Uftoral 100 mg/224 mg hard capsules

Each Uftoral capsule contains tegafur (100 mg) and uracil (224 mg).

For excipients, see 6.1.

Capsule, hard

The capsules are white, opaque and imprinted with the code TC434.

Uftoral is indicated for firstline treatment of metastatic colorectal cancer in combination with calcium folinate (see 5.1).

Adults: the dose of Uftoral is 300 mg/m²/day tegafur and 672 mg/m²/day uracil combined with 90 mg/day oral calcium folinate, given in three divided doses (preferably every 8 hours). Calcium folinate should be taken at the same time as Uftoral. Doses should be taken at least one hour before or one hour after meals for 28 consecutive days. Subsequent cycles should start after 7 days without Uftoral/calcium folinate (i.e. 35 days per treatment cycle). The daily dose per body surface area (BSA) is presented below:

Dose modification: to manage toxicity, the following dose reduction and stopping guidelines are provided:

† Calcium folinate dose remains unchanged, even if < 3 Uftoral capsules/day are required. If Uftoral therapy is interrupted, calcium folinate must also be stopped. When Uftoral therapy is interrupted, doses that are missed during 28 consecutive days of treatment should not be taken later.

Adolescents, children, and infants: the safety and efficacy of the Uftoral and calcium folinate combination has not been established and should not be used in these patient populations (see 4.3).

Elderly: the elderly population has been well studied as 45% of patients studied were at least 65 years old and 26% of these were at least 75 years old. However, elderly patients should be monitored for agerelated impaired renal, hepatic or cardiac function or for concomitant medications or diseases (see 4.4 and 4.8).

Renal impairment: the effect of renal impairment on the excretion of Uftoral has not been assessed. Although the primary route of elimination for Uftoral is not renal, caution should be exercised in patients with impaired renal function. These patients should be monitored closely for any emergent toxicities (see 4.4).

Hepatic impairment: the effect of hepatic impairment on the elimination of Uftoral has not been assessed (see 4.3 and 4.4).

Uftoral is contraindicated in patients who:

• have a known hypersensitivity to 5FU, tegafur, uracil, or any of the excipients;

• are pregnant or attempting to become pregnant;

• are breast feeding;

• are adolescents, children or infants;

• have severe hepatic impairment;

• present with evidence of bone marrow suppression from previous radiotherapy or antineoplastic agents;

• have a known deficiency of hepatic CYP2A6;

• have a known or suspected dihydropyrimidine dehydrogenase deficiency;

• are treated or have recently been treated with dihydropyrimidine dehydrogenase inhibitors such as brivudine (see 4.5).

Patient compliance with oral therapy: the physician should instruct the patient on the importance of full compliance with the posology and method of administration of this medicinal product. Specific guidance on the importance of following physician recommendations for dose reductions or treatment interruptions in cases of emerging toxicities should be provided (see 4.2 and 4.8). Individual patient characteristics that may negatively impact on this compliance should be considered in the selection of therapy for this disease.

Patients receiving the Uftoral/calcium folinate combination should be monitored by a physician experienced in the use of cytotoxic agents and who has the facilities for regular monitoring of clinical, biochemical and haematological effects during and after administration of chemotherapy. Any emergent toxicity should be handled as described in dose modifications (see 4.2).

The Uftoral/calcium folinate combination should be used with caution in patients with, renal or hepatic impairment, signs and symptoms of bowel obstruction and in elderly patients.

Patients treated with coumarin anticoagulants (such as warfarin) concomitantly with Uftoral should be monitored regularly for alterations in prothrombin time or International Normalised Ratio.

Patients taking phenytoin concomitantly with Uftoral should be regularly monitored for increased phenytoin plasma concentrations.

Hepatic disorders: since hepatic disorders, including fatal fulminant hepatitis, have been reported in patients receiving single agent Uftoral, appropriate testing should be performed on any patient receiving the Uftoral/calcium folinate combination who presents signs and symptoms of hepatitis, other liver disease or hepatic impairment. Liver function should be monitored during treatment in patients with mild to moderate hepatic dysfunction.

Renal insufficiency: there is no experience with the Uftoral/calcium folinate combination in patients with renal impairment. Physicians should exercise caution when Uftoral/calcium folinate is administered to such patients.

