Adverse reaction

Severity¹

Afinitor dose adjustment

Non‑infectious pneumonitis

Grade 2

Consider interruption of therapy until symptoms improve to Grade £1.

Re‑initiate treatment at 5 mg daily.

Discontinue treatment if failure to recover within 4 weeks.

Grade 3

Interrupt treatment until symptoms resolve to Grade £1.

Consider re‑initiating treatment at 5 mg daily. If toxicity recurs at Grade 3, consider discontinuation.

Grade 4

Discontinue treatment.

Stomatitis

Grade 2

Temporary dose interruption until recovery to Grade £1.

Re‑initiate treatment at same dose.

If stomatitis recurs at Grade 2, interrupt dose until recovery to Grade £1. Re‑initiate treatment at 5 mg daily.

Grade 3

Temporary dose interruption until recovery to Grade £1.

Re‑initiate treatment at 5 mg daily.

Grade 4

Discontinue treatment.

Other non‑haematological toxicities

(excluding metabolic events)

Grade 2

If toxicity is tolerable, no dose adjustment required.

If toxicity becomes intolerable, temporary dose interruption until recovery to Grade £1. Re‑initiate treatment at same dose.

If toxicity recurs at Grade 2, interrupt treatment until recovery to Grade £1. Re‑initiate treatment at 5 mg daily.

Grade 3

Temporary dose interruption until recovery to Grade £1.

Consider re‑initiating treatment at 5 mg daily. If toxicity recurs at Grade 3, consider discontinuation.

Grade 4

Discontinue treatment.

Metabolic events

(e.g. hyperglycaemia, dyslipidaemia)

Grade 2

No dose adjustment required.

Grade 3

Temporary dose interruption.

Re‑initiate treatment at 5 mg daily.

Grade 4

Discontinue treatment.

Thrombocytopenia

Grade 2
(<75, ≥50x10⁹/l)

Temporary dose interruption until recovery to Grade £1 (≥75x10⁹/l). Re‑initiate treatment at same dose.

Grade 3 & 4
(<50x10⁹/l)

Temporary dose interruption until recovery to Grade £1 (≥75x10⁹/l). Re‑initiate treatment at 5 mg daily.

Neutropenia

Grade 2
(≥1x10⁹/l)

No dose adjustment required.

Grade 3
(<1, ≥0.5x10⁹/l)

Temporary dose interruption until recovery to Grade £2 (≥1x10⁹/l). Re‑initiate treatment at same dose.

Grade 4
(<0.5x10⁹/l)

Temporary dose interruption until recovery to Grade £2 (≥1x10⁹/l). Re‑initiate treatment at 5 mg daily.

Febrile neutropenia

Grade 3

Temporary dose interruption until recovery to Grade £2 (≥1.25x10⁹/l) and no fever.

Re‑initiate treatment at 5 mg daily.

Grade 4

Discontinue treatment.

¹        Grading based on National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) v3.0

Non‑infectious pneumonitis

Non‑infectious pneumonitis is a class effect of rapamycin derivatives, including everolimus. Non‑infectious pneumonitis (including interstitial lung disease) has been frequently reported in patients taking Afinitor (see section 4.8). Some cases were severe and on rare occasions, a fatal outcome was observed. A diagnosis of non‑infectious pneumonitis should be considered in patients presenting with non‑specific respiratory signs and symptoms such as hypoxia, pleural effusion, cough or dyspnoea, and in whom infectious, neoplastic and other non‑medicinal causes have been excluded by means of appropriate investigations. Opportunistic infections such as pneumocystis jirovecii (carinii) pneumonia (PJP, PCP) should be ruled out in the differential diagnosis of non-infectious pneumonitis (see “Infections” below). Patients should be advised to report promptly any new or worsening respiratory symptoms.

Patients who develop radiological changes suggestive of non‑infectious pneumonitis and have few or no symptoms may continue Afinitor therapy without dose adjustments. If symptoms are moderate (Grade 2) or severe (Grade 3) the use of corticosteroids may be indicated until clinical symptoms resolve.

For patients who require use of corticosteroids for treatment of non-infectious pneumonitis, prophylaxis for pneumocystis jirovecii (carinii) pneumonia (PJP, PCP) may be considered.

Infections

Everolimus has immunosuppressive properties and may predispose patients to bacterial, fungal, viral or protozoan infections, including infections with opportunistic pathogens (see section 4.8). Localised and systemic infections, including pneumonia, other bacterial infections, invasive fungal infections such as aspergillosis, candidiasis or pneumocystis jirovecii (carinii) pneumonia (PJP, PCP) and viral infections including reactivation of hepatitis B virus, have been described in patients taking Afinitor. Some of these infections have been severe (e.g. leading to sepsis, respiratory or hepatic failure) and occasionally fatal.

