Imatinib is indicated for the treatment of

paediatric patients with newly diagnosed Philadelphia chromosome (bcr-abl) positive (Ph+)
chronic myeloid leukaemia (CML) for whom bone marrow transplantation is not considered as
the first line of treatment.
paediatric patients with Ph+ CML in chronic phase after failure of interferon-alpha therapy, or
in accelerated phase or blast crisis.
Adult patients with Ph+ CML in blast crisis.
Adult and paediatric patients with newly diagnosed Philadelphia chromosome positive acute
lymphoblastic leukaemia (Ph+ ALL) integrated with chemotherapy.
Adult patients with relapsed or refractory Ph+ ALL as monotherapy.
Adult patients with myelodysplastic/myeloproliferative diseases (MDS/MPD) associated with
platelet-derived growth factor receptor (PDGFR) gene re-arrangements.
adult patients with advanced hypereosinophilic syndrome (HES) and/or chronic eosinophilic
leukaemia (CEL) with FIP1L1-PDGFRα rearrangement.
The effect of imatinib on the outcome of bone marrow transplantation has not been determined.
Imatinib is indicated for
• The treatment of adult patients with Kit (CD 117) positive unresectable and/or metastatic
malignant gastrointestinal stromal tumours (GIST).
The adjuvant treatment of adult patients who are at significant risk of relapse following
resection of Kit (CD117)-positive GIST. Patients who have a low or very low risk of recurrence
should not receive adjuvant treatment. the treatment of adult patients with unresectable
dermatofibrosarcoma protuberans (DFSP) and adult patients with recurrent and/or metastatic
DFSP who are not eligible for surgery.
In adult and paediatric patients, the effectiveness of imatinib is based on overall haematological
and cytogenetic response rates and progression-free survival in CML, on haematological and
cytogenetic response rates in Ph+ ALL, MDS/MPD, on haematological response rates in
HES/CEL and on objective response rates in adult patients with unresectable and/or metastatic
GIST and DFSP. And on recurrencefree survival in adjuvant GIST. The experience with imatinib
in patients with MDS/MPD associated with PDGFR gene re-arrangements is very limited (see
section 5.1). There are no controlled trials demonstrating a clinical benefit or increased survival
for these diseases.

Therapy should be initiated by a physician experienced in the treatment of patients with
haematological malignancies and malignant sarcomas, as appropriate.
The prescribed dose should be administered orally with a meal and a large glass of water to
minimise the risk of gastrointestinal irritations. Doses of 400 mg or 600 mg should be
administered once daily, whereas a daily dose of 800 mg should be administered as 400 mg
twice a day, in the morning and in the evening.
For patients (children) unable to swallow the capsules, their content may be dispersed in a glass
of either still water or apple juice. The suspension should be administered immediately after its
preparation.
Since studies in animals have shown reproductive toxicity, and the potential risk for the human
foetus is unknown, women of child-bearing potential who open capsules should be advised to
handle the contents with caution and avoid skin-eye contact or inhalation (see section 4.6).
Hands should be washed immediately after handling open capsules.
Posology for CML in adult patients
The recommended dosage of Imutin is 400 mg/day for adult patients in chronic phase CML.
Chronic phase CML is defined when all of the following criteria are met: blasts < 15% in blood
and bone marrow, peripheral blood basophils < 20%, platelets > 100 x 109/l.
The recommended dosage of Imutin is 600 mg/day for adult patients in accelerated phase.
Accelerated phase is defined by the presence of any of the following: blasts ≥ 15% but < 30% in
blood or bone marrow, blasts plus promyelocytes ≥ 30% in blood or bone marrow (providing <
30% blasts), peripheral blood basophils ≥ 20%, platelets < 100 x 109/l unrelated to therapy.
The recommended dose of imatinib for adult patients with CML in blast crisis is 600 mg/day.
Blast crisis is defined as blasts 30% in blood or bone marrow or extramedullary disease other
than hepatosplenomegaly.
Treatment duration: In clinical trials, treatment with imatinib was continued until disease
progression. The effect of stopping treatment after the achievement of a complete cytogenetic
response has not been investigated.
Dose increases from 600 mg to a maximum of 800 mg (given as 400 mg twice daily) in patients
with blast crisis may be considered in the absence of severe adverse drug reaction and severe
non-leukaemia-related neutropenia or thrombocytopenia in the following circumstances: disease
progression (at any time); failure to achieve a satisfactory haematological response after at least
3 months of treatment; failure to achieve a cytogenetic response after 12 months of treatment; or
loss of a previously achieved haematological and/or cytogenetic response. Patients should be
monitored closely following dose escalation given the potential for an increased incidence of
adverse reactions at higher dosages.
Posology for CML in paediatric patients
Dosing for children should be on the basis of body surface area (mg/m2). The dose of 340
mg/m2 daily is recommended for children with chronic phase CML and advanced phase CML
(not to exceed the total dose of 800 mg). Treatment can be given as a once daily dose or
alternatively the daily dose may be split into two administrations – one in the morning and one in
the evening. The dose recommendation is currently based on a small number of paediatric
patients (see sections 5.1 and 5.2).
There is no experience with the treatment of children below 2 years of age.
Dose increases from 340 mg/m2 daily to 570 mg/m2 daily (not to exceed the total dose of 800
mg) may be considered in children in the absence of severe adverse drug reaction and severe
non-leukaemia-related neutropenia or thrombocytopenia in the following circumstances: disease
progression (at any time); failure to achieve a satisfactory haematological response after at least
3 months of treatment; failure to achieve a cytogenetic response after 12 months of treatment; or
loss of a previously achieved haematological and/or cytogenetic response. Patients should be
monitored closely following dose escalation given the potential for an increased incidence of
adverse reactions at higher dosages.
Posology for Ph+ ALL in adults patients
The recommended dose of imatinib is 600 mg/day for adult patients with Ph+ ALL.
Haematological experts in the management of this disease should supervise the therapy
throughout all phases of care.
Treatment schedule: On the basis of the existing data, imatinib has been shown to be effective
and safe when administered at 600 mg/day in combination with chemotherapy in the induction
phase, the consolidation and maintenance phases of chemotherapy (see section 5.1) for adult
patients with newly diagnosed Ph+ ALL. The duration of imatinib therapy can vary with the
treatment programme selected, but generally longer exposures to imatinib have yielded better
results.
For adult patients with relapsed or refractory Ph+ALL imatinib monotherapy at 600 mg/day is
safe, effective and can be given until disease progression occurs.
Posology for Ph+ ALL in children
Dosing for children should be on the basis of body surface area (mg/m2). The dose of 340
mg/m2 daily is recommended for children with Ph+ ALL (not to exceed the total dose of 600
mg).
Posology for MDS/MPD
The recommended dose of imatinib is 400 mg/day for adult patients with MDS/MPD.
Treatment duration: In the only clinical trial performed up to now, treatment with imatinib was
continued until disease progression (see section 5.1). At the time of analysis, the treatment
duration was a median of 47 months (24 days - 60 months).
Posology for HES/CEL
The recommended dose of imatinib is 100 mg/day for adult patients with HES/CEL.
Dose increase from 100 mg to 400 mg may be considered in the absence of adverse drug
reactions if assessments demonstrate an insufficient response to therapy.
Treatment should be continued as long as the patient continues to benefit.
Posology for GIST
The recommended dose of imatinib is 400 mg/day for adult patients with unresectable and/or
metastatic malignant GIST.
Limited data exist on the effect of dose increases from 400 mg to 600 mg or 800 mg in patients
progressing at the lower dose (see section 5.1).
Treatment duration: In clinical trials in GIST patients, treatment with imatinib was continued
until disease progression. At the time of analysis, the treatment duration was a median of 7
months (7 days to 13 months). The effect of stopping treatment after achieving a response has
not been investigated.
The recommended dose of imatinib is 400 mg/day for the adjuvant treatment of adult patients
following resection of GIST. Optimal treatment duration is not yet established. Length of
treatment in the clinical trial supporting this indication was 36 months (see section 5.1).
Posology for DFSP
The recommended dose of imatinib is 800 mg/day for adult patients with DFSP.
Dose adjustment for adverse reactions
Non-haematological adverse reactions
If a severe non-haematological adverse reaction develops with imatinib use, treatment must be
withheld until the event has resolved. Thereafter, treatment can be resumed as appropriate
depending on the initial severity of the event.
If elevations in bilirubin > 3 x institutional upper limit of normal (IULN) or in liver
transaminases > 5 x IULN occur, imatinib should be withheld until bilirubin levels have returned
to < 1.5 x IULN and transaminase levels to < 2.5 x IULN. Treatment with imatinib may then be
continued at a reduced daily dose. In adults the dose should be reduced from 400 to 300 mg or
from 600 mg to 400 mg, or from 800 mg to 600 mg. In children the dose should be reduced from
340 mg/m2/day to 260 mg/m2/day.
Haematological adverse reactions
Dose reduction or treatment interruption for severe neutropenia and thrombocytopenia are
recommended as indicated in the table below.
Dose adjustments for neutropenia and thrombocytopenia:

Special populations
Paediatric use: There is no experience in children with CML below 2 years of age (see section
5.1).
There is limited experience in children with Ph+ ALL and very limited experience in children
with MDS/MPD, DFSP, GIST and HES/CEL.
The safety and efficacy of imatinib in children with MDS/MPD, DFSP , GIST and HES/CEL
aged less than 18 years of age have not been established in clinical trials. Currently available
published data are summarised in section 5.1 but no recommendation on a posology can be
made.
Hepatic insufficiency: imatinib is mainly metabolised through the liver. Patients with mild,
moderate or severe liver dysfunction should be given the minimum recommended dose of 400
mg daily. The dose can be reduced if not tolerated (see sections 4.4, 4.8 and 5.2).
Liver dysfunction classification:

ULN = upper limit of normal for the institution
AST = aspartate aminotransferase
Renal insufficiency: Patients with renal dysfunction or on dialysis should be given the minimum
recommended dose of 400 mg daily as starting dose. However, in these patients caution is
recommended.
The dose can be reduced if not tolerated. If tolerated, the dose can be increased for lack of
efficacy (see sections 4.4 and 5.2).
Elderly patients: imatinib pharmacokinetics has not been specifically studied in the elderly. No
significant age-related pharmacokinetic differences have been observed in adult patients in
clinical trials which included over 20% of patients age 65 and older. No specific dose
recommendation is necessary in the elderly.