Diarrhoea: Uftoral/calcium folinate often induces diarrhoea, however, this is mild in the majority of cases. Patients with severe diarrhoea should be carefully monitored and given fluid and electrolyte replacement to avoid the potentially fatal complications of dehydration (see 4.2). Special attention should also be paid to the requirement to withhold therapy with Uftoral/calcium folinate upon occurrence of grade 2 or worse diarrhoea.

Significant cardiac disease: caution should also be exercised in patients with a history of significant cardiac disease as myocardial ischaemia and angina have been associated with fluoropyrimidinebased therapy and rare cardiac events of uncertain causality, including myocardial infarction, have been reported in patients receiving Uftoral.

Pharmacokinetic interactions of Uftoral with other concomitantly administered medications have not been formally investigated.

Coadministration of 5-fluorouracil or its pro-drugs with medicinal products that inhibit dihydropyrimidine dehydrogenase, an enzyme responsible for the catabolism of endogenous and fluorinated pyrimidines, may lead to increased fluoropyrimidine toxicity which is potentially fatal. Therefore, Uftoral must not be co-administered with dihydropyrimidine dehydrogenase inhibitors such as brivudine. In patients treated with brivudine, a time interval of 4 weeks must be respected before administration of Uftoral to allow for recovery of enzyme activity.

Marked elevations in prothrombin time (PT) or International Normalised Ratio (INR) have been reported in patients stabilised on warfarin therapy following initiation of Uftoral therapy.

Increased phenytoin plasma concentrations resulting in symptoms of phenytoin intoxication have been reported with the concomitant use of Uftoral and phenytoin (see 4.4).

In vitro, tegafur is partially metabolised by CYP2A6 (see 4.3). Uftoral should be administered with caution in combination with substrates or inhibitors of this enzyme. e.g. coumarin, methoxypsoralen, clotrimazole, ketoconazole, miconazole. Neither tegafur nor uracil significantly inhibits the in vitro activity of CYP3A4 or CYP2D6. Furthermore, in vitro, tegafur is not metabolised by CYP1A1, 1A2, 2B6, 2C8, 2C9, 2C19, 2D6, 2E1, or 3A4 suggesting it is unlikely that there will be interactions with medications metabolised by these enzymes.

The absorption of Uftoral is affected by food (see 5.2).

Pregnancy: for Uftoral, no clinical data on exposed pregnancies are available. Uracil/tegafur is suspected to cause serious birth defects when administered during pregnancy. Uftoral is therefore contraindicated (see 4.3) in pregnancy. Contraceptive measures must be taken by both male and female patients during (and up to 3 months after) treatment. If pregnancy occurs during treatment with Uftoral, genetic counselling would be considered.

Lactation: it is not known whether tegafur, uracil, and 5FU are excreted in human milk following Uftoral administration. Because of the potential for serious adverse reactions in nursing infants, the use of Uftoral in lactating women is contraindicated (see 4.3).

The Uftoral/calcium folinate combination has not been demonstrated to interfere with the ability to drive or use machines. However, as confusion has occasionally been reported (see 4.8), patients should be advised to exercise caution.

Unless otherwise indicated, the undesirable effect information relates to the 594 patients that have been treated with Uftoral/calcium folinate combination in two Phase III trials with a median of 3 to 3.5 courses (see 5.1).

As with all cytotoxic agents, adverse reactions can be expected in the majority of patients. Most undesirable effects observed, including diarrhoea, nausea and vomiting were reversible and rarely required permanent discontinuation of therapy, although doses were withheld or reduced in some patients (see 4.2). The most common severe and clinically relevant adverse events, regardless of attribution to Uftoral/calcium folinate were diarrhoea (20%), nausea/vomiting (12%), abdominal pain (12%) and asthenia (9%).

Approximately 45% of these patients were 65 years of age, and about 26% of these were 75 years. No clinically relevant differences in safety were observed, although older patients tended to have a higher incidence of anaemia, diarrhoea and stomatitis/mucositis.

The following information specifies undesirable effects of any severity, reported at a frequency of 1% and attributed to Uftoral/calcium folinate. Additionally, terms are (^*) when severe and clinically relevant undesirable effects, regardless of treatment attribution to Uftoral/calcium folinate, were reported in a proportion of patients at a frequency of 0.1%.

