Gemcitabine (Page 3 of 8)

5.3 Pulmonary Toxicity and Respiratory Failure

Pulmonary toxicity, including interstitial pneumonitis, pulmonary fibrosis, pulmonary edema, and adult respiratory distress syndrome (ARDS), has been reported. In some cases, these pulmonary events can lead to fatal respiratory failure despite the discontinuation of therapy. The onset of pulmonary symptoms may occur up to 2 weeks after the last dose of gemcitabine for injection [see Adverse Reactions (6.1, 6.2)].

Permanently discontinue gemcitabine for injection in patients who develop unexplained dyspnea, with or without bronchospasm, or evidence of severe pulmonary toxicity.

5.4 Hemolytic Uremic Syndrome

Hemolytic uremic syndrome (HUS), including fatalities from renal failure or the requirement for dialysis, can occur with gemcitabine for injection. In clinical trials, HUS occurred in 0.25% of 2429 patients. Most fatal cases of renal failure were due to HUS [see Adverse Reactions (6.1)]. Serious cases of thrombotic microangiopathy other than HUS have been reported with gemcitabine for injection [see Adverse Reactions (6.2)].

Assess renal function prior to initiation of gemcitabine for injection and periodically during treatment. Consider the diagnosis of HUS in patients who develop anemia with evidence of microangiopathic hemolysis; increased bilirubin or LDH; reticulocytosis; severe thrombocytopenia; or renal failure (increased serum creatinine or BUN). Permanently discontinue gemcitabine for injection in patients with HUS or severe renal impairment. Renal failure may not be reversible even with the discontinuation of therapy.

5.5 Hepatic Toxicity

Drug-induced liver injury, including liver failure and death, has been reported in patients receiving gemcitabine for injection alone or with other potentially hepatotoxic drugs [see Adverse Reactions (6.1, 6.2)]. Administration of gemcitabine for injection in patients with concurrent liver metastases or a pre-existing medical history of hepatitis, alcoholism, or liver cirrhosis can lead to exacerbation of the underlying hepatic insufficiency. Assess hepatic function prior to initiation of gemcitabine for injection and periodically during treatment. Permanently discontinue gemcitabine for injection in patients who develop severe hepatic toxicity.

5.6 Embryo-Fetal Toxicity

Based on animal data and its mechanism of action, gemcitabine for injection can cause fetal harm when administered to a pregnant woman. Gemcitabine was teratogenic, embryotoxic, and fetotoxic in mice and rabbits.

Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment with gemcitabine for injection and for 6 months after the final dose. Advise male patients with female partners of reproductive potential to use effective contraception during treatment with gemcitabine for injection and for 3 months following the final dose [see Use in Specific Populations (8.1, 8.3)].

5.7 Exacerbation of Radiation Therapy Toxicity

Gemcitabine for injection is not recommended for use in combination with radiation therapy.

Concurrent (given together or ≤7 days apart)

Life-threatening mucositis, especially esophagitis and pneumonitis occurred in a trial in which gemcitabine for injection was administered at a dose of 1000 mg/m2 to patients with non-small cell lung cancer for up to 6 consecutive weeks concurrently with thoracic radiation.

Non-concurrent (given >7 days apart)

Excessive toxicity has not been observed when gemcitabine for injection is administered more than 7 days before or after radiation. Radiation recall has been reported in patients who received gemcitabine for injection after prior radiation.

5.8 Capillary Leak Syndrome

Capillary leak syndrome (CLS) with severe consequences has been reported in patients receiving gemcitabine for injection as a single agent or in combination with other chemotherapeutic agents [see Adverse Reactions (6.2)]. Permanently discontinue gemcitabine for injection if CLS develops during therapy.

5.9 Posterior Reversible Encephalopathy Syndrome

Posterior reversible encephalopathy syndrome (PRES) has been reported in patients receiving gemcitabine for injection as a single agent or in combination with other chemotherapeutic agents [see Adverse Reactions (6.2)]. PRES can present with headache, seizure, lethargy, hypertension, confusion, blindness, and other visual and neurologic disturbances. Confirm the diagnosis of PRES with magnetic resonance imaging (MRI). Permanently discontinue gemcitabine for injection if PRES develops during therapy.

