Eloxatin

Oxaliplatin.

1 ml concentrate for solution for infusion contains 5 mg oxaliplatin.
10 ml of concentrate for solution for infusion contains 50 mg of oxaliplatin.
20 ml of concentrate for solution for infusion contains 100 mg of oxaliplatin.
Excipients/Inactive Ingredients: Water for injections.

Pharmacotherapeutic group: other antineoplastic agents, platinum compounds. ATC code: L01XA 03.
Pharmacology: Pharmacodynamics: Mechanism of action: Oxaliplatin is an antineoplastic active substance belonging to a new class of platinum-based compounds in which the platinum atom is complexed with 1,2-diaminocyclohexane ("DACH") and an oxalate group.
Oxaliplatin is a single enantiomer, (SP-4-2)-[(1R,2R)-Cyclohexane-1,2-diamine-kN, kN'] [ethanedioato(2-)-kO¹, kO²] platinum.
Oxaliplatin exhibits a wide spectrum of both in vitro cytotoxicity and in vivo antitumour activity in a variety of tumour model systems including human colorectal cancer models. Oxaliplatin also demonstrates in vitro and in vivo activity in various cisplatin resistant models.
A synergistic cytotoxic action has been observed in combination with 5-fluorouracil (5-FU) both in vitro and in vivo.
Studies on the mechanism of action of oxaliplatin, although not completely elucidated, show that the aqua-derivatives resulting from the biotransformation of oxaliplatin, interact with DNA to form both inter and intra-strand cross-links, resulting in the disruption of DNA synthesis leading to cytotoxic and antitumour effects.
Clinical efficacy and safety: In patients with metastatic colorectal cancer, the efficacy of oxaliplatin (85 mg/m² repeated every two weeks) combined with 5-fluorouracil (5-FU)/folinic acid (5-FU/FA) is reported in three clinical studies: In front-line treatment, the 2-arm comparative phase III EFC2962 study randomised 420 patients either to 5-FU/FA alone (LV5FU2, N=210) or the combination of oxaliplatin with 5-FU/FA (FOLFOX4, N=210); In pretreated patients, the comparative three arms phase III study EFC4584 randomised 821 patients refractory to an irinotecan (CPT-11) + 5-FU/FA combination either to 5-FU/FA alone (LV5FU2, N=275), oxaliplatin single agent (N=275), or combination of oxaliplatin with 5-FU/FA (FOLFOX4, N=271); Finally, the uncontrolled phase II EFC2964 study included patients refractory to 5-FU/FA alone, that were treated with the oxaliplatin and 5-FU/FA combination (FOLFOX4, N=57).
The two randomised clinical trials, EFC2962 in front-line therapy and EFC4584 in pretreated patients, demonstrated a significantly higher response rate and a prolonged progression free survival (PFS)/time to progression (TTP) as compared to treatment with 5-FU/FA alone.
In EFC4584 performed in refractory pretreated patients, the difference in median overall survival (OS) between the combination of oxaliplatin and 5-FU/FA did not reach statistical significance. (See Tables 1, 2 and 3.)

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In pretreated patients (EFC4584), who were symptomatic at baseline, a higher proportion of those treated with oxaliplatin and 5-FU/FA experienced a significant improvement of their disease-related symptoms compared to those treated with 5 FU/FA alone (27.7% versus 14.6% p = 0.0033).
In non-pretreated patients (EFC2962), no statistically significant difference between the two treatment groups was found for any of the quality of life dimensions.
However, the quality of life scores were generally better in the control arm for measurement of global health status and pain and worse in the oxaliplatin arm for nausea and vomiting.
In the adjuvant setting, the MOSAÏC comparative phase III study (EFC3313) randomised 2246 patients (899 stage II/Dukes B2 and 1347 stage III/Dukes C) further to complete resection of the primary tumour of colon cancer either to 5-FU/FA alone (LV5FU2, N=1123 (B2/C = 448/675) or to combination of oxaliplatin and 5-FU/FA (FOLFOX4, N=1123 (B2/C) = 451/672). (See Table 4.)

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The study demonstrated an overall significant advantage in 3-year disease free survival for the oxaliplatin and 5-FU/FA combination (FOLFOX4) over 5-FU/FA alone (LV5FU2). (See Table 5.)