[MedDRA convention: very common ( 10%), common ( 1% to < 10%) or uncommon ( 0.1% to < 1%)]:

Infections and infestations:

• common: moniliasis

• uncommon: infection *, sepsis *

Blood and lymphatic system disorders:

• very common: myelosuppression, anaemia, trombocytopenia, leukopenia, neutropenia

• uncommon: coagulation disorder *, febrile neutropenia

Metabolism and nutrition disorders:

• common: dehydration * cachexia *

Nervous system disorders:

• common: taste perversion *, taste loss, somnolence, dizziness, insomnia, depression, paresthesia, confusion *

Eye disorders:

• common: lacrimation, conjunctivitis

Cardiac disorders:

• common: peripheral oedema *

• uncommon: arrhythmia *, congestive heart failure *, myocardial infarction *, heart arrest *

Vascular disorders:

• common: deep thrombophlebitis *

• uncommon: shock *

Respiratory, thoracic and mediastinal disorders:

• common: dyspnoea *, increased coughing, pharyngitis

• uncommon: pulmonary embolism *

Gastrointestinal disorders:

• very common: diarrhoea *, nausea *, stomatitis *, anorexia, vomiting *, abdominal pain *

• common: constipation *, flatulence, dyspepsia, mucositis *, dry mouth, eructation, anorexia *, intestinal obstruction *

• uncommon: enteritis *, gastritis *, ileitis *, intestinal perforation *

Hepatobiliary disorders:

• uncommon: hepatitis ^*, jaundice ^*, liver failure ^*

Skin and subcutaneous tissue disorders:

• common: alopecia, rash, exfoliative dermatitis, skin discoloration, pruritus, photosensitivity, sweating, dry skin, nail disorder

Musculoskeletal, connective tissue and bone disorders:

• common: myalgia, back pain *, arthralgia *

Renal and urinary disorders:

• uncommon: abnormal kidney function *, urinary retention *, haematuria *

Reproductive system and breast disorders:

• uncommon: impotence *

General disorders and administration site conditions:

• very common: asthenia *

• common: fever *, headache, malaise, chills, pain *

• uncommon: chest pain *

Investigations:

• very common: increased alkaline phosphatase, increased ALT, increased AST, increased total bilirubin **

• common: weight loss *

(^**)Hyperbilirubinaemia was reported approximately twice as often when compared with the bolus 5FU/calcium folinate control arm. When reported, it was usually isolated, reversible and not associated with an adverse clinical outcome.

After marketing the following additional adverse reactions, have been reported for single-agent Uftoral. Only those adverse reactions that are not described in the Uftoral plus CF clinical trial experience are noted.

Infections and infestations:

• rare: leukoencephalopathy

Blood and lymphatic system disorders:

• very rare: haemolytic anaemia, myelodysplastic syndrome, acute myeloic leukaemia, acute promyelocytic leukaemia, agranulocytosis, pancytopenia, disseminated intravascular coagulation

Nervous system disorders:

• rare: anosmia, parosmia

• very rare: memory loss, movement disorders including extrapyramidal symptoms and paralysis in the extremities, speech disturbance, gait disturbance, disturbance of consciousness, hypoesthesia

Cardiac disorders:

• very rare: angina

Respiratory, thoracic and mediastinal disorders:

• rare: interstitial pneumonia

• very rare: pneumonia

Gastrointestinal disorders:

• very rare: acute pancreatitis, gastro/duodenal ulcer, enterocolitis, ileus paralytic, ascites, ischemic colitis

Hepato-biliary disorders:

• very rare: hepatic cirrhosis, fulminant hepatitis, hepatic fibrosis ***

Skin and subcutaneous tissue disorders:

• very rare: discoid lupus erythematosuslike eruption, skin dyscrasia (including blistering, and dermatitis), urticaria, Stevens Jonhson syndrome, palmar-plantar erythrodysaesthesia

Renal and urinary disorders:

• very rare: acute renal failure, nephrotic syndrome, urinary incontinence

General disorders and administration site conditions:

• rare: fatigue

• very rare: multi-organ failure

(^***) Very rare cases of mild to moderate hepatic fibrosis without elevation of serum transaminase levels have been reported in patients with elevated serum 7S collagen and PIIINP levels receiving Uftoral alone.

In case of overdosing, the frequency and severity of undesirable effects can increase, leading to possibly fatal conditions. Anticipated manifestations include nausea, vomiting, diarrhoea, gastrointestinal ulceration, bleeding, and bone marrow suppression (thrombocytopenia, leukopenia, and agranulocytosis). No specific antidote is available; supportive care should be provided.