When imatinib is co-administered with other medicinal products, there is a potential for drug
interactions.
Caution should be used when taking imatinib with protease inhibitors, azole antifungals, certain
macrolides (see section 4.5), CYP3A4 substrates with a narrow therapeutic window (e.g.
cyclosporine, pimozide, tacrolimus, sirolimus, ergotamine, diergotamine, fentanyl, alfentanil,
terfenadine, bortezomib, docetaxel, quinidine) or warfarin and other coumarin derivatives (see
section 4.5).
Concomitant use of imatinib and medicinal products that induce CYP3A4 (e.g. dexamethasone,
phenytoin, carbamazepine, rifampicin, phenobarbital or Hypericum perforatum, also known as
St. John's Wort) may significantly reduce exposure to imatinib, potentially increasing the risk of
therapeutic failure.
Therefore, concomitant use of strong CYP3A4 inducers and imatinib should be avoided (see
section 4.5).
Hypothyroidism
Clinical cases of hypothyroidism have been reported in thyroidectomy patients undergoing
levothyroxine replacement during treatment with imatinib (see section 4.5). Thyroid-stimulating
hormone (TSH) levels should be closely monitored in such patients.
Hepatotoxicity
Metabolism of imatinib is mainly hepatic, and only 13% of excretion is through the kidneys. In
patients with hepatic dysfunction (mild, moderate or severe), peripheral blood counts and liver
enzymes should be carefully monitored (see sections 4.2, 4.8 and 5.2). It should be noticed that
GIST patients may have hepatic metastases, which could lead to hepatic impairment.
Cases of liver injury, including hepatic failure and hepatic necrosis, have been observed with
imatinib.
When imatinib is combined with high dose chemotherapy regimens, an increase in serious
hepatic reactions has been detected. Hepatic function should be carefully monitored in
circumstances where
imatinib is combined with chemotherapy regimens also known to be associated with hepatic
dysfunction (see section 4.5 and 4.8).
Fluid retention
Occurrences of severe fluid retention (pleural effusion, oedema, pulmonary oedema, ascites,
superficial
oedema) have been reported in approximately 2.5% of newly diagnosed CML patients taking
imatinib.
Therefore, it is highly recommended that patients be weighed regularly. An unexpected rapid
weight gain should be carefully investigated and if necessary appropriate supportive care and
therapeutic measures should be undertaken. In clinical trials, there was an increased incidence of
these events in elderly patients and those with a prior history of cardiac disease. Therefore,
caution should be exercised in patients with cardiac dysfunction.
Patients with cardiac disease
Patients with cardiac disease or risk factors for cardiac failure or history of renal failure should
be monitored carefully and any patient with signs or symptoms consistent with cardiac or renal
failure should be evaluated and treated.
In patients with hypereosinophilic syndrome (HES) with occult infiltration of HES cells within
the myocardium , isolated cases of cardiogenic shock/left ventricular dysfunction have been
associated with
HES cell degranulation upon the initiation of imatinib therapy. The condition was reported to be
reversible with the administration of systemic steroids, circulatory support measures and
temporarily withholding
imatinib. As cardiac adverse events have been reported uncommonly with imatinib, a careful
assessment of the benefit/risk of imatinib therapy should be considered in the HES/CEL
population before treatment initiation.
Myelodysplastic/myeloproliferative diseases with PDGFR gene re-arrangements could be
associated with high eosinophil levels. Evaluation by a cardiology specialist, performance of an
echocardiogram and determination of serum troponin should therefore be considered in patients
with HES/CEL, and in patients with MDS/MPD associated with high eosinophil levels before
imatinib is administered. If either is abnormal, follow-up with a cardiology specialist and the
prophylactic use of systemic steroids (1-2 mg/kg) for one to two weeks concomitantly with
imatinib should be considered at the initiation of therapy.
Gastrointestinal haemorrhage
In the study in patients with unresectable and/or metastatic GIST, both gastrointestinal and
intratumoural
haemorrhages were reported (see section 4.8). Based on the available data, no predisposing
factors (e.g. tumour size, tumour location, coagulation disorders) have been identified that place
patients with GIST at a higher risk of either type of haemorrhage. Since increased vascularity
and propensity for bleeding is a part of the nature and clinical course of GIST, standard practices
and procedures for the monitoring and management of haemorrhage in all patients should be
applied.
Tumor lysis syndrome
Due to the possible occurrence of tumour lysis syndrome (TLS), correction of clinically
significant dehydration and treatment of high uric acid levels are recommended prior to initiation
of imatinib (see section 4.8).
Laboratory tests
Complete blood counts must be performed regularly during therapy with imatinib. Treatment of
CML patients with imatinib has been associated with neutropenia or thrombocytopenia.
However, the occurrence of these cytopenias is likely to be related to the stage of the disease
being treated and they were more frequent in patients with accelerated phase CML or blast crisis
as compared to patients with chronic phase CML. Treatment with imatinib may be interrupted or
the dose may be reduced, as recommended in section 4.2.
Liver function (transaminases, bilirubin, alkaline phosphatase) should be monitored regularly in
patients receiving imatinib.
In patients with impaired renal function, imatinib plasma exposure seems to be higher than that
in patients with normal renal function, probably due to an elevated plasma level of alpha-acid
glycoprotein (AGP), an
imatinib-binding protein, in these patients. Patients with renal impairment should be given the
minimum starting dose. Patients with severe renal impairment should be treated with caution.
The dose can be reduced if not tolerated (see section 4.2 and 5.2).
Paediatric population
There have been case reports of growth retardation occurring in children and pre-adolescents
receiving imatinib. The long-term effects of prolonged treatment with imatinib on growth in
children are unknown.
Therefore, close monitoring of growth in children under imatinib treatment is recommended (see
section
4.8).
Lactose
Imutin contains lactose.
Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or
glucosegalactose malabsorption should not take this medicine.