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Overall Survival (ITT analysis): At time of the analysis of the 3-year disease free survival, which was the primary endpoint of the MOSAIC trial, 85.1% of the patients were still alive in the FOLFOX4 arm versus 83.8% in the LV5FU2 arm. This translated into an overall reduction in mortality risk of 10% in favour of FOLFOX4 not reaching statistical significance (hazard ratio = 0.90).
The figures were 92.2% versus 92.4% in the stage II (Dukes B2) sub-population (hazard ratio = 1.01) and 80.4% versus 78.1% in the stage III (Dukes C) sub-population (hazard ratio = 0.87), for FOLFOX4 and LV5FU2, respectively.
Paediatric population: Oxaliplatin single agent has been evaluated in paediatric population in 2 Phase I (69 patients) and 2 Phase II (166 patients) studies. A total of 235 paediatric patients (7 months-22 years of age) with solid tumours have been treated. The effectiveness of oxaliplatin single agent in the paediatric populations treated has not been established.
Accrual in both Phase II studies was stopped for lack of tumours response.
Pharmacokinetics: Adsorption and distribution: The pharmacokinetics of individual active compounds have not been determined. The pharmacokinetics of ultrafiltrable platinum, representing a mixture of all unbound, active and inactive platinum species, following a two-hour infusion of oxaliplatin at 130 mg/m² every three weeks for 1 to 5 cycles and oxaliplatin at 85 mg/m² every two weeks for 1 to 3 cycles are as follows: See Table 6.

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At the end of a 2-hour infusion, 15% of the administered platinum is present in the systemic circulation, the remaining 85% being rapidly distributed into tissues or eliminated in the urine. Irreversible binding to red blood cells and plasma, results in half-lives in these matrices that are close to the natural turnover of red blood cells and serum albumin. No accumulation was observed in plasma ultrafiltrate following 85 mg/m² every two weeks or 130 mg/m² every three weeks and steady state was attained by cycle one in this matrix. Inter- and intra-subject variability is generally low.
Biotransformations: Biotransformation in vitro is considered to be the result of non-enzymatic degradation and there is no evidence of cytochrome P450-mediated metabolism of the diaminocyclohexane (DACH) ring.
Oxaliplatin undergoes extensive biotransformation in patients, and no intact active substance was detectable in plasma ultrafiltrate at the end of a 2h-infusion. Several cytotoxic biotransformation products including the monochloro-, dichloro- and diaquo-DACH platinum species have been identified in the systemic circulation together with a number of inactive conjugates at later time points.
Elimination: Platinum is predominantly excreted in urine, with clearance mainly in the 48 hours following administration.
By day 5, approximately 54% of the total dose was recovered in the urine and < 3% in the faeces.
Special populations: Renal impairment: The effect of renal impairment on the disposition of oxaliplatin was studied in patients with varying degrees of renal function. Oxaliplatin was administered at a dose of 85 mg/m² in the control group with a normal renal function (CLcr > 80 ml/min, n = 12) and in patients with mild (CLcr = 50 to 80 ml/min, n = 13) and moderate (CLcr = 30 to 49 ml/min, n = 11) renal impairment, and at a dose of 65 mg/m² in patients with severe renal impairment (CLcr < 30 ml/min, n = 5).
Median exposure was 9, 4, 6, and 3 cycles, respectively, and PK data at cycle 1 were obtained in 11, 13, 10 and 4 patients, respectively.
There was an increase in plasma ultrafiltrate (PUF) platinum AUC , AUC/dose and a decrease in total and renal CL and Vss with increasing renal impairment especially in the (small) group of patients with severe renal impairment: point estimates (90% CI) of estimated mean ratios by renal status versus normal renal function for AUC/dose were 1.36 (1.08, 1.71), 2.34 (1.82, 3.01) and 4.81 (3.49, 6.64) for patients with mild and moderate and in severe renal failure respectively.
Elimination of oxaliplatin is significantly correlated with the creatinine clearance. Total PUF platinum CL was respectively 0.74 (0.59, 0.92), 0.43 (0.33, 0.55) and 0.21 (0.15, 0.29) and for Vss respectively 0.52 (0.41, 0.65), 0.73 (0.59, 0.91) and 0.27 (0.20, 0.36) for patients with mild, moderate and severe renal failure respectively. Total body clearance of PUF platinum was therefore reduced by respectively 26% in mild, 57% in moderate, and 79% in severe renal impairment compared to patients with normal function.
Renal clearance of PUF platinum was reduced in patients with impaired renal function by 30% in mild, 65% in moderate, and 84% in severe renal impairment, compared to patients with normal function.
There was an increase in beta half life of PUF platinum with increasing degree of renal impairment mainly in the severe group. Despite the small number of patients with severe renal dysfunction, these data are of concern in patients in severe renal failure and should be taken into account when prescribing oxaliplatin in patients with renal impairment (see Dosage & Administration, Contraindications and Precautions).
Toxicology: Preclinical safety data: The target organs identified in preclinical species (mice, rats, dogs, and/or monkeys) in single- and multiple-dose studies included the bone marrow, the gastrointestinal system, the kidney, the testes, the nervous system, and the heart. The target organ toxicities observed in animals are consistent with those produced by other platinum-containing medicinal products and DNA-damaging, cytotoxic medicinal products used in the treatment of human cancers with the exception of the effects produced on the heart. Effects on the heart were observed only in the dog and included electrophysiological disturbances with lethal ventricular fibrillation. Cardiotoxicity is considered specific to the dog not only because it was observed in the dog alone but also because doses similar to those producing lethal cardiotoxicity in dogs (150 mg/m²) were well-tolerated by humans.
Preclinical studies using rat sensory neurons suggest that the acute neurosensory symptoms related to Oxaliplatin may involve an interaction with voltage-gated Na⁺ channels.
Oxaliplatin was mutagenic and clastogenic in mammalian test systems and produced embryo-fetal toxicity in rats. Oxaliplatin is considered a probable carcinogen, although carcinogenic studies have not been conducted.

