Article Contents
- 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. PHARMACOLOGICAL PROPERTIES
- 6. PHARMACEUTICAL PARTICULARS
- 7. MARKETING AUTHORISATION HOLDER
- 8. MARKETING AUTHORISATION NUMBER(S)
- 9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
- 10. DATE OF REVISION OF THE TEXT
1.NAME OF THE MEDICINAL PRODUCT
SANCUSO 3.1 mg/24 hours transdermal patch
2.QUALITATIVE AND QUANTITATIVE COMPOSITION
Each 52 cm2 transdermal patch contains 34.3 mg of granisetron releasing 3.1 mg of granisetron per 24 hours.
For the full list of excipients, see section 6.1.
3.PHARMACEUTICAL FORM
Transdermal patch.
Thin, translucent,
4.CLINICAL PARTICULARS
4.1Therapeutic indications
SANCUSO transdermal patch is indicated in adults for the prevention of nausea and vomiting associated with moderately or highly emetogenic chemotherapy, for a planned duration of
3 to 5 consecutive days, where oral
4.2Posology and method of administration
Posology
Adults
Apply a single transdermal patch 24 to 48 hours before chemotherapy, as appropriate.
Due to a gradual increase in plasma levels of granisetron following application of the transdermal patch, a slower onset of efficacy compared to 2 mg oral granisetron may be observed at the start of chemotherapy; the patch should be applied
The transdermal patch should be removed a minimum of 24 hours after completion of chemotherapy. The transdermal patch can be worn for up to 7 days depending on the duration of the chemotherapy regimen.
Following routine haematological monitoring, the transdermal patch should only be applied to patients whose chemotherapy treatment is unlikely to be delayed in order to reduce the possibility of unnecessary exposure to granisetron.
Use of concomitant corticosteroids
The Multinational Association of Supportive Care in Cancer (MASCC) guidelines recommend the administration of dexamethasone with 5HT3 antagonist prior to chemotherapy. In the pivotal SANCUSO study, the concomitant use of corticosteroids, e.g. dexamethasone, was permitted provided it was part of the chemotherapy regimen. Any increase in corticosteroid use during the study was reported as rescue treatment.
Special populations
Elderly
Dosing as for adults (see sections 4.4 and 5.2).
Renal or hepatic impairment
No dose adjustment is necessary. Dosing as for adults (see sections 4.4 and 5.2). Although no evidence of an increased incidence of adverse reactions have been observed in patients with renal or hepatic impairment receiving granisetron orally and intravenously, based on granisetron pharmacokinetics, a degree of caution must be exercised in this population.
Paediatric population
The safety and efficacy of SANCUSO in children aged 0 to 18 years have not yet been established. No data are available.
Method of administration
The transdermal patch should be applied to clean, dry, intact healthy skin on the outer part of the upper arm. If it is not possible to apply the transdermal patch to the arm, it can be applied to the abdomen.
The transdermal patch should not be placed on skin that is red, irritated or damaged.
Each transdermal patch is packed in a sachet and should be applied directly after the sachet has been opened. The release liner is removed prior to application.
The transdermal patch should not be cut into pieces.
In the event of a transdermal patch becoming completely or partially detached, the original transdermal patch should be reattached in the same position using medical tape (if necessary). If reattachment is not possible or the transdermal patch is damaged, a new transdermal patch should be applied in the same position as the original transdermal patch. If this is not possible, a new transdermal patch should be applied on the opposite arm. The newly applied transdermal patch should be removed in line with the timing recommended above.
4.3Contraindications
Hypersensitivity to the active substance, to other
4.4Special warnings and precautions for use
Application site reactions
In clinical trials with SANCUSO, application site reactions were reported which were generally mild in intensity and did not lead to discontinuation of use. If severe reactions, or a generalised skin reaction occur (e.g. allergic rash, including erythematous, macular, papular rash or pruritus), the transdermal patch must be removed.
Gastrointestinal disorders
As granisetron may reduce lower bowel motility, patients with signs of
Cardiac disorders
Exposure to sunlight
Granisetron may be affected by direct natural or artificial sunlight, see section 5.3 for further information. Patients must be advised to cover the transdermal patch application site, e.g. with clothing, if there is a risk of exposure to sunlight throughout the period of wear and for 10 days following its removal.