6 ADVERSE REACTIONS

The following clinically significant adverse reactions are described elsewhere in the labeling:

  • Hypersensitivity [see Contraindications (4)]
  • Schedule-Dependent Toxicity [see Warnings and Precautions (5.1)]
  • Myelosuppression [see Warnings and Precautions (5.2)]
  • Pulmonary Toxicity and Respiratory Failure [see Warnings and Precautions (5.3)]
  • Hemolytic Uremic Syndrome [see Warnings and Precautions (5.4)]
  • Hepatic Toxicity [see Warnings and Precautions (5.5)]
  • Exacerbation of Radiation Therapy Toxicity [see Warnings and Precautions (5.7)]
  • Capillary Leak Syndrome [see Warnings and Precautions (5.8)]
  • Posterior Reversible Encephalopathy Syndrome [see Warnings and Precautions (5.9)]

6.1 Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Single Agent

The data described below reflect exposure to gemcitabine for injection as a single agent administered at doses between 800 mg/m2 to 1250 mg/m2 intravenously over 30 minutes once weekly in 979 patients with various malignancies. The most common (≥20%) adverse reactions of single agent gemcitabine for injection are nausea/vomiting, anemia, increased alanine aminotransferase (ALT), increased aspartate aminotransferase (AST), neutropenia, increased alkaline phosphatase, proteinuria, fever, hematuria, rash, thrombocytopenia, dyspnea, and edema. The most common (≥5%) Grade 3 or 4 adverse reactions were neutropenia, nausea/vomiting, increased ALT, increased alkaline phosphatase, anemia, increased AST, and thrombocytopenia. Approximately 10% of the 979 patients discontinued gemcitabine for injection due to adverse reactions. Adverse reactions resulting in discontinuation of gemcitabine for injection in 2% of 979 patients were cardiovascular adverse reactions (myocardial infarction, cerebrovascular accident, arrhythmia, and hypertension) and adverse reactions resulting in discontinuation of gemcitabine for injection in <1% of 979 patients were anemia, thrombocytopenia, hepatic dysfunction, renal dysfunction, nausea/vomiting, fever, rash, dyspnea, hemorrhage, infection, stomatitis, somnolence, flu-like syndrome, and edema.

Tables 5 and 6 present the incidence of selected adverse reactions and laboratory abnormalities reported in patients with various malignancies receiving single agent gemcitabine for injection across 5 clinical trials. Additional clinically significant adverse reactions are provided following Table 6.

Table 5: Selected Adverse Reactions Occurring in ≥10% of Patients Receiving Single Agent Gemcitabine For Injectiona

a Grade based on criteria from the World Health Organization (WHO).

b For approximately 60% of patients, non-laboratory adverse reactions were graded only if assessed to be possibly drug-related.

c N=699-974; all patients with laboratory or non-laboratory data.

Adverse Reactions b Gemcitabine For Injection c
All Grades (%) Grade 3 (%) Grade 4 (%)
Nausea and Vomiting 69 13 1
Fever 41 2 0
Rash 30 <1 0
Dyspnea 23 3 <1
Diarrhea 19 1 0
Hemorrhage 17 <1 <1
Infection 16 1 <1
Alopecia 15 <1 0
Stomatitis 11 <1 0
Somnolence 11 <1 <1
Paresthesias 10 <1 0
Table 6: Selected Laboratory Abnormalities Occurring in Patients Receiving Single Agent Gemcitabine For Injectiona

a Grade based on criteria from the WHO.

b Regardless of causality.

c N=699-974; all patients with laboratory or non-laboratory data.

