Decapeptyl Sr 22.5mg Powder And Solvent For Suspension For Injection.
SUMMARY OF PRODUCT CHARACTERISTICS
1 NAME OF THE MEDICINAL PRODUCT
Decapeptyl SR 22.5mg powder and solvent for suspension for injection.
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
Triptorelin (I.N.N) 28mg as triptorelin pamoate.
The vial contains an overage to ensure that a dose of 22.5mg is administered to the patient.
For a full list of excipients see section 6.1.
3 PHARMACEUTICAL FORM
Powder and solvent for suspension for injection, sustained release formulation. Powder: White to off-white powder. Solvent: Clear solution.
4 CLINICAL PARTICULARS
4.1 Therapeutic indications
Treatment of patients with locally advanced, non-metastatic prostate cancer, as an alternative to surgical castration.
Treatment of metastatic prostate cancer.
As adjuvant treatment to radiotherapy in patients with high-risk localised or locally advanced prostate cancer.
As neoadjuvant treatment prior to radiotherapy in patients with high-risk localised or locally advanced prostate cancer.
As adjuvant treatment to radical prostatectomy in patients with locally advanced prostate cancer at high risk of disease progression.
4.2 Posology and method of administration
One intramuscular injection should be administered every 6 months.
As with other medicinal products administered by injection, the injection site should be varied periodically.
Since Decapeptyl SR 22.5 mg is a suspension of microparticles, inadvertent intravascular injection must be strictly avoided.
Safety and efficacy of Decapeptyl SR 22.5 mg has not been established in neonates, infants, children and adolescents, therefore Decapeptyl SR 22.5 mg is not indicated for use in these populations.
Decapeptyl is also available as a 1-month treatment (Decapeptyl SR 3 mg) and as a 3-month treatment (Decapeptyl SR 11.25 mg).
In patients treated with GnRH analogues for metastatic prostate cancer, treatment is usually continued upon development of castrate-resistant prostate cancer. Reference should be made to relevant guidelines.
4.3 Contraindications
Hypersensitivity to GnRH, its analogues or to any of the excipients of the medicinal product listed in section 6.1 (see also section 4.8).
4.4 Special warnings and precautions for use
The use of GnRH agonists may cause a reduction in bone mineral density. In men, preliminary data suggest that the use of a bisphosphonate in combination with a GnRH agonist may reduce bone mineral loss. No specific data is available for patients with established osteoporosis or with risk factors for osteoporosis (e.g. chronic alcohol abuse, smokers, long-term therapy with drugs that reduce bone mineral density, e.g. anti-convulsants or corticosteroids, family history of osteoporosis, malnutrition, e.g. anorexia nervosa). Particular caution is therefore necessary since reduction in bone mineral density is likely to be more detrimental in these patients. Treatment with Decapeptyl SR should be considered on an individual basis and only be initiated if the benefits of treatment outweigh the risk following a very careful appraisal. Consideration should be given to additional measures in order to counteract loss of bone mineral density.
Rarely, treatment with GnRH agonists may reveal the presence of a previously unknown gonadotroph cell pituitary adenoma. These patients may present with a pituitary apoplexy characterised by sudden headache, vomiting, visual impairment and ophthalmoplegia.
There is an increased risk of incident depression (which may be severe) in patients undergoing treatment with GnRH agonists, such as triptorelin. Patients should be informed accordingly and treated as appropriate if symptoms occur. Patients with known depression should be monitored closely during therapy.
Initially, Decapeptyl SR 22.5mg, like other GnRH agonists, causes a transient increase in serum testosterone levels. As a consequence, isolated cases of transient worsening of signs and symptoms of prostate cancer may occasionally develop during the first weeks of treatment. During the initial phase of treatment, consideration should be given to the additional administration of a suitable anti-androgen to counteract the initial rise in serum testosterone levels and the worsening of clinical symptoms.
A small number of patients may experience a temporary worsening of signs and symptoms of their prostate cancer (tumour flare) and temporary increase in cancer related pain (metastatic pain), which can be managed symptomatically.
As with other GnRH agonists, isolated cases of spinal cord compression or urethral obstruction have been observed. If spinal cord compression or renal impairment develops, standard treatment of these complications should be implemented, and in extreme cases, an immediate surgical castration considered. Careful monitoring is indicated during the first weeks of treatment, particularly in patients suffering from vertebral metastases, at risk of spinal cord compression, and in patients with urinary tract obstruction.