Active substances that may increase imatinib plasma concentrations:
Substances that inhibit the cytochrome P450 isoenzyme CYP3A4 activity (e.g. protease
inhibitors such as indinavir, lopinavir/ritonavir, ritonavir, saquinavir, telaprevir, nelfinavir,
boceprevir; azole antifungals including ketoconazole, itraconazole, posaconazole, voriconazole;
certain macrolides such as erythromycin, clarithromycin and telithromycin)) could decrease
metabolism and increase imatinib concentrations. There was a significant increase in exposure to
imatinib (the mean Cmax and AUC of imatinib rose by 26% and 40%, respectively) in healthy
subjects when it was co-administered with a single dose of ketoconazole (a CYP3A4 inhibitor).
Caution should be taken when administering imatinib with inhibitors of the CYP3A4 family.
Active substances that may decrease imatinib plasma concentrations:
Substances that are inducers of CYP3A4 activity (e.g. dexamethasone, phenytoin,
carbamazepine, rifampicin, phenobarbital, fosphenytoin, primidone or Hypericum perforatum,
also known as St. John's Wort) may significantly reduce exposure to imatinib, potentially
increasing the risk of therapeutic failure.
Pretreatment with multiple doses of rifampicin 600 mg followed by a single 400 mg dose of
imatinib resulted in decrease in Cmax and AUC(0-∞) by at least 54% and 74%, of the respective
values without rifampicin treatment. Similar results were observed in patients with malignant
gliomas treated with imatinib while taking enzyme-inducing anti-epileptic drugs (EIAEDs) such
as carbamazepine, oxcarbazepine and phenytoin. The plasma AUC for imatinib decreased by
73% compared to patients not on EIAEDs. Concomitant use of rifampicin or other strong
CYP3A4 inducers and imatinib should be avoided.
Active substances that may have their plasma concentration altered by imatinib
Imatinib increases the mean Cmax and AUC of simvastatin (CYP3A4 substrate) 2- and 3.5-fold,
respectively, indicating an inhibition of the CYP3A4 by imatinib. Therefore, caution is
recommended when administering imatinib with CYP3A4 substrates with a narrow therapeutic
window (e.g. cyclosporine, pimozide, tacrolimus, sirolimus, ergotamine, diergotamine, fentanyl,
alfentanil, terfenadine, bortezomib, docetaxel and quinidine). Imatinib may increase plasma
concentration of other CYP3A4 metabolised drugs (e.g. triazolo-benzodiazepines,
dihydropyridine calcium channel blockers, certain HMG-CoA reductase inhibitors, i.e. statins,
etc.).
Because of known increased risks of bleeding in conjunction with the use of imatinib (e.g.
haemorrhage), patients who require anticoagulation should receive low-molecular-weight or
standard heparin, instead of coumarin derivatives such as warfarin.
In vitro imatinib inhibits the cytochrome P450 isoenzyme CYP2D6 activity at concentrations
similar to those that affect CYP3A4 activity. Imatinib at 400 mg twice daily had an inhibitory
effect on CYP2D6- mediated metoprolol metabolism, with metoprolol Cmax and AUC being
increased by approximately 23% (90%CI [1.16-1.30]). Dose adjustments do not seem to be
necessary when imatinib is co-administrated with CYP2D6 substrates, however caution is
advised for CYP2D6 substrates with a narrow therapeutic window such as metoprolol. In
patients treated with metoprolol clinical monitoring should be considered.
In vitro, imatinib inhibits paracetamol O-glucuronidation with Ki value of 58.5 micromol/l. This
inhibition has not been observed in vivo after the administration of imatinib 400 mg and
paracetamol 1000 mg.
Higher doses of imatinib and paracetamol have not been studied.
Caution should therefore be exercised when using high doses of imatinib and paracetamol
concomitantly.
In thyroidectomy patients receiving levothyroxine, the plasma exposure to levothyroxine may be
decreased when imatinib is co-administered (see section 4.4). Caution is therefore recommended.
However, the mechanism of the observed interaction is presently unknown.
In Ph+ ALL patients, there is clinical experience of co-administering imatinib with
chemotherapy (see section 5.1), but drug-drug interactions between imatinib and chemotherapy
regimens are not well characterised. Imatinib adverse events, i.e. hepatotoxicity, myelo
suppression or others, may increase and it has been reported that concomitant use with Lasparaginase
could be associated with increased hepatotoxicity (see section 4.8). Therefore, the
use of imatinib in combination requires special precaution.

Pregnancy
Pregnancy Category D
There are limited data on the use of imatinib in pregnant women. Studies in animals have
however shown reproductive toxicity (see section 5.3) and the potential risk for the foetus is
unknown. Imatinib should not be used during pregnancy unless clearly necessary. If it is used
during pregnancy, the patient must be informed of the potential risk to the foetus.
Women of childbearing potential must be advised to use effective contraception during
treatment.
Breast-feeding
There is limited information on imatinib distribution on human milk. Studies in two breastfeeding
women revealed that both imatinib and its active metabolite can be distributed into
human milk. The milk plasma ratio studied in a single patient was determined to be 0.5 for
imatinib and 0.9 for the metabolite, suggesting greater distribution of the metabolite into the
milk. Considering the combined concentration of imatinib and the metabolite and the maximum
daily milk intake by infants, the total exposure would be expected to be low (~10% of a
therapeutic dose). However, since the effects of low-dose exposure of the infant to imatinib are
unknown, women taking imatinib should not breast-feed.
Fertility
In non-clinical studies, the fertility of male and female rats was not affected (see section 5.3).
Studies on patients receiving imatinib and its effect on fertility and gametogenesis have not been
performed. Patients on imatinib treatment who are concerned about their fertility should consult
their physician.

Patients should be advised that they may experience undesirable effects such as dizziness,
blurred vision or somnolence during treatment with imatinib. Therefore, caution should be
recommended when driving a car or operating machinery.

Summary of the safety profile
Patients with advanced stages of malignancies may have numerous confounding medical
conditions that make causality of adverse reactions difficult to assess due to the variety of
symptoms related to the underlying disease, its progression, and the co-administration of
numerous medicinal products.
In clinical trials in CML, drug discontinuation for drug-related adverse reactions was observed in
2.4% of newly diagnosed patients, 4% of patients in late chronic phase after failure of interferon
therapy, 4% of patients in accelerated phase after failure of interferon therapy and 5% of blast
crisis patients after failure of interferon therapy. In GIST the study drug was discontinued for
drug-related adverse reactions in 4% of patients.
The adverse reactions were similar in all indications, with two exceptions. There was more
myelosuppression seen in CML patients than in GIST, which is probably due to the underlying
disease. In the study in patients with unresectable and/or metastatic GIST, 7 (5%) patients
experienced CTC grade
3/4 GI bleeds (3 patients), intra-tumoural bleeds (3 patients) or both (1 patient). GI tumour sites
may have been the source of the GI bleeds (see section 4.4). GI and tumoural bleeding may be
serious and sometimes fatal. The most commonly reported (≥ 10%) drug-related adverse
reactions in both settings were mild nausea, vomiting, diarrhoea, abdominal pain, fatigue,
myalgia, muscle cramps and rash.
Superficial oedemas were a common finding in all studies and were described primarily as
periorbital or lower limb oedemas. However, these oedemas were rarely severe and may be
managed with diuretics, other supportive measures, or by reducing the dose of imatinib.
When imatinib was combined with high dose chemotherapy in Ph+ ALL patients, transient liver
toxicity in the form of transaminase elevation and hyperbilirubinaemia were observed.
Considering the limited safety database, the adverse events thus far reported in children are
consistent with the known safety profile in adult patients with Ph+ ALL. The safety database for
children with Ph+ALL is very limited though no new safety concerns have been identified.
Miscellaneous adverse reactions such as pleural effusion, ascites, pulmonary oedema and rapid
weight gain with or without superficial oedema may be collectively described as “fluid
retention”. These reactions can usually be managed by withholding imatinib temporarily and
with diuretics and other appropriate supportive care measures. However, some of these reactions
may be serious or life-threatening and several patients with blast crisis died with a complex
clinical history of pleural effusion, congestive heart failure and renal failure. There were no
special safety findings in paediatric clinical trials.
Adverse reactions
Adverse reactions reported as more than an isolated case are listed below, by system organ class
and by frequency. 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, undesirable effects are presented in order of frequency, the
most frequent first.
Adverse reactions and their frequencies reported in Table 1 are based on the main registration
studies.
Table 1 Adverse reactions in clinical studies

