- 1. NAME OF THE MEDICINAL PRODUCT
- 2. QUALITATIVE AND QUANTITATIVE COMPOSITION
- 3. PHARMACEUTICAL FORM
- 4. CLINICAL PARTICULARS
- 4.1 Therapeutic indications
- 4.2 Posology and method of administration
- 4.3 Contraindications
- 4.4 Special warnings and precautions for use
- 4.5 Interaction with other medicinal products and other forms of interaction
- 4.6 Fertility, pregnancy and lactation
- 4.7 Effects on ability to drive and use machines
- 4.8 Undesirable effects
- 4.9 Overdose
- 5. PHARMACOLOGIC PROPERTIES
- 6. PHARMACEUTICAL PARTICULARS
- 7. MARKETING AUTHORISATION HOLDER
- 8. MARKETING AUTHORISATION NUMBER
- 9. DATE OF FIRST AUTHORISATION/RENEWAL OF AUTHORISATION
- 10. DATE OF REVISION OF THE TEXT
- 11. DOSIMETRY
- 12. INSTRUCTIONS FOR PREPARATION OF RADIOPHARMACEUTICALS
1.NAME OF THE MEDICINAL PRODUCT
Quadramet 1.3 GBq/mL solution for injection.
2.QUALITATIVE AND QUANTITATIVE COMPOSITION
Each ml of solution contains 1.3 GBq Samarium (153Sm) lexidronam pentasodium at the reference date (corresponding to 20 to 80 µg/ml of samarium per vi al)
Samarium specific activity is approximately 16 – 65 MBq/µg of samarium.
Each vial contains
TABLE 1 :
*Maximum energies are listed for the beta emissions, the average beta particle energy is 233 keV.
Excipient with known effect: sodium 8.1 mg/mL.
For the full list of excipients, see section 6.1.
Solution for injection.
Clear, colourless to light amber solution with pH ranging between 7.0 and 8.5.
Quadramet is indicated for the relief of bone pain in patients with multiple painful osteoblastic skeletal metastases which take up technetium
The presence of osteoblastic metastases which take up technetium
4.2Posology and method of administration
Quadramet should only be administered by physicians experienced in the use of radiopharmaceuticals and after full oncological evaluation of the patient by qualified physicians.
The recommended dose of Quadramet is 37 MBq per kg body weight.
Quadramet is not recommended for use in children below the age of 18 years due to a lack of data on safety and efficacy.
Method of administration
Quadramet is to be administered by slow intravenous route through an established intravenous line over a period of one minute. Quadramet should not be diluted before use.
Patients who respond to Quadramet generally experience the onset of pain relief within 1 week after treatment. Relief of pain may persist for 4 weeks up to 4 months. Patients who experience a reduction in pain may be encouraged to decrease their use of opioid analgesics.
Repeat administration of Quadramet should be based on an individual patient's response to prior treatment and on clinical symptoms. A minimum interval of 8 weeks should be respected, subject to recovery of adequate bone marrow function.
The data on the safety of repeated dosing are limited and based on compassionate use of the product.
For instructions on preparation of the medicinal product before administration, see section 12.
∙Hypersensitivity to the active substance (ethylenediaminetetramethylenephosphonate (EDTMP) or similar phosphonates) or to any of the excipients excipients listed in section 6.1.
∙in pregnant women (See section 4.6).
∙in patients having received chemotherapy or
Quadramet is used only as a palliative agent and should not be used concurrently with myelotoxic chemotherapy as this may enhance myelotoxicity.
It should not be used concurrently with other biphosphonates if an interference is shown on the technetium
4.4Special warnings and precautions for use
In absence of clinical data, the injected activity should be adapted to the renal function.
Use of Quadramet in patients with evidence of compromised bone marrow reserve from previous therapy or disease involvement is not recommended unless the potential benefit of the treatment outweighs its risks.
Because of potential bone marrow suppression after administration, blood counts should be monitored weekly for at least 8 weeks, beginning 2 weeks after administration of Quadramet, or until recovery of adequate bone marrow function.
The patient should be encouraged to ingest (or receive by intravenous administration) a minimum of 500 ml of fluids prior to injection and should be encouraged to void as often as possible after injection to minimise radiation exposure to the bladder.