Pharmacotherapeutic group/ATC code: antineoplastic agents, antimetabolites, pyrimidine analogues. L01B C.

Uftoral, an orally administered dihydropyrimidine dehydrogenase (DPD) inhibitory fluoropyrimidine, is a fixed molar ratio (1:4) of tegafur and uracil. Uracil is a competitive inhibitor of 5FU degradation.

The combined individual activities of uracil and calcium folinate give rise to dual biomodulation:

• Tegafur is an oral prodrug of 5FU and uracil reversibly inhibits DPD, the primary catabolic enzyme for 5FU, and

• Calcium folinate enhances the cytotoxicity of 5FU via one of its intracellular metabolites, 5,10methylenetetrahydrofolate.

5FU undergoes intracellular activation into its active metabolites, 5fluorodeoxyuridine-monophosphate (FdUMP) and 5fluorouridinetriphosphate (FUTP). FdUMP inhibits DNA synthesis by forming inhibitory tertiary complexes with thymidylate synthetase (TS) and reduced intracellular folates. FUTP is integrated into cellular RNA, causing disruption of RNA function. Following competitive inhibition of DPD by uracil, tegafurderived plasma concentrations of 5FU are elevated.

The efficacy of the Uftoral/calcium folinate combination in metastatic colorectal carcinoma has been established in 2 randomised and comparative phase III trials vs. the Mayo regimen (IV 5FU [425 mg/m²/day] and calcium folinate [20 mg/m²/day]) administered for 5 days every 4 weeks (study011) or every 5 weeks (study012).

In study 011 (n= 816), there was no statistically significant difference in the primary endpoint of survival between the two treatment arms. The median survival time was 12.4 months (95% CI: 11.213.6 months) and 13.4 months (95% CI: 11.615.4 months) in the Uftoral/calcium folinate and the 5FU/calcium folinate treatment groups, respectively. The hazard ratio for 5FU/calcium folinate over Uftoral/calcium folinate was 0.96 (95% CI: 0.831.13). The assessment of the secondary endpoint of time to progression in this study was complicated by the difference in cycle duration between the two treatment arms. The median time to progression was 3.5 months (95% CI: 3.04.4 months) and 3.8 months (95% CI: 3.65.0 months) in the Uftoral/calcium folinate and 5FU/calcium folinate treatment groups, respectively (p= 0.01).

In study 012 (n= 380), there was no statistically significant difference in the primary endpoint of time to progression nor in the secondary endpoint of survival between the two treatment arms. The median time to progression was 3.4 months (95% CI: 2.63.8 months) and 3.3 months (95% CI: 2.53.7 months) in the Uftoral/calcium folinate and 5FU/calcium folinate treatment groups, respectively. The median survival time was 12.2 months (95% CI: 10.413.8 months) and 10.3 months (95% CI: 8.213.0 months) in the Uftoral/calcium folinate and 5FU/calcium folinate treatment groups, respectively. The hazard ratio for 5FU/calcium folinate over Uftoral/calcium folinate was 1.14 (95% CI: 0.921.42).

In the firstline treatment of metastatic colorectal carcinoma, combinations of novel agents with 5FU have been authorised. However, the use of Uftoral in combination with novel agents is still under investigation.

The single dose and steadystate plasma pharmacokinetics of oral Uftoral have been evaluated in patients with colorectal cancer.

Absorption

Following Uftoral administration, tegafur and uracil are rapidly absorbed. C_max of tegafur, uracil, and 5FU were achieved within 1 to 2 hours. Concurrent administration of oral calcium folinate with Uftoral did not significantly alter the plasma pharmacokinetics of tegafur, uracil, or 5FU. Similarly, Uftoral did not affect the absorption of oral calcium folinate. Following a highfat meal, plasma AUC for uracil and 5FU were 66% and 37% lower, respectively, compared with Uftoral under fasting conditions. Plasma tegafur AUC was not significantly altered. C_max was reduced and delayed for tegafur, uracil, and 5FU.

Distribution

Following oral administration of Uftoral, plasma concentrations over time for Uftoral and uracil generally display monoexponential absorption and elimination processes. The mean apparent oral volume of distribution for tegafur and uracil following Uftoral dosing at steady state are 59 and 474 L, respectively. Serum protein binding is 52% for tegafur but negligible for uracil.