Physicians and patients should be aware of the increased risk of infection with Afinitor. Pre‑existing infections should be treated appropriately and should have resolved fully before starting treatment with Afinitor. While taking Afinitor, be vigilant for symptoms and signs of infection; if a diagnosis of infection is made, institute appropriate treatment promptly and consider interruption or discontinuation of Afinitor.

If a diagnosis of invasive systemic fungal infection is made, the Afinitor treatment should be promptly and permanently discontinued and the patient treated with appropriate antifungal therapy.

Cases of PJP/PCP, some with fatal outcome, have been reported in patients who received everolimus. PJP/PCP may be associated with concomitant use of corticosteroids or other immunosuppressive agents. Prophylaxis for PJP/PCP should be considered when concomitant use of corticosteroids or other immunosuppressive agents are required.

Hypersensitivity reactions

Hypersensitivity reactions manifested by symptoms including, but not limited to, anaphylaxis, dyspnoea, flushing, chest pain or angioedema (e.g. swelling of the airways or tongue, with or without respiratory impairment) have been observed with everolimus (see section 4.3).

Concomitant use of angiotensin-converting enzyme (ACE) inhibitors

Patients taking concomitant ACE inhibitor (e.g. ramipril) therapy may be at increased risk for angioedema (e.g. swelling of the airways or tongue, with or without respiratory impairment) (see section 4.5).

Stomatitis

Stomatitis, including mouth ulcerations and oral mucositis, is the most commonly reported adverse reaction in patients treated with Afinitor (see section 4.8). Stomatitis mostly occurs within the first 8 weeks of treatment. A single-arm study in postmenopausal breast cancer patients treated with Afinitor plus exemestane suggested that an alcohol-free corticosteroid oral solution, administered as a mouthwash during the initial 8 weeks of treatment, may decrease the incidence and severity of stomatitis (see section 5.1). Management of stomatitis may therefore include prophylactic and/or therapeutic use of topical treatments, such as an alcohol-free corticosteroid oral solution as a mouthwash. However, products containing alcohol, hydrogen peroxide, iodine and thyme derivatives should be avoided as they may exacerbate the condition. Monitoring for and treatment of fungal infection is recommended, especially in patients being treated with steroid-based medications. Antifungal agents should not be used unless fungal infection has been diagnosed (see section 4.5).

Renal failure events

Cases of renal failure (including acute renal failure), some with a fatal outcome, have been observed in patients treated with Afinitor (see section 4.8). Renal function should be monitored particularly where patients have additional risk factors that may further impair renal function.

Laboratory tests and monitoring

Renal function

Elevations of serum creatinine, usually mild, and proteinuria have been reported (see section 4.8). Monitoring of renal function, including measurement of blood urea nitrogen (BUN), urinary protein or serum creatinine, is recommended prior to the start of Afinitor therapy and periodically thereafter.

Blood glucose

Hyperglycaemia has been reported (see section 4.8). Monitoring of fasting serum glucose is recommended prior to the start of Afinitor therapy and periodically thereafter. More frequent monitoring is recommended when Afinitor is co‑administered with other medicinal products that may induce hyperglycaemia. When possible optimal glycaemic control should be achieved before starting a patient on Afinitor.

Blood lipids

Dyslipidaemia (including hypercholesterolaemia and hypertriglyceridaemia) has been reported. Monitoring of blood cholesterol and triglycerides prior to the start of Afinitor therapy and periodically thereafter, as well as management with appropriate medical therapy, is recommended.

Haematological parameters

Decreased haemoglobin, lymphocytes, neutrophils and platelets have been reported (see section 4.8). Monitoring of complete blood count is recommended prior to the start of Afinitor therapy and periodically thereafter.

Functional carcinoid tumours

In a randomised, double‑blind, multi‑centre trial in patients with functional carcinoid tumors, Afinitor plus depot octreotide was compared to placebo plus depot octreotide. The study did not meet the primary efficacy endpoint (progression‑free‑survival [PFS]) and the overall survival (OS) interim analysis numerically favoured the placebo plus depot octreotide arm. Therefore, the safety and efficacy of Afinitor in patients with functional carcinoid tumors have not been established.

Prognostic factors in neuroendocrine tumours of gastrointestinal or lung origin

In patients with non-functional gastrointestinal or lung neuroendocrine tumours and good prognostic baseline factors, e.g. ileum as primary tumour origin and normal chromogranin A values or without bone involvement, an individual benefit-risk assessment should be performed prior to the start of Afinitor therapy. Limited evidence of PFS benefit was reported in the subgroup of patients with ileum as primary tumour origin (see section 5.1).

