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Capecitabine Medac (capecitabine) – Summary of product characteristics - L01BC06

Updated on site: 05-Oct-2017

Medication nameCapecitabine Medac
ATC CodeL01BC06
Substancecapecitabine
Manufacturermedac Gesellschaft für klinische Spezialpräparate mbH

1.NAME OF THE MEDICINAL PRODUCT

Capecitabine medac 150 mg film-coated tablets

Capecitabine medac 300 mg film-coated tablets

Capecitabine medac 500 mg film-coated tablets

2.QUALITATIVE AND QUANTITATIVE COMPOSITION

Capecitabine medac 150 mg film-coated tablets

Each film-coated tablet contains 150 mg capecitabine.

Capecitabine medac 300 mg film-coated tablets

Each film-coated tablet contains 300 mg capecitabine.

Capecitabine medac 500 mg film-coated tablets

Each film-coated tablet contains 500 mg capecitabine.

Excipients with known effect

Capecitabine medac 150 mg film-coated tablets

Each film-coated tablet contains 7 mg anhydrous lactose.

Capecitabine medac 300 mg film-coated tablets

Each film-coated tablet contains 15 mg anhydrous lactose.

Capecitabine medac 500 mg film-coated tablets

Each film-coated tablet contains 25 mg anhydrous lactose.

For the full list of excipients, see section 6.1.

3.PHARMACEUTICAL FORM

Film-coated tablet (tablet).

Capecitabine medac 150 mg film-coated tablets

The film-coated tablets are light peach coloured, oblong shaped, biconvex tablets of 11.4 mm in length and 5.3 mm in width, debossed with ‘150’ on one side and plain on other side.

Capecitabine medac 300 mg film-coated tablets

The film-coated tablets are white to off white, oblong shaped, biconvex tablets of 14.6 mm in length and 6.7 mm in width, debossed with ‘300’ on one side and plain on other side.

Capecitabine medac 500 mg film-coated tablets

The film-coated tablets are peach coloured, oblong shaped, biconvex tablets of 15.9 mm in length and 8.4 mm in width, debossed with ‘500’ on one side and plain on other side.

4.CLINICAL PARTICULARS

4.1Therapeutic indications

Capecitabine medac is indicated:

for the adjuvant treatment of patients following surgery of stage III (Dukes’ stage C) colon cancer (see section 5.1).

for the treatment of metastatic colorectal cancer (see section 5.1).

for first-line treatment of advanced gastric cancer in combination with a platinum based regimen (see section 5.1).

in combination with docetaxel (see section 5.1) for the treatment of patients with locally advanced or metastatic breast cancer after failure of cytotoxic chemotherapy. Previous therapy should have included an anthracycline.

as monotherapy for the treatment of patients with locally advanced or metastatic breast cancer after failure of taxanes and an anthracycline containing chemotherapy regimen or for whom further anthracycline therapy is not indicated.

4.2Posology and method of administration

Capecitabine medac should only be prescribed by a qualified physician experienced in the utilisation of anti-neoplastic medicinal products. Careful monitoring during the first cycle of treatment is recommended for all patients.

Treatment should be discontinued if progressive disease or intolerable toxicity is observed. Standard and reduced dose calculations according to body surface area for starting doses of Capecitabine medac of 1,250 mg/m² and 1,000 mg/m² are provided in tables 1 and 2, respectively.

Posology

Recommended posology (see section 5.1):

Monotherapy

Colon, colorectal and breast cancer

Given as monotherapy, the recommended starting dose for capecitabine in the adjuvant treatment of colon cancer, in the treatment of metastatic colorectal cancer or of locally advanced or metastatic breast cancer is 1,250 mg/m² administered twice daily (morning and evening; equivalent to

2,500 mg/m² total daily dose) for 14 days followed by a 7-day rest period. Adjuvant treatment in patients with stage III colon cancer is recommended for a total of 6 months.

Combination therapy

Colon, colorectal and gastric cancer

In combination treatment, the recommended starting dose of capecitabine should be reduced to 800-1,000 mg/m² when administered twice daily for 14 days followed by a 7-day rest period, or to 625 mg/m² twice daily when administered continuously (see section 5.1). For combination with irinotecan, the recommended starting dose is 800 mg/m² when administered twice daily for 14 days followed by a 7-day rest period combined with irinotecan 200 mg/m² on day 1. The inclusion of bevacizumab in a combination regimen has no effect on the starting dose of capecitabine. Premedication to maintain adequate hydration and anti-emesis according to the cisplatin summary of product characteristics should be started prior to cisplatin administration for patients receiving the capecitabine plus cisplatin combination. Premedication with antiemetics according to the oxaliplatin summary of product characteristics is recommended for patients receiving the capecitabine plus oxaliplatin combination.Adjuvant treatment in patients with stage III colon cancer is recommended for a duration of 6 months.

Breast cancer

In combination with docetaxel, the recommended starting dose of capecitabine in the treatment of metastatic breast cancer is 1,250 mg/m² twice daily for 14 days followed by a 7-day rest period, combined with docetaxel at 75 mg/m² as a 1-hour intravenous infusion every 3 weeks. Pre-medication

with an oral corticosteroid such as dexamethasone according to the docetaxel summary of product characteristics should be started prior to docetaxel administration for patients receiving the capecitabine plus docetaxel combination.

Capecitabine medac dose calculations

Table 1 Standard and reduced dose calculations according to body surface area for a starting dose of capecitabine of 1,250 mg/m².

 

 

Dose level 1,250 mg/m² (twice daily)

 

 

Full dose

Number of 150 mg tablets,

Reduced dose

Reduced dose

 

 

300 mg tablets and/or

(75 %)

(50 %)

 

 

500 mg tablets per

 

 

 

1,250 mg/m²

administration (each

950 mg/m²

625 mg/m²

 

 

administration to be given

 

 

 

 

morning and evening)

 

 

Body surface area

Dose per

150 mg

300 mg

500 mg

Dose per

Dose per

(m²)

administration

administration

administration

 

(mg)

 

 

 

(mg)

(mg)

≤ 1.26

1,500

-

-

1,150

1.27 - 1.38

1,650

-

1,300

1.39 - 1.52

1,800

-

1,450

1.53 - 1.66

2,000

-

-

1,500

1,000

1.67 - 1.78

2,150

-

1,650

1,000

1.79 - 1.92

2,300

-

1,800

1,150

1.93 - 2.06

2,500

-

-

1,950

1,300

2.07 - 2.18

2,650

-

2,000

1,300

≥ 2.19

2,800

-

2,150

1,450

Table 2 Standard and reduced dose calculations according to body surface area for a starting dose of capecitabine of 1,000 mg/m²

 

 

Dose level 1,000 mg/m² (twice daily)

 

 

Full dose

Number of 150 mg tablets,

Reduced dose

Reduced dose

 

 

300 mg tablets and/or 500 mg

(75 %)

(50 %)

 

 

tablets per administration

 

 

 

1,000 mg/m²

(each administration to be

750 mg/m²

500 mg/m²

 

 

given morning and evening)

 

 

Body surface

Dose per

150 mg

300 mg

500 mg

Dose per

Dose per

area (m²)

administration

administration

administration

 

(mg)

 

 

 

(mg)

(mg)

≤1.26

1,150

-

1.27 - 1.38

1,300

-

1,000

1.39 - 1.52

1,450

1,100

1.53 - 1.66

1,600

-

1,200

1.67 - 1.78

1,750

1,300

1.79 - 1.92

1,800

-

1,400

1.93 - 2.06

2,000

-

-

1,500

1,000

2.07 - 2.18

2,150

-

1,600

1,050

≥ 2.19

2,300

-

1,750

1,100

Posology adjustments during treatment

General

Toxicity due to capecitabine administration may be managed by symptomatic treatment and/or modification of the dose (treatment interruption or dose reduction). Once the dose has been reduced, it

should not be increased at a later time. For those toxicities considered by the treating physician to be unlikely to become serious or life-threatening, e.g. alopecia, altered taste, nail changes, treatment can be continued at the same dose without reduction or interruption. Patients taking capecitabine should be informed of the need to interrupt treatment immediately if moderate or severe toxicity occurs. Doses of capecitabine omitted for toxicity are not replaced. The following are the recommended dose modifications for toxicity:

Table 3 Capecitabine dose reduction schedule (3-weekly cycle or continuous treatment)

 

Toxicity

Dose changes within a treatment cycle

Dose adjustment for next

 

grades*

 

cycle/dose

 

 

 

(% of starting dose)

Grade 1

Maintain dose level

Maintain dose level

Grade 2

 

-1st appearance

100%

 

-2nd appearance

 

75%

 

-3rd appearance

 

50%

 

-4th appearance

Discontinue treatment permanently

Not applicable

Grade 3

 

 

 

 

 

 

 

-1st appearance

75%

 

-2nd appearance

 

50%

 

-3rd appearance

Discontinue treatment permanently

Not applicable

Grade 4

 

 

 

 

 

 

 

-1st appearance

Discontinue permanently

50%

 

 

or

 

 

 

If physician deems it to be in the

 

 

 

patient’s best interest to continue,

 

 

 

 

-2nd appearance

Discontinue permanently

Not applicable

*According to the National Cancer Institute of Canada Clinical Trial Group (NCIC CTG) Common Toxicity Criteria (version 1) or the Common Terminology Criteria for Adverse Events (CTCAE) of the Cancer Therapy Evaluation Program, US National Cancer Institute, version 4.0. For hand-foot syndrome (HFS) and hyperbilirubinaemia, see section 4.4.

Haematology

Patients with baseline neutrophil counts of < 1.5 x 109/L and/or thrombocyte counts of < 100 x 109/L should not be treated with capecitabine. If unscheduled laboratory assessments during a treatment cycle show that the neutrophil count drops below 1.0 x 109/L or that the platelet count drops below 75 x 109/L treatment with capecitabine should be interrupted.

Dose modifications for toxicity when capecitabine is used as a 3-weekly cycle in combination with other medicinal products

Dose modifications for toxicity when capecitabine is used as a 3-weekly cycle in combination with other medicinal products should be made according to table 3 above for capecitabine and according to the appropriate summary of product characteristics for the other medicinal product(s).

At the beginning of a treatment cycle, if a treatment delay is indicated for either capecitabine or the other medicinal product(s), then administration of all therapy should be delayed until the requirements for restarting all medicinal products are met.