1 Pneumonia was reported most commonly in patients with transformed CML and in patients
with GIST
2 Headache was the most common in GIST patients.
3 On a patient-year basis, cardiac events including congestive heart failure were more commonly
observed in patients with transformed CML than in patients with chronic CML.
4 Flushing was most common in GIST patients and bleeding (haematoma, haemorrhage) was
most common in patients with GIST and with transformed CML (CML-AP and CML-BC).
5 Pleural effusion was reported more commonly in patients with GIST and in patients with
transformed CML (CML-AP and CML-BC) than in patients with chronic CML.
6+7 Abdominal pain and gastrointestinal haemorrhage were most commonly observed in GIST
patients.
8 Some fatal cases of hepatic failure and of hepatic necrosis have been reported.
9 Musculoskeletal pain and related events were more commonly observed in patients with CML
than in GIST patients.
The following types of reactions have been reported mainly from post-marketing experience with
imatinib. This includes spontaneous case reports as well as serious adverse events from ongoing
studies, the expanded access programmes, clinical pharmacology studies and exploratory studies
in unapproved indications. Because these reactions are reported from a population of uncertain
size, it is not always possible to reliably estimate their frequency or establish a causal
relationship to imatinib exposure.
Table 2 Adverse reactions from post-marketing reports

Laboratory test abnormalities
Haematology
In CML, cytopenias, particularly neutropenia and thrombocytopenia, have been a consistent
finding in all studies, with the suggestion of a higher frequency at high doses ≥750 mg (phase I
study). However, the occurrence of cytopenias was also clearly dependent on the stage of the
disease, the frequency of grade 3 or 4 neutropenias (ANC < 1.0 x 109/l) and thrombocytopenias
(platelet count < 50 x 109/l) being between
4 and 6 times higher in blast crisis and accelerated phase (59–64% and 44–63% for neutropenia
and thrombocytopenia, respectively) as compared to newly diagnosed patients in chronic phase
CML (16.7% neutropenia and 8.9% thrombocytopenia). In newly diagnosed chronic phase CML
grade 4 neutropenia (ANC < 0.5 x 109/l) and thrombocytopenia (platelet count < 10 x 109/l)
were observed in 3.6% and < 1% of patients, respectively. The median duration of the
neutropenic and thrombocytopenic episodes usually ranged from 2 to 3 weeks, and from 3 to 4
weeks, respectively. These events can usually be managed with either a reduction of the dose or
an interruption of treatment with imatinib, but can in rare cases lead to permanent
discontinuation of treatment. In paediatric CML patients the most frequent toxicities observed
were grade 3 or 4 cytopenias involving neutropenia, thrombocytopenia and anaemia. These
generally occur within the first several months of therapy.
In the study in patients with unresectable and/or metastatic GIST, grade 3 and 4 anaemia was
reported in
5.4% and 0.7% of patients, respectively, and may have been related to gastrointestinal or intratumoural
bleeding in at least some of these patients. Grade 3 and 4 neutropenia was seen in 7.5%
and 2.7% of patients, respectively, and grade 3 thrombocytopenia in 0.7% of patients. No patient
developed grade 4 thrombocytopenia. The decreases in white blood cell (WBC) and neutrophil
counts occurred mainly during the first six weeks of therapy, with values remaining relatively
stable thereafter.
Biochemistry
Severe elevation of transaminases (<5%) or bilirubin (<1%) was seen in CML patients and was
usually managed with dose reduction or interruption (the median duration of these episodes was
approximately one week). Treatment was discontinued permanently because of liver laboratory
abnormalities in less than 1% of CML patients. In GIST patients (study B2222), 6.8% of grade 3
or 4 ALT (alanine aminotransferase) elevations and 4.8% of grade 3 or 4 AST (aspartate
aminotransferase) elevations were observed. Bilirubin elevation was below 3%.
There have been cases of cytolytic and cholestatic hepatitis and hepatic failure; in some of them
outcome was fatal, including one patient on high dose paracetamol.

Experience with doses higher than the recommended therapeutic dose is limited. Isolated cases
of imatinib overdose have been reported spontaneously and in the literature. In the event of
overdose the patient should be observed and appropriate symptomatic treatment given. Generally
the reported outcome in these cases was “improved” or “recovered”. Events that have been
reported at different dose ranges are as follows:
Adult population
1200 to 1600 mg (duration varying between 1 to 10 days): Nausea, vomiting, diarrhoea, rash,
erythema, oedema, swelling, fatigue, muscle spasms, thrombocytopenia, pancytopenia,
abdominal pain, headache, decreased appetite.
1800 to 3200 mg (as high as 3200 mg daily for 6 days): Weakness, myalgia, increased creatine
phosphokinase, increased bilirubin, gastrointestinal pain.
6400 mg (single dose): One case reported in the literature of one patient who experienced
nausea, vomiting, abdominal pain, pyrexia, facial swelling, decreased neutrophil count, increased
transaminases.
8 to 10 g (single dose): Vomiting and gastrointestinal pain have been reported.
Paediatric population
One 3-year-old male exposed to a single dose of 400 mg experienced vomiting, diarrhoea and
anorexia and another 3-year-old male exposed to a single dose of 980 mg experienced decreased
white blood cell count and diarrhoea.
In the event of overdose, the patient should be observed and appropriate supportive treatment
given.