Interactions

Co‑administration with inhibitors and inducers of CYP3A4 and/or the multidrug efflux pump P‑glycoprotein (PgP) should be avoided. If co‑administration of a moderate CYP3A4 and/or PgP inhibitor or inducer cannot be avoided, the clinical condition of the patient should be monitored closely. Dose adjustments of Afinitor can be taken into consideration based on predicted AUC (see section 4.5).

Concomitant treatment with potent CYP3A4/PgP inhibitors result in dramatically increased plasma concentrations of everolimus (see section 4.5). There are currently not sufficient data to allow dosing recommendations in this situation. Hence, concomitant treatment of Afinitor and potent inhibitors is not recommended.

Caution should be exercised when Afinitor is taken in combination with orally administered CYP3A4 substrates with a narrow therapeutic index due to the potential for drug interactions. If Afinitor is taken with orally administered CYP3A4 substrates with a narrow therapeutic index (e.g. pimozide, terfenadine, astemizole, cisapride, quinidine or ergot alkaloid derivatives), the patient should be monitored for undesirable effects described in the product information of the orally administered CYP3A4 substrate (see section 4.5).

Hepatic impairment

Exposure to everolimus was increased in patients with mild (Child‑Pugh A), moderate (Child‑Pugh B) and severe (Child‑Pugh C) hepatic impairment (see section 5.2).

Afinitor is only recommended for use in patients with severe hepatic impairment (Child‑Pugh C) if the potential benefit outweighs the risk (see sections 4.2 and 5.2).

No clinical safety or efficacy data are currently available to support dose adjustment recommendations for the management of adverse reactions in patients with hepatic impairment.

Vaccinations

The use of live vaccines should be avoided during treatment with Afinitor (see section 4.5).

Lactose

Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose‑galactose malabsorption should not take this medicinal product.

Wound healing complications

Impaired wound healing is a class effect of rapamycin derivatives, including everolimus. Caution should therefore be exercised with the use of Afinitor in the peri‑surgical period.

Radiation therapy complications

Serious and severe radiation reactions (such as radiation oesophagitis, radiation pneumonitis and radiation skin injury), including fatal cases, have been reported when everolimus was taken during, or shortly after, radiation therapy. Caution should therefore be exercised for the potentiation of radiotherapy toxicity in patients taking everolimus in close temporal relationship with radiation therapy.

Additionally, radiation recall syndrome (RRS) has been reported in patients taking everolimus who had received radiation therapy in the past. In the event of RRS, interrupting or stopping everolimus treatment should be considered.

Everolimus is a substrate of CYP3A4, and also a substrate and moderate inhibitor of PgP. Therefore, absorption and subsequent elimination of everolimus may be influenced by products that affect CYP3A4 and/or PgP. In vitro, everolimus is a competitive inhibitor of CYP3A4 and a mixed inhibitor of CYP2D6.

Known and theoretical interactions with selected inhibitors and inducers of CYP3A4 and PgP are listed in Table 2 below.

CYP3A4 and PgP inhibitors increasing everolimus concentrations

Substances that are inhibitors of CYP3A4 or PgP may increase everolimus blood concentrations by decreasing metabolism or the efflux of everolimus from intestinal cells.

CYP3A4 and PgP inducers decreasing everolimus concentrations

Substances that are inducers of CYP3A4 or PgP may decrease everolimus blood concentrations by increasing metabolism or the efflux of everolimus from intestinal cells.

Table 2 Effects of other active substances on everolimus

Agents whose plasma concentration may be altered by everolimus

Based on in vitro results, the systemic concentrations obtained after oral daily doses of 10 mg make inhibition of PgP, CYP3A4 and CYP2D6 unlikely. However, inhibition of CYP3A4 and PgP in the gut cannot be excluded. An interaction study in healthy subjects demonstrated that co‑administration of an oral dose of midazolam, a sensitive CYP3A substrate probe, with everolimus resulted in a 25% increase in midazolam C_max and a 30% increase in midazolam AUC_(0‑inf). The effect is likely to be due to inhibition of intestinal CYP3A4 by everolimus. Hence everolimus may affect the bioavailability of orally co‑administered CYP3A4 substrates. However, a clinically relevant effect on the exposure of systemically administered CYP3A4 substrates is not expected (see section 4.4).

Co‑administration of everolimus and depot octreotide increased octreotide C_min with a geometric mean ratio (everolimus/placebo) of 1.47. A clinically significant effect on the efficacy response to everolimus in patients with advanced neuroendocrine tumours could not be established.

Co‑administration of everolimus and exemestane increased exemestane C_min and C_2h by 45% and 64%, respectively. However, the corresponding oestradiol levels at steady state (4 weeks) were not different between the two treatment arms. No increase in adverse events related to exemestane was observed in patients with hormone receptor‑positive advanced breast cancer receiving the combination. The increase in exemestane levels is unlikely to have an impact on efficacy or safety.