During a treatment cycle for those toxicities considered by the treating physician not to be related to capecitabine, capecitabine should be continued and the dose of the other medicinal product should be adjusted according to the appropriate Prescribing Information.

If the other medicinal product(s) have to be discontinued permanently, capecitabine treatment can be resumed when the requirements for restarting capecitabine are met.

This advice is applicable to all indications and to all special populations.

Dose modifications for toxicity when capecitabine is used continuously in combination with other medicinal products

Dose modifications for toxicity when capecitabine is used continuously in combination with other medicinal products should be made according to table 3 above for capecitabine and according to the appropriate summary of product characteristics for the other medicinal product(s).

Posology adjustments for special populations

Hepatic impairment

Insufficient safety and efficacy data are available in patients with hepatic impairment to provide a dose adjustment recommendation. No information is available on hepatic impairment due to cirrhosis or hepatitis.

Renal impairment

Capecitabine is contraindicated in patients with severe renal impairment (creatinine clearance below 30 ml/min [Cockcroft and Gault] at baseline). The incidence of grade 3 or 4 adverse reactions in patients with moderate renal impairment (creatinine clearance 30 - 50 ml/min at baseline) is increased compared to the overall population. In patients with moderate renal impairment at baseline, a dose reduction to 75 % for a starting dose of 1,250 mg/m² is recommended. In patients with moderate renal impairment at baseline, no dose reduction is required for a starting dose of 1,000 mg/m². In patients with mild renal impairment (creatinine clearance 51 - 80 ml/min at baseline) no adjustment of the starting dose is recommended. Careful monitoring and prompt treatment interruption is recommended if the patient develops a grade 2, 3 or 4 adverse event during treatment and subsequent dose adjustment as outlined in table 3 above. If the calculated creatinine clearance decreases during treatment to a value below 30 ml/min, Capecitabine medac should be discontinued. These dose adjustment recommendations for renal impairment apply both to monotherapy and combination use (see also section “Elderly” below).

Elderly

During capecitabine monotherapy, no adjustment of the starting dose is needed. However, grade 3 or 4 treatment-related adverse reactions were more frequent in patients ≥ 60 years of age compared to younger patients.

When capecitabine was used in combination with other medicinal products, elderly patients (≥ 65 years) experienced more grade 3 and grade 4 adverse drug reactions (ADRs), including those leading to discontinuation, compared to younger patients. Careful monitoring of patients ≥ 60 years of age is advisable.

-In combination with docetaxel: an increased incidence of grade 3 or 4 treatment-related adverse reactions and treatment-related serious adverse reactions were observed in patients 60 years of age or more (see section 5.1). For patients 60 years of age or more, a starting dose reduction of capecitabine to 75 % (950 mg/m² twice daily) is recommended. If no toxicity is observed in patients ≥ 60 years of age treated with a reduced capecitabine starting dose in combination with docetaxel, the dose of capecitabine may be cautiously escalated to 1,250 mg/m² twice daily.

Paediatric population

There is no relevant use of Capecitabine medac in the paediatric population in the indications colon, colorectal, gastric and breast cancer.

Method of administration

Capecitabine medac tablets should be swallowed with water within 30 minutes after a meal.

4.3Contraindications

History of severe and unexpected reactions to fluoropyrimidine therapy,

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

In patients with known complete absence of dihydropyrimidine dehydrogenase (DPD) activity (see section 4.4),

During pregnancy and lactation,

In patients with severe leukopenia, neutropenia, or thrombocytopenia,

In patients with severe hepatic impairment,

In patients with severe renal impairment (creatinine clearance below 30 ml/min),

Treatment with sorivudine or its chemically related analogues, such as brivudine (see section 4.5),

If contraindications exist to any of the medicinal products in the combination regimen, that medicinal product should not be used.

4.4Special warnings and precautions for use

Dose limiting toxicities

Dose limiting toxicities include diarrhoea, abdominal pain, nausea, stomatitis and hand-foot syndrome (HFS, hand-foot skin reaction, palmar-plantar erythrodysesthesia). Most adverse reactions are reversible and do not require permanent discontinuation of therapy, although doses may need to be withheld or reduced.

Diarrhoea

Patients with severe diarrhoea should be carefully monitored and given fluid and electrolyte replacement if they become dehydrated. Standard antidiarrhoeal treatments (e.g. loperamide) may be used. NCIC CTC grade 2 diarrhoea is defined as an increase of 4 to 6 stools/day or nocturnal stools, grade 3 diarrhoea as an increase of 7 to 9 stools/day or incontinence and malabsorption. Grade 4 diarrhoea is an increase of ≥ 10 stools/day or grossly bloody diarrhoea or the need for parenteral support. Dose reduction should be applied as necessary (see section 4.2).

Dehydration

Dehydration should be prevented or corrected at the onset. Patients with anorexia, asthenia, nausea, vomiting or diarrhoea may rapidly become dehydrated. Dehydration may cause acute renal failure, especially in patients with pre-existing compromised renal function or when capecitabine is given concomitantly with known nephrotoxic medicinal products. Acute renal failure secondary to dehydration might be potentially fatal. If grade 2 (or higher) dehydration occurs, capecitabine treatment should be immediately interrupted and the dehydration corrected. Treatment should not be restarted until the patient is rehydrated and any precipitating causes have been corrected or controlled. Dose modifications applied should be applied for the precipitating adverse event as necessary (see section 4.2).

Hand--foot syndrome

HFS also known as hand-foot skin reaction or palmar-plantar erythrodysesthesia or chemotherapy induced acral erythema. Grade 1 HFS is defined as numbness, dysesthesia/paresthesia, tingling, painless swelling or erythema of the hands and/or feet and/or discomfort which does not disrupt the patient’s normal activities.

Grade 2 HFS is painful erythema and swelling of the hands and/or feet and/or discomfort affecting the patient’s activities of daily living.

Grade 3 HFS is moist desquamation, ulceration, blistering and severe pain of the hands and/or feet and/or severe discomfort that causes the patient to be unable to work or perform activities of daily living. Persistent or severe HFS (Grade 2 and above) can eventually lead to loss of fingerprints which could impact patient identification. If grade 2 or 3 HFS occurs, administration of capecitabine should

be interrupted until the event resolves or decreases in intensity to grade 1. Following grade 3 HFS, subsequent doses of capecitabine should be decreased. When capecitabine and cisplatin are used in combination, the use of vitamin B6 (pyridoxine) is not advised for symptomatic or secondary prophylactic treatment of HFS, because of published reports that it may decrease the efficacy of cisplatin. There is some evidence that dexpanthenol is effective for HFS prophylaxis in patients treated with capecitabine.

Cardiotoxicity

Cardiotoxicity has been associated with fluoropyrimidine therapy, including myocardial infarction, angina, dysrhythmias, cardiogenic shock, sudden death and electrocardiographic changes (including very rare cases of QT prolongation). These adverse reactions may be more common in patients with a prior history of coronary artery disease. Cardiac arrhythmias (including ventricular fibrillation, torsade de pointes, and bradycardia), angina pectoris, myocardial infarction, heart failure and cardiomyopathy have been reported in patients receiving capecitabine. Caution must be exercised in patients with history of significant cardiac disease, arrhythmias and angina pectoris (see section 4.8).

Hypo- or hypercalcaemia

Hypo- or hypercalcaemia has been reported during capecitabine treatment. Caution must be exercised in patients with pre-existing hypo- or hypercalcaemia (see section 4.8).

Central or peripheral nervous system disease

Caution must be exercised in patients with central or peripheral nervous system disease, e.g. brain metastasis or neuropathy (see section 4.8).

Diabetes mellitus or electrolyte disturbances

Caution must be exercised in patients with diabetes mellitus or electrolyte disturbances, as these may be aggravated during capecitabine treatment.

Coumarin-derivative anticoagulation

In an interaction study with single-dose warfarin administration, there was a significant increase in the mean AUC (+57 %) of S-warfarin. These results suggest an interaction, probably due to an inhibition of the cytochrome P450 2C9 isoenzyme system by capecitabine. Patients receiving concomitant capecitabine and oral coumarin-derivative anticoagulant therapy should have their anticoagulant response (International Normalised Ratio [INR] or prothrombin time) monitored closely and the anticoagulant dose adjusted accordingly (see section 4.5).

Hepatic impairment

In the absence of safety and efficacy data in patients with hepatic impairment, capecitabine use should be carefully monitored in patients with mild to moderate liver dysfunction, regardless of the presence or absence of liver metastasis. Administration of capecitabine should be interrupted if treatment-related elevations in bilirubin of > 3.0 x ULN or treatment-related elevations in hepatic aminotransferases (ALT, AST) of > 2.5 x ULN occur. Treatment with capecitabine monotherapy may be resumed when bilirubin decreases to ≤ 3.0 x ULN or hepatic aminotransferases decrease to

≤ 2.5 x ULN.

Renal impairment

The incidence of grade 3 or 4 adverse reactions in patients with moderate renal impairment (creatinine clearance 30 - 50 ml/min) is increased compared to the overall population (see sections 4.2 and 4.3).

Dihydropyrimidine dehydrogenase deficiency

Rarely, unexpected, severe toxicity (e.g. stomatitis, diarrhoea, mucosal inflammation, neutropenia and neurotoxicity) associated with 5-fluorouracil (5-FU) has been attributed to a deficiency of DPD activity.

Patients with low or absent DPD activity, an enzyme involved in fluorouracil degradation, are at increased risk for severe, life-threatening, or fatal adverse reactions caused by fluorouracil. Although DPD deficiency cannot be precisely defined, it is known that patients with certain homozygous or

certain compound heterozygous mutations in the DPYD gene locus, which can cause complete or near complete absence of DPD enzymatic activity (as determined from laboratory assays), have the highest risk of life-threatening or fatal toxicity and should not be treated with capecitabine (see section 4.3).

No dose has been proven safe for patients with complete absence of DPD activity.

For patients with partial DPD deficiency (such as those with heterozygous mutations in the DPYD gene) and where the benefits of capecitabine are considered to outweigh the risks (taking into account the suitability of an alternative non-fluoropyrimidine chemotherapeutic regimen), these patients must be treated with extreme caution and frequent monitoring with dose adjustment according to toxicity.There is insufficient data to recommend a specific dose in patients with partial DPD activity as measured by specific test.