Oxaliplatin in combination with 5-fluorouracil (5-FU) and folinic acid (FA) is indicated for: Adjuvant treatment of stage III (Dukes C) colon cancer after complete resection of primary tumour; Treatment of metastatic colorectal cancer.

The preparation of injectable solutions of cytotoxic agents must be carried out by trained specialist personnel with knowledge of the medicinal products used, in conditions that guarantee the integrity of the medicinal product, the protection of the environment and in particular the protection of the personnel handling the medicinal products, in accordance with the hospital policy. It requires a preparation area reserved for this purpose. It is forbidden to smoke, eat or drink in this area (see Warnings).
Posology: FOR ADULTS ONLY.
The recommended dose for oxaliplatin in adjuvant setting is 85 mg/m² intravenously repeated every two weeks for 12 cycles (6 months).
The recommended dose for oxaliplatin in treatment of metastatic colorectal cancer is 85 mg/m² intravenously repeated every 2 weeks until disease progression or unacceptable toxicity.
Dose given should be adjusted according to tolerability (see Precautions).
Oxaliplatin should always be administered before fluoropyrimidines - i.e. 5-fluorouracil (5 FU).
Oxaliplatin is administered as a 2- to 6-hour intravenous infusion in 250 to 500 ml of glucose 5% (50 mg/ml) solution to give a concentration between 0.2 mg/ml and 0.70 mg/ml; 0.70 mg/ml is the highest concentration in clinical practice for an oxaliplatin dose of 85 mg/m².
Oxaliplatin was mainly used in combination with continuous infusion 5-fluorouracil (5-FU) based regimens. For the two-weekly treatment schedule 5-fluorouracil (5-FU) regimens combining bolus and continuous infusion were used.
Special Populations: Renal impairment: Oxaliplatin must not be administered in patients with severe renal impairment (see Contraindications and Pharmacology: Pharmacokinetics under Actions).
In patients with mild to moderate renal impairment, the recommended dose of oxaliplatin is 85 mg/m² (see Precautions and Pharmacology: Pharmacokinetics under Actions).
Hepatic insufficiency: In a phase I study including patients with several levels of hepatic impairment, frequency and severity of hepato-biliary disorders appeared to be related to progressive disease and impaired liver function tests at baseline.
No specific dose adjustment for patients with abnormal liver function tests was performed during clinical development.
Elderly patients: No increase in severe toxicities was observed when oxaliplatin was used as a single agent or in combination with 5-fluorouracil (5-FU) in patients over the age of 65. In consequence no specific dose adaptation is required for elderly patients.
Paediatric patients: There is no relevant indication for use of oxaliplatin in children. The effectiveness of oxaliplatin single agent in the paediatric populations with solid tumours has not been established (see Pharmacology: Pharmacodynamics under Actions).
Method of administration: Oxaliplatin is administered by intravenous infusion.
The administration of oxaliplatin does not require hyperhydration.
Oxaliplatin diluted in 250 to 500 ml of glucose 5% (50 mg/ml) solution to give a concentration not less than 0.2 mg/ml must be infused via a central venous line or peripheral vein over 2 to 6 hours. Oxaliplatin infusion must always precede the administration of 5-fluorouracil (5-FU).
In the event of extravasation, administration must be discontinued immediately.
Instructions for use: Oxaliplatin must be diluted before use. Only glucose 5% (50 mg/ml) diluent is to be used to dilute the concentrate for solution for infusion product (see Special precautions for disposal under Cautions for Usage).

Symptoms: There is no known antidote to oxaliplatin. In cases of overdose, exacerbation of adverse events can be expected.
Management: Monitoring of haematological parameters should be initiated and symptomatic treatment given.