After surgical castration, triptorelin does not induce any further decrease in serum testosterone levels.
Long-term androgen deprivation either by bilateral orchidectomy or administration of GnRH agonists is associated with increased risk of bone loss and may lead to osteoporosis and increased risk of bone fracture.
Long-term androgen deprivation therapy may prolong the QT interval. Physicians should consider whether the benefits of androgen deprivation therapy outweigh the potential risks in patients with congenital long QT syndrome, electrolyte abnormalities, or congestive heart failure or in patients receiving class IA or class III antiarrhythmic medications
In addition, from epidemiological data, it has been observed that patients may experience metabolic changes (e.g. glucose intolerance), or an increased risk of cardiovascular disease during androgen deprivation therapy. Patients at high risk of metabolic or cardiovascular diseases should be carefully assessed before commencing treatment and their glucose, cholesterol and blood pressure adequately monitored during androgen deprivation therapy.
Metabolic changes may be more severe in these high-risk patients. Patients at high risk of metabolic or cardiovascular disease and receiving androgen deprivation therapy should be monitored at appropriate intervals not exceeding 3 months.
Administration of triptorelin in therapeutic doses results in suppression of the pituitary gonadal system. Normal function is usually restored after treatment is discontinued. Diagnostic tests of pituitary gonadal function conducted during treatment and after discontinuation of therapy with GnRH agonists may therefore be misleading.
Decapeptyl SR 22.5mg contains less than 1mmol (23mg) sodium per dose.
4.5 Interaction with other medicinal products and other forms of interaction
Drugs which raise prolactin levels should not be prescribed concomitantly as they reduce the level of GnRH receptors in the pituitary.When Decapeptyl SR 22.5mg is co-administered with drugs affecting pituitary secretion of gonadotropins, caution should be exercised and it is recommended that the patient’s hormonal status be supervised.
Since androgen deprivation treatment may prolong the QT interval, the concomitant use of triptorelin with medicinal products known to prolong the QT interval or medicinal products able to induce torsade de pointes such as class IA (e.g. quinidine, procainamide) or class III (e.g. amiodarone, sotalol) antiarrhythmic medicinal products should be carefully evaluated (see Section 4.4).
4.6 Pregnancy and lactation
Decapeptyl SR 22.5mg is not indicated for use in females.
Animal studies have shown effects on reproductive parameters (see section
5.3 Preclinical safety data).
4.7 Effects on ability to drive and use machines
No studies of the effects on the ability to drive and use machines have been performed. However, the ability to drive and use machines may be impaired should the patient experience dizziness, somnolence and visual disturbances (being possible undesirable effects of treatment), or resulting from the underlying disease.
4.8 Undesirable effects
Since patients suffering from locally advanced or metastatic, hormone-dependent prostate cancer are generally old and have other diseases frequently encountered in this aged population, more than 90 % of the patients included in clinical trials reported adverse events, and often the causality is difficult to assess. As seen with other GnRH agonist therapies or after surgical castration, the most commonly observed adverse events related to triptorelin treatment were due to its expected pharmacological effects. These effects included hot flushes and decreased libido.
With the exception of immuno-allergic (rare) and injection site (< 5 %) reactions, all adverse events are known to be related to testosterone changes.
The following adverse reactions considered as at least possibly related to triptorelin treatment were reported. Most of these events are known to be related to biochemical or surgical castration.
The frequency of the adverse reactions is classified as follows: very common ( >1/10); common (>1/100, < 1/10); uncommon (>1/1000, < 1/100); rare (> 1/10000, < 1/1000).
