Strengths and forms
The FDA lists each strength of a product separately; these pages share one label.
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