Laboratory Abnormality b Gemcitabine For Injection c
All Grades (%) Grade 3 (%) Grade 4 (%)
Hematologic
Anemia 68 7 1
Neutropenia 63 19 6
Thrombocytopenia 24 4 1
Hepatic
Increased ALT 68 8 2
Increased AST 67 6 2
Increased Alkaline Phosphatase 55 7 2
Hyperbilirubinemia 13 2 <1
Renal
Proteinuria 45 <1 0
Hematuria 35 <1 0
Increased BUN 16 0 0
Increased Creatinine 8 <1 0

Additional adverse reactions include the following:

  • Transfusion requirements: Red blood cell transfusions (19%); platelet transfusions (<1%)
  • Edema: Edema (13%), peripheral edema (20%), generalized edema (<1%)
  • Flu-like symptoms: Fever, asthenia, anorexia, headache, cough, chills, myalgia, asthenia insomnia, rhinitis, sweating, and/or malaise (19%)
  • Infection: Sepsis (<1%)
  • Extravasation: Injection-site reactions (4%)
  • Allergic: Bronchospasm (<2%); anaphylactoid reactions

Ovarian Cancer

Tables 7 and 8 present the incidence of selected adverse reactions and laboratory abnormalities, occurring in ≥10% of gemcitabine for injection-treated patients and at a higher incidence in the gemcitabine for injection with carboplatin arm, reported in a randomized trial (Study 1) of gemcitabine for injection with carboplatin (n=175) compared to carboplatin alone (n=174) for the second-line treatment of ovarian cancer in women with disease that had relapsed more than 6 months following first-line platinum-based chemotherapy [see Clinical Studies (14.1)]. Additional clinically significant adverse reactions, occurring in <10% of patients, are provided following Table 8.

The proportion of patients with dose adjustments for carboplatin (1.8% versus 3.8%), doses of carboplatin omitted (0.2% versus 0) and discontinuing treatment for adverse reactions (11% versus 10%), were similar between arms. Dose adjustment for gemcitabine for injection occurred in 10% of patients and gemcitabine for injection dose was omitted in 14% of patients in the gemcitabine for injection/carboplatin arm.

Table 7: Adverse Reactions Occurring in >10% of Patients Receiving Gemcitabine with Carboplatin and at Higher Incidence than in Patients Receiving Single Agent Carboplatin [Between Arm Difference of ≥5% (All Grades) or ≥2% (Grades 3-4)] in Study 1a

a Grade based on National Cancer Institute CTC Version 2.0.

b Regardless of causality.

Adverse Reactions b Gemcitabine for Injection/Carboplatin (N=175) Carboplatin (N=174)
All Grades (%) Grade 3 (%) Grade 4 (%) All Grades (%) Grade 3 (%) Grade 4 (%)
Nausea 69 6 0 61 3 0
Alopecia 49 0 0 17 0 0
Vomiting 46 6 0 36 2 <1
Constipation 42 6 1 37 3 0
Fatigue 40 3 <1 32 5 0
Diarrhea 25 3 0 14 <1 0
Stomatitis/Pharyngitis 22 <1 0 13 0 0
Table 8: Laboratory Abnormalities Occurring in Patients Receiving Gemcitabine with Carboplatin and at Higher Incidence than in Patients Receiving Single Agent Carboplatin [Between Arm Difference of ≥5% (All Grades) or ≥2% (Grades 3-4)] in Study 1a

a Grade based on National Cancer Institute CTC Version 2.0.

b Regardless of causality.

c Percent of patients receiving transfusions. Transfusions are not CTC-graded events. Blood transfusions included both packed red blood cells and whole blood.

Laboratory Abnormality b Gemcitabine for Injection/Carboplatin (N=175) Carboplatin (N=174)
All Grades (%) Grade 3 (%) Grade 4 (%) All Grades (%) Grade 3 (%) Grade 4 (%)
Hematologic
Neutropenia 90 42 29 58 11 1
Anemia 86 22 6 75 9 2
Thrombocytopenia 78 30 5 57 10 1
RBC Transfusionsc 38 15
Platelet Transfusionsc 9 3

Hematopoietic growth factors were administered more frequently in the gemcitabine for injection-containing arm: leukocyte growth factor (24% and 10%) and erythropoiesis-stimulating agent (7% and 3.9%).

