Torisel · 4.5 Interaction with other medicinal products and other forms of interaction · 1

HOS-154228 · has-adverse-reaction-information · PDF-Seite 12

Summary of the safety profile The most serious reactions observed with temsirolimus in clinical trials are hypersensitivity/infusion reactions (including some life-threatening and rare fatal reactions), hyperglycaemia/glucose intolerance, infections, interstitial lung disease (pneumonitis), hyperlipaemia, intracranial haemorrhage, renal failure, intestinal perforation, wound healing complication, thrombocytopenia, neutropenia (including febrile neutropenia), pulmonary embolism. The adverse reactions (all grades) experienced by at least 20% of the patients in RCC and MCL registration studies include anaemia, nausea, rash (including rash, pruritic rash, maculopapular rash, pustular rash), decreased appetite, oedema asthenia, fatigue, thrombocytopenia, diarrhoea, pyrexia, epistaxis, mucosal inflammation, stomatitis, vomiting, hyperglycaemia, hypercholesterolemia, dysgeusia, pruritus, cough, infection, pneumonia, dyspnoea. Cataracts have been observed in some patients who received the combination of temsirolimus and IFN-α. Based on the results of the phase 3 studies, elderly patients may be more likely to experience certain adverse reactions, including face oedema, pneumonia, pleural effusion, anxiety, depression, insomnia, dyspnoea, leukopenia, lymphopenia, myalgia, arthralgia, ageusia, dizziness, upper respiratory infection, mucositis, and rhinitis. Serious adverse reactions observed in clinical trials of temsirolimus for advanced RCC, but not in clinical trials of temsirolimus for MCL include: anaphylaxis, impaired wound healing, renal failure with fatal outcomes, and pulmonary embolism. Serious adverse reactions observed in clinical trials of temsirolimus for MCL, but not in clinical trials of temsirolimus for advanced RCC include: thrombocytopenia, and neutropenia (including febrile neutropenia). See section 4.4 for additional information concerning serious adverse reactions, including appropriate actions to be taken if specific reactions occur. The occurrence of undesirable effects following the dose of 175 mg temsirolimus/week for MCL, e.g. Grade 3 or 4 infections or thrombocytopenia, is associated with a higher incidence than that observed with either 75 mg temsirolimus/week or conventional chemotherapy. Tabulated list of adverse reactions Adverse reactions that were reported in RCC and MCL patients in the phase 3 studies are listed below (Table 1), by system organ class, frequency and grade of severity (NCI-CTCAE). Frequencies are defined as

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HOS-154224 · has-contraindication-information · PDF-Seite 4

Hypersensitivity to temsirolimus, its metabolites (including sirolimus), polysorbate 80, or to any of the excipients listed in section 6.1. Use of temsirolimus in patients with MCL with moderate or severe hepatic impairment.

HOS-154223 · has-indication-information · PDF-Seite 2

Renal cell carcinoma Torisel is indicated for the first-line treatment of adult patients with advanced renal cell carcinoma (RCC) who have at least three of six prognostic risk factors (see section 5.1). Mantle cell lymphoma Torisel is indicated for the treatment of adult patients with relapsed and/or refractory mantle cell lymphoma (MCL) (see section 5.1).

HOS-154226 · has-interaction-information · PDF-Seite 9

Interaction studies have only been performed in adults. Concomitant use of temsirolimus with sunitinib The combination of temsirolimus and sunitinib resulted in dose-limiting toxicity. Dose-limiting toxicities (Grade 3/4 erythematous maculopapular rash, gout/cellulitis requiring hospitalisation) were observed in 2 out of 3 patients treated in the first cohort of a Phase 1 study at doses of temsirolimus 15 mg intravenous per week and sunitinib 25 mg oral per day (Days 1-28 followed by a 2-week rest) (see section 4.4). Concomitant use of angiotensin-converting enzyme (ACE) inhibitors and/or calcium channel blockers An increased incidence of angioneurotic oedema (including delayed reactions occurring two months following initiation of therapy) has been observed in patients who received temsirolimus or other mTOR inhibitors in combination with an ACE inhibitor (e.g. ramipril) and/or a calcium channel blocker (e.g. amlodipine) (see sections 4.4 and 4.8). Agents inducing CYP3A metabolism Co-administration of temsirolimus with rifampicin, a potent CYP3A4/5 inducer, had no significant effect on temsirolimus maximum concentration (Cmax) and area under the concentration vs. time curve (AUC) after intravenous administration, but decreased sirolimus Cmax by 65% and AUC by 56%, compared to temsirolimus treatment alone. Therefore, concomitant treatment with agents that have CYP3A4/5 induction potential should be avoided (e.g. carbamazepine, phenobarbital, phenytoin, rifampicin, and St. John’s wort) (see section 4.4). 9 Agents inhibiting CYP3A metabolism Co-administration of temsirolimus 5 mg with ketoconazole, a potent CYP3A4 inhibitor, had no significant effect on temsirolimus Cmax or AUC; however, sirolimus AUC increased 3.1-fold, and AUCsum (temsirolimus + sirolimus) increased 2.3-fold compared to temsirolimus alone. The effect on the unbound concentrations of sirolimus has not been determined, but is expected to be larger than the effect on whole-blood concentrations due to the saturable binding to red blood cells. The effect may also be more pronounced at a 25 mg dose. Therefore, substances that are potent inhibitors of CYP3A4 activity (e.g. nelfinavir, ritonavir, itraconazole, ketoconazole, voriconazole, nefazodone) increase sirolimus blood concentrations. Concomitant treatment of temsirolimus with these agents should be avoided (see section 4.4). Concomitant treatment with moderate CYP3A4 inhibitors (