Concomitant use of angiotensin-converting enzyme (ACE) inhibitors

Patients taking concomitant ACE inhibitor (e.g. ramipril) therapy may be at increased risk for angioedema (see section 4.4).

Vaccinations

The immune response to vaccination may be affected and, therefore, vaccination may be less effective during treatment with Afinitor. The use of live vaccines should be avoided during treatment with Afinitor (see section 4.4). Examples of live vaccines are: intranasal influenza, measles, mumps, rubella, oral polio, BCG (Bacillus Calmette‑Guérin), yellow fever, varicella, and TY21a typhoid vaccines.

Radiation treatment

Potentiation of radiation treatment toxicity has been reported in patients receiving everolimus (see sections 4.4 and 4.8).

Summary of the safety profile

The safety profile is based on pooled data from 2,879 patients treated with Afinitor in eleven clinical studies, consisting of five randomised, double‑blind, placebo controlled phase III studies and six open-label phase I and phase II studies, related to the approved indications.

The most common adverse reactions (incidence ≥1/10) from the pooled safety data were (in decreasing order): stomatitis, rash, fatigue, diarrhoea, infections, nausea, decreased appetite, anaemia, dysgeusia, pneumonitis, oedema peripheral, hyperglycaemia, asthenia, pruritus, weight decreased, hypercholesterolaemia, epistaxis, cough and headache.

The most frequent Grade 3‑4 adverse reactions (incidence ≥1/100 to <1/10) were stomatitis, anaemia, hyperglycaemia, infections, fatigue, diarrhoea, pneumonitis, asthenia, thrombocytopenia, neutropenia, dyspnoea, proteinuria, lymphopenia, haemorrhage, hypophosphataemia, rash, hypertension, pneumonia, alanine aminotransferase (ALT) increased, aspartate aminotransferase (AST) increased and diabetes mellitus. The grades follow CTCAE Version 3.0 and 4.03.

Tabulated list of adverse reactions

Table 3 presents the frequency category of adverse reactions reported in the pooled analysis considered for the safety pooling. Adverse reactions are listed according to MedDRA system organ class and frequency category. Frequency categories are defined using the following convention: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000) ; not known (cannot be estimated from the available data). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.

Table 3        Adverse reactions reported in clinical studies

Description of selected adverse reactions

In clinical studies and post‑marketing spontaneous reports, everolimus has been associated with serious cases of hepatitis B reactivation, including fatal outcome. Reactivation of infection is an expected event during periods of immunosuppression.

In clinical studies and post‑marketing spontaneous reports, everolimus has been associated with renal failure events (including fatal outcome) and proteinuria. Monitoring of renal function is recommended (see section 4.4).

In clinical studies and post‑marketing spontaneous reports, everolimus has been associated with cases of amenorrhoea (secondary amenorrhoea and other menstrual irregularities).

In clinical studies and post‑marketing spontaneous reports, everolimus has been associated with cases of PJP, PCP, some with fatal outcome (see section 4.4).

In clinical studies and post-marketing spontaneous reports, angioedema has been reported with and without concomitant use of ACE inhibitors (see section 4.4).

Elderly patients

In the safety pooling, 37% of the Afinitor‑treated patients were ≥65 years of age. The number of patients with an adverse reaction leading to discontinuation of the medicinal product was higher in patients ≥65 years of age (20% vs. 13%). The most common adverse reactions leading to discontinuation were pneumonitis (including interstitial lung disease), stomatitis, fatigue and dyspnoea.

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

---To reports any side effect(s):

·    Saudi Arabia:

Saudi Food and Drug Authority National Pharmacovigilance Center (NPC):

o SFDA call center: 19999

o E-mail: npc.drug@sfda.gov.sa

o Website: https://ade.sfda.gov.sa

Patient Safety Department Novartis Consulting AG - Saudi Arabia:

o Toll Free Number: 8001240078

o Phone: +996112658100

o Fax: +966112658107

o Email: adverse.events@novartis.com 

Other GCC States:

-- Please contact the relevant competent authority.