In patients with unrecognised DPD deficiency treated with capecitabine, life-threatening toxicities manifesting as acute overdose may occur (see section 4.9). In the event of grade 2-4 acute toxicity, treatment must be discontinued immediately. Permanent discontinuation should be considered based on clinical assessment of the onset, duration and severity of the observed toxicities.

Ophthalmologic complications

Patients should be carefully monitored for ophthalmological complications such as keratitis and corneal disorders, especially if they have a prior history of eye disorders. Treatment of eye disorders should be initiated as clinically appropriate.

Severe skin reactions

Capecitabine can induce severe skin reactions such as Stevens-Johnson syndrome and Toxic Epidermal Necrolysis. Capecitabine should be permanently discontinued in patients who experience a severe skin reaction during treatment.

Excipients

As this medicinal product contains anhydrous lactose as an excipient, patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.

4.5Interaction with other medicinal products and other forms of interaction

Interaction studies have only been performed in adults.

Interaction with other medicinal products

Cytochrome P450 2C9 (CYP2C9) substrates

Other than warfarin, no formal interaction studies between capecitabine and other CYP2C9 substrates have been conducted. Care should be exercised when capecitabine is co-administered with 2C9 substrates (e.g. phenytoin). See also interaction with coumarin-derivative anticoagulants below, and section 4.4.

Coumarin-derivative anticoagulants

Altered coagulation parameters and/or bleeding have been reported in patients taking capecitabine concomitantly with coumarin-derivative anticoagulants such as warfarin and phenprocoumon. These reactions occurred within several days and up to several months after initiating capecitabine therapy and, in a few cases, within one month after stopping capecitabine.

In a clinical pharmacokinetic interaction study, after a single 20 mg dose of warfarin, capecitabine treatment increased the AUC of S-warfarin by 57 % with a 91 % increase in INR value. Since metabolism of R-warfarin was not affected, these results indicate that capecitabine down-regulates isozyme 2C9, but has no effect on isozymes 1A2 and 3A4. Patients taking coumarin-derivative anticoagulants concomitantly with capecitabine should be monitored regularly for alterations in their coagulation parameters (PT or INR) and the anticoagulant dose adjusted accordingly.

Phenytoin

Increased phenytoin plasma concentrations resulting in symptoms of phenytoin intoxication in single cases have been reported during concomitant use of capecitabine with phenytoin. Patients taking phenytoin concomitantly with capecitabine should be regularly monitored for increased phenytoin plasma concentrations.

Folinic acid/folic acid

A combination study with capecitabine and folinic acid indicated that folinic acid has no major effect on the pharmacokinetics of capecitabine and its metabolites. However, folinic acid has an effect on the pharmacodynamics of capecitabine and its toxicity may be enhanced by folinic acid: the maximum tolerated dose (MTD) of capecitabine alone using the intermittent regimen is 3,000 mg/m² per day whereas it is only 2,000 mg/m² per day when capecitabine was combined with folinic acid (30 mg orally bid). The enhanced toxicity may be relevant when switching from 5-FU/LV to a capecitabine regimen. This may also be relevant with folic acid supplementation for folate deficiency due to the similarity between folinic acid and folic acid.

Sorivudine and analogues

A clinically significant interaction between sorivudine and 5-FU, resulting from the inhibition of DPD by sorivudine, has been described.

This interaction, which leads to increased fluoropyrimidine toxicity, is potentially fatal. Therefore, capecitabine must not be administered concomitantly with sorivudine or its chemically related analogues, such as brivudine (see section 4.3). There must be at least a 4-week waiting period between end of treatment with sorivudine or its chemically related analogues such as brivudine and start of capecitabine therapy.

Antacid

The effect of an aluminium hydroxide and magnesium hydroxide-containing antacid on the pharmacokinetics of capecitabine was investigated. There was a small increase in plasma concentrations of capecitabine and one metabolite 5’-deoxy-5-fluorocytidine (5’-DFCR); there was no effect on the 3 major metabolites: 5’-deoxy-5-fluorouridine (5’-DFUR), 5-FU and α-fluoro-β-alanine (FBAL).

Allopurinol

Interactions with allopurinol have been observed for 5-FU; with possible decreased efficacy of 5-FU. Concomitant use of allopurinol with capecitabine should be avoided.

Interferon alpha

The MTD of capecitabine was 2,000 mg/m² per day when combined with interferon alpha- 2a (3 MIU/m² per day) compared to 3,000 mg/m² per day when capecitabine was used alone.

Radiotherapy

The MTD of capecitabine alone using the intermittent regimen is 3,000 mg/m² per day, whereas, when combined with radiotherapy for rectal cancer, the MTD of capecitabine is 2,000 mg/m² per day using either a continuous schedule or given daily Monday through Friday during a 6-week course of radiotherapy.

Oxaliplatin

No clinically significant differences in exposure to capecitabine or its metabolites, free platinum or total platinum occurred when capecitabine was administered in combination with oxaliplatin or in combination with oxaliplatin and bevacizumab.

Bevacizumab

There was no clinically significant effect of bevacizumab on the pharmacokinetic parameters of capecitabine or its metabolites in the presence of oxaliplatin.

Food interaction

In all clinical trials, patients were instructed to administer capecitabine within 30 minutes after a meal. Since current safety and efficacy data are based upon administration with food, it is recommended that capecitabine be administered with food. Administration with food decreases the rate of capecitabine absorption (see section 5.2).

4.6Fertility, pregnancy and lactation

Women of childbearing potential/Contraception in males and females

Women of childbearing potential should be advised to avoid becoming pregnant while receiving treatment with capecitabine. If the patient becomes pregnant while receiving capecitabine, the potential hazard to the foetus must be explained. An effective method of contraception should be used during treatment.

Pregnancy

There are no studies in pregnant women using capecitabine; however, it should be assumed that capecitabine may cause foetal harm if administered to pregnant women. In reproductive toxicity studies in animals, capecitabine administration caused embryolethality and teratogenicity. These findings are expected effects of fluoropyrimidine derivatives. Capecitabine is contraindicated during pregnancy.

Breast-feeding

It is not known whether capecitabine is excreted in human breast milk. In lactating mice, considerable amounts of capecitabine and its metabolites were found in milk. Breast-feeding should be discontinued while receiving treatment with capecitabine.

Fertility

There is no data on capecitabine and impact on fertility. The capecitabine pivotal studies included females of childbearing potential and males only if they agreed to use an acceptable method of birth control to avoid pregnancy for the duration of the study and for a reasonable period thereafter.

In animal studies effects on fertility were observed (see section 5.3).

4.7Effects on ability to drive and use machines

Capecitabine has minor or moderate influence on the ability to drive and use machines. Capecitabine may cause dizziness, fatigue and nausea.

4.8Undesirable effects

Summary of the safety profile

The overall safety profile of capecitabine is based on data from over 3,000 patients treated with capecitabine as monotherapy or capecitabine in combination with different chemotherapy regimens in multiple indications. The safety profiles of capecitabine monotherapy for the metastatic breast cancer, metastatic colorectal cancer and adjuvant colon cancer populations are comparable. See section 5.1 for details of major studies, including study designs and major efficacy results.

The most commonly reported and/or clinically relevant treatment-related ADRs were gastrointestinal disorders (especially diarrhoea, nausea, vomiting, abdominal pain, stomatitis), HFS (palmar-plantar erythrodysesthesia), fatigue, asthenia, anorexia, cardiotoxicity, increased renal dysfunction on those with pre-existing compromised renal function, and thrombosis/embolism.

Tabulated list of adverse reactions

ADRs considered by the investigator to be possibly, probably, or remotely related to the administration of capecitabine are listed in table 4 for capecitabine given as monotherapy and in

table 5 for capecitabine given in combination with different chemotherapy regimens in multiple indications. The following headings are used to rank the ADRs by frequency: very common (≥ 1/10), common (≥ 1/100 to < 1/10), uncommon (≥ 1/1,000 to < 1/100), rare (≥ 1/10,000 to < 1/1,000), very rare (< 1/10,000). Within each frequency grouping, ADRs are presented in order of decreasing seriousness.

Capecitabine monotherapy

Table 4 lists ADRs associated with the use of capecitabine monotherapy based on a pooled analysis of safety data from three major studies including over 1,900 patients (studies M66001, SO14695, and SO14796). ADRs are added to the appropriate frequency grouping according to the overall incidence from the pooled analysis.

Table 4 Summary of related ADRs reported in patients treated with capecitabine monotherapy

 

 

 

 

 

 

 

Body system

Very

Common

Uncommon

Rare/Very rare

 

 

common

All grades

Severe and/or

(Post-marketing

 

 

All grades

experience)

 

 

 

life-threatening

 

 

 

 

 

(grade 3 - 4) or

 

 

 

 

 

considered medically

 

 

 

 

 

relevant

 

 

Infections and

-

Herpes viral

Sepsis, Urinary tract

 

 

infestations

 

infection,

infection, Cellulitis,

 

 

 

 

Nasopharyngitis,

Tonsillitis,

 

 

 

 

Lower respiratory

Pharyngitis, Oral

 

 

 

 

tract infection

candidiasis, Influenza,

 

 

 

 

 

Gastroenteritis, Fungal

 

 

 

 

 

infection, Infection,

 

 

 

 

 

Tooth abscess

 

 

Neoplasm

-

-

Lipoma

 

 

benign,

 

 

 

 

 

malignant and

 

 

 

 

 

unspecified

 

 

 

 

 

Blood and

-

Neutropenia,

Febrile neutropenia,

 

 

lymphatic

 

Anaemia

Pancytopenia,

 

 

system disorders

 

 

Granulocytopenia,

 

 

 

 

 

Thrombocytopenia,

 

 

 

 

 

Leukopenia,

 

 

 

 

 

Haemolytic anaemia,

 

 

 

 

 

INR

 

 

 

 

 

increased/Prothrombin

 

 

 

 

 

time prolonged

 

 

Immune system

-

-

Hypersensitivity

 

 

disorders

 

 

 

 

 

Metabolism and

Anorexia

Dehydration, Weight

Diabetes,

 

 

nutrition

 

decreased

Hypokalaemia,

 

 

disorders

 

 

Appetite disorder,

 

 

 

 

 

Malnutrition,

 

 

 

 

 

Hypertriglyceridaemia

 

 

Psychiatric

-

Insomnia, Depression

Confusional state,

 

 

disorders

 

 

Panic attack,

 

 

 

 

 

Depressed mood,

 

 

 

 

 