|
System Organ Class |
Very Common |
Common |
Uncommon |
Rare |
Additional postmarketing Frequency not known |
|
Blood and lymphatic system disorders |
Thrombocytos is | ||||
|
Cardiac disorders |
Palpitations | ||||
|
Ear and labyrinth disorders |
Tinnitus Vertigo | ||||
|
Eye disorders |
Visual impairment |
Abnormal sensation in eye Visual disturbance | |||
|
Gastrointestinal disorders |
Dry mouth Nausea |
Abdominal pain Constipation Diarrhoea Vomiting |
Abdominal distension Dysgeusia Flatulence |
|
General disorders and administration site conditions |
Asthenia |
Injection site reaction (including erythema inflammation and pain) Oedema |
Lethargy Oedema peripheral Pain Rigors Somnolence |
Chest pain Dysstasia Influenza like illness Pyrexia |
Malaise |
|
Immune system disorders |
Hypersensiti vity |
Anaphylactic reaction |
Anaphylact ic shock | ||
|
Infections and infestations |
Nasopharyng itis | ||||
|
Investigations |
Weight increase |
Alanine aminotransfera se increased Aspartate aminotransfera se increased, Blood creatinine increased Blood pressure increased Blood urea increased Gamma- glutamyl transferase increased Weight decreased |
Blood alkaline phosphatase increased | ||
|
Metabolism and nutrition disorders |
Anorexia Diabetes mellitus Gout Hyperlipidaem ia Increased appetite | ||||
|
Musculoskeletal and connective tissue disorders |
Back pain |
Musculoskel etal pain Pain in extremity |
Arthralgia Bone pain Muscle cramp Muscular weakness Myalgia |
Joint stiffness Joint swelling Musculoskel etal stiffness Osteoarthritis | |
|
Nervous system disorders |
Paraesthesia in lower limbs |
Dizziness Headache |
Paraesthesia |
Memory impairment | |
|
Psychiatric disorders |
Libido decreased |
Loss of libido Depression* |
Insomnia Irritability |
Confusional state Decreased |
Anxiety |
|
Mood changes* |
activity Euphoric mood | ||||
|
Renal and urinary disorders |
Nocturia Urinary retention |
Unrinary incontinenc e | |||
|
Reproductive system and breast disorders |
Erectile dysfunction (including ejaculation failure, ejaculation disorder) |
Pelvic plain |
Gynaecomasti a Breast pain Testicular atrophy Testicular pain | ||
|
Respiratory, thoracic and mediastinal disorders |
Dyspnoea Epitaxis |
Orthopnoea | |||
|
Skin and subcutaneous tissue disorders |
Hyperhidros is |
Acne Alopecia Erythema Pruritus Rash Urticaria |
Blister Purpura |
Angioneuro tic oedema | |
|
Vascular disorders |
Hot flush |
Hypertension |
Hypotension |
*This frequency is based on class-effect frequencies common for al
GnRH agonists
Triptorelin causes a transient increase in circulating testosterone levels within the first week after the initial injection of the sustained release formulation. With this initial increase in circulating testosterone levels, a small percentage of patients (< 5 %) may experience a temporary worsening of signs and symptoms of their prostate cancer (tumour flare), usually manifested by an increase in urinary symptoms (< 2%) and metastatic pain (5 %) which can be managed symptomatically. These symptoms are transient and usually disappear in one to two weeks. Isolated cases of exacerbation of disease symptoms, either urethral obstruction or spinal cord compression by metastasis have occurred. Therefore, patients with metastatic vertebral lesions and/or with upper or lower urinary tract obstruction should be closely observed during the first few weeks of therapy (see section 4.4 Special warnings and precautions for use).
The use of GnRH agonists to treat prostate cancer may be associated with increased bone loss and may lead to osteoporosis and increases the risk of bone fracture. This may also lead to an incorrect diagnosis of bone metastases.
Increased lymphocytes count has been reported with patients undergoing GnRH analogue treatment. This secondary lymphocytosis is apparently related to GnRH induced castration and seems to indicate that gonadal hormones are involved in thymic involution.
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 Y ellow Card Scheme at: www.mhra.gov.uk/yellowcard.
4.9 Overdose
The pharmaceutical properties of Decapeptyl SR 22.5mg and its mode of administration make accidental or intentional overdose unlikely. There is no human experience of overdose. Animal tests suggest that no effect other than the intended therapeutic effects on sex hormone concentration and on the reproductive tract will be evident with higher doses of Decapeptyl SR 22.5mg. If overdose occurs, this should be managed symptomatically.
5 PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic group:
Hormones and related agents, gonadotropin releasing hormone agonists. ATC code:
L02AE04
Mechanism of action and pharmacodynamic effects
Triptorelin, a GnRH agonist, acts as a potent inhibitor of gonadotropin secretion when given continuously and in therapeutic doses. In males, animal and human studies show that after administration of triptorelin there is an initial and transient increase in circulating levels of luteinising hormone (LH), follicle stimulating hormone (FSH), and testosterone.