Pharmacotherapeutic group: antineoplastic agents, protein kinase inhibitor, ATC code: L01XE01

Mechanism of actionImatinib is a small molecule protein-tyrosine kinase inhibitor that potently inhibits the activity of the Bcr-Abl tyrosine kinase (TK), as well as several receptor TKs: Kit, the receptor for stem cell factor (SCF) coded for by the c-Kit proto-oncogene, the discoidin domain receptors (DDR1 and DDR2), the colony stimulating factor receptor (CSF-1R) and the platelet-derived growth factor receptors alpha and beta (PDGFR-alpha and PDGFR-beta). Imatinib can also inhibit cellular events mediated by activation of these receptor kinases.

Pharmacodynamic effects

Imatinib is a protein-tyrosine kinase inhibitor which potently inhibits the Bcr-Abl tyrosine kinase at the in vitro, cellular and in vivo levels. The compound selectively inhibits proliferation and induces apoptosis in Bcr-Abl positive cell lines as well as fresh leukaemic cells from Philadelphia chromosome positive CML and acute lymphoblastic leukaemia (ALL) patients.

In vivo the compound shows anti-tumour activity as a single agent in animal models using Bcr-Abl positive tumour cells.

Imatinib is also an inhibitor of the receptor tyrosine kinases for platelet-derived growth factor (PDGF), PDGF-R , and stem cell factor (SCF), c-Kit, and inhibits PDGF - and SCF-mediated cellular events. In vitro, imatinib inhibits proliferation and induces apoptosis in gastrointestinal stromal tumour (GIST) cells, which express an activating kit mutation. Constitutive activation of the PDGF receptor or the Abl protein tyrosine kinases as a consequence of fusion to diverse partner proteins or constitutive production of PDGF have been implicated in the pathogenesis of MDS/MPD, HES/CEL and DFSP. Imatinib inhibits signalling

and proliferation of cells driven by dysregulated PDGFR and Abl kinase activity.

Clinical studies in chronic myeloid leukaemia

The effectiveness of imatinib is based on overall haematological and cytogenetic response rates and progression-free survival. There are no controlled trials demonstrating a clinical benefit, such as improvement in disease-related symptoms or increased survival.

One large, international, open-label, non-controlled phase II study was conducted in patients with Philadelphia chromosome positive (Ph+) CML in blast crisis.

In addition, children have been treated in two phase I studies and one phase II study.

Myeloid blast crisis: 260 patients with myeloid blast crisis were enrolled. 95 (37%) had received prior chemotherapy for treatment of either accelerated phase or blast crisis (“pretreated patients”) whereas 165

(63%) had not (“untreated patients”). The first 37 patients were started at 400 mg, the protocol was subsequently amended to allow higher dosing and the remaining 223 patients were started at 600 mg.

The primary efficacy variable was the rate of haematological response, reported as either complete haematological response, no evidence of leukaemia, or return to chronic phase CML using the same criteria as for the study in accelerated phase. In this study, 31% of patients achieved a haematological response (36% in previously untreated patients and 22% in previously treated patients). The rate of response was also higher in the patients treated at 600 mg (33%) as compared to the patients treated at 400 mg (16%, p=0.0220). The current estimate of the median survival of the previously untreated and treated patients was 7.7 and 4.7 months, respectively.

Lymphoid blast crisis: a limited number of patients were enrolled in phase I studies (n=10). The rate of haematological response was 70% with a duration of 2-3 months.

Table 4. Response in adult CML study

Paediatric patients: A total of 26 paediatric patients of age <18 years with either chronic phase CML

(n=11) or CML in blast crisis or Ph+ acute leukaemias (n=15) were enrolled in a dose-escalation phase I trial. This was a population of heavily pretreated patients, as 46% had received prior BMT and 73% a prior multi-agent chemotherapy. Patients were treated at doses of imatinib of 260 mg/m2/day (n=5), 340 mg/m2/day (n=9), 440 mg/m2/day (n=7) and 570 mg/m2/day (n=5). Out of 9 patients with chronic phase

CML and cytogenetic data available, 4 (44%) and 3 (33%) achieved a complete and partial cytogenetic response, respectively, for a rate of MCyR of 77%.

A total of 51 paediatric patients with newly diagnosed and untreated CML in chronic phase have been enrolled in an open-label, multicentre, single-arm phase II trial. Patients were treated with imatinib 340 mg/m2/day, with no interruptions in the absence of dose limiting toxicity. matinib treatment induces a rapid response in newly diagnosed paediatric CML patients with a CHR of 78% after 8 weeks of therapy.

The high rate of CHR is accompanied by the development of a complete cytogenetic response (CCyR) of 65% which is comparable to the results observed in adults. Additionally, partial cytogenetic response

(PCyR) was observed in 16% for a MCyR of 81%. The majority of patients who achieved a CCyR developed the CCyR between months 3 and 10 with a median time to response based on the Kaplan-Meier estimate of 5.6 months.

The European Medicines Agency has waived the obligation to submit the results of studies with imatinib in all subsets of the paediatric population in Philadelphia chromosome (bcr-abl translocation)-positive chronic myeloid leukaemia (see section 4.2 for information on paediatric use).

Clinical studies in Ph+ ALL

Newly diagnosed Ph+ ALL: In a controlled study (ADE10) of imatinib versus chemotherapy induction in

55 newly diagnosed patients aged 55 years and over, imatinib used as single agent induced a significantly higher rate of complete haematological response than chemotherapy (96.3% vs. 50%; p=0.0001). When salvage therapy with imatinib was administered in patients who did not respond or who responded poorly to chemotherapy, it resulted in 9 patients (81.8%) out of 11 achieving a complete haematological response. This clinical effect was associated with a higher reduction in bcr-abl transcripts in the imatinibtreated patients than in the chemotherapy arm after 2 weeks of therapy (p=0.02). All patients received imatinib and consolidation chemotherapy (see Table 5) after induction and the levels of bcr-abl transcripts were identical in the two arms at 8 weeks. As expected on the basis of the study design, no difference was observed in remission duration, disease-free survival or overall survival, although patients with complete molecular response and remaining in minimal residual disease had a better outcome in terms of both remission duration (p=0.01) and disease-free survival (p=0.02).