Libido decreased

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Body system

Very

Common

Uncommon

Rare/Very rare

 

 

common

All grades

Severe and/or

(Post-marketing

 

 

All grades

experience)

 

 

 

life-threatening

 

 

 

 

 

(grade 3 - 4) or

 

 

 

 

 

considered medically

 

 

 

 

 

relevant

 

 

Nervous system

-

Headache, Lethargy,

Aphasia, Memory

Toxic

 

disorders

 

Dizziness,

impairment, Ataxia,

leukoencephalopathy

 

 

 

Paraesthesia,

Syncope, Balance

(very rare)

 

 

 

Dysgeusia

disorder, Sensory

 

 

 

 

 

disorder, Neuropathy

 

 

 

 

 

peripheral

 

 

Eye disorders

-

Lacrimation

Visual acuity reduced,

Lacrimal duct

 

 

 

increased,

Diplopia

stenosis (rare),

 

 

 

Conjunctivitis, Eye

 

Corneal disorders

 

 

 

irritation

 

(rare), Keratitis

 

 

 

 

 

(rare), Punctate

 

 

 

 

 

keratitis (rare)

 

Ear and

-

-

Vertigo, Ear pain

 

 

labyrinth

 

 

 

 

 

disorders

 

 

 

 

 

Cardiac

-

-

Angina unstable,

Ventricular

 

 

disorders

 

 

Angina pectoris,

fibrillation (rare), QT

 

 

 

 

Myocardial ischaemia,

prolongation (rare),

 

 

 

 

Atrial fibrillation,

Torsade de pointes

 

 

 

 

Arrhythmia,

(rare), Bradycardia

 

 

 

 

Tachycardia, Sinus

(rare), Vasospasm

 

 

 

 

tachycardia,

(rare)

 

 

 

 

Palpitations

 

 

Vascular

-

Thrombophlebitis

Deep vein thrombosis,

 

 

disorders

 

 

Hypertension,

 

 

 

 

 

Petechiae,

 

 

 

 

 

Hypotension, Hot

 

 

 

 

 

flush, Peripheral

 

 

 

 

 

coldness

 

 

Respiratory,

-

Dyspnoea, Epistaxis,

Pulmonary embolism,

 

 

thoracic and

 

Cough, Rhinorrhoea

Pneumothorax,

 

 

mediastinal

 

 

Haemoptysis, Asthma,

 

 

disorders

 

 

Dyspnoea exertional

 

 

Gastrointestinal

Diarrhoea,

Gastrointestinal

Intestinal obstruction,

 

 

disorders

Vomiting, Nausea,

haemorrhage,

Ascites, Enteritis,

 

 

 

Stomatitis,

Constipation, Upper

Gastritis, Dysphagia,

 

 

 

Abdominal pain

abdominal pain,

Abdominal pain lower,

 

 

 

 

Dyspepsia,

Oesophagitis,

 

 

 

 

Flatulence, Dry

Abdominal

 

 

 

 

mouth

discomfort,

 

 

 

 

 

Gastrooesophageal

 

 

 

 

 

reflux disease, Colitis,

 

 

 

 

 

Blood in stool

 

 

Hepatobiliary

-

Hyperbilirubinaemia,

Jaundice

Hepatic failure (rare),

 

disorders

 

Liver function test

 

Cholestatic hepatitis

 

 

 

 

 

 

 

 

 

 

 

 

 

Body system

Very

Common

Uncommon

Rare/Very rare

 

 

common

All grades

Severe and/or

(Post-marketing

 

 

All grades

experience)

 

 

 

life-threatening

 

 

 

 

 

(grade 3 - 4) or

 

 

 

 

 

considered medically

 

 

 

 

 

relevant

 

 

 

 

abnormalities

 

(rare)

 

Skin and

Palmar-plantar

Rash, Alopecia,

Blister, Skin ulcer,

Cutaneous lupus

 

subcutaneous

erythrodysaesthesia

Erythema, Dry skin,

Rash, Urticaria,

erythematosus (rare),

 

tissue disorders

syndrome**

Pruritus, Skin hyper-

Photosensitivity

Severe skin reactions

 

 

 

pigmentation, Rash

reaction, Palmar

such as

 

 

 

macular, Skin

erythema, Swelling

Stevens-Johnson

 

 

 

desquamation,

face, Purpura,

Syndrome and toxic

 

 

 

Dermatitis,

Radiation recall

Epidermal Necrolysis

 

 

 

Pigmentation

syndrome

(very rare) (see

 

 

 

disorder, Nail

 

section 4.4)

 

 

 

disorder

 

 

 

Musculoskeletal

-

Pain in extremity,

Joint swelling, Bone

 

 

and connective

 

Back pain, Arthralgia

pain, Facial pain,

 

 

tissue disorders

 

 

Musculoskeletal

 

 

 

 

 

stiffness, Muscular

 

 

 

 

 

weakness

 

 

Renal and

-

-

Hydronephrosis,

 

 

urinary

 

 

Urinary incontinence,

 

 

disorders

 

 

Haematuria, Nocturia,

 

 

 

 

 

Blood creatinine

 

 

 

 

 

increased

 

 

Reproductive

-

-

Vaginal haemorrhage

 

 

system and

 

 

 

 

 

breast disorders

 

 

 

 

 

General

Fatigue, Asthenia

Pyrexia, Oedema

Oedema, Chills,

 

 

disorders and

 

peripheral, Malaise,

Influenza-like illness,

 

 

administration

 

Chest pain

Rigors, Body

 

 

site conditions

 

 

temperature increased

 

 

 

 

 

 

 

**Based on the post-marketing experience, persistent or severe palmar-plantar erythrodysaesthesia syndrome can eventually lead to loss of fingerprints (see section 4.4)

Capecitabine in combination therapy

Table 5 lists ADRs associated with the use of capecitabine in combination with different chemotherapy regimens in multiple indications based on safety data from over 3,000 patients. ADRs are added to the appropriate frequency grouping (Very common or Common) according to the highest incidence seen in any of the major clinical trials and are only added when they were seen in addition to those seen with capecitabine monotherapy or seen at a higher frequency grouping compared to capecitabine monotherapy (see table 4). Uncommon ADRs reported for capecitabine in combination therapy are consistent with the ADRs reported for capecitabine monotherapy or reported for monotherapy with the combination medicinal product (in literature and/or respective summary of product characteristics).

Some of the ADRs are reactions commonly seen with the combination medicinal product (e.g. peripheral sensory neuropathy with docetaxel or oxaliplatin, hypertension seen with bevacizumab); however an exacerbation by capecitabine therapy can not be excluded.

Table 5 Summary of related ADRs reported in patients treated with capecitabine in combination treatment in addition to those seen with capecitabine monotherapy or seen at a higher frequency grouping compared to capecitabine monotherapy

Body system

Very common

Common

Rare/Very rare

 

All grades

All grades

(Post-marketing

 

experience)

Infections and

-

Herpes zoster, Urinary

 

infestations

 

tract infection, Oral

 

 

 

candidiasis, Upper

 

 

 

respiratory tract infection,

 

 

 

Rhinitis, Influenza,

 

 

 

+Infection, Oral herpes

 

Blood and

+Neutropenia,

Bone marrow depression,

 

lymphatic system

+Leukopenia, +Anaemia,

+Febrile neutropenia

 

disorders

+Neutropenic fever,

 

 

 

Thrombocytopenia

 

 

 

 

 

 

Immune system

-

Hypersensitivity

 

disorders

 

 

 

 

 

 

 

Metabolism and

Appetite decreased

Hypokalaemia,

 

nutrition disorders

 

Hyponatraemia,

 

 

 

Hypomagnesaemia,

 

 

 

Hypocalcaemia,

 

 

 

Hyperglycaemia

 

Psychiatric

-

Sleep disorder, Anxiety

 

disorders

 

 

 

Nervous system

Paraesthesia,

Neurotoxicity, Tremor,

 

disorders

Dysaesthesia, Peripheral

Neuralgia,

 

 

neuropathy, Peripheral

Hypersensitivity reaction,

 

 

sensory neuropathy,

Hypoaesthesia

 

 

Dysgeusia, Headache

 

 

Eye disorders

Lacrimation increased

Visual disorders, Dry eye,

 

 

 

Eye pain, Visual

 

 

 

impairment, Vision blurred

 

Ear and labyrinth

-

Tinnitus, Hypoacusis

 

disorders

 

 

 

Cardiac disorders

-

Atrial fibrillation, Cardiac

 

 

 

ischaemia/infarction

 

Vascular disorders

Lower limb oedema,

Flushing, Hypotension,

 

 

Hypertension,

Hypertensive crisis, Hot

 

 

+Embolism and

flush, Phlebitis

 

 

thrombosis

 

 

Respiratory,

Sore throat, Dysaesthesia

Hiccups,

 

thoracic and

pharynx

Pharyngolaryngeal pain,

 

mediastinal system

 

Dysphonia

 

disorders

 

 

 

Gastrointestinal

Constipation, Dyspepsia

Upper gastrointestinal

 

disorders

 

haemorrhage, Mouth

 

 

 

ulceration, Gastritis,

 

 

 

Abdominal distension,

 

 

 

 

 

 

 

Gastroesophageal reflux

 

 

 

disease, Oral pain,

 

 

 

Dysphagia, Rectal

 

 

 

haemorrhage, Abdominal

 

 

 

pain lower, Oral

 

 

 

dysaesthesia, Paraesthesia

 

 

 

oral, Hypoaesthesia oral,

 

 

 

Abdominal discomfort

 

 

 

 

 

Hepatobiliary

-

Hepatic function abnormal

 

disorders

 

 

 

 

 

 

 

Skin and

Alopecia, Nail disorder

Hyperhidrosis, Rash

 

subcutaneous tissue

 

erythematous, Urticaria,

 

disorders

 

Night sweats

 

 

 

 

 

Musculoskeletal and

Myalgia, Arthralgia, Pain

Pain in jaw, Muscle

 

connective tissue

in extremity

spasms, Trismus, Muscular

 

disorders

 

weakness

 

 

 

 

 

Renal and urinary

-

Haematuria, Proteinuria,

Acute renal failure

disorders

 

Creatinine renal clearance

secondary to

 

 

decreased, Dysuria

dehydration (rare)

 

 

 

 

General disorders

Pyrexia, Weakness,

Mucosal inflammation,

 

and administration

+Lethargy, Temperature

Pain in limb, Pain, Chills,

 

site conditions

intolerance

Chest pain, Influenza-like

 

 

 

illness, +Fever,

 

 

 

Infusion-related reaction,

 

 

 

Injection site reaction,

 

 

 

Infusion site pain, Injection

 

 

 

site pain

 

 

 

 

 

Injury, poisoning

-

Contusion

 

and procedural

 

 

 

complications

 

 

 

+ For each term, the frequency count was based on ADRs of all grades. For terms marked with a “+”, the frequency count was based on grade 3 - 4 ADRs. ADRs are added according to the highest incidence seen in any of the major combination trials.