The clearance of Quadramet being rapid, the precautions relating to the excreted urinary radioactivity need not be taken after
Special precautions, such as bladder catheterisation, should be taken during six hours following administration to incontinent patients to minimise the risk of radioactive contamination of clothing, bed linen, and the patient's environment. For the other patients the urine should be collected for at least six (6) hours.
Bladder catheterisation should be undertaken in patients with urinary obstruction.
Radiopharmaceuticals may be received, used and administered only by authorised persons in designated clinical settings. Its receipt, storage, use, transfer and disposal are subject to the regulations and the appropriate licences of the local competent official organisations.
Radiopharmaceuticals should be prepared by the user in a manner which satisfies both radiation safety and pharmaceutical quality requirements. Appropriate aseptic precautions should be taken, complying with the requirements of Good Manufacturing Practice for pharmaceuticals.
4.5Interaction with other medicinal products and other forms of interaction
Because of the potential for additive effects on bone marrow, the treatment should not be given concurrently with chemotherapy or external beam radiation therapy. Quadramet may be given subsequent to either of these treatments after allowing for adequate marrow recovery.
4.6Fertility, pregnancy and lactation
There are no available clinical data relating to the excretion of Quadramet in human milk. If therefore Quadramet administration is deemed necessary, formula feeding should be substituted for breast- feeding and the expressed feeds discarded.
4.7Effects on ability to drive and use machines
No studies on the effects on the ability to drive and use machines have been performed.
Decreases in white blood cell and platelet counts and anaemia were observed in patients receiving Quadramet.
In clinical trials white blood cell and platelet counts decreased to a nadir of approximately 40 % to 50 % of baseline 3 to 5 weeks after a dose, and generally returned to
The few patients who experienced Grade 3 or 4 hematopoietic toxicity usually either had a history of recent external beam radiation therapy or chemotherapy or had rapidly progressive disease with probable bone marrow involvement.
Postmarketing reports of thrombocytopenia have included isolated reports of intracranial haemorrhage, and cases in which the outcome was fatal.
A small number of patients have reported a transient increase in bone pain shortly after injection (flare reaction). This is usually mild and
Adverse drug reactions such as nausea, vomiting, diarrhoea and sweating were reported.
Hypersensitivity reactions including rare cases of anaphylactic reaction have been reported after Quadramet administration.
A few patients experienced cord/root compressions, disseminated intravascular coagulation and cerebrovascular accidents. The occurrence of these events may be linked to the patients’ disease evolution. When there are spinal metastases at the
The radiation dose resulting from therapeutic exposure may result in higher incidence of cancer and mutations. In all cases, it is necessary to ensure that the risks of the radiation are less than from the disease itself.
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.
The product should only be administered by qualified personnel in authorised settings. The possibility of pharmacological overdose is therefore remote.
The risks to be expected are associated with the inadvertent administration of excess radioactivity. Radiation dose to the body can be limited by promoting a diuresis and frequent voiding of urine.
Pharmacotherapeutic group: Various pain palliation radiopharmaceuticals.
ATC Code: V10BX02
Mechanism of action
Quadramet has an affinity for skeletal tissue and concentrates in areas of bone turnover in intimate association with hydroxyapatite.
Studies in rats have demonstrated that Quadramet is cleared rapidly from the blood and localises to growing areas of bone matrix, specifically the layer of osteoid undergoing mineralisation.
Clinical efficacy and safety
In clinical studies employing planar imaging techniques, Quadramet accumulates with a
Total skeletal uptake of Quadramet in studies of 453 patients with a variety of primary malignancies was 65.5 ± 15.5 % of the administered activity. A positive correlation was found between skeletal uptake and the number of metastatic sites. In contrast, skeletal uptake was inversely proportional to plasma radioactivity at 30 minutes.
In patients, Quadramet is rapidly cleared from the blood. Thirty minutes after injection of the agent to 22 patients, only 9.6 ± 2.8 % of the administered activity remained in plasma. At 4 and 24 hours, plasma radioactivity had decreased from 1.3 ± 0.7 % to 0.05 ± 0.03 %.