Pharmacotherapeutic group: Antineoplastic agents, other antineoplastic agents, protein kinase inhibitors, ATC code: L01XE10

Mechanism of action

Everolimus is a selective mTOR (mammalian target of rapamycin) inhibitor. mTOR is a key serine‑threonine kinase, the activity of which is known to be upregulated in a number of human cancers. Everolimus binds to the intracellular protein FKBP‑12, forming a complex that inhibits mTOR complex‑1 (mTORC1) activity. Inhibition of the mTORC1 signalling pathway interferes with the translation and synthesis of proteins by reducing the activity of S6 ribosomal protein kinase (S6K1) and eukaryotic elongation factor 4E‑binding protein (4EBP‑1) that regulate proteins involved in the cell cycle, angiogenesis and glycolysis. S6K1is thought to phosphorylate the activation function domain 1 of the oestrogen receptor, which is responsible for ligand‑independent receptor activation. Everolimus reduces levels of vascular endothelial growth factor (VEGF), which potentiates tumour angiogenic processes. Everolimus is a potent inhibitor of the growth and proliferation of tumour cells, endothelial cells, fibroblasts and blood‑vessel‑associated smooth muscle cells and has been shown to reduce glycolysis in solid tumours in vitro and in vivo.

Clinical efficacy and safety

Hormone receptor‑positive advanced breast cancer

BOLERO‑2 (study CRAD001Y2301), a randomised, double‑blind, multicentre phase III study of Afinitor + exemestane versus placebo + exemestane, was conducted in postmenopausal women with oestrogen receptor‑positive, HER2/neu negative advanced breast cancer with recurrence or progression following prior therapy with letrozole or anastrozole. Randomisation was stratified by documented sensitivity to prior hormonal therapy and by the presence of visceral metastasis. Sensitivity to prior hormonal therapy was defined as either (1) documented clinical benefit (complete response [CR], partial response [PR], stable disease ≥24 weeks) from at least one prior hormonal therapy in the advanced setting or (2) at least 24 months of adjuvant hormonal therapy prior to recurrence.

The primary endpoint for the study was progression‑free survival (PFS) evaluated by RECIST (Response Evaluation Criteria in Solid Tumors), based on the investigator’s assessment (local radiology). Supportive PFS analyses were based on an independent central radiology review.

Secondary endpoints included overall survival (OS), objective response rate, clinical benefit rate, safety, change in quality of life (QoL) and time to ECOG PS (Eastern Cooperative Oncology Group performance status) deterioration.

A total of 724 patients were randomised in a 2:1 ratio to the combination everolimus (10 mg daily) + exemestane (25 mg daily) (n=485) or to the placebo + exemestane arm (25 mg daily) (n=239). At the time of the final OS analysis, the median duration of everolimus treatment was 24.0 weeks (range 1.0‑199.1 weeks). The median duration of exemestane treatment was longer in the everolimus + exemestane group at 29.5 weeks (1.0‑199.1) compared to 14.1 weeks (1.0‑156.0) in the placebo + exemestane group.

The efficacy results for the primary endpoint were obtained from the final PFS analysis (see Table 4 and Figure 1). Patients in the placebo + exemestane arm did not cross over to everolimus at the time of progression.

Table 4 BOLERO‑2 efficacy results

Figure 1      BOLERO‑2 Kaplan‑Meier progression‑free survival curves (investigator radiological review)

The estimated PFS treatment effect was supported by planned subgroup analysis of PFS per investigator assessment. For all analysed subgroups (age, sensitivity to prior hormonal therapy, number of organs involved, status of bone‑only lesions at baseline and presence of visceral metastasis, and across major demographic and prognostic subgroups) a positive treatment effect was seen with everolimus + exemestane with an estimated hazard ratio versus placebo + exemestane ranging from 0.25 to 0.60.

No differences in the time to ≥5% deterioration in the global and functional domain scores of QLQ‑C30 were observed in the two arms.

BOLERO-6 (Study CRAD001Y2201), a three-arm, randomised, open‑label, phase II study of everolimus in combination with exemestane versus everolimus alone versus capecitabine in the treatment of postmenopausal women with oestrogen receptor‑positive, HER2/neu negative, locally advanced, recurrent, or metastatic breast cancer after recurrence or progression on prior letrozole or anastrozole.

The primary objective of the study was to estimate the HR of PFS for everolimus + exemestane versus everolimus alone. The key secondary objective was to estimate the HR of PFS for everolimus + exemestane versus capecitabine.

Other secondary objectives included the evaluation of OS, objective response rate, clinical benefit rate, safety, time to ECOG performance deterioration, time to QoL deterioration, and treatment satisfaction (TSQM). No formal statistical comparisons were planned.

A total of 309 patients were randomised in a 1:1:1 ratio to the combination of everolimus (10 mg daily) + exemestane (25 mg daily) (n=104), everolimus alone (10 mg daily) (n=103), or capecitabine (1250 mg/m² dose twice daily for 2 weeks followed by one week rest, 3-week cycle) (n=102). At the time of data cut-off, the median duration of treatment was 27.5 weeks (range 2.0‑165.7) in the everolimus + exemestane arm, 20 weeks (1.3‑145.0) in the everolimus arm, and 26.7 weeks (1.4‑177.1) in the capecitabine arm.