Description of selected adverse reactions

HFS (see section 4.4)

For the capecitabine dose of 1,250 mg/m² twice daily on days 1 to 14 every 3 weeks, a frequency of 53 % to 60 % of all-grades HFS was observed in capecitabine monotherapy trials (comprising studies in adjuvant therapy in colon cancer, treatment of metastatic colorectal cancer, and treatment of breast cancer) and a frequency of 63 % was observed in the capecitabine/docetaxel arm for the treatment of metastatic breast cancer. For the capecitabine dose of 1,000 mg/m² twice daily on days 1 to 14 every 3 weeks, a frequency of 22 % to 30 % of all-grade HFS was observed in capecitabine combination therapy.

A meta-analysis of 14 clinical trials with data from over 4,700 patients treated with capecitabine monotherapy or capecitabine in combination with different chemotherapy regimens in multiple indications (colon, colorectal, gastric and breast cancer) showed that HFS (all grades) occurred in 2,066 (43 %) patients after a median time of 239 [95 % CI 201, 288] days after starting treatment with capecitabine. In all studies combined, the following covariates were statistically significantly associated with an increased risk of developing HFS: increasing capecitabine starting dose (gram), decreasing cumulative capecitabine dose (0.1*kg), increasing relative dose intensity in the first six weeks, increasing duration of study treatment (weeks), increasing age (by 10 year increments), female

gender, and good Eastern Cooperative Oncology Group (ECOG) performance status at baseline (0 versus ≥ 1).

Diarrhoea (see section 4.4)

Capecitabine can induce the occurrence of diarrhoea, which has been observed in up to 50 % of patients.

The results of a meta-analysis of 14 clinical trials with data from over 4,700 patients treated with capecitabine showed that in all studies combined, the following covariates were statistically significantly associated with an increased risk of developing diarrhoea: increasing capecitabine starting dose (gram), increasing duration of study treatment (weeks), increasing age (by 10 year increments), and female gender. The following covariates were statistically significantly associated with a decreased risk of developing diarrhoea: increasing cumulative capecitabine dose (0.1*kg) and increasing relative dose intensity in the first six weeks.

Cardiotoxicity (see section 4.4)

In addition to the ADRs described in tables 4 and 5, the following ADRs with an incidence of less than 0.1 % were associated with the use of capecitabine monotherapy based on a pooled analysis from clinical safety data from 7 clinical trials including 949 patients (2 phase III and 5 phase II clinical trials in metastatic colorectal cancer and metastatic breast cancer): cardiomyopathy, cardiac failure, sudden death, and ventricular extrasystoles.

Encephalopathy

In addition to the ADRs described in tables 4 and 5, and based on the above pooled analysis from clinical safety data from 7 clinical trials, encephalopathy was also associated with the use of capecitabine monotherapy with an incidence of less than 0.1 %.

Special populations

Elderly patients (see section 4.2)

An analysis of safety data in patients ≥ 60 years of age treated with capecitabine monotherapy and an analysis of patients treated with capecitabine plus docetaxel combination therapy showed an increase in the incidence of treatment-related grade 3 and 4 adverse reactions and treatment-related serious adverse reactions compared to patients < 60 years of age. Patients ≥ 60 years of age treated with capecitabine plus docetaxel also had more early withdrawals from treatment due to adverse reactions compared to patients < 60 years of age.

The results of a meta-analysis of 14 clinical trials with data from over 4,700 patients treated with capecitabine showed that in all studies combined, increasing age (by 10 year increments) was statistically significantly associated with an increased risk of developing HFS and diarrhoea and with a decreased risk of developing neutropenia.

Gender

The results of a meta-analysis of 14 clinical trials with data from over 4,700 patients treated with capecitabine showed that in all studies combined, female gender was statistically significantly associated with an increased risk of developing HFS and diarrhoea and with a decreased risk of developing neutropenia.

Patients with renal impairment (see section 4.2, 4.4, and 5.2)

An analysis of safety data in patients treated with capecitabine monotherapy (colorectal cancer) with baseline renal impairment showed an increase in the incidence of treatment-related grade 3 and 4 adverse reactions compared to patients with normal renal function (36 % in patients without renal impairment n = 268, vs. 41 % in mild n = 257 and 54 % in moderate n = 59, respectively) (see section 5.2). Patients with moderately impaired renal function show an increased rate of dose reduction (44 %) vs. 33 % and 32 % in patients with no or mild renal impairment and an increase in

early withdrawals from treatment (21 % withdrawals during the first two cycles) vs. 5 % and 8 % in patients with no or mild renal impairment.

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 national reporting system listed in Appendix V.

4.9Overdose

The manifestations of acute overdose include nausea, vomiting, diarrhoea, mucositis, gastrointestinal irritation and bleeding, and bone marrow depression. Medical management of overdose should include customary therapeutic and supportive medical interventions aimed at correcting the presenting clinical manifestations and preventing their possible complications.

5.PHARMACOLOGICAL PROPERTIES

5.1Pharmacodynamic properties

Pharmacotherapeutic group: Pyrimidine analogues, antineoplastic agents, ATC code: L01BC06

Capecitabine is a non-cytotoxic fluoropyrimidine carbamate, which functions as an orally administered precursor of the cytotoxic moiety 5-FU. Capecitabine is activated via several enzymatic steps (see section 5.2). The enzyme involved in the final conversion to 5-FU, thymidine phosphorylase (ThyPase), is found in tumour tissues, but also in normal tissues, albeit usually at lower levels. In human cancer xenograft models capecitabine demonstrated a synergistic effect in combination with docetaxel, which may be related to the upregulation of ThyPase by docetaxel.

There is evidence that the metabolism of 5-FU in the anabolic pathway blocks the methylation reaction of deoxyuridylic acid to thymidylic acid, thereby interfering with the synthesis of deoxyribonucleic acid (DNA). The incorporation of 5-FU also leads to inhibition of ribonucleic acid (RNA) and protein synthesis. Since DNA and RNA are essential for cell division and growth, the effect of 5-FU may be to create a thymidine deficiency that provokes unbalanced growth and death of a cell. The effects of DNA and RNA deprivation are most marked on those cells which proliferate more rapidly and which metabolise 5-FU at a more rapid rate.

Colon and colorectal cancer

Monotherapy with capecitabine in adjuvant colon cancer

Data from one multicentre, randomised, controlled phase III clinical trial in patients with stage III (Dukes’ C) colon cancer supports the use of capecitabine for the adjuvant treatment of patients with colon cancer (XACT Study; M66001). In this trial, 1,987 patients were randomised to treatment with capecitabine (1,250 mg/m² twice daily for 2 weeks followed by a 1-week rest period and given as 3-week cycles for 24 weeks) or 5-FU and leucovorin (Mayo Clinic regimen: 20 mg/m² leucovorin intravenous followed by 425 mg/m² intravenous bolus 5-FU, on days 1 to 5, every 28 days for

24 weeks). Capecitabine was at least equivalent to intravenous 5-FU/LV in disease-free survival in per protocol population (hazard ratio 0.92; 95 % CI 0.80 - 1.06). In the all-randomised population, tests for difference of capecitabine vs 5-FU/LV in disease-free and overall survival showed hazard ratios of 0.88 (95 % CI 0.77 - 1.01; p = 0.068) and 0.86 (95 % CI 0.74 - 1.01; p = 0.060), respectively. The median follow up at the time of the analysis was 6.9 years. In a pre-planned multivariate Cox analysis, superiority of capecitabine compared with bolus 5-FU/LV was demonstrated. The following factors were pre-specified in the statistical analysis plan for inclusion in the model: age, time from surgery to randomisation, gender, carcinoembryonic antigen (CEA) levels at baseline, lymph nodes at baseline, and country. In the all-randomised population, capecitabine was shown to be superior to 5-FU/LV for disease-free survival (hazard ratio 0.849; 95 % CI 0.739–0.976; p = 0.0212), as well as for overall survival (hazard ratio 0.828; 95 % CI 0.705–0.971; p = 0.0203).

Combination therapy in adjuvant colon cancer

Data from one multicentre, randomised, controlled phase 3 clinical trial in patients with stage III (Dukes’ C) colon cancer supports the use of capecitabine in combination with oxaliplatin (XELOX) for the adjuvant treatment of patients with colon cancer (NO16968 study). In this trial, 944 patients were randomised to 3-week cycles for 24 weeks with capecitabine (1,000 mg/m² twice daily for

2 weeks followed by a 1-week rest period) in combination with oxaliplatin (130 mg/m² intravenous infusion over 2 hours on day 1 every 3 weeks); 942 patients were randomised to bolus 5-FU and leucovorin. In the primary analysis for DFS in the ITT population, XELOX was shown to be significantly superior to 5-FU/LV (HR = 0.80, 95 % CI = [0.69; 0.93]; p = 0.0045). The 3 year DFS rate was 71 % for XELOX versus 67 % for 5-FU/LV. The analysis for the secondary endpoint of RFS supports these results with a HR of 0.78 (95 % CI = [0.67; 0.92]; p = 0.0024) for XELOX vs. 5-FU/LV. XELOX showed a trend towards superior OS with a HR of 0.87 (95 % CI = [0.72; 1.05]; p = 0.1486) which translates into a 13 % reduction in risk of death. The 5 year OS rate was 78 % for XELOX versus 74 % for 5-FU/LV. The efficacy data is based on a median observation time of

59 months for OS and 57 months for DFS. The rate of withdrawal due to adverse events was higher in the XELOX combination therapy arm (21 %) as compared with that of the 5-FU/LV monotherapy arm (9 %) in the ITT population.