However, chronic and continuous administration of triptorelin results in decreased LH and FSH secretion and suppression of testicular and ovarian steroidogenesis. A reduction of serum testosterone levels into the range normally seen after bilateral orchidectomy occurs approximately 2 to 4 weeks after initiation of therapy. Decapeptyl SR 22.5mg is designed to deliver 22.5mg of triptorelin over a 6-month period. Once the castration levels of testosterone have been achieved by the end of the first month, serum testosterone levels are maintained for as long as the patients receive their injection according to the recommended posology.
This results in accessory sexual organ atrophy. These effects are generally reversible upon discontinuation of the medicinal product. The effectiveness of treatment can be monitored by measuring serum levels of testosterone and prostate specific antigen. As shown during the clinical trial programme, there was a 97% median relative reduction in PSA at Month 6 for Decapeptyl SR 22.5mg.
In animals, administration of triptorelin resulted in the inhibition of growth of some hormone-sensitive prostate tumours in experimental models.
Clinical efficacy
Administration of Decapeptyl SR 22.5mg to patients with advanced prostate cancer as an intramuscular injection for a total of 2 doses (48 weeks) resulted in both achievement of castration levels of testosterone in 97.5% of patients after four weeks and maintenance of castration levels of testosterone in 93.0% of the patients from Month 2 through Month 12 of treatment.
In a phase III randomized clinical trial including 970 patients with locally advanced prostate cancer (mainly T2c-T4 with some T1c to T2b patients with pathological regional nodal disease) of whom 483 were assigned to short-term androgen suppression (6 months) in combination with radiation therapy and 487 to long-term therapy (3 years), a non-inferiority analysis compared the short-term to long-term concomitant and adjuvant hormonal treatment with triptorelin (62.2%) or goserelin (30.1%). The 5-year overall mortality was 19.0% and 15.2%, in the short-term and long-term groups, respectively. The observed Hazard Ratio of 1.42 with an upper one-sided 95.71% CI of 1.79 or two-sided 95.71% CI of 1.09; 1.85 (p = 0.65 for non-inferiority), demonstrate that the combination of radiotherapy plus 6 months of androgen deprivation therapy provides inferior survival as compared with radiotherapy plus 3 years of androgen deprivation therapy. Overall survival at 5 years of long-term treatment and short-term treatment shows 84.8% survival and 81.0%, respectively.
Overall quality of life using QLQ-C30 did not differ significantly between the two groups (p= 0.37).
Neoadjuvant triptorelin prior to radiotherapy has been shown to significantly reduce prostate volume.
The use of a GnRH agonist may be considered after radical prostatectomy in selected patients considered at high risk of disease progression. There are no disease-free survival data or survival data with triptorelin in this setting.
5.2 Pharmacokinetic properties
Absorption:
Following a single intramuscular injection of Decapeptyl SR 22.5mg in patients with prostate cancer, Tmax was 3 (2-12) hours and Cmax (0-169 days) was 40.0 (22.2-76.8)ng/mL. Triptorelin did not accumulate over 12 months of treatment.
Distribution:
Results of pharmacokinetic investigations conducted in healthy men indicate that after intravenous bolus administration, triptorelin is distributed and eliminated according to a 3-compartment model and corresponding half-lives are approximately 6 minutes, 45 minutes, and 3 hours.
The volume of distribution at steady state of triptorelin following intravenous administration of 0.5mg triptorelin is approximately 30L in healthy male volunteers. Since there is no evidence that triptorelin at clinically relevant concentrations binds to plasma proteins, medicinal product interactions involving binding-site displacement are unlikely.
Biotransformation:
Metabolites of triptorelin have not been determined in humans. However, human pharmacokinetic data suggest that C-terminal fragments produced by tissue degradation are either completely degraded within tissues or are rapidly further degraded in plasma, or cleared by the kidneys.