The result of the final PFS analysis with 154 PFS events observed based on local investigator assessment showed an estimated HR of 0.74 (90% CI: 0.57, 0.97) in favour of the everolimus + exemestane arm relative to everolimus arm. The median PFS was 8.4 months (90% CI: 6.6, 9.7) and 6.8 months (90% CI: 5.5, 7.2), respectively.

Figure 2      BOLERO‑6 Kaplan‑Meier progression‑free survival curves (investigator radiological review)

For the key secondary endpoint PFS the estimated HR was 1.26 (90% CI: 0.96, 1.66) in favour of capecitabine over the everolimus + exemestane combination arm based on a total of 148 PFS events observed.

Results of the secondary endpoint OS were not consistent with the primary endpoint PFS, with a trend observed favouring the everolimus alone arm. The estimated HR was 1.27 (90% CI: 0.95, 1.70) for the comparison of OS in the everolimus alone arm relative to the everolimus + exemestane arm. The estimated HR for the comparison of OS in the everolimus + exemestane combination arm relative to capecitabine arm was 1.33 (90% CI: 0.99, 1.79).

Advanced neuroendocrine tumours of pancreatic origin (pNET)

RADIANT‑3 (study CRAD001C2324), a phase III, multicentre, randomised, double‑blind study of Afinitor plus best supportive care (BSC) versus placebo plus BSC in patients with advanced pNET, demonstrated a statistically significant clinical benefit of Afinitor over placebo by a 2.4-fold prolongation of median progression‑free‑survival (PFS) (11.04 months versus 4.6 months), (HR 0.35; 95% CI: 0.27, 0.45; p<0.0001) (see Table 5 and Figure 2).

RADIANT‑3 involved patients with well‑ and moderately‑differentiated advanced pNET whose disease had progressed within the prior 12 months. Treatment with somatostatin analogues was allowed as part of BSC.

The primary endpoint for the study was PFS evaluated by RECIST (Response Evaluation Criteria in Solid Tumors). Following documented radiological progression, patients could be unblinded by the investigator. Those randomised to placebo were then able to receive open‑label Afinitor.

Secondary endpoints included safety, objective response rate, response duration and overall survival (OS).

In total, 410 patients were randomised 1:1 to receive either Afinitor 10 mg/day (n=207) or placebo (n=203). Demographics were well balanced (median age 58 years, 55% male, 78.5% Caucasian). Fifty‑eight percent of the patients in both arms received prior systemic therapy. The median duration of blinded study treatment was 37.8 weeks (range 1.1‑129.9 weeks) for patients receiving everolimus and 16.1 weeks (range 0.4‑147.0 weeks) for those receiving placebo.

Following disease progression or after study unblinding, 172 of the 203 patients (84.7%) initially randomised to placebo crossed over to open-label Afinitor. The median duration of open-label treatment was 47.7 weeks among all patients; 67.1 weeks in the 53 patients randomised to everolimus who switched to open-label everolimus and 44.1 weeks in the 172 patients randomised to placebo who switched to open-label everolimus.

Table 5 RADIANT‑3 – efficacy results

Figure 2      RADIANT‑3 – Kaplan-Meier progression‑free survival curves (investigator radiological review)

Advanced neuroendocrine tumours of gastrointestinal or lung origin

RADIANT-4 (study CRAD001T2302), a randomised, double-blind, multicentre, phase III study of Afinitor plus best supportive care (BSC) versus placebo plus BSC was conducted in patients with advanced, well-differentiated (Grade 1 or Grade 2) non-functional neuroendocrine tumours of gastrointestinal or lung origin without a history of and no active symptoms related to carcinoid syndrome.

The primary endpoint for the study was progression-free survival (PFS) evaluated by Response Evaluation Criteria in Solid Tumors (RECIST), based on independent radiology assessment. Supportive PFS analysis was based on local investigator review. Secondary endpoints included overall survival (OS), overall response rate, disease control rate, safety, change in quality of life (FACT-G) and time to World Health Organisation performance status (WHO PS) deterioration.

A total of 302 patients were randomised in a 2:1 ratio to receive either everolimus (10 mg daily) (n=205) or placebo (n=97). Demographics and disease characteristics were generally balanced (median age 63 years [range 22 to 86], 76% Caucasian, history of prior somatostatin analogue [SSA] use). The median duration of blinded treatment was 40.4 weeks for patients receiving Afinitor and 19.6 weeks for those receiving placebo. After primary PFS analysis, 6 patients from the placebo arm crossed over to open-label everolimus.

The efficacy results for the primary endpoint PFS (independent radiological review) were obtained from the final PFS analysis (see Table 6 and Figure 4). The efficacy results for PFS (investigator radiological review) were obtained from the final OS analysis (see Table 6).