Monotherapy with capecitabine in metastatic colorectal cancer

Data from two identically designed, multi centre, randomised, controlled phase III clinical trials (SO14695; SO14796) support the use of capecitabine for first line treatment of metastatic colorectal cancer. In these trials, 603 patients were randomised to treatment with capecitabine (1,250 mg/m² twice daily for 2 weeks followed by a 1-week rest period and given as 3-week cycles). 604 patients were randomised to treatment with 5-FU and leucovorin (Mayo regimen: 20 mg/m² leucovorin intravenous followed by 425 mg/m² intravenous bolus 5-FU, on days 1 to 5, every 28 days). The overall objective response rates in the all-randomised population (investigator assessment) were 25.7 % (capecitabine) vs. 16.7 % (Mayo regimen); p < 0.0002. The median time to progression was 140 days (capecitabine) vs. 144 days (Mayo regimen). Median survival was 392 days (capecitabine) vs. 391 days (Mayo regimen). Currently, no comparative data are available on capecitabine monotherapy in colorectal cancer in comparison with first line combination regimens.

Combination therapy in first-line treatment of metastatic colorectal cancer

Data from a multicentre, randomised, controlled phase III clinical study (NO16966) support the use of capecitabine in combination with oxaliplatin or in combination with oxaliplatin and bevacizumab for the first-line treatment of metastatic colorectal cancer. The study contained two parts: an initial 2-arm

part in which 634 patients were randomised to two different treatment groups, including XELOX or FOLFOX-4, and a subsequent 2x2 factorial part in which 1,401 patients were randomised to four different treatment groups, including XELOX plus placebo, FOLFOX-4 plus placebo, XELOX plus bevacizumab, and FOLFOX-4 plus bevacizumab. See table 6 for treatment regimens.

Table 6 Treatment regimens in study NO16966 (mCRC)

 

Treatment

Starting dose

Schedule

 

 

 

 

FOLFOX-4

Oxaliplatin

85 mg/m² intravenous

Oxaliplatin on Day 1, every 2 weeks

or

 

2 hr

 

FOLFOX-4 +

 

 

Leucovorin on Days 1 and 2, every

Leucovorin

200 mg/m² intravenous

Bevacizumab

2 weeks

 

 

2 hr

5-fluorouracil intravenous bolus/infusion,

 

5-Fluorouracil

400 mg/m² intravenous

each on Days 1 and 2, every 2 weeks

 

 

bolus, followed by

 

 

 

600 mg/ m² intravenous

 

 

 

22 hr

 

 

 

 

 

 

Placebo or

5 mg/kg intravenous

Day 1, prior to FOLFOX-4, every 2 weeks

 

Bevacizumab

30 - 90 mins

 

 

 

 

 

XELOX

Oxaliplatin

130 mg/m² intravenous

Oxaliplatin on Day 1, every 3 weeks

or

 

2 hr

capecitabine oral twice daily for 2 weeks

XELOX+

 

 

(followed by 1 week off- treatment)

Capecitabine

1,000 mg/m² oral twice

Bevacizumab

 

 

daily

 

 

 

 

 

 

 

 

 

Placebo or

7.5 mg/kg intravenous

Day 1, prior to XELOX, every 3 weeks

 

Bevacizumab

30 - 90 mins

 

 

 

 

 

5-Fluorouracil: intravenous bolus injection immediately after leucovorin

Non-inferiority of the XELOX-containing arms compared with the FOLFOX-4-containing arms in the overall comparison was demonstrated in terms of progression-free survival (PFS) in the eligible patient population and the intent-to-treat population (see table 7). The results indicate that XELOX is equivalent to FOLFOX-4 in terms of overall survival (see table 7). A comparison of XELOX plus bevacizumab versus FOLFOX-4 plus bevacizumab was a pre-specified exploratory analysis. In this treatment subgroup comparison, XELOX plus bevacizumab was similar compared to FOLFOX-4 plus bevacizumab in terms of PFS (hazard ratio 1.01; 97.5 % CI 0.84 – 1.22). The median follow up at the time of the primary analyses in the intent-to-treat population was 1.5 years; data from analyses following an additional 1 year of follow up are also included in table 7. However, the on-treatment PFS analysis did not confirm the results of the general PFS and OS analysis: the hazard ratio of XELOX versus FOLFOX-4 was 1.24 with 97.5 % CI 1.07–1.44. Although sensitivity analyses show that differences in regimen schedules and timing of tumour assessments impact the on-treatment PFS analysis, a full explanation for this result has not been found.

Table 7 Key efficacy results for the non-inferiority analysis of study NO16966

PRIMARY ANALYSIS

 

 

 

 

 

 

 

 

 

XELOX/ XELOX+P/

FOLFOX-4/FOLFOX-4+P

 

 

 

 

XELOX+BV

/FOLFOX-4+BV

 

 

 

 

(EPP*: N = 967; ITT**:

(EPP*: N = 937; ITT**:

 

 

 

 

N = 1,017)

N = 1,017)

 

 

 

Population

Median time to event (days)

HR

 

 

(97.5 % CI)

 

 

 

 

 

 

 

 

 

 

 

 

 

Parameter: Progression-free survival

 

 

 

 

 

EPP

 

1.05 (0.94; 1.18)

 

 

ITT

 

1.04 (0.93; 1.16)

 

 

 

 

 

 

 

 

 

Parameter: Overall survival

 

 

 

 

 

 

 

 

 

 

EPP

 

0.97 (0.84; 1.14)

 

 

ITT

 

0.96 (0.83; 1.12)

 

 

 

 

 

 

 

 

 

ADDITIONAL 1 YEAR OF FOLLOW UP

 

 

 

Population

Median time to event (days)

HR

 

 

(97.5 % CI)

 

 

 

 

 

 

Parameter: Progression-free survival

 

 

 

 

 

EPP

 

1.02 (0.92; 1.14)

 

 

ITT

 

1.01 (0.91; 1.12)

 

 

 

 

 

 

 

 

 

Parameter: Overall survival

 

 

 

 

 

 

 

 

 

 

 

EPP

1.00 (0.88; 1.13)

 

 

ITT

0.99 (0.88; 1.12)

 

*EPP = eligible patient population; **ITT = intent-to-treat population.

In a randomised, controlled phase III study (CAIRO), the effect of using capecitabine at a starting dose of 1,000 mg/m² for 2 weeks every 3 weeks in combination with irinotecan for the first-line treatment of patients with metastatic colorectal cancer was studied. 820 Patients were randomised to receive either sequential treatment (n = 410) or combination treatment (n = 410). Sequential treatment consisted of first-line capecitabine (1,250 mg/m² twice daily for 14 days), second-line irinotecan

(350 mg/m² on day 1), and third-line combination of capecitabine (1,000 mg/m² twice daily for 14 days) with oxaliplatin (130 mg/m² on day 1). Combination treatment consisted of first-line

capecitabine (1,000 mg/m² twice daily for 14 days) combined with irinotecan (250 mg/m² on day 1) (XELIRI) and second-line capecitabine (1,000 mg/m² twice daily for 14 days) plus oxaliplatin (130 mg/m² on day 1). All treatment cycles were administered at intervals of 3 weeks. In first-line

treatment the median PFS in the intent-to-treat population was 5.8 months (95 %CI 5.1 - 6.2 months) for capecitabine monotherapy and 7.8 months (95 %CI 7.0-8.3 months; p = 0.0002) for XELIRI. However this was associated with an increased incidence of gastrointestinal toxicity and neutropenia during first-line treatment with XELIRI (26 % and 11 % for XELIRI and first line capecitabine respectively).

The XELIRI has been compared with 5-FU + irinotecan (FOLFIRI) in three randomised studies in patients with metastatic colorectal cancer. The XELIRI regimens included capecitabine 1,000 mg/m² twice daily on days 1 to 14 of a 3-week cycle combined with irinotecan 250 mg/m² on day 1. In the largest study (BICC-C), patients were randomised to receive either open label FOLFIRI (n = 144), bolus 5-FU (mIFL) (n = 145) or XELIRI (n = 141) and were additionally randomised to receive either double-blind treatment with celecoxib or placebo. Median PFS was 7.6 months for FOLFIRI,

5.9 months for mIFL (p = 0.004) for the comparison with FOLFIRI), and 5.8 months for XELIRI (p = 0.015). Median OS was 23.1 months for FOLFIRI, 17.6 months for mIFL (p = 0.09), and

18.9 months for XELIRI (p = 0.27). Patients treated with XELIRI experienced excessive gastrointestinal toxicity compared with FOLFIRI (diarrhoea 48 % and 14 % for XELIRI and FOLFIRI respectively).

In the EORTC study patients were randomised to receive either open label FOLFIRI (n = 41) or XELIRI (n = 44) with additional randomisation to either double-blind treatment with celecoxib or placebo. Median PFS and overall survival (OS) times were shorter for XELIRI versus FOLFIRI (PFS 5.9 versus 9.6 months and OS 14.8 versus 19.9 months), in addition to which excessive rates of diarrhoea were reported in patients receiving the XELIRI regimen (41 % XELIRI, 5.1 % FOLFIRI).

In the study published by Skof et al, patients were randomised to receive either FOLFIRI or XELIRI. Overall response rate was 49 % in the XELIRI and 48 % in the FOLFIRI arm (p = 0.76). At the end of treatment, 37 % of patients in the XELIRI and 26 % of patients in the FOLFIRI arm were without evidence of the disease (p = 0.56). Toxcity was similar between treatments with the exception of neutropenia reported more commonly in patients treated with FOLFIRI.

Montagnani et al used the results from the above three studies to provide an overall analysis of randomised studies comparing FOLFIRI and XELIRI treatment regimens in the treatment of mCRC. A significant reduction in the risk of progression was associated with FOLFIRI (HR, 0.76; 95 % CI, 0.62-0.95; P < 0.01), a result partly due to poor tolerance to the XELIRI regimens used.

Data from a randomised clinical study (Souglakos et al, 2012) comparing FOLFIRI + bevacizumab with XELIRI + bevacizumab showed no significant differences in PFS or OS between treatments. Patients were randomised to receive either FOLFIRI plus bevacizumab (Arm-A, n = 167) or XELIRI plus bevacizumab (Arm-B, n-166). For Arm B, the XELIRI regimen used capecitabine 1,000 mg/m² twice daily for 14 days + irinotecan 250 mg/m² on day 1. Median PFS was 10.0 and 8.9 months;

p = 0.64, overall survival 25.7 and 27.5 months; p = 0.55 and response rates 45.5 and 39.8 %; p = 0.32 for FOLFIRI-Bev and XELIRI-Bev, respectively. Patients treated with XELIRI + bevacizumab reported a significantly higher incidence of diarrhoea, febrile neutropenia and hand-foot skin reactions than patients treated with FOLFIRI + bevacizumab with significantly increased treatment delays, dose reductions and treatment discontinuations.