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HOS-154227 · has-pregnancy-information · PDF-Seite 11

Women of childbearing potential/Contraception in males and females Due to the unknown risk related to potential exposure during early pregnancy, women of childbearing potential must be advised not to become pregnant while using Torisel. Men with partners of childbearing potential should use medically acceptable contraception while receiving Torisel (see section 5.3). Pregnancy There are no adequate data from the use of temsirolimus in pregnant women. Studies in animals have shown reproductive toxicity. In reproduction studies in animals, temsirolimus caused embryo/foetotoxicity that was manifested as mortality and reduced foetal weights (with associated delays in skeletal ossification) in rats and rabbits. Teratogenic effects (omphalocele) were seen in rabbits (see section 5.3). The potential risk for humans is unknown. Torisel must not be used during pregnancy, unless the risk for the embryo is justified by the expected benefit for the mother. The ethanol content of this product should also be taken into account for pregnant women (see section 4.4). Torisel contains propylene glycol (see section 4.4). Propylene glycol has not been shown to cause reproductive or developmental toxicity in animals or humans, however, it may reach the foetus. Administration of ≥50 mg/kg/day propylene glycol to pregnant women should only be considered on a case by case basis. Breast-feeding It is unknown whether temsirolimus is excreted in human breast milk. The excretion of temsirolimus in milk has not been studied in animals. However, sirolimus, the main metabolite of temsirolimus, is excreted in milk of lactating rats. Because of the potential for adverse reactions in breast-fed infants from temsirolimus, breast-feeding should be discontinued during therapy. The ethanol content of this product should be taken into account in women who are breast-feeding (see section 4.4). Torisel contains propylene glycol (see section 4.4). Propylene glycol has not been shown to cause reproductive or developmental toxicity in animals or humans, however, it has been found in milk and may be orally absorbed by a nursing infant. Administration of ≥50 mg/kg/day propylene glycol to lactating women should only be considered on a case by case basis. Fertility In male rats, decreased fertility and partly reversible reductions in sperm counts were reported (see section 5.3). 11

HOS-154225 · has-warning-information · PDF-Seite 4

The incidence and severity of adverse events is dose-dependent. Patients receiving the starting dose of 175 mg weekly for the treatment of MCL must be followed closely to decide on dose reductions/delays. Paediatric population Temsirolimus is not recommended for use in paediatric patients (see sections 4.2, 4.8 and 5.1). Elderly Based on the results of a Phase 3 study in RCC, elderly patients (65 years of age) may be more likely to experience certain adverse reactions, including oedema, diarrhoea, and pneumonia. Based on the 4 results of a Phase 3 study in MCL, elderly patients (65 years of age) may be more likely to experience certain adverse reactions, including pleural effusion, anxiety, depression, insomnia, dyspnoea, leukopenia, lymphopenia, myalgia, arthralgia, taste loss, dizziness, upper respiratory infection, mucositis, and rhinitis. Renal impairment/renal failure Temsirolimus elimination by the kidneys is negligible; studies in patients with varying renal impairment have not been conducted (see sections 4.2 and 5.2). Temsirolimus has not been studied in patients undergoing haemodialysis. Renal failure (including fatal outcomes) has been observed in patients receiving temsirolimus for advanced RCC and/or with pre-existing renal insufficiency (see section 4.8). Hepatic impairment Caution should be used when treating patients with hepatic impairment. Temsirolimus is cleared predominantly by the liver. In an open-label, dose-escalation Phase 1 study in 110 subjects with advanced malignancies and either normal or impaired hepatic function, concentrations of temsirolimus and its metabolite sirolimus were increased in patients with elevated aspartate aminotransferase (AST) or bilirubin levels. Assessment of AST and bilirubin levels is recommended before initiation of temsirolimus and periodically after. An increased rate of fatal events was observed in patients with moderate and severe hepatic impairment. The fatal events included those due to progression of disease; however a causal relationship cannot be excluded. Based on the Phase 1 study, no dose adjustment of temsirolimus is recommended for RCC patients with baseline platelet counts 100 x 109/l and mild to moderate hepatic impairment (total bilirubin up to 3 times upper limit of normal [ULN] with any abnormality of AST, or as defined by Child-Pugh Class A or B). For patients with RCC and severe hepatic impairment (total bilirubin

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