The following clinically relevant Grade 3 and 4 adverse reactions occurred more frequently in the gemcitabine for injection with carboplatin arm: dyspnea (3.4% versus 2.9%), febrile neutropenia (1.1% versus 0), hemorrhagic event (2.3% versus 1.1 %), motor neuropathy (1.1% versus 0.6%), and rash/desquamation (0.6% versus 0).

Breast Cancer

Tables 9 and 10 present the incidence of selected adverse reactions and laboratory abnormalities, occurring in ≥10% of gemcitabine for injection-treated patients and at a higher incidence in the gemcitabine for injection with paclitaxel arm, reported in a randomized trial (Study 2) of gemcitabine for injection with paclitaxel (n=262) compared to paclitaxel alone (n=259) for the first-line treatment of metastatic breast cancer (MBC) in women who received anthracycline-containing chemotherapy in the adjuvant/neo-adjuvant setting or for whom anthracyclines were contraindicated [see Clinical Studies (14.2)]. Additional clinically significant adverse reactions, occurring in <10% of patients, are provided following Table 10.

The requirement for dose reduction of paclitaxel were higher for patients in the gemcitabine for injection/paclitaxel arm (5% versus 2%). The number of paclitaxel doses omitted (<1%), the proportion of patients discontinuing treatment for adverse reactions (7% versus 5%) and the number of treatment-related deaths (1 patient in each arm) were similar between the two arms.

Table 9: Selected Adverse Reactions Occurring in Patients Receiving Gemcitabine with Paclitaxel and at Higher Incidence than in Patients Receiving Single Agent Paclitaxel [Between Arm Difference of ≥5% (All Grades) or ≥2% (Grades 3-4)] in Study 2a

a Grade based on National Cancer Institute CTC Version 2.0.

b Non-laboratory events were graded only if assessed to be possibly drug-related.

Adverse Reactions b Gemcitabine for Injection/Paclitaxel (N=262) Paclitaxel (N=259)
All Grades (%) Grade 3 (%) Grade 4 (%) All Grades (%) Grade 3 (%) Grade 4 (%)
Alopecia 90 14 4 92 19 3
Neuropathy-Sensory 64 5 <1 58 3 0
Nausea 50 1 0 31 2 0
Fatigue 40 6 <1 28 1 <1
Vomiting 29 2 0 15 2 0
Diarrhea 20 3 0 13 2 0
Anorexia 17 0 0 12 <1 0
Neuropathy-Motor 15 2 <1 10 <1 0
Stomatitis/Pharyngitis 13 1 <1 8 <1 0
Fever 13 <1 0 3 0 0
Rash/Desquamation 11 <1 <1 5 0 0
Febrile Neutropenia 6 5 <1 2 1 0
Table 10: Selected Laboratory Abnormalities Occurring in >10% of Patients Receiving Gemcitabine with Paclitaxel and at a Higher Incidence than Patients Receiving Single Agent Paclitaxel [Between Arm Difference of ≥5% (All Grades) or ≥2% (Grades 3-4)] in Study 2a

a Grade based on National Cancer Institute CTC Version 2.0.

b Regardless of causality.

Laboratory Abnormality b Gemcitabine for Injection/Paclitaxel (N=262) Paclitaxel (N=259)
All Grades (%) Grade 3 (%) Grade 4 (%) All Grades (%) Grade 3 (%) Grade 4 (%)
Hematologic
Anemia 69 6 1 51 3 <1
Neutropenia 69 31 17 31 4 7
Thrombocytopenia 26 5 <1 7 <1 <1
Hepatobiliary
Increased ALT 18 5 <1 6 <1 0
Increased AST 16 2 0 5 <1 0

Clinically relevant Grade 3 or 4 dyspnea occurred with a higher incidence in the gemcitabine for injection with paclitaxel arm compared with the paclitaxel arm (1.9% versus 0).

Non-Small Cell Lung Cancer

Tables 11 and 12 present the incidence of selected adverse reactions and laboratory abnormalities occurring in ≥10% of gemcitabine for injection-treated patients and at a higher incidence in the gemcitabine for injection with cisplatin arm, reported in a randomized trial (Study 3) of gemcitabine for injection with cisplatin (n=260) administered in 28-day cycles as compared to cisplatin alone (n=262) in patients receiving first-line treatment for locally advanced or metastatic NSCLC [see Clinical Studies (14.3)].