Metabolism

Conversion of tegafur to 5FU occurs via C5' oxidation (microsomal enzymes) and C2' hydrolysis (cytosolic enzymes). Microsomal oxidation of tegafur is partially mediated by CYP2A6. The cytosolic enzymes responsible for the metabolism of tegafur are not known. Other metabolic products of tegafur include 3'hydroxy tegafur, 4'hydroxy tegafur, and dihydro tegafur which are all significantly less cytotoxic than 5FU. The metabolism of 5FU formed from tegafur follows the intrinsic de novo pathways for the naturally occurring pyrimidine, uracil.

Neither tegafur, uracil or 5FU inhibited the catalytic conversion of cDNAderived cytochrome P450 CYP1A2, 2C9, 2C19, 2D6 and 3A4 at concentrations of at least 100 μM. This data suggests that Uftoral is unlikely to significantly alter the metabolic clearance of drugs metabolised by these routes.

Elimination

Less than 20% of tegafur is excreted intact into the urine. The terminal elimination halflives of tegafur and uracil following Uftoral are approximately 11 hours and 2040 minutes, respectively. The three hydroxy metabolites of tegafur are excreted in the urine. The plasma halflife for Stegafur (10.3 hours) is 4.4 times longer relative to Rtegafur (2.4 hours).

Following Uftoral 300 mg/m²/day, in three divided doses, tegafur plasma concentrations of > 1,000 ng/mL are maintained, whereas uracil concentrations decline rapidly following C_max 5FU plasma concentrations peak in 30 to 60 minutes at approximately 200 ng/mL, and remain detectable (> 1 ng/mL) over each 8hour dosing interval. No significant accumulation of tegafur, uracil or 5FU occurred over a 28day course of Uftoral therapy.

Linearity/NonLinearity

Following single dose Uftoral (100 to 400 mg), increases in plasma exposures (C_max and AUC) of tegafur were generally in proportion to dose. Increases in uracil and 5FU plasma exposures were greater than in proportion to dose.

Pharmacokinetics in Special Populations

A pooled statistical analysis of single dose Uftoral (200 mg) pharmacokinetic data (C_max and AUC) from three studies (46 patients, average age 60 years, 28 male, 18 female) did not identify clinically significant associations between patient age, gender and presence of metastatic liver involvement and the pharmacokinetics of tegafur, uracil or 5FU following single dose Uftoral. In view of the predominant reliance of hepatic processes for the metabolism and elimination of both tegafur and uracil, renal abnormalities are unlikely to have significant effect on the pharmacokinetics of Uftoral.

In rats and dogs, repeated dosing with Uftoral produces toxicity in the gastrointestinal tract, lymphoid organs, bone marrow, liver, kidney and testes. Round vacuoles, were observed histologically in the cerebrum of dogs that did not exhibit any clinical signs. With the exception of testicular changes and the vacuoles in the cerebrum of dogs, all of these findings were reversible.

Following Uftoral administration, tegafur, uracil and 5FU are excreted in breast milk in rats. Also in rats, Uftoral showed maternal toxicity and a decrease in conception rate. Embryomortality, foetal toxicity and teratogenicity were observed in rats, mice and rabbits. Uftoral was not mutagenic in bacterial strains but did induce chromosomal aberrations in Chinese Hamster Ovary cells and was genotoxic in a rat micronucleus test. Longterm animal carcinogenicity studies have not been conducted. However, the positive mutagenicity data are indicative of a carcinogenic potential.

Low-substituted hydroxypropylcellulose, sodium laurilsulfate.

Capsule shell: gelatin and titanium dioxide (E171).

Capsule shell imprints (edible ink): titanium dioxide (E171), synthetic iron oxide red (E172), carnauba wax, shellac and glyceryl monooleate.

Not applicable.

2 years

Do not store above 25°C

PVC/PVDC/Aluminium blisters.

Packs of 21, 28, 35, 36, 42, 56, 70, 84, 112, 120, 140 or 168 capsules.

Not all pack sizes may be marketed.

Procedures for the proper handling and disposal of cytotoxic drugs should be followed.

Merck Serono Ltd

Bedfont Cross

Stanwell Road

Feltham

Middlesex

TW14 8NX

UK

PL 11648/0065

31 October 2005

16 April 2009