Data from a multicentre, randomised, controlled phase II study (AIO KRK 0604) supports the use of capecitabine at a starting dose of 800 mg/m² for 2 weeks every 3 weeks in combination with irinotecan and bevacizumab for the first-line treatment of patients with metastatic colorectal cancer. 120 Patients were randomised to a modified XELIRI regimen with capecitabine 800 mg/m² twice daily for two weeks followed by a 7-day rest period), irinotecan (200 mg/m² as a 30 minute infusion on day 1 every 3 weeks), and bevacizumab (7.5 mg/kg as a 30 to 90 minute infusion on day 1every 3 weeks);

127 patients were randomised to treatment with capecitabine (1,000 mg/m² twice daily for two weeks followed by a 7-day rest period), oxaliplatin (130 mg/m² as a 2 hour infusion on day 1 every 3 weeks), and bevacizumab (7.5 mg/kg as a 30 to 90 minute infusion on day 1 every 3 weeks). Following a mean duration of follow-up for the study population of 26.2 months, treatment responses were as shown below:

Table 8 Key efficacy results for AIO KRK study

 

 

XELOX + bevacizumab

Modified

Hazard ratio

 

 

 

XELIRI + bevacizumab

95 % CI

 

 

(ITT: N = 127)

(ITT: N = 120)

P value

Progression-free Survival after 6 months

 

 

ITT

 

76 %

84 %

 

95 % CI

 

69-84 %

77-90 %

--

Median progression free survival

 

 

ITT

 

10.4 months

12.1 months

0.93

95 % CI

 

9.0-12.0

10.8-13.2

0.82-1.07

 

 

 

 

P = 0.30

Median overall survival

 

 

 

ITT

 

24.4 months

25.5 months

0.90

95 % CI

 

19.3-30.7

21.0-31.0

0.68-1.19

 

 

 

 

P = 0.45

Combination therapy in second-line treatment of metastatic colorectal cancer

Data from a multicentre, randomised, controlled phase III clinical study (NO16967) support the use of capecitabine in combination with oxaliplatin for the second-line treatment of metastastic colorectal cancer. In this trial, 627 patients with metastatic colorectal carcinoma who have received prior treatment with irinotecan in combination with a fluoropyrimidine regimen as first line therapy were randomised to treatment with XELOX or FOLFOX-4. For the dosing schedule of XELOX and FOLFOX-4 (without addition of placebo or bevacizumab), refer to table 6. XELOX was demonstrated to be non-inferior to FOLFOX-4 in terms of PFS in the per-protocol population and intent-to-treat population (see table 9). The results indicate that XELOX is equivalent to FOLFOX-4 in terms of overall survival (see table 9). The median follow up at the time of the primary analyses in the intent- to-treat population was 2.1 years; data from analyses following an additional 6 months of follow up are also included in table 9.

Table 9 Key efficacy results for the non-inferiority analysis of study NO16967

PRIMARY ANALYSIS

 

 

 

 

 

 

 

 

 

XELOX

 

FOLFOX-4

 

 

 

 

(PPP*: N = 251; ITT**:

 

(PPP*: N = 252; ITT**:

 

 

 

 

N = 313)

 

N = 314)

 

 

 

Population

Median time to event (days)

HR

 

 

(95 % CI)

 

 

 

 

 

 

Parameter: Progression-free survival

 

 

 

 

 

 

 

 

 

 

 

 

PPP

 

1.03 (0.87; 1.24)

 

 

ITT

 

0.97 (0.83; 1.14)

 

 

Parameter: Overall survival

 

 

 

 

 

 

 

 

 

 

PPP

 

1.07 (0.88; 1.31)

 

 

ITT

 

1.03 (0.87; 1.23)

 

 

 

ADDITIONAL 6 MONTHS OF FOLLOW UP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Population

Median time to event (days)

HR

 

 

(95 % CI)

 

 

 

 

 

 

Parameter: Progression-free survival

 

 

 

 

 

 

 

 

 

 

PPP

 

1.04 (0.87; 1.24)

 

 

ITT

 

0.97 (0.83; 1.14)

 

 

Parameter: Overall survival

 

 

 

 

 

 

 

 

 

 

PPP

1.05 (0.88; 1.27)

 

 

ITT

1.02 (0.86; 1.21)

 

*PPP = per-protocol population; **ITT = intent-to-treat population.

Advanced gastric cancer

Data from a multicentre, randomised, controlled phase III clinical trial in patients with advanced gastric cancer supports the use of capecitabine for the first-line treatment of advanced gastric cancer (ML17032). In this trial, 160 patients were randomised to treatment with capecitabine (1,000 mg/m² twice daily for 2 weeks followed by a 7-day rest period) and cisplatin (80 mg/m² as a 2-hour infusion every 3 weeks). A total of 156 patients were randomised to treatment with 5-FU (800 mg/m² per day, continuous infusion on days 1 to 5 every 3 weeks) and cisplatin (80 mg/m² as a 2-hour infusion on day 1, every 3 weeks). Capecitabine in combination with cisplatin was non-inferior to 5-FU in combination with cisplatin in terms of PFS in the per protocol analysis (hazard ratio 0.81; 95 % CI 0.63 – 1.04). The median PFS was 5.6 months (capecitabine + cisplatin) versus 5.0 months

(5-FU + cisplatin). The hazard ratio for duration of survival (overall survival) was similar to the hazard ratio for PFS (hazard ratio 0.85; 95 % CI 0.64 – 1.13). The median duration of survival was 10.5 months (capecitabine + cisplatin) versus 9.3 months (5-FU + cisplatin).

Data from a randomised multicentre, phase III study comparing capecitabine to 5-FU and oxaliplatin to cisplatin in patients with advanced gastric cancer supports the use of capecitabine for the first-line treatment of advanced gastric cancer (REAL-2). In this trial, 1,002 patients were randomised in a 2x2 factorial design to one of the following 4 arms:

-ECF: epirubicin (50 mg/ m² as a bolus on day 1 every 3 weeks), cisplatin (60 mg/m² as a two hour infusion on day 1 every 3 weeks) and 5-FU (200 mg/m² daily given by continuous infusion via a central line).

-ECX: epirubicin (50 mg/m² as a bolus on day 1 every 3 weeks), cisplatin (60 mg/m² as a two hour infusion on day 1 every 3 weeks), and capecitabine (625 mg/m² twice daily continuously).

-EOF: epirubicin (50 mg/m² as a bolus on day 1 every 3 weeks), oxaliplatin (130 mg/m² given as a 2 hour infusion on day 1 every three weeks), and 5-FU (200 mg/m² daily given by continuous infusion via a central line).

-EOX: epirubicin (50 mg/m² as a bolus on day 1 every 3 weeks), oxaliplatin (130 mg/m² given as a 2 hour infusion on day 1 every three weeks), and capecitabine (625 mg/m² twice daily continuously).

The primary efficacy analyses in the per protocol population demonstrated non-inferiority in overall survival for capecitabine- vs 5-FU-based regimens (hazard ratio 0.86; 95 % CI 0.8 – 0.99) and for oxaliplatin- vs cisplatin-based regimens (hazard ratio 0.92; 95 % CI 0.80 – 1.1). The median overall survival was 10.9 months in capecitabine-based regimens and 9.6 months in 5-FU based regimens. The median overall survival was 10.0 months in cisplatin-based regimens and 10.4 months in oxaliplatin-based regimens.

Capecitabine has also been used in combination with oxaliplatin for the treatment of advanced gastric cancer. Studies with capecitabine monotherapy indicate that capecitabine has activity in advanced gastric cancer.

Colon, colorectal and advanced gastric cancer: meta-analysis

A meta-analysis of six clinical trials (studies SO14695, SO14796, M66001, NO16966, NO16967, M17032) supports capecitabine replacing 5-FU in mono- and combination treatment in gastrointestinal cancer. The pooled analysis includes 3,097 patients treated with capecitabine-containing regimens and 3,074 patients treated with 5-FU-containing regimens. Median overall survival time was 703 days

(95 % CI: 671; 745) in patients treated with capecitabine-containing regimens and 683 days (95 % CI: 646; 715) in patients treated with 5-FU-containing regimens. The hazard ratio for overall survival was 0.94 (95 % CI: 0.89; 1.00, p = 0.0489) indicating that capecitabine-containing regimens are non-inferior to 5-FU-containing regimens.

Breast cancer

Combination therapy with capecitabine and docetaxel in locally advanced or metastatic breast cancer

Data from one multicentre, randomised, controlled phase III clinical trial support the use of capecitabine in combination with docetaxel for treatment of patients with locally advanced or metastatic breast cancer after failure of cytotoxic chemotherapy, including an anthracycline. In this trial, 255 patients were randomised to treatment with capecitabine (1,250 mg/m² twice daily for

2 weeks followed by 1-week rest period and docetaxel 75 mg/m² as a 1 hour intravenous infusion every 3 weeks). 256 patients were randomised to treatment with docetaxel alone (100 mg/m² as a 1 hour intravenous infusion every 3 weeks). Survival was superior in the capecitabine + docetaxel

combination arm (p = 0.0126). Median survival was 442 days (capecitabine + docetaxel) vs. 352 days (docetaxel alone). The overall objective response rates in the all-randomised population (investigator assessment) were 41.6 % (capecitabine + docetaxel) vs. 29.7 % (docetaxel alone); p = 0.0058. Time to progressive disease was superior in the capecitabine + docetaxel combination arm (p < 0.0001). The median time to progression was 186 days (capecitabine + docetaxel) vs. 128 days (docetaxel alone).

Monotherapy with capecitabine after failure of taxanes, anthracycline containing chemotherapy, and for whom anthracycline therapy is not indicated

Data from two multicentre phase II clinical trials support the use of capecitabine monotherapy for treatment of patients after failure of taxanes and an anthracycline-containing chemotherapy regimen or for whom further anthracycline therapy is not indicated. In these trials, a total of 236 patients were treated with capecitabine (1,250 mg/m² twice daily for 2 weeks followed by 1-week rest period). The overall objective response rates (investigator assessment) were 20 % (first trial) and 25 % (second trial). The median time to progression was 93 and 98 days. Median survival was 384 and 373 days.