Oxaliplatin is contraindicated in patients who: have a known history of hypersensitivity to the active substance or to any of the excipients listed in Description; are breastfeeding; have myelosuppression prior to starting first course, as evidenced by baseline neutrophils <2x10⁹/L and/or platelet count of <100x10⁹/L; have a peripheral sensitive neuropathy with functional impairment prior to first course; have a severely impaired renal function (creatinine clearance less than 30 ml/min) (see Pharmacology: Pharmacokinetics under Actions).

Oxaliplatin should only be used in specialised departments of oncology and should be administered under the supervision of an experienced oncologist.
The preparation of injectable solutions of cytotoxic agents must be carried out by trained specialist personnel with knowledge of the medicines used, in conditions that guarantee the integrity of the medicinal product, the protection of the environment and in particular the protection of the personnel handling the medicines, in accordance with the hospital policy. It requires a preparation area reserved for this purpose. It is forbidden to smoke, eat or drink in this area.
Personnel must be provided with appropriate handling materials, notably long sleeved gowns, protection masks, caps, protective goggles, sterile single-use gloves, protective covers for the work area, containers and collection bags for waste.
Excreta and vomit must be handled with care.
Pregnant women must be warned to avoid handling cytotoxic agents.
Any broken container must be treated with the same precautions and considered as contaminated waste. Contaminated waste should be incinerated in suitably labelled rigid containers. See Special precautions for disposal: Disposal under Cautions for Usage.
If oxaliplatin concentrate or solution for infusion, should come into contact with skin, wash immediately and thoroughly with water.
If oxaliplatin concentrate or solution for infusion, should come into contact with mucous membranes, wash immediately and thoroughly with water.