Showering or washing
Showering or washing normally can be continued while wearing SANCUSO. Activities such as swimming, strenuous exercise or using a sauna should be avoided.
External heat
External heat (for example hot water bottles or heat pads) should be avoided on the area of the transdermal patch.
Special populations
No dose adjustments are necessary for the elderly or patients with renal or hepatic impairment. Although no evidence of an increased incidence of adverse reactions have been observed in patients with renal or hepatic impairment receiving granisetron orally and intravenously, based on granisetron pharmacokinetics, a degree of caution must be exercised in this population.
Serotonin syndrome
There have been reports of serotonin syndrome with the use of
4.5Interaction with other medicinal products and other forms of interaction
For serotonergic medicinal products (e.g. SSRIs and SNRIs), there have been reports of serotonin syndrome following concomitant use of
As granisetron is metabolised by hepatic cytochrome P450 active
In human subjects, hepatic enzyme induction by phenobarbital has led to an increase in total plasma clearance (approximately 25%) following intravenous administration of granisetron.
In vitro studies have shown that ketoconazole may inhibit the metabolism of granisetron via the cytochrome P450 3A isoenzyme family. The clinical significance of this is unknown.
In vitro studies using human microsomes indicate that granisetron neither stimulates nor inhibits the cytochrome P450 enzyme system.
In studies in healthy subjects, no evidence of any interaction has been indicated between granisetron and benzodiazepines (lorazepam), neuroleptics (haloperidol) or
No clinically relevant interactions between SANCUSO and emetogenic cancer chemotherapies have been seen. Furthermore, no interaction has been observed between granisetron and emetogenic cancer therapies. In agreement with these data, no clinically relevant interactions have been reported in clinical studies with SANCUSO. In clinical interaction studies, aprepitant did not have clinically important effects on the pharmacokinetics of granisetron.
Paediatric population
Interaction studies have only been performed in adults.
4.6Fertility, pregnancy and lactation
Pregnancy
There are no data on the use of granisetron in pregnant women. Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity (see section 5.3). As a precautionary measure, it is preferable to avoid the use of SANCUSO during pregnancy.
It is unknown whether granisetron or its metabolites are excreted in human milk.
Fertility
There are no data on the effect of granisetron on human fertility. Fertility was unaffected following granisetron treatment in rats.
4.7Effects on ability to drive and use machines
SANCUSO has no or negligible influence on the ability to drive and use machines.
4.8Undesirable effects
Summary of the safety profile
The safety profile of SANCUSO is derived from controlled clinical trials and from
Tabulated list of adverse reactions
Adverse reactions from clinical studies and spontaneous reports with SANCUSO are listed in the table below.
Within the system organ class, the adverse reactions are listed by frequency using the following convention: 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) and not known (cannot be estimated from the available data).
Adverse reactions are presented in order of decreasing seriousness within each frequency grouping.
Table 1: | Adverse reactions reported for SANCUSO |
| |
System Organ Class | Adverse reaction | Frequency | |
Immune system disorder | Hypersensitivity reactions | Not known | |
Metabolism and nutrition disorders | Decreased appetite | Uncommon | |
|
|
| |
Nervous system disorders | Headache | Uncommon | |
|
| Dystonia | Rare |
|
| Dyskinesia | Rare |
Ear and labyrinth disorders | Vertigo | Uncommon | |
Vascular disorders | Flushing | Uncommon | |
Gastrointestinal disorders | Constipation | Common | |
|
| Dry mouth, nausea, retching | Uncommon |

Hepatobiliary disorders | Alanine aminotransferase | Uncommon |
| increased, aspartate |
|
| aminotransferase increased, |
|
|
| |
| increased |
|
Skin and subcutaneous tissue | Application site irritation | Uncommon |
disorders | Application site reactions | Not known |
| (application site pain, |
|
| application site pruritus, |
|
| application site erythema, |
|
| application site rash, |
|
| application site irritation) * |
|
Musculoskeletal and connective | Arthralgia | Uncommon |
tissue disorders |
|
|
General disorders and | Generalised oedema | Uncommon |
administration site conditions |
|
|
*Spontaneous reports |
|
|
Description of selected adverse reactions
Patients who are being treated with moderately or highly emetogenic chemotherapy may still experience vomiting despite treatment with antiemetic therapy, including SANCUSO.