All indications

A meta-analysis of 14 clinical trials with data from over 4,700 patients treated with capecitabine monotherapy or capecitabine in combination with different chemotherapy regimens in multiple indications (colon, colorectal, gastric and breast cancer) showed that patients on capecitabine who developed HFS had a longer overall survival compared to patients who did not develop HFS: median overall survival 1,100 days (95 % CI 1,007;1,200) vs 691 days (95 % CI 638;754) with a hazard ratio of 0.61 (95 % CI 0.56; 0.66).

Paediatric population

The European Medicines Agency has waived the obligation to conduct studies with capecitabine in all subsets of the paediatric population in adenocarcinoma of the colon and rectum, gastric adenocarcinoma and breast carcinoma (see section 4.2 for information on paediatric use).

5.2Pharmacokinetic properties

The pharmacokinetics of capecitabine have been evaluated over a dose range of 502 –

3,514 mg/m²/day. The parameters of capecitabine, 5’-DFCR and 5’-DFUR measured on days 1 and 14 were similar. The AUC of 5-FU was 30 % - 35 % higher on day 14. Capecitabine dose reduction decreases systemic exposure to 5-FU more than dose-proportionally, due to non--linear pharmacokinetics for the active metabolite.

Absorption

After oral administration, capecitabine is rapidly and extensively absorbed, followed by extensive conversion to the metabolites, 5’-DFCR and 5’-DFUR. Administration with food decreases the rate of capecitabine absorption, but only results in a minor effect on the AUC of 5’-DFUR, and on the AUC of the subsequent metabolite 5-FU. At the dose of 1,250 mg/m² on day 14 with administration after food intake, the peak plasma concentrations (Cmax in µg/ml) for capecitabine, 5’-DFCR, 5’-DFUR, 5-FU and FBAL were 4.67, 3.05, 12.1, 0.95 and 5.46 respectively. The time to peak plasma

concentrations (Tmax in hours) were 1.50, 2.00, 2.00, 2.00 and 3.34. The AUC0-∞ values in μg•h/ml were 7.75, 7.24, 24.6, 2.03 and 36.3.

Distribution

In vitro human plasma studies have determined that capecitabine, 5’-DFCR, 5’-DFUR and 5-FU are 54 %, 10 %, 62 % and 10 % protein bound, mainly to albumin.

Biotransformation

Capecitabine is first metabolised by hepatic carboxylesterase to 5’-DFCR, which is then converted to 5’-DFUR by cytidine deaminase, principally located in the liver and tumour tissues. Further catalytic activation of 5’-DFUR then occurs by ThyPase. The enzymes involved in the catalytic activation are found in tumour tissues but also in normal tissues, albeit usually at lower levels. The sequential enzymatic biotransformation of capecitabine to 5-FU leads to higher concentrations within tumour tissues. In the case of colorectal tumours, 5-FU generation appears to be in large part localised in tumour stromal cells. Following oral administration of capecitabine to patients with colorectal cancer, the ratio of 5-FU concentration in colorectal tumours to adjacent tissues was 3.2 (ranged from 0.9 to 8.0). The ratio of 5-FU concentration in tumour to plasma was 21.4 (ranged from 3.9 to 59.9, n = 8) whereas the ratio in healthy tissues to plasma was 8.9 (ranged from 3.0 to 25.8, n = 8). ThyPase activity was measured and found to be 4 times greater in primary colorectal tumour than in adjacent normal tissue. According to immunohistochemical studies, ThyPase appears to be in large part localised in tumour stromal cells.

5-FU is further catabolised by the enzyme DPD to the much less toxic dihydro-5-fluorouracil (FUH2). Dihydropyrimidinase cleaves the pyrimidine ring to yield 5-fluoro-ureidopropionic acid (FUPA). Finally, β-ureido-propionase cleaves FUPA to FBAL which is cleared in the urine. DPD activity is the rate limiting step. Deficiency of DPD may lead to increased toxicity of capecitabine (see section 4.3 and 4.4).

Elimination

The elimination half-life (t1/2 in hours) of capecitabine, 5’-DFCR, 5’-DFUR, 5-FU and FBAL were 0.85, 1.11, 0.66, 0.76 and 3.23 respectively. Capecitabine and its metabolites are predominantly excreted in urine; 95.5 % of administered capecitabine dose is recovered in urine. Faecal excretion is minimal (2.6 %). The major metabolite excreted in urine is FBAL, which represents 57 % of the administered dose. About 3 % of the administered dose is excreted in urine unchanged.

Combination therapy

Phase I studies evaluating the effect of capecitabine on the pharmacokinetics of either docetaxel or paclitaxel and vice versa showed no effect by capecitabine on the pharmacokinetics of docetaxel or paclitaxel (Cmax and AUC) and no effect by docetaxel or paclitaxel on the pharmacokinetics of 5’-DFUR.

Pharmacokinetics in special populations

A population pharmacokinetic analysis was carried out after capecitabine treatment of 505 patients with colorectal cancer dosed at 1,250 mg/m² twice daily. Gender, presence or absence of liver metastasis at baseline, Karnofsky Performance Status, total bilirubin, serum albumin, aspartate-aminotransferase (ASAT) and alanine-aminotransferase (ALAT) had no statistically significant effect on the pharmacokinetics of 5’-DFUR, 5-FU and FBAL.

Patients with hepatic impairment due to liver metastases

According to a pharmacokinetic study in cancer patients with mild to moderate liver impairment due to liver metastases, the bioavailability of capecitabine and exposure to 5-FU may increase compared to patients with no liver impairment. There are no pharmacokinetic data on patients with severe hepatic impairment.

Patients with renal impairment

Based on a pharmacokinetic study in cancer patients with mild to severe renal impairment, there is no evidence for an effect of creatinine clearance on the pharmacokinetics of intact drug and 5-FU. Creatinine clearance was found to influence the systemic exposure to 5’ -DFUR (35 % increase in AUC when creatinine clearance decreases by 50 %) and to FBAL (114 % increase in AUC when creatinine clearance decreases by 50 %). FBAL is a metabolite without antiproliferative activity.

Elderly

Based on the population pharmacokinetic analysis, which included patients with a wide range of ages (27 to 86 years) and included 234 (46 %) patients greater or equal to 65, age has no influence on the pharmacokinetics of 5’-DFUR and 5-FU. The AUC of FBAL increased with age (20 % increase in age results in a 15 % increase in the AUC of FBAL). This increase is likely due to a change in renal function.

Ethnic factors

Following oral administration of 825 mg/m² capecitabine twice daily for 14 days, Japanese patients (n = 18) had about 36 % lower Cmax and 24 % lower AUC for capecitabine than Caucasian patients

(n = 22). Japanese patients had also about 25 % lower Cmax and 34 % lower AUC for FBAL than Caucasian patients. The clinical relevance of these differences is unknown. No significant differences

occurred in the exposure to other metabolites (5’-DFCR, 5’-DFUR, and 5-FU).

5.3Preclinical safety data

In repeat-dose toxicity studies, daily oral administration of capecitabine to cynomolgus monkeys and mice produced toxic effects on the gastrointestinal, lymphoid and haemopoietic systems, typical for fluoropyrimidines. These toxicities were reversible. Skin toxicity, characterised by degenerative/regressive changes, was observed with capecitabine. Capecitabine was devoid of hepatic and CNS toxicities. Cardiovascular toxicity (e.g. PR- and QT-interval prolongation) was detectable in cynomolgus monkeys after intravenous administration (100 mg/kg) but not after repeated oral dosing (1,379 mg/m²/day).

A two-year mouse carcinogenicity study produced no evidence of carcinogenicity by capecitabine.

During standard fertility studies, impairment of fertility was observed in female mice receiving capecitabine; however, this effect was reversible after a drug-free period. In addition, during a 13-week study, atrophic and degenerative changes occurred in reproductive organs of male mice; however these effects were reversible after a drug-free period (see section 4.6).

In embryotoxicity and teratogenicity studies in mice, dose-related increases in foetal resorption and teratogenicity were observed. In monkeys, abortion and embryolethality were observed at high doses, but there was no evidence of teratogenicity.

Capecitabine was not mutagenic in vitro to bacteria (Ames test) or mammalian cells (Chinese hamster V79/HPRT gene mutation assay). However, similar to other nucleoside analogues (i.e., 5-FU), capecitabine was clastogenic in human lymphocytes (in vitro) and a positive trend occurred in mouse bone marrow micronucleus tests (in vivo).

6.PHARMACEUTICAL PARTICULARS

6.1List of excipients

Tablet core

Anhydrous lactose

Cellulose, microcrystalline (E460)

Croscarmellose sodium (E468)

Hypromellose (E464)

Magnesium stearate (E572)

Tablet coating

Capecitabine medac 150 mg film-coated tablets

Hypromellose (E464)

Talc

Titanium dioxide (E171)

Iron oxide red (E172)

Iron oxide yellow (E172)

Capecitabine medac 300 mg film-coated tablets

Hypromellose (E464)

Talc

Titanium dioxide (E171)

Capecitabine medac 500 mg film-coated tablets

Hypromellose (E464)

Talc

Titanium dioxide (E171)

Iron oxide red (E172)

Iron oxide yellow (E172)

6.2Incompatibilities

Not applicable.

6.3Shelf life

Aluminium/aluminium blisters 3 years

PVC/PVdC/Aluminium blisters 3 years

6.4Special precautions for storage

Aluminium/aluminium blisters

This medicinal product does not require any special storage conditions.

PVC/PVdC/Aluminium blisters

Do not store above 30 °C.

6.5Nature and contents of container

Aluminium/aluminium or PVC/PVdC/Aluminium blisters.

Pack sizes: 28, 30, 56, 60, 84, 112 or 120 film-coated tablets.

Not all pack sizes may be marketed.

6.6Special precautions for disposal

No special requirements.

7.MARKETING AUTHORISATION HOLDER

medac

Gesellschaft für klinische Spezialpräparate mbH Theaterstr. 6

22880 Wedel Germany

8.MARKETING AUTHORISATION NUMBER(S)

EU/1/12/802/001-014

EU/1/12/802/015-028

EU/1/12/802/029-042

9.DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

Date of first authorisation: 19 November 2012

Date of latest renewal:

10.DATE OF REVISION OF THE TEXT

Detailed information on this medicinal product is available on the website of the European Medicines Agency http://www.ema.europa.eu.

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