Renal impairment: Patients with mild to moderate renal impairment should be closely monitored for adverse reactions and dose adjusted according to toxicity (see Pharmacology: Pharmacokinetics under Actions).
Hypersensitivity reactions: Special surveillance should be ensured for patients with a history of allergic manifestations to other products containing platinum. In case of anaphylactic manifestations the infusion should be interrupted immediately and an appropriate symptomatic treatment started. Re-administration of oxaliplatin to such patients is contraindicated. Cross reactions, sometimes fatal, have been reported with all platinum compounds.
In case of oxaliplatin extravasation, the infusion must be stopped immediately and usual local symptomatic treatment initiated.
Neurological symptoms: Neurological toxicity of oxaliplatin should be carefully monitored, especially if co-administered with other medicinal products with specific neurological toxicity. A neurological examination should be performed before each administration and periodically thereafter.
For patients who develop acute laryngopharyngeal dysaesthesia (see Adverse Reactions), during or within the hours following the 2-hour infusion, the next oxaliplatin infusion should be administered over 6 hours.
Peripheral neuropathy: If neurological symptoms (paraesthesia, dysaesthesia) occur, the following recommended oxaliplatin dose adjustment should be based on the duration and severity of these symptoms: If symptoms last longer than seven days and are troublesome, the subsequent oxaliplatin dose should be reduced from 85 to 65 mg/m² (metastatic setting) or 75 mg/m² (adjuvant setting); If paraesthesia without functional impairment persists until the next cycle, the subsequent oxaliplatin dose should be reduced from 85 to 65 mg/m² (metastatic setting) or 75 mg/m² (adjuvant setting); If paraesthesia with functional impairment persists until the next cycle, oxaliplatin should be discontinued; If these symptoms improve following discontinuation of oxaliplatin therapy, resumption of therapy may be considered.
Patients should be informed of the possibility of persistent symptoms of peripheral sensory neuropathy after the end of the treatment. Localized moderate paresthesias or paresthesias that may interfere with functional activities can persist after up to 3 years following treatment cessation in the adjuvant setting.
Reversible Posterior Leukoencephalopathy Syndrome (RPLS): Cases of Reversible Posterior Leukoencephalopathy Syndrome (RPLS, also known as PRES, Posterior Reversible Encephalopathy Syndrome) have been reported in patients receiving oxaliplatin in combination chemotherapy. RPLS is a rare, reversible, rapidly evolving neurological condition, which can include seizure, hypertension, headache, confusion, blindness, and other visual and neurological disturbances (see Adverse Reactions). Diagnosis of RPLS is based upon confirmation by brain imaging, preferably MRI (Magnetic Resonance Imaging).
Nausea, vomiting, diarrhoea, dehydration, and haematologic changes: Gastrointestinal toxicity, which manifests as nausea and vomiting, warrants prophylactic and/or therapeutic anti-emetic therapy (see Adverse Reactions).
Dehydration, paralytic ileus, intestinal obstruction, hypokalaemia, metabolic acidosis and renal impairment may be caused by severe diarrhoea/emesis particularly when combining oxaliplatin with 5-fluorouracil (5-FU).
Cases of intestinal ischaemia, including fatal outcomes, have been reported with oxaliplatin treatment. In case of intestinal ischaemia, oxaliplatin treatment should be discontinued and appropriate measures initiated (see Adverse Reactions).
If haematological toxicity occurs (neutrophils <1.5x10⁹/L or platelets <50x10⁹/L), administration of the next course of therapy should be postponed until haemotological values return to acceptable levels. A full blood count with white cell differential should be performed prior to start of therapy and before each subsequent course. Myelosuppressive effects may be additive to those of concomitant chemotherapy. Patient with severe and persistent myelosuppression are at high risk of infectious complications. Sepsis, neutropenic sepsis and septic shock have been reported in patients treated with oxaliplatin including fatal outcomes (see Adverse Reactions). If any of these events occurs, oxaliplatin should be discontinued.
Patients must be adequately informed of the risk of diarrhoea/emesis, mucositis/stomatitis and neutropenia after oxaliplatin and 5-fluorouracil (5-FU) administration so that they can urgently contact their treating physician for appropriate management.
If mucositis/stomatitis occurs with or without neutropenia, the next treatment should be delayed until recovery from mucositis/stomatitis to grade 1 or less and/or until the neutrophil count is ≥1.5x10⁹/L.
For oxaliplatin combined with 5-fluorouracil (5-FU) (with or without folinic acid (FA), the usual dose adjustments for 5-fluorouracil (5-FU) associated toxicities should apply.
If grade 4 diarrhoea, grade 3-4 neutropenia (neutrophils <1.0x10⁹/L), febrile neutropenia (fever of unknown origin without clinically or microbiologically documented infection with an absolute neutrophil count <1.0x10⁹/L, a single temperature of > 38.3°C or a sustained temperature of > 38°C for more than one hour), or grade 3-4 thrombocytopenia (platelets <50x10⁹/L) occur, the dose of oxaliplatin should be reduced from 85 to 65 mg/m² (metastatic setting) or 75 mg/m² (adjuvant setting), in addition to any 5-fluorouracil (5-FU) dose reductions required.
Pulmonary: In the case of unexplained respiratory symptoms such as non-productive cough, dyspnoea, crackles or radiological pulmonary infiltrates, oxaliplatin should be discontinued until further pulmonary investigations exclude an interstitial lung disease (see Adverse Reactions).
Blood disorders: Haemolytic-uraemic syndrome (HUS) is a life-threatening side effect (frequency not known). Oxaliplatin should be discontinued at the first signs of any evidence of microangiopathic haemolytic anaemia, such as rapidly falling haemoglobin with concomitant thrombocytopenia, elevation of serum bilirubin, serum creatinine, blood urea nitrogen, or LDH. Renal failure may not be reversible with discontinuation of therapy and dialysis may be required.
Disseminated intravascular coagulation (DIC), including fatal outcomes, has been reported in association with oxaliplatin treatment. If DIC is present, oxaliplatin treatment should be discontinued and appropriate treatment should be administered (see Adverse Reactions). Caution should be exercised in patients with conditions that are associated with DIC such as infections, sepsis, etc.
QT prolongation: QT prolongation may lead to an increased risk for ventricular arrhythmias including Torsade de Pointes, which can be fatal (see Adverse Reactions). The QT interval should be closely monitored on a regular basis before and after administration of oxaliplatin. Caution should be exercised in patients with a history or a predisposition for prolongation of QT, those who are taking medicinal products known to prolong QT interval, and those with electrolyte disturbances such as hypokalemia, hypocalcaemia, or hypomagnesaemia. In case of QT prolongation, oxaliplatin treatment should be discontinued (see Interactions and Adverse Reactions).
Rhabdomyolysis: Rhabdomyolysis has been reported in patients treated with oxaliplatin, including fatal outcomes. In case of muscle pain and swelling, in combination with weakness, fever or darkened urine, oxaliplatin treatment should be discontinued. If rhabdomyolysis is confirmed, appropriate measures should be taken. Caution is recommended if medicinal products associated with rhabdomyolysis are administered concomitantly with oxaliplatin (see Interactions and Adverse Reactions).
Gastrointestinal ulcer / Gastrointestinal ulcer haemorrhage and perforation: Oxaliplatin treatment can cause gastrointestinal ulcer and potential complications, such as gastrointestinal hemorrhage and perforation, which can be fatal. In case of gastrointestinal ulcer, oxaliplatin treatment should be discontinued and appropriate measures taken (see Adverse Reactions).
Hepatic: In case of abnormal liver function test results or portal hypertension which does not obviously result from liver metastases, very rare cases of drug-induced hepatic vascular disorders should be considered.
Fertility: Genotoxic effects were observed with oxaliplatin in the preclinical studies. Therefore male patients treated with oxaliplatin are advised not to father a child during and up to 6 months after treatment and to seek advice on conservation of sperm prior to treatment because oxaliplatin may have an anti-fertility effect which could be irreversible.
Women should not become pregnant during treatment with oxaliplatin and should use an effective method of contraception (see Use in Pregnancy & Lactation).
Peritoneal hemorrhage may occur when oxaliplatin is administered by intraperitoneal route (off-label route of administration).
Effects on ability to drive and use machines: No studies on the effects on the ability to drive and use machines have been performed. However oxaliplatin treatment resulting in an increase risk of dizziness, nausea and vomiting, and other neurologic symptoms that affect gait and balance may lead to a minor or moderate influence on the ability to drive and use machines.
Vision abnormalities, in particular transient vision loss (reversible following therapy discontinuation), may affect patients' ability to drive and use machines. Therefore, patients should be warned of the potential effect of these events on the ability to drive or use machines.
Use in Pregnancy: For use in pregnant women, see Use in Pregnancy & Lactation.