The results observed in a population of 211 newly diagnosed Ph+ ALL patients in four uncontrolled clinical studies (AAU02, ADE04, AJP01 and AUS01) are consistent with the results described above.

Imatinib in combination with chemotherapy induction (see Table 5) resulted in a complete haematological response rate of 93% (147 out of 158 evaluable patients) and in a major cytogenetic response rate of 90% (19 out of 21 evaluable patients). The complete molecular response rate was 48% (49 out of 102 evaluable patients). Disease-free survival (DFS) and overall survival (OS) constantly exceeded 1 year and were superior to historical control (DFS p<0.001; OS p<0.0001) in two studies (AJP01 and AUS01).

Table 5 Chemotherapy regimen used in combination with imatinib

Paediatric patients: In study I2301, a total of 93 paediatric, adolescent and young adult patients (from 1 to 22 years old) with Ph+ ALL were enrolled in an open-label, multicentre, sequential cohort, nonrandomized phase III trial, and were treated with Glivec (340 mg/m2/day) in combination with intensive chemotherapy after induction therapy. Glivec was administered intermittently in cohorts 1-5, with increasing duration and earlier start of Glivec from cohort to cohort; cohort 1 receiving the lowest intensitiy and cohort 5 receiving the highest intensity of Glivec (longest duration in days with continuous daily Glivec dosing during the first chemotherapy treatment courses). Continuous daily exposure to Glivec early in the course of treatment in combination with chemotherapy in cohort 5-patients (n=50) improved the 4-year event-free survival (EFS) compared to historical controls (n=120), who received standard chemotherapy without Glivec (69.6% vs. 31.6%, respectively). The estimated 4-year OS in cohort 5- patients was 83.6% compared to 44.8% in the historical controls. 20 out of the 50 (40%) patients in cohort 5 received haematopoietic stem cell transplant.

Table 6 Chemotherapy regimen used in combination with imatinib in study I2301

G-CSF = granulocyte colony stimulating factor, VP-16 = etoposide, MTX = methotrexate, IV = intravenous, SC = subcutaneous, IT = intrathecal, PO = oral, IM = intramuscular, ARA-C = cytarabine, CPM = cyclophosphamide, VCR = vincristine, DEX = dexamethasone, DAUN = daunorubicin, 6-MP = 6- mercaptopurine, E.Coli L-ASP = L-asparaginase, PEG-ASP = PEG asparaginase, MESNA= 2- mercaptoethane sulfonate sodium, iii= or until MTX level is < 0.1 μM, q6h = every 6 hours, Gy= Gray Study AIT07 was a multicentre, open-label, randomised, phase II/III study that included 128 patients (1 to

< 18 years) treated with imatinib in combination with chemotherapy. Safety data from this study seem to be in line with the safety profile of imatinib in Ph+ ALL patients.

Relapsed/refractory Ph+ ALL: When imatinib was used as single agent in patients with

relapsed/refractory Ph+ ALL, it resulted, in the 53 out of 411 patients evaluable for response, in a haematological response rate of 30% (9% complete) and a major cytogenetic response rate of 23%. (Of note, out of the 411 patients, 353 were treated in an expanded access program without primary response data collected.) The median time to progression in the overall population of 411 patients with relapsed/refractory Ph+ ALL ranged from 2.6 to 3.1 months, and median overall survival in the 401 evaluable patients ranged from 4.9 to 9 months. The data was similar when re-analysed to include only those patients age 55 or older.

Clinical studies in MDS/MPD

Experience with imatinib in this indication is very limited and is based on haematological and cytogenetic response rates. There are no controlled trials demonstrating a clinical benefit or increased survival. One open label, multicentre, phase II clinical trial (study B2225) was conducted testing imatinib in diverse populations of patients suffering from life-threatening diseases associated with Abl, Kit or PDGFR protein tyrosine kinases. This study included 7 patients with MDS/MPD who were treated with imatinib 400 mg daily. Three patients presented a complete haematological response (CHR) and one patient experienced a partial haematological response (PHR). At the time of the original analysis, three of the four patients with detected PDGFR gene rearrangements developed haematological response (2 CHR and 1 PHR). The age of these patients ranged from 20 to 72 years. In addition a further 24 patients with MDS/MPD were reported in 13 publications. 21 patients were treated with imatinib 400 mg daily, while the other 3 patients received lower doses. In eleven patients PDGFR gene rearrangements was detected, 9 of them achieved a CHR and 1 PHR. The age of these patients ranged from 2 to 79 years. In a recent publication updated information from 6 of these 11 patients revealed that all these patients remained in cytogenetic remission (range 32-38 months). The same publication reported long term follow-up data from 12 MDS/MPD patients with PDGFR gene rearrangements (5 patients from study B2225). These patients received imatinib for a median of 47 months (range 24 days – 60 months). In 6 of these patients follow-up now exceeds 4 years. Eleven patients achieved rapid CHR; ten had complete resolution of cytogenetic abnormalities and a decrease or disappearance of fusion transcripts as measured by RT-PCR.

Haematological and cytogenetic responses have been sustained for a median of 49 months (range 19-60) and 47 months (range 16-59), respectively. The overall survival is 65 months since diagnosis (range 25-

234). imatinib administration to patients without the genetic translocation generally results in no improvement.

There are no controlled trials in paediatric patients with MDS/MPD. Five (5) patients with MDS/MPD associated with PDGFR gene re-arrangements were reported in 4 publications. The age of these patients

ranged from 3 months to 4 years and imatinib was given at dose 50 mg daily or doses ranging from 92.5 to 340 mg/m2 daily. All patients achieved complete haematological response, cytogenetic response and/or clinical response.