Patients randomized to gemcitabine for injection with cisplatin received a median of 4 cycles of treatment and those randomized to cisplatin alone received a median of 2 cycles of treatment. In this trial, the requirement for dose adjustments (>90% versus 16%), discontinuation of treatment for adverse reactions (15% versus 8%), and the proportion of patients hospitalized (36% versus 23%) were all higher for patients receiving gemcitabine for injection with cisplatin compared to those receiving cisplatin alone. The incidence of febrile neutropenia (3% versus <1%), sepsis (4% versus 1%), Grade 3 cardiac dysrhythmias (3% versus <1%) were all higher in the gemcitabine for injection with cisplatin arm compared to the cisplatin alone arm. The two-drug combination was more myelosuppressive with 4 (1.5%) possibly treatment-related deaths, including 3 resulting from myelosuppression with infection and one case of renal failure associated with pancytopenia and infection. No deaths due to treatment were reported on the cisplatin arm.

Table 11: Selected Adverse Reactions Occurring in ≥10% of Patients Receiving Gemcitabine with Cisplatin and at Higher Incidence than in Patients Receiving Single Agent Cisplatin [Between Arm Difference of ≥5% (All Grades) or ≥2% (Grades 3-4)] in Study 3a

a Grade based on National Cancer Institute Common Toxicity Criteria (CTC).

b Non-laboratory events were graded only if assessed to be possibly drug-related.

c N=217-253; all gemcitabine for injection/cisplatin patients with laboratory or non-laboratory data

d N=213-248; all cisplatin patients with laboratory or non-laboratory data

Adverse Reactions b Gemcitabine For Injection/Cisplatin c Cisplatin d
All Grades (%) Grade 3 (%) Grade 4 (%) All Grades (%) Grade 3 (%) Grade 4 (%)
Nausea 93 25 2 87 20 <1
Vomiting 78 11 12 71 10 9
Alopecia 53 1 0 33 0 0
Neuro Motor 35 12 0 15 3 0
Diarrhea 24 2 2 13 0 0
Neuro Sensory 23 1 0 18 1 0
Infection 18 3 2 12 1 0
Fever 16 0 0 5 0 0
Neuro Cortical 16 3 1 9 1 0
Neuro Mood 16 1 0 10 1 0
Local 15 0 0 6 0 0
Neuro Headache 14 0 0 7 0 0
Stomatitis 14 1 0 5 0 0
Hemorrhage 14 1 0 4 0 0
Hypotension 12 1 0 7 1 0
Rash 11 0 0 3 0 0
Table 12: Selected Laboratory Abnormalities Occurring in >10% of Patients Receiving Gemcitabine with Cisplatin and at Higher Incidence than in Patients Receiving Single Agent Cisplatin [Between Arm Difference of ≥5% (All Grades) or ≥2% (Grades 3-4)] in Study 3a

a Grade based on National Cancer Institute CTC.

b Regardless of causality.

c N=217-253; all gemcitabine for injection/cisplatin patients with laboratory or non-laboratory data

d N=213-248; all cisplatin patients with laboratory or non-laboratory data

e Percent of patients receiving transfusions. Percent transfusions are not CTC-graded events.

Laboratory Abnormality b Gemcitabine For Injection/Cisplatinc Cisplatind
All Grades (%) Grade 3 (%) Grade 4 (%) All Grades (%) Grade 3 (%) Grade 4 (%)
Hematologic
Anemia 89 22 3 67 6 1
Thrombocytopenia 85 25 25 13 3 1
Neutropenia 79 22 35 20 3 1
Lymphopenia 75 25 18 51 12 5
RBC Transfusionse 39 13
Platelet Transfusionse 21 <1
Hepatic
Increased Transaminases 22 2 1 10 1 0
Increased Alkaline Phosphatase 19 1 0 13 0 0
Renal
Increased Creatinine 38 4 <1 31 2 <1
Proteinuria 23 0 0 18 0 0
Hematuria 15 0 0 13 0 0
Other Laboratory
Hyperglycemia 30 4 0 23 3 0
Hypomagnesemia 30 4 3 17 2 0
Hypocalcemia 18 2 0 7 0 <1