Pregnancy: To date there is no available information on safety of use in pregnant women. In animal studies, reproductive toxicity was observed. Consequently, oxaliplatin is not recommended during pregnancy and in women of childbearing potential not using contraceptive measures. The use of oxaliplatin should only be considered after suitably appraising the patient of the risk to the foetus and with the patient's consent.
Appropriate contraceptive measures must be taken during and after cessation of therapy during 4 months for women.
Breast-feeding: Excretion in breast milk has not been studied. Breast-feeding is contra-indicated during oxaliplatin therapy.
Fertility: Oxaliplatin may have an anti-fertility effect (see Precautions).
Due to the potential genotoxic effects of oxaliplatin, appropriate contraceptive measures must be taken during and after cessation of therapy during 4 months for women and 6 months for men.

Summary of the safety profile: The most frequent adverse events of oxaliplatin in combination with 5-fluorouracil (5-FU)/folinic acid (5-FU/FA) were gastrointestinal (diarrhoea, nausea, vomiting and mucositis), haematological (neutropenia, thrombocytopenia) and neurological (acute and dose cumulative peripheral sensory neuropathy). Overall, these adverse events were more frequent and severe with oxaliplatin and 5-FU/FA combination than with 5-FU/FA alone.
Tabulated list of adverse reactions: The frequencies reported in the following table are derived from clinical trials in the metastatic and adjuvant settings (having included 416 and 1108 patients respectively in the oxaliplatin + 5-FU/FA treatment arms) and from post marketing experience.
Frequencies in this table are defined using the following convention: very common (≥1/10), common (≥1/100, <1/10), uncommon (≥1/1000, <1/100), rare (≥1/10000, <1/1000), very rare (<1/10000), not known (cannot be estimated from the available data).
Further details are given after the table. (See Table 7.)

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Description of selected adverse reactions: Blood and lymphatic system disorders: See Table 8.

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Rare (>1/10000, <1/1000): Disseminated intravascular coagulation (DIC), including fatal outcomes (see Precautions).
Post-marketing experience with frequency not known: Haemolytic uremic syndrome; Autoimmune pancytopenia; Pancytopenia; Secondary leukemia.
Infections and infestations: See Table 9.

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Post-marketing experience with frequency not known: Septic shock, including fatal outcomes.
Immune system disorders: See Table 10.