Elimination:
Triptorelin is eliminated by both the liver and the kidneys. Following intravenous administration of 0.5mg triptorelin to healthy male volunteers, 42% of the dose was excreted in urine as intact triptorelin, which increased to 62% in subjects with hepatic impairment. Since creatinine clearance (Clcreat) in healthy volunteers was 150mL/min and only 90mL/min in subjects with hepatic impairment, this indicates that the liver is a major site of triptorelin elimination. In these healthy volunteers, the true terminal half-life of triptorelin was 2.8 hours and total clearance of triptorelin 212mL/min, the latter being dependent on a combination of hepatic and renal elimination.
Special populations:
Following intravenous administration of 0.5mg triptorelin to subjects with moderate renal insufficiency (Clcreat 40mL/min), triptorelin had an elimination half-life of 6.7 hours, 7.81 hours in subjects with severe renal insufficiency (Clcreat 8.9mL/min) and 7.65 hours in patients with impaired hepatic function (Clcreat 89.9 mL/min).
The effects of age and race on triptorelin pharmacokinetics have not been systematically studied. However, pharmacokinetic data obtained in young healthy male volunteers aged 20 to 22 years with an elevated creatinine clearance (approximately 150mL/min) indicated that triptorelin was eliminated twice as fast in the young population. This is related to the fact that triptorelin clearance is correlated to total creatinine clearance, which is well known to decrease with age.
Because of the large safety margin of triptorelin and since Decapeptyl SR 22.5mg is a sustained release formulation, no dose adjustment is recommended in patients with renal or hepatic impairment.
Pharmacokinetic/pharmacodynamic relationship
The pharmacokinetics/pharmacodynamics relationship of triptorelin is not straightforward to assess, since it is non-linear and time-dependent. Thus, after acute administration in naive subjects, triptorelin induces a dose-dependent increase of LH and FSH responses.
When administered as a sustained release formulation, triptorelin stimulates LH and FSH secretion during the first days post dosing and, in consequence, testosterone secretion. As shown by the results of the different bioequivalence studies, the maximal increase in testosterone is reached after around 4 days with an equivalent Cmax which is independent from the release rate of triptorelin. This initial response is not maintained despite continuous exposure to triptorelin and is followed by a progressive and equivalent decrease of testosterone levels. In this case too, the extent of triptorelin exposure can vary markedly without affecting the overall effect on testosterone serum levels.
5.3 Preclinical safety data
The compound did not demonstrate any specific toxicity in animal toxicological studies. The effects observed are related to the pharmacological properties of triptorelin on the endocrine system.
6 PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Powder:
poly (d,l-lactide-co-glycolide) mannitol
carmellose sodium polysorbate 80
Solvent:
water for injections
6.2 Incompatibilities
In the absence of compatibility studies, this medicinal product must not be reconstituted with other medicinal products.
6.3 Shelf life
3 years.
6.4 Special precautions for storage
Do not store above 25oC. Keep the container in the outer carton. The reconstituted suspension for injection should be used immediately.
6.5 Nature and contents of container
6mL septum vial with bromobutyl stopper and aluminium flip-off cap. Ampoule containing 2mL of sterile solvent for suspension.
Box of:
1 vial, 1 ampoule and 1 blister containing 1 injection syringe and 2 injection needles.
6.6 Special precautions for disposal and other handling
The suspension for injection must be reconstituted using an aseptic technique and only using the ampoule of solvent for injection.
The instructions for reconstitution hereafter and in the leaflet must be strictly followed.
The solvent should be drawn into the syringe provided using the reconstitution needle (20 G, without safety device) and transferred to the vial containing the powder. The suspension should be reconstituted by swirling the vial gently from side to side for long enough until a homogeneous, milky suspension is formed. Do not invert the vial. It is important to check there is no unsuspended powder in the vial. The suspension obtained should then be drawn back into the syringe, without inverting the vial. The reconstitution needle should then be changed and the injection needle (20 G, with safety device) used to administer the product.
As the product is a suspension, the injection should be administered immediately after reconstitution to prevent precipitation.
For single use only.
Used needles, any unused suspension or other waste materials should be disposed of in accordance with local requirements.
7 MARKETING AUTHORISATION HOLDER
Ipsen Limited
190 Bath Road Slough SL1 3XE
United Kingdom
8 MARKETING AUTHORISATION NUMBER(S)
PL 34926/0013
9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
14/09/2010
10 DATE OF REVISION OF THE TEXT
28/04/2016