Tables 13 and 14 present the incidence of selected adverse reactions and laboratory abnormalities occurring in ≥10% of gemcitabine for injection-treated patients and at a higher incidence in the gemcitabine for injection with cisplatin arm, reported in a randomized trial (Study 4) of gemcitabine for injection with cisplatin (n=69) administered in 21-day cycles as compared to etoposide with cisplatin (n=66) in patients receiving first-line treatment for locally advanced or metastatic NSCLC [see Clinical Studies (14.3)]. Additional clinically significant adverse reactions are provided following Table 14.

Patients in the gemcitabine for injection/cisplatin (GC) arm received a median of 5 cycles and those in the etoposide/cisplatin (EC) arm received a median of 4 cycles. The majority of patients receiving more than one cycle of treatment required dose adjustments; 81% in the GC arm and 68% in the EC arm. The incidence of hospitalizations for adverse reactions was 22% in the GC arm and 27% in the EC arm. The proportion of patients who discontinued treatment for adverse reactions was higher in the GC arm (14% versus 8%). The proportion of patients who were hospitalized for febrile neutropenia was lower in the GC arm (7% versus 12%). There was one death attributed to treatment, a patient with febrile neutropenia and renal failure, which occurred in the GC arm.

Table 13: Selected Adverse Reactions in Patients Receiving Gemcitabine with Cisplatin in Study 4a

a Grade based on criteria from the WHO.

b Non-laboratory events were graded only if assessed to be possibly drug-related. Pain data were not collected.

c N=67-69; all gemcitabine for injection/cisplatin patients with laboratory or non-laboratory data.

d N=57-63; all Etoposide/cisplatin patients with laboratory or non-laboratory data.

e Flu-like syndrome and edema were not graded.

Adverse Reactions b Gemcitabine For Injection/Cisplatin c Etoposide/Cisplatin d
All Grades (%) Grade 3 (%) Grade 4 (%) All Grades (%) Grade 3 (%) Grade 4 (%)
Nausea and Vomiting 96 35 4 86 19 7
Alopecia 77 13 0 92 51 0
Paresthesias 38 0 0 16 2 0
Infection 28 3 1 21 8 0
Stomatitis 20 4 0 18 2 0
Diarrhea 14 1 1 13 0 2
Edemae 12 2
Rash 10 0 0 3 0 0
Hemorrhage 9 0 3 3 0 3
Fever 6 0 0 3 0 0
Somnolence 3 0 0 3 2 0
Flu-like Syndromee 3 0
Dyspnea 1 0 1 3 0 0
Table 14: Selected Laboratory Abnormalities Occurring in Patients Receiving Gemcitabine with Cisplatin in Study 4a

a Grade based on criteria from the WHO.

b Regardless of causality.

c N=67-69; all gemcitabine for injection/cisplatin patients with laboratory or non-laboratory data.

d N=57-63; all Etoposide/cisplatin patients with laboratory or non-laboratory data.

e WHO grading scale not applicable to proportion of patients with transfusions.

Laboratory Abnormality b Gemcitabine For Injection/Cisplatin c Etoposide/Cisplatin d
All Grades (%) Grade 3 (%) Grade 4 (%) All Grades (%) Grade 3 (%) Grade 4 (%)
Hematologic
Anemia 88 22 0 77 13 2
Neutropenia 88 36 28 87 20 56
Thrombocytopenia 81 39 16 45 8 5
RBC Transfusionsc 29 21
Platelet Transfusionse 3 8
Hepatic
Increased Alkaline Phosphatase 16 0 0 11 0 0
Increased ALT 6 0 0 12 0 0
Increased AST 3 0 0 11 0 0
Renal
Hematuria 22 0 0 10 0 0
Proteinuria 12 0 0 5 0 0
Increased BUN 6 0 0 4 0 0
Increased Creatinine 2 0 0 2 0 0

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