Table 6 RADIANT-4 – Progression‑free survival results

Figure 4      RADIANT-4 – Kaplan-Meier progression‑free survival curves (independent radiological review)

				100
						90
					80
																															Kaplan-Meier medians
																																Everolimus + BSC: 11.01 [9.23;13.31] months
						70
																															Placebo + BSC: 3.91 [3.58;7.43] months
						60
																														Log‑rank p value = <0.001
						50
						40
						30
					20
					10
							0
											0			2				4		6		8		10					18					21		24					27		30

In supportive analyses, positive treatment effect has been observed in all subgroups with the exception of the subgroup of patients with ileum as primary site of tumour origin (Ileum: HR=1.22 [95% CI: 0.56 to 2.65]; Non-ileum: HR=0.34 [95% CI: 0.22 to 0.54]; Lung: HR=0.43 [95% CI: 0.24 to 0.79]) (see Figure 5).

Figure 5      RADIANT-4 – Progression free survival results by pre-specified patient subgroup (independent radiological review)

The final overall survival (OS) analysis did not show a statistically significant difference between those patients who received Afinitor or placebo during the blinded treatment period of the study (HR=0.90 [95% CI: 0.66 to 1.22]).

No difference in the time to definitive deterioration of WHO PS (HR=1.02; [95% CI: 0.65, 1.61]) and time to definitive deterioration in quality of life (FACT-G total score HR=0.74; [95% CI: 0.50, 1.10]) was observed between the two arms.

Advanced renal cell carcinoma

RECORD‑1 (study CRAD001C2240), a phase III, international, multicentre, randomised, double‑blind study comparing everolimus 10 mg/day and placebo, both in conjunction with best supportive care, was conducted in patients with metastatic renal cell carcinoma whose disease had progressed on or after treatment with VEGFR‑TKI (vascular endothelial growth factor receptor tyrosine kinase inhibitor) therapy (sunitinib, sorafenib, or both sunitinib and sorafenib). Prior therapy with bevacizumab and interferon‑α was also permitted. Patients were stratified according to Memorial Sloan‑Kettering Cancer Center (MSKCC) prognostic score (favourable‑ vs. intermediate‑ vs. poor‑risk groups) and prior anticancer therapy (1 vs. 2 prior VEGFR‑TKIs).

Progression‑free survival, documented using RECIST (Response Evaluation Criteria in Solid Tumours) and assessed via a blinded, independent central review, was the primary endpoint. Secondary endpoints included safety, objective tumour response rate, overall survival, disease‑related symptoms, and quality of life. After documented radiological progression, patients could be unblinded by the investigator: those randomised to placebo were then able to receive open‑label everolimus 10 mg/day. The Independent Data Monitoring Committee recommended termination of this trial at the time of the second interim analysis as the primary endpoint had been met.

In total, 416 patients were randomised 2:1 to receive Afinitor (n=277) or placebo (n=139). Demographics were well balanced (pooled median age [61 years; range 27‑85], 78% male, 88% Caucasian, number of prior VEGFR‑TKI therapies [1‑74%, 2‑26%]). The median duration of blinded study treatment was 141 days (range 19‑451 days) for patients receiving everolimus and 60 days (range 21‑295 days) for those receiving placebo.

Afinitor was superior to placebo for the primary endpoint of progression‑free survival, with a statistically significant 67% reduction in the risk of progression or death (see Table 7 and Figure 6).

Table 7 RECORD‑1 – Progression‑free survival results

Figure 6      RECORD‑1 – Kaplan-Meier progression‑free survival curves (independent central review)

Six‑month PFS rates were 36% for Afinitor therapy compared with 9% for placebo.

Confirmed objective tumour responses were observed in 5 patients (2%) receiving Afinitor, while none were observed in patients receiving placebo. Therefore, the progression‑free survival advantage primarily reflects the population with disease stabilisation (corresponding to 67% of the Afinitor treatment group).

No statistically significant treatment‑related difference in overall survival was noted (hazard ratio 0.87; confidence interval: 0.65‑1.17; p=0.177). Crossover to open‑label Afinitor following disease progression for patients allocated to placebo confounded the detection of any treatment‑related difference in overall survival.

Other studies

Stomatitis is the most commonly reported adverse reaction in patients treated with Afinitor (see sections 4.4 and 4.8). In a post-marketing single-arm study in postmenopausal women with advanced breast cancer (N=92), topical treatment with dexamethasone 0.5 mg/5 ml alcohol-free oral solution was administered as a mouthwash (4 times daily for the initial 8 weeks of treatment) to patients at the time of initiating treatment with Afinitor (10 mg/day) plus exemestane (25 mg/day) to reduce the incidence and severity of stomatitis. The incidence of Grade ≥2 stomatitis at 8 weeks was 2.4% (n=2/85 evaluable patients) which was lower than historically reported. The incidence of Grade 1 stomatitis was 18.8% (n=16/85) and no cases of Grade 3 or 4 stomatitis were reported. The overall safety profile in this study was consistent with that established for everolimus in the oncology and tuberous sclerosis complex (TSC) settings, with the exception of a slightly increased frequency of oral candidiasis which was reported in 2.2% (n=2/92) of patients.