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Nervous system disorders: The dose limiting toxicity of oxaliplatin is neurological. It involves a sensory peripheral neuropathy characterised by dysaesthesia and/or paraesthesia of the extremities with or without cramps, often triggered by the cold. These symptoms occur in up to 95% of patients treated. The duration of these symptoms, which usually regress between courses of treatment, increases with the number of treatment cycles.
The onset of pain and/or a functional disorder are indications, depending on the duration of the symptoms, for dose adjustment, or even treatment discontinuation (see Precautions).
This functional disorder includes difficulties in executing delicate movements and is a possible consequence of sensory impairment. The risk of occurrence of persistent symptoms for a cumulative dose of 850 mg/m² (10 cycles) is approximately 10% and 20% for a cumulative dose of 1020 mg/m² (12 cycles).
In the majority of the cases, the neurological signs and symptoms improve or totally recover when treatment is discontinued. In the adjuvant setting of colon cancer, 6 months after treatment cessation, 87% of patients had no or mild symptoms. After up to 3 years of follow up, about 3% of patients presented either with persisting localized paresthesias of moderate intensity (2.3%) or with paresthesias that may interfere with functional activities (0.5%).
Acute neurosensory manifestations (see Pharmacology: Toxicology: Preclinical safety data under Actions) have been reported. They start within hours of administration and often occur on exposure to cold. They usually present as transient paresthesia, dysesthesia and hypoesthesia. An acute syndrome of pharyngolaryngeal dysesthesia occurs in 1% - 2% of patients and is characterised by subjective sensations of dysphagia or dyspnoea / feeling of suffocation, without any objective evidence of respiratory distress (no cyanosis or hypoxia) or of laryngospasm or bronchospasm (no stridor or wheezing); Although antihistamines and bronchodilators have been administered in such cases, the symptoms are rapidly reversible even in the absence of treatment. Prolongation of the infusion helps to reduce the incidence of this syndrome (see Precautions). Occasionally other symptoms that have been observed include jaw spasm / muscle spasms / muscle contractions-involuntary / muscle twitching / myoclonus, coordination abnormal / gait abnormal / ataxia / balance disorders, throat or chest tightness/pressure/discomfort/pain. In addition, cranial nerve dysfunctions may be associated with previously mentioned events, or also occur as an isolated event such as ptosis, diplopia, aphonia/dysphonia/hoarseness, sometimes described as vocal cord paralysis, abnormal tongue sensation or dysarthria, sometimes described as aphasia, trigeminal neuralgia / facial pain / eye pain, decrease in visual acuity, visual field disorders.
Other neurological symptoms such as dysarthria, loss of deep tendon reflex and Lhermitte's sign were reported during treatment with oxaliplatin. Isolated cases of optic neuritis have been reported.
Post-marketing experience with frequency not known: Convulsion; Ischemic or haemorrhagic cerebrovascular disorder.
Cardiac disorders: Post-marketing experience with frequency not known: QT prolongation, which may lead to ventricular arrhythmias including Torsade de Pointes, which may be fatal (see Precautions); Acute coronary syndrome, including myocardial infarction and coronary arteriospasm and angina pectoris in patients treated with oxaliplatin in combination with 5-FU and bevacizumab.
Respiratory, thoracic and mediastinal disorders: Post-marketing experience with frequency not known: Laryngospasm; Pneumonia and bronchopneumonia, including fatal outcomes.
Gastrointestinal disorders: See Table 11.

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Prophylaxis and/or treatment with potent antiemetic agents is indicated.
Dehydration, paralytic ileus, intestinal obstruction, hypokalemia, metabolic acidosis and renal impairment may be caused by severe diarrhoea/emesis particularly when combining oxaliplatin with 5-fluorouracil (5-FU) (see Precautions).
Post-marketing experience with frequency not known: Intestinal ischaemia, including fatal outcomes (see Precautions); Gastrointestinal ulcer and perforation, which can be fatal (see Precautions); Oesophagitis.
Hepato-biliary disorders: Very rare (<1/10,000): Liver sinusoidal obstruction syndrome, also known as veno-occlusive disease of liver, or pathological manifestations related to such liver disorder, including peliosis hepatis, nodular regenerative hyperplasia, perisinusoidal fibrosis. Clinical manifestations may be portal hypertension and/or increased transaminases.
Musculoskeletal and connective tissue disorders: Post-marketing experience with frequency not known: Rhabdomyolysis, including fatal outcomes (see Precautions).
Renal and urinary disorders: Very rare (<1/10,000): Acute tubular necrosis, acute interstitial nephritis and acute renal failure.
Skin and subcutaneous tissue disorders: Post-marketing experience with frequency not known: Hypersensitivity vasculitis.

In patients who have received a single dose of 85 mg/m² of oxaliplatin, immediately before administration of 5-fluorouracil (5-FU), no change in the level of exposure to 5-fluorouracil (5-FU) has been observed.
In vitro, no significant displacement of oxaliplatin binding to plasma proteins has been observed with the following agents: erythromycin, salicylates, granisetron, paclitaxel, and sodium valproate.
Caution is advised when oxaliplatin treatment is co-administered with other medicinal products known to cause QT interval prolongation. In case of combination with such medicinal products, the QT interval should be closely monitored (see Precautions). Caution is advised when oxaliplatin treatment is administered concomitantly with other medicinal products known to be associated with rhabdomyolysis (see Precautions).