Urinary excretion occurred predominantly during the first 4 hours (30.3 ± 13.5 %). At 12 hours, 35.3 ± 13.6 % of the administered activity had been excreted into the urine. Less urinary excretion occurred in patients who had extensive bony metastases, regardless of the amount of radiopharmaceutical administered.
Analysis of urine samples found the radioactivity to be present as the intact complex
5.3Preclinical safety data
The radiolysis products of
Repeated dose administration of samarium
In a carcinogenic potential study of EDTMP, osteosarcomas occurred in rats at high doses. In the absence of genotoxic properties, these effects can be assigned to the EDTMP chelatant properties leading to osseous metabolism disturbances.
No studies have been performed to assess the effect of Quadramet on reproduction.
6.1List of excipients
Total EDTMP (as EDTMP.H2O)
Total sodium (as Na)
Water for Injections
In the absence of compatibility studies, this medicinal product must not be mixed with the other medicinal products.
1 day from the activity reference time stated on the label.
Use within 6 hours of thawing. After thawing, do not freeze again.
6.4Special precautions for storage
Quadramet is delivered frozen in dry ice.
Store in a freezer at
Storage procedures should be in accordance with local regulations for radioactive substances.
6.5Nature and contents of container
15 ml colourless European Pharmacopoeia Type I drawn glass vial closed with
Each vial contains 1.5 ml (2 GBq at calibration) to 3.1 ml (4 GBq at calibration) of solution for injection.
6.6Special precautions for disposal and other handling
The administration of radiopharmaceuticals creates risks for other persons from external radiation or contamination from spills of urine, vomiting etc. Radiation protection precautions in accordance with national regulations must therefore be taken.
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
(See section 12, for detailed instructions of product preparation)
7.MARKETING AUTHORISATION HOLDER
CIS bio international
Boîte Postale 32
8.MARKETING AUTHORISATION NUMBER
9.DATE OF FIRST AUTHORISATION/RENEWAL OF AUTHORISATION
Date of first authorisation: 05 February 1998
Date of latest renewal: 12 December 2007
10.DATE OF REVISION OF THE TEXT
The estimated absorbed radiation doses to an average adult patient from an intravenous injection of Quadramet are shown in Table 2. The dosimetry estimates were based on clinical biodistribution studies using methods developed for radiation dose calculations by the Medical Internal Radiation Dose (MIRD) Committee of the Society of Nuclear Medicine.
Because Quadramet is excreted in the urine, radiation exposure was based on a urinary voiding interval of 4.8 hours. Radiation dose estimates for bone and marrow assume that radioactivity is deposited on bone surfaces, in accordance with autoradiograms of bone samples taken from patients who received Quadramet.
Radiation dose to specific organs, which may not be the target organ of therapy, may be influenced significantly by pathophysiological changes induced by the disease process. This should be taken into consideration when using the following information:
TABLE 2 : RADIATION ABSORBED DOSES
Absorbed dose per injected activity (mGy/MBq)
Ascending colon wall
Descending colon wall
Urinary bladder wall
For this product the effective dose resulting from an injected activity of 2 590 MBq is 796 mSv.
For an administered activity of 2 590 MBq, the typical radiation dose to the target organ, skeletal metastases, is 86.5 Gy and the typical radiation doses to the critical organs are: normal bone surfaces 17.5 Gy, red marrow 4.0 Gy, urinary bladder wall 2.5 Gy, kidneys 0.047 Gy and ovaries 0.021 Gy.
12.INSTRUCTIONS FOR PREPARATION OF RADIOPHARMACEUTICALS
Allow the product to thaw at room temperature before administration.
The solution for injection should be visually inspected before use. It should be clear without particles. The operator should be careful to protect the eyes while inspecting the solution for clarity.
The activity should be measured by a dose calibrator immediately before administration. Verification of the dose to be administered and patient identification are necessary prior to administration of Quadramet.
For radiation safety reasons, the patient should be treated in a facility with the appropriate agreement for the therapeutic use of radioactive
Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
Detailed information on this medicinal product is available on the website of the European Medicines Agency http://www.ema.europa.eu.