Paediatric population

Absorption

In patients with advanced solid tumours, peak everolimus concentrations (C_max) are reached at a median time of 1 hour after daily administration of 5 and 10 mg everolimus under fasting conditions or with a light fat‑free snack. C_max is dose‑proportional between 5 and 10 mg. Everolimus is a substrate and moderate inhibitor of PgP.

Food effect

In healthy subjects, high fat meals reduced systemic exposure to everolimus 10 mg (as measured by AUC) by 22% and the peak plasma concentration C_max by 54%. Light fat meals reduced AUC by 32% and C_max by 42%. Food, however, had no apparent effect on the post absorption phase concentration‑time profile.

Distribution

The blood‑to‑plasma ratio of everolimus, which is concentration‑dependent over the range of 5 to 5,000 ng/ml, is 17% to 73%. Approximately 20% of the everolimus concentration in whole blood is confined to plasma in cancer patients given everolimus 10 mg/day. Plasma protein binding is approximately 74% both in healthy subjects and in patients with moderate hepatic impairment. In patients with advanced solid tumours, V_d was 191 l for the apparent central compartment and 517 l for the apparent peripheral compartment.

Biotransformation

Everolimus is a substrate of CYP3A4 and PgP. Following oral administration, everolimus is the main circulating component in human blood. Six main metabolites of everolimus have been detected in human blood, including three monohydroxylated metabolites, two hydrolytic ring‑opened products, and a phosphatidylcholine conjugate of everolimus. These metabolites were also identified in animal species used in toxicity studies, and showed approximately 100 times less activity than everolimus itself. Hence, everolimus is considered to contribute the majority of the overall pharmacological activity.

Elimination

Mean oral clearance (CL/F) of everolimus after 10 mg daily dose in patients with advanced solid tumours was 24.5 l/h. The mean elimination half‑life of everolimus is approximately 30 hours.

No specific excretion studies have been undertaken in cancer patients; however, data are available from the studies in transplant patients. Following the administration of a single dose of radiolabelled everolimus in conjunction with ciclosporin, 80% of the radioactivity was recovered from the faeces, while 5% was excreted in the urine. The parent substance was not detected in urine or faeces.

Steady‑state pharmacokinetics

After administration of everolimus in patients with advanced solid tumours, steady‑state AUC_0‑τ was dose‑proportional over the range of 5 to 10 mg daily dose. Steady‑state was achieved within 2 weeks. C_max is dose‑proportional between 5 and 10 mg. t_max occurs at 1 to 2 hours post‑dose. There was a significant correlation between AUC_0‑τ and pre‑dose trough concentration at steady‑state.

Special populations

Hepatic impairment

The safety, tolerability and pharmacokinetics of everolimus were evaluated in two single oral dose studies of Afinitor tablets in 8 and 34 subjects with impaired hepatic function relative to subjects with normal hepatic function.

In the first study, the average AUC of everolimus in 8 subjects with moderate hepatic impairment (Child‑Pugh B) was twice that found in 8 subjects with normal hepatic function.

In the second study of 34 subjects with different impaired hepatic function compared to normal subjects, there was a 1.6‑fold, 3.3‑fold and 3.6‑fold increase in exposure (i.e. AUC_0‑inf) for subjects with mild (Child‑Pugh A), moderate (Child‑Pugh B) and severe (Child‑Pugh C) hepatic impairment, respectively.

Simulations of multiple dose pharmacokinetics support the dosing recommendations in subjects with hepatic impairment based on their Child‑Pugh status.

Based on the results of the two studies, dose adjustment is recommended for patients with hepatic impairment (see sections 4.2 and 4.4).

Renal impairment

In a population pharmacokinetic analysis of 170 patients with advanced solid tumours, no significant influence of creatinine clearance (25‑178 ml/min) was detected on CL/F of everolimus. Post‑transplant renal impairment (creatinine clearance range 11‑107 ml/min) did not affect the pharmacokinetics of everolimus in transplant patients.

Elderly patients

In a population pharmacokinetic evaluation in cancer patients, no significant influence of age (27‑85 years) on oral clearance of everolimus was detected.

Ethnicity

Oral clearance (CL/F) is similar in Japanese and Caucasian cancer patients with similar liver functions. Based on analysis of population pharmacokinetics, CL/F is on average 20% higher in black transplant patients.