Remosta contains the active substance sunitinib, which is a protein kinase inhibitor. It is used to treat cancer by preventing the activity of a special group of proteins which are known to be involved in the growth and spread of cancer cells.

Remosta is used to treat adults with the following types of cancer:

- Gastrointestinal stromal tumour (GIST), a type of cancer of the stomach and bowel, where imatinib (another anticancer medicine) no longer works or you cannot take imatinib.

- Metastatic renal cell carcinoma (MRCC), a type of kidney cancer that has spread to other parts of the body.

- Pancreatic neuroendocrine tumours (pNET) (tumours of the hormone-producing cells in the pancreas) that have progressed or cannot be removed with surgery.

If you have any questions about how Remosta works or why this medicine has been prescribed for you, ask your doctor.

Do not take Remosta:

- If you are allergic to sunitinib or any of the other ingredients of Remosta (listed in section 6).

Warnings and precautions

Talk to your doctor before taking Remosta:

- If you have high blood pressure. Remosta can raise blood pressure. Your doctor may check your blood pressure during treatment with Remosta, and you may be treated with medicines to reduce the blood pressure, if needed.

- If you have or have had blood disease, bleeding problems, or bruising. Treatment with Remosta may lead to a higher risk of bleeding or lead to changes in the number of certain cells in the blood which may lead to anaemia or affect the ability of your blood to clot. If you are taking warfarin or acenocoumarole, medicines which thin the blood to prevent blood clots, there may be a greater risk of bleeding. Tell your doctor if you have any bleeding while on treatment with Remosta.

- If you have heart problems. Remosta can cause heart problems. Tell your doctor if you feel very tired, are short of breath, or have swollen feet and ankles.

- If you have abnormal heart rhythm changes. Remosta can cause abnormality of your heart rhythm. Your doctor may obtain electrocardiograms to evaluate for these problems during your treatment with Remosta. Tell your doctor if you feel dizzy, faint, or have abnormal heartbeats while taking Remosta.

- If you have had a recent problem with blood clots in your veins and/or arteries (types of blood vessels), including stroke, heart attack, embolism, or thrombosis. Call your doctor immediately if you get symptoms such as chest pain or pressure, pain in your arms, back, neck or jaw, shortness of breath, numbness or weakness on 1 side of your body, trouble talking, headache, or dizziness while on treatment with Remosta.

- If you have or have had an aneurysm (enlargement and weakening of a blood vessel wall) or a tear in a blood vessel wall.

- If you have or have had damage to the smallest blood vessels known as thrombotic microangiopathy (TMA). Tell your doctor if you develop fever, fatigue, tiredness, bruising, bleeding, swelling, confusion, vision loss, and seizures.

- If you have thyroid glands problems. Remosta can cause thyroid gland problems. Tell your doctor if you get tired more easily, generally feel colder than other people, or your voice deepens whilst taking Remosta. Your thyroid function should be checked before you take Remosta and regularly while you are taking it. If your thyroid gland is not producing enough thyroid hormone, you may be treated with thyroid hormone replacement.

- If you have or have had pancreatic or gallbladder disorders. Tell your doctor if you develop any of the following signs and symptoms: pain in the area of the stomach (upper abdomen), nausea, vomiting, and fever. These may be caused by inflammation of the pancreas or gallbladder.

- If you have or have had liver problems. Tell your doctor if you develop any of the following signs and symptoms of liver problems during Remosta treatment: itching, yellow eyes or skin, dark urine, and pain or discomfort in the right upper stomach area. Your doctor should do blood tests to check your liver function before and during treatment with Remosta, and as clinically indicated.

- If you have or have had kidney problems. Your doctor will monitor your kidney function.

- If you are going to have surgery or if you had an operation recently. Remosta may affect the way your wounds heal. You will usually be taken off Remosta if you are having an operation. Your doctor will decide when to start Remosta again.

- You may be advised to have a dental check-up before you start treatment with Remosta.

- If you have or have had pain in the mouth, teeth and/or jaw, swelling or sores inside the mouth, numbness or a feeling of heaviness in the jaw, or loosening of a tooth, tell your doctor and dentist immediately.

- If you need to undergo an invasive dental treatment or dental surgery, tell your dentist that you are being treated with Remosta in particular when you are also receiving or have received intravenous bisphosphonates. Bisphosphonates are medicines used to prevent bone complications that may have been given for another medical condition.

- If you have or have had skin and subcutaneous tissue disorders. While you are on this medicine "pyoderma gangrenosum" (painful skin ulceration) or “necrotising fasciitis” (rapidly spreading infection of the skin/soft tissue that may be life-threatening) may occur. Contact your doctor immediately if symptoms of infection occur around a skin injury, including fever, pain, redness, swelling, or drainage of pus or blood. This event is generally reversible after sunitinib discontinuation. Severe skin rashes (Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiforme) have been reported with the use of sunitinib, appearing initially as reddish target-like spots or circular patches often with central blisters on the trunk. The rash may progress to widespread blistering or peeling of the skin and may be life-threatening. If you develop a rash or these skin symptoms, seek immediate advice from a doctor.