Special precautions for disposal: As with other potentially toxic compounds, caution should be exercised when handling and preparing oxaliplatin solutions.
Instructions for Handling: The handling of this cytotoxic agent by healthcare personnel requires every precaution to guarantee the protection of the handler and his surroundings.
Special precautions for administration: DO NOT use injection equipment containing aluminium.
DO NOT administer undiluted.
Only glucose 5% (50 mg/ml) infusion solution is to be used as a diluent. DO NOT dilute for infusion with sodium chloride or chloride containing solutions.
DO NOT mix with any other medicinal products in the same infusion bag or administer simultaneously by the same infusion line.
DO NOT mix with alkaline medicinal products or solutions, in particular 5-fluorouracil (5-FU), folinic acid (FA) preparations containing trometamol as an excipient and trometamol salts of others active substances. Alkaline medicinal products or solutions will adversely affect the stability of oxaliplatin.
Instructions for use with folinic acid (FA) (as calcium folinate or disodium folinate): Oxaliplatin 85 mg/m² intravenous infusion in 250 to 500 ml of glucose 5% (50 mg/ml) solution is given at the same time as folinic acid (FA) intravenous infusion in glucose 5% (50 mg/ml) solution, over 2 to 6 hours, using a Y-line placed immediately before the site of infusion. These two medicinal products should not be combined in the same infusion bag. Folinic acid (FA) must not contain trometamol as an excipient and must only be diluted using isotonic glucose 5% (50 mg/ml) solution, never in alkaline solutions or sodium chloride or chloride containing solutions.
Instructions for use with 5-fluorouracil (5-FU): Oxaliplatin should always be administered before fluoropyrimidines - i.e. 5-fluorouracil (5-FU).
After oxaliplatin administration, flush the line and then administer 5-fluorouracil (5-FU).
For additional information on medicinal products combined with oxaliplatin, see the corresponding manufacturer's summary of product characteristics.
Concentrate for solution for infusion: Inspect visually prior to use. Only clear solutions without particles should be used.
The medicinal product is for single use only. Any unused concentrate should be discarded.
Dilution for intravenous infusion: Withdraw the required amount of concentrate from the vial(s) and then dilute with 250 ml to 500 ml of a glucose 5% (50 mg/ml) solution to give an oxaliplatin concentration between 0.2 mg/ml and 0.7 mg/ml. The concentration range over which the physico-chemical stability of oxaliplatin has been demonstrated is 0.2 mg/ml to 2.0 mg/ml.
Administer by intravenous infusion.
After dilution in glucose 5% (50 mg/ml) solution, chemical and physical in-use stability has been demonstrated for 48 hours at +2°C and +8°C and for 24 hours at +25°C.
From a microbiological point of view, this infusion preparation should be used immediately.
If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2°C to 8°C unless dilution has taken place in controlled and validated aseptic conditions (not to exceed 48 hours).
Inspect visually prior to use. Only clear solutions without particles should be used.
The medicinal product is for single use only. Any unused infusion solution should be discarded (see Disposal as follows).
NEVER use sodium chloride or chloride containing solutions for dilution.
The compatibility of Oxaliplatin solution for infusion has been tested with representative, PVC-based, administration sets.
Infusion: The administration of oxaliplatin does not require prehydration.
Oxaliplatin diluted in 250 to 500 ml of a glucose 5% (50 mg/ml) solution to give a concentration not less than 0.2 mg/ml must be infused either by peripheral vein or central venous line over 2 to 6 hours. When oxaliplatin is administered with 5-fluorouracil (5-FU), the oxaliplatin infusion must precede the administration of 5-fluorouracil (5-FU).
Disposal: Remnants of the medicinal product as well as all materials that have been used for dilution and administration must be destroyed according to hospital standard procedures applicable to cytotoxic agents in accordance with local requirements related to the disposal of hazardous waste.
Incompatibilities: The diluted medicinal product should not be mixed with other medicinal products in the same infusion bag or infusion line. Under instructions for use as previously described in Special precautions for disposal, oxaliplatin can be co-administered with folinic acid (FA) via a Y-line.
DO NOT mix with alkaline medicinal products or solutions, in particular 5-fluorouracil (5-FU), folinic acid (FA) preparations containing trometamol as an excipient and trometamol salts of others active substances. Alkaline medicinal products or solutions will adversely affect the stability of oxaliplatin (see Special precautions for disposal as previously mentioned).
DO NOT dilute oxaliplatin with saline or other solutions containing chloride ions (including calcium, potassium or sodium chlorides).
DO NOT mix with other medicinal products in the same infusion bag or infusion line (see Special precautions for disposal as previously mentioned for instructions concerning simultaneous administration with folinic acid (FA)).
DO NOT use injection equipment containing aluminium.

Keep the vial in the outer carton in order to protect from light.
Do not freeze.
Shelf life: After dilution in glucose 5% (50 mg/ml), chemical and physical in-use stability has been demonstrated for 48 hours at +2°C to +8°C and for 24 hours at +25°C.
From a microbiological point of view, the solution for infusion should be used immediately.
If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2°C to 8°C unless dilution has taken place in controlled and validated aseptic conditions.

Cytotoxic Chemotherapy

L01XA03 - oxaliplatin ; Belongs to the class of platinum-containing antineoplastic agents. Used in the treatment of cancer.

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