Class effects
Class effects for granisetron seen with other formulations (oral and intravenous) include the following:
-Hypersensitivity reactions, e.g. anaphylaxis, urticaria
-Insomnia
-Headache
-Extrapyramidal reactions
-Somnolence
-Dizziness
-QT prolongation
-Constipation
-Diarrhoea
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-Elevated hepatic transaminases
-Rash
-Asthenia
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
There is no specific antidote for granisetron. In the event of overdose, the transdermal patch should be removed. Symptomatic treatment should be given.
5.PHARMACOLOGICAL PROPERTIES
5.1Pharmacodynamic properties
Pharmacotherapeutic group: Antiemetics and antinauseants, serotonin (5HT3) antagonists, ATC code: A04AA02.
Granisetron is a potent
A pivotal, randomised,
The population randomised into the trial included 48% males and 52% females aged 16 to 86 years receiving moderately emetogenic (ME) or highly emetogenic (HE)
The granisetron transdermal patch was applied 24 to 48 hours prior to the first dose of chemotherapy, and kept in place for 7 days. Oral granisetron was administered daily for the duration of the chemotherapy regimen, one hour prior to each dose of chemotherapy.
Due to the gradual increase in plasma levels of granisetron following application of the transdermal patch, initial plasma levels at the start of chemotherapy may be lower than 2 mg oral granisetron and a slower onset of efficacy may therefore be observed. Consequently, SANCUSO is indicated for use in patients where oral
Complete control by day is illustrated below.

In clinical trials with SANCUSO, there were no
An assessment of transdermal patch adhesion in 621 patients receiving either active or placebo transdermal patches showed that less than 1% of transdermal patches became detached over the course of the 7 day period of transdermal patch application.
There is no clinical trial experience with SANCUSO and patients on chemotherapy for less than
3 consecutive days, or over multiple cycles of chemotherapy, or with
5.2Pharmacokinetic properties
Absorption
Granisetron crosses intact skin into the systemic circulation by a passive diffusion process. Following SANCUSO application, granisetron is absorbed slowly, with maximal concentrations reached between 24 and 48 hours.
Based on the measure of residual content of the transdermal patch after removal, approximately 65% of granisetron is delivered resulting in an average daily dose of 3.1 mg per day.
Concurrent administration of a single intravenous bolus of 0.01 mg/kg (maximum 1 mg) granisetron at the same time a SANCUSO transdermal patch was applied was investigated in healthy subjects. An initial peak in plasma concentrations of granisetron, attributable to the intravenous dose, was reached at 10 minutes
Following consecutive application of two SANCUSO transdermal patches in healthy subjects, each for seven days, granisetron levels were maintained over the study period with evidence of minimal accumulation.
In a study designed to assess the effect of heat on the transdermal delivery of granisetron from SANCUSO in healthy subjects, a heat pad generating an average temperature of 42°C was applied over the transdermal patch for 4 hours each day over the 5 day period of wear. While application of the heat pad was associated with a minor and transient increase in the transdermal patch flux during the period of heat pad application, no overall increase in granisetron exposure was observed when compared to a control group.
In a pharmacokinetic study in healthy volunteers, where SANCUSO was applied for a period of
7 days, mean total exposure
variability of 77%. This variability is similar to the known high variability in granisetron pharmacokinetics after oral or intravenous administration.
Distribution
Granisetron is distributed with a mean volume of distribution of approximately 3 l/kg. Plasma protein binding is approximately 65%. Granisetron distributes freely between plasma and red blood cells.
Biotransformation
No differences in the metabolic profiles of granisetron were observed between the oral and transdermal uses.
Granisetron is mainly metabolised to
Elimination
Granisetron is cleared primarily by hepatic metabolism. After intravenous dosing, the mean plasma clearance ranged from 33.4 to 75.7 l/h in healthy subjects and from 14.7 to 33.6 l/h in patients with wide
In clinical studies conducted with SANCUSO, clearance in cancer patients was shown to be approximately half that of healthy subjects.