- If you have or have had seizures. Notify your doctor as soon as possible if you have high blood pressure, headache, or loss of sight.

- If you have diabetes. Blood sugar levels in diabetic patients should be checked regularly in order to assess if antidiabetic medicine’s dosage needs to be adjusted to minimise the risk of low blood sugar. Notify your doctor as soon as possible if you experience any signs and symptoms of low blood sugar (fatigue, palpitations, sweating, hunger and loss of consciousness).

Children and adolescents

Remosta is not recommended for people aged under 18.

Other medicines and Remosta

Tell your doctor or pharmacist if you are taking, have recently taken, or might take any other medicines, including medicines obtained without a prescription and even those not prescribed.

Some medicines can affect the levels of Remosta in your body. You should inform your doctor if you are taking medicines containing the following active substances:

·       ketoconazole, itraconazole – used to treat fungal infections

·       erythromycin, clarithromycin, rifampicin –used to treat infections

·       ritonavir –used to treat HIV

·       dexamethasone – a corticosteroid used for various conditions (such as allergic/breathing disorders or skin diseases)

·       phenytoin, carbamazepine, phenobarbital – used to treat epilepsy and other neurological conditions

·       herbal preparations containing St. John’s Wort (Hypericum perforatum) – used to treat depression and anxiety

Remosta with food and drink

You should avoid drinking grapefruit juice while on treatment with Remosta.

Pregnancy and breast-feeding

If you are pregnant or breast-feeding, think you may be pregnant, or are planning to have a baby, ask your doctor or pharmacist for advice before taking this medicine.

If you might get pregnant, you should use a reliable method of contraception during treatment with Remosta.

If you are breast-feeding, tell your doctor. You should not breast-feed during treatment with Remosta.

Driving and using machines

If you experience dizziness or you feel unusually tired, take special care when driving or using machines.

Always take this medicine exactly as your doctor has told you. Check with your doctor if you are not sure.

Your doctor will prescribe a dose that is right for you, depending on the type of cancer to be treated. If you are being treated for:

− GIST or MRCC: the usual dose is 50 mg once daily taken for 28 days (4 weeks), followed by 14 days (2 weeks) of rest (no medicine), in 6-week cycles.

− pNET: the usual dose is 37.5 mg once daily without a rest period.

Your doctor will determine the appropriate dose you need to take, as well as if and when you need to stop treatment with Remosta.

Remosta can be taken with or without food.

If you take more Remosta than you should

If you have accidentally taken too many capsules, talk to your doctor straight away. You may require medical attention.

If you forget to take Remosta

Do not take a double dose to make up for a forgotten dose.

Like all medicines, this medicine can cause side effects, although not everybody gets them. You must immediately contact your doctor if you experience any of those serious side effects (see also What you need to know before you take Remosta):

Heart problems. Tell your doctor if you feel very tired, are short of breath, or have swollen feet and ankles. These may be symptoms of heart problems that may include heart failure and heart muscle problems (cardiomyopathy).

Lung or breathing problems. Tell your doctor if you develop cough, chest pain, sudden onset of shortness of breath, or coughing up blood. These may be symptoms of a condition called pulmonary embolism that occurs when blood clots travel to your lungs.

Kidney disorders. Tell your doctor if you experience altered frequency or absence of urination which may be symptoms of kidney failure.

Bleeding. Tell your doctor if you have any of these symptoms or a serious bleeding problem during treatment with Remosta: painful, swollen stomach (abdomen); vomiting blood; black, sticky stools; bloody urine; headache or change in your mental status; coughing up of blood or bloody sputum from the lungs or airway.

Tumour destruction leading to hole in the intestine. Tell your doctor if you have severe abdominal pain, fever, nausea, vomiting, blood in your stool, or changes in bowel habits.

Other side effects with Remosta may include:

Very common: may affect more than 1 in 10 people

• Reduction in the number of platelets, red blood cells and/or white blood cells (e.g. neutrophils).

• Shortness of breath.

• High blood pressure.

• Extreme tiredness, loss of strength.

• Swelling caused by fluid under the skin and around the eye, deep allergic rash.

• Mouth pain/irritation, mouth sores/inflammation/dryness, taste disturbances, upset stomach, nausea, vomiting, diarrhoea, constipation, abdominal pain/swelling, loss/decrease of appetite.

• Decreased activity of thyroid gland (hypothyroidism).

• Dizziness.

• Headache.

• Nose bleeding.

• Back pain, joint pain.

• Pain in arms and legs.

• Yellow skin/skin discoloration, excess pigmentation of the skin, hair colour change, rash on the palms of the hands and soles of the feet, rash, dryness of the skin.

• Cough.

• Fever.

• Difficulty in falling asleep.

Common: may affect up to 1 in 10 people

• Blood clots in the blood vessels.

• Deficiency of blood supply to the heart muscle, due to obstruction or constriction of the coronary arteries.

• Chest pain.

• Decreased in the amount of blood pumped by the heart.

• Fluid retention including around the lungs.

• Infections.

• Complication of severe infection (infection is present in the bloodstream) that can lead to tissue damage, organ failure, and death.

• Decreased blood sugar level (see section 2).

• Loss of protein in the urine sometime resulting in swelling.

• Influenza-like syndrome.

• Abnormal blood tests including pancreatic and liver enzymes.

• High level of uric acid in the blood.

• Haemorrhoids, pain in the rectum, gingival bleeding, difficulty in swallowing or inability to swallow.

• Burning or painful sensation in the tongue, inflammation of the digestive tract lining, excessive gas in the stomach or intestine.

• Weight loss.

• Musculoskeletal pain (pain in muscles and bones), muscular weakness, muscular fatigue, muscle pain, muscle spasms.

• Nasal dryness, congested nose.

• Excessive tear flow.

• Abnormal sensation of the skin, itching, flaking and inflammation of the skin, blisters, acne, nail discolouration, hair loss.

• Abnormal sensations in extremities.

• Abnormally decreased/increased sensitivity, particularly to touch.

• Acid heartburn.

• Dehydration.

• Hot flushes.

• Abnormally coloured urine.

• Depression.

• Chills.

Uncommon: may affect up to 1 in 100 people

• Life-threatening infection of the soft tissue including the ano-genital region (see section 2).

• Stroke.

• Heart attack caused by an interrupted or decreased blood supply to the heart.

• Changes in the electrical activity or abnormal rhythm of the heart.

• Fluid around the heart (pericardial effusion).

• Liver failure.

• Pain in the stomach (abdomen) caused by inflammation of the pancreas.

• Tumour destruction leading to hole in the intestine (perforation).

• Inflammation (swelling and redness) of the gallbladder with or without associated gallstones.

• Abnormal tube like passage from one normal body cavity to another body cavity or the skin.

• Pain in the mouth, teeth and/or jaw, swelling or sores inside the mouth, numbness or a feeling of heaviness in the jaw, or loosening of a tooth. These could be signs and symptoms of bone damage in the jaw (osteonecrosis), see section 2.

• Overproduction of thyroid hormones which increases the amount of energy the body uses at rest.

• Problems with wound healing after surgery.

• Increased blood level of enzyme (creatine phosphokinase) from muscle.

• Excessive reaction to an allergen including hay fever, skin rash, itchy skin, hives, swelling of body parts, and trouble breathing.

• Inflammation of the colon (colitis, colitis ischaemic).

Rare: may affect up to 1 in 1,000 people

• Severe reaction of the skin and/or mucous membranes (Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiforme).

• Tumour lysis syndrome (TLS) – TLS consists of a group of metabolic complications that can occur during treatment of cancer. These complications are caused by the break-down products of dying cancer cells and may include the following: nausea, shortness of breath, irregular heartbeat, muscular cramps, seizure, clouding of urine and tiredness associated with abnormal laboratory test results (high potassium, uric acid and phosphorous levels and low calcium levels in the blood) that can lead to changes in kidney function and acute renal failure.

• Abnormal muscle breakdown which can lead to kidney problems (rhabdomyolysis).

• Abnormal changes in the brain that can cause a collection of symptoms including headache, confusion, seizures, and vision loss (reversible posterior leukoencephalopathy syndrome).

• Painful skin ulceration (pyoderma gangrenosum).

• Inflammation of the liver (hepatitis).

• Inflammation of the thyroid gland.

• Damage to the smallest blood vessels known as thrombotic microangiopathy (TMA).

Not known (frequency cannot be estimated from available data):

• An enlargement and weakening of a blood vessel wall or a tear in a blood vessel wall (aneurysms and artery dissections).

Reporting of side effects

If you get any side effects, talk to your doctor. This includes any possible side effects not listed in this leaflet. You can also report side effects directly (see details below). By reporting side effects you can help provide more information on the safety of this medicine.

- Keep out of the reach and sight of children.

- Do not use this medicine after the expiry date which is stated on carton, bottle and blister foil after “EXP”. The expiry date refers to the last day of that month.

- Do not store above 30° C.

- Do not use this medicine if you notice that the pack is damaged or shows signs of tampering.

Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to throw away medicines you no longer use. These measures will help protect the environment.