After intravenous injection, approximately 12% of the dose is excreted unchanged in the urine of healthy subjects in 48 hours. The remainder of the dose is excreted as metabolites, with 49% in the urine and 34% in the faeces.
Pharmacokinetics in special populations
The effects of gender on the pharmacokinetics of SANCUSO have not been specifically studied. No consistent gender effects on pharmacokinetics were observed in clinical studies with SANCUSO, with a large
Elderly
In a clinical study no differences were seen in the plasma pharmacokinetics of SANCUSO in male and female elderly subjects (≥ 65 years) compared with younger subjects (aged
Renal or hepatic impairment
No clinical studies have been performed specifically to investigate the pharmacokinetics of SANCUSO in patients with renal or hepatic impairment. No clear relationship between renal function (as measured by creatinine clearance) and granisetron clearance was identified in population PK modelling. In patients with renal failure or hepatic impairment, the pharmacokinetics of granisetron were determined
following a single 40 g/kg intravenous dose of granisetron hydrochloride.
Hepatic impairment
In patients with hepatic impairment due to neoplastic liver involvement, total plasma clearance was approximately halved compared to patients without hepatic impairment. Given the wide variability in pharmacokinetic parameters of granisetron and the good tolerance well above the recommended dose, dose adjustment in patients with functional hepatic impairment is not necessary.
Renal impairment
No correlation between creatinine clearance and total clearance was observed in cancer patients, indicating no influence of renal impairment on the pharmacokinetics of granisetron.
Body Mass Index (BMI)
In a clinical study designed to assess granisetron exposure from SANCUSO in subjects with differing levels of body fat, using BMI as a surrogate measure for body fat, no differences were seen in the plasma pharmacokinetics of SANCUSO in male and female subjects with a low BMI [<19.5 kg/m2 (males), <18.5 kg/m2 (females)] and a high BMI (30.0 to 39.9 kg/m2 inclusive) compared to a control group (BMI 20.0 to 24.9 kg/m2inclusive).
Paediatric population
No studies have been performed to investigate the pharmacokinetics of SANCUSO in paediatrics.
5.3Preclinical safety data
Preclinical data did not reveal any special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, reproductive toxicity and genotoxicity. Carcinogenicity studies showed no special hazard for humans when used at the recommended dose. However, when administered in higher doses and over a prolonged period of time, the risk of carcinogenicity cannot be ruled out but with the short application period recommended for the transdermal delivery system, a carcinogenic risk for humans is not expected.
SANCUSO transdermal patches did not show any potential for photoirritation or photosensitivity when tested in vivo in
When tested for skin sensitising potential in guinea pigs, SANCUSO showed a low potential for irritancy.
A study in cloned human cardiac ion channels has shown that granisetron has the potential to affect cardiac repolarisation via blockade of hERG potassium channels. Granisetron has been shown to block both sodium and potassium channels, which could affect cardiac depolorisation and repolarisation and therefore PR, QRS, and QT intervals. These data help to clarify the mechanisms by which some of the ECG changes (particularly QT and QRS prolongation) associated with this class of substance can occur. However, no clinically relevant effects on ECG have been observed in clinical studies with SANCUSO, including a through QT study in 240 healthy subjects (section 5.1).
6.PHARMACEUTICAL PARTICULARS
6.1List of excipients
Backing layer
Polyester
Matrix layer
Release liner
Siliconised polyester
6.2Incompatibilities
Not applicable.
6.3Shelf life
3 years
6.4Special precautions for storage
Store in the original package in order to protect from light.
6.5Nature and contents of container
Each transdermal patch is packaged in a
Each carton contains 1 transdermal patch.
6.6Special precautions for disposal
The transdermal patch will still contain active substance following use. After removal, the used transdermal patch should be folded firmly in half, adhesive side inwards and then discarded out of the reach of children.
7.MARKETING AUTHORISATION HOLDER
Kyowa Kirin Limited
Galabank Business Park
Galashiels
TD1 1QH
United Kingdom
Tel: +44 (0)1896 664000
Fax: +44 (0)1896 664001
8.MARKETING AUTHORISATION NUMBER(S)
EU/1/12/766/001
9.DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
Date of first authorisation: 20 April 2012
Date of latest renewal: 9 January 2017
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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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