Clinical studies in HES/CEL

One open-label, multicentre, phase II clinical trial (study B2225) was conducted testing imatinib in diverse populations of patients suffering from life-threatening diseases associated with Abl, Kit or PDGFR protein tyrosine kinases. In this study, 14 patients with HES/CEL were treated with 100 mg to 1,000 mg of imatinib daily. A further 162 patients with HES/CEL, reported in 35 published case reports and case series received imatinib at doses from 75 mg to 800 mg daily. Cytogenetic abnormalities were evaluated in 117 of the total population of 176 patients. In 61 of these 117 patients FIP1L1-PDGFRα fusion kinase was identified. An additional four HES patients were found to be FIP1L1-PDGFRα-positive in other 3 published reports. All 65 FIP1L1-PDGFRα fusion kinase positive patients achieved a CHR sustained for months (range from 1+ to 44+ months censored at the time of the reporting). As reported in a recent

publication 21 of these 65 patients also achieved complete molecular remission with a median follow-up of 28 months (range 13-67 months). The age of these patients ranged from 25 to 72 years. Additionally, improvements in symptomatology and other organ dysfunction abnormalities were reported by the investigators in the case reports. Improvements were reported in cardiac, nervous, skin/subcutaneous tissue, respiratory/thoracic/mediastinal, musculoskeletal/connective tissue/vascular, and gastrointestinal organ systems.

There are no controlled trials in paediatric patients with HES/CEL. Three (3) patients with HES and CEL associated with PDGFR gene re-arrangements were reported in 3 publications. The age of these patients ranged from 2 to 16 years and imatinib was given at dose 300 mg/m2 daily or doses ranging from 200 to 400 mg daily. All patients achieved complete haematological response, complete cytogenetic response and/or complete molecular response.

Clinical studies in unresectable and/or metastatic GIST

One phase II, open-label, randomised, uncontrolled multinational study was conducted in patients with unresectable or metastatic malignant gastrointestinal stromal tumours (GIST). In this study 147 patients were enrolled and randomised to receive either 400 mg or 600 mg orally once daily for up to 36 months.

These patients ranged in age from 18 to 83 years old and had a pathologic diagnosis of Kit-positive malignant GIST that was unresectable and/or metastatic. Immunohistochemistry was routinely performed with Kit antibody (A-4502, rabbit polyclonal antiserum, 1:100; DAKO Corporation, Carpinteria, CA) according to analysis by an avidin-biotin-peroxidase complex method after antigen retrieval.

The primary evidence of efficacy was based on objective response rates. Tumours were required to be measurable in at least one site of disease, and response characterisation based on Southwestern Oncology Group (SWOG) criteria. Results are provided in Table 7.

Table 7 Best tumour response in trial STIB2222 (GIST)

There were no differences in response rates between the two dose groups. A significant number of patients who had stable disease at the time of the interim analysis achieved a partial response with longer treatment (median follow-up 31 months). Median time to response was 13 weeks (95% C.I. 12–23). Median time to treatment failure in responders was 122 weeks (95% C.I 106–147), while in the overall study population it was 84 weeks (95% C.I 71–109). The median overall survival has not been reached. The Kaplan-Meier estimate for survival after 36-month follow-up is 68%.

In two clinical studies (study B2222 and an intergroup study S0033) the daily dose of imatinib was escalated to 800 mg in patients progressing at the lower daily doses of 400 mg or 600 mg. The daily dose was escalated to 800 mg in a total of 103 patients; 6 patients achieved a partial response and 21 stabilization of their disease after dose escalation for an overall clinical benefit of 26%. From the safety data available, escalating the dose to 800 mg daily in patients progressing at lower doses of 400 mg or 600 mg daily does not seem to affect the safety profile of imatinib.

Clinical study in adjuvant GIST

In the adjuvant setting, imatinib was investigated in a multicentre, double-blind, long-term, placebocontrolled phase III study (Z9001) involving 773 patients. The ages of these patients ranged from 18 to 91 years. Patients were included who had a histological diagnosis of primary GIST expressing Kit protein by immunochemistry and a tumour size ≥ 3 cm in maximum dimension, with complete gross resection of primary GIST within 14-70 days prior to registration. After resection of primary GIST, patients were randomised to one of the two arms: imatinib at 400 mg/day or matching placebo for one year.

The primary endpoint of the study was recurrence-free survival (RFS), defined as the time from date of randomisation to the date of recurrence or death from any cause.

Imatinib significantly prolonged RFS, with 75% of patients being recurrence-free at 38 months in the imatinib group vs. 20 months in the placebo group (95% CIs, [30 - non-estimable]; [14 - non-estimable], respectively); (hazard ratio = 0.398 [0.259-0.610], p<0.0001). At one year the overall RFS was significantly better for imatinib (97.7%) vs. placebo (82.3%), (p<0.0001). The risk of recurrence was thus reduced by approximately 89% as compared with placebo (hazard ratio = 0.113 [0.049-0.264]).

The risk of recurrence in patients after surgery of their primary GIST was retrospectively assessed based on the following prognostic factors: tumour size, mitotic index, tumour location. Mitotic index data were available for 556 of the 713 intention-to-treat (ITT) population. The results of subgroup analyses according to the United States National Institutes of Health (NIH) and the Armed Forces Institute of Pathology (AFIP) risk classifications are shown in Table 8. No benefit was observed in the low and very low risk groups. No overall survival benefit has been observed.

Table 8 Summary of Z9001 trial RFS analyses by NIH and AFIP risk classifications

* Full follow-up period; NE – Not estimable

A second multicentre, open label phase III study (SSG XVIII/AIO) compared 400 mg/day imatinib 12 months treatment vs. 36 months treatment in patients after surgical resection of GIST and one of the following: tumour diameter > 5 cm and mitotic count > 5/50 high power fields (HPF); or tumour diameter > 10 cm and any mitotic count or tumour of any size with mitotic count > 10/50 HPF or tumours ruptured into the peritoneal cavity. There were a total of 397 patients consented and randomised to the study (199 patients on 12-month arm and 198 patients on 36-month arm), median age was 61 years (range 22 to 84 years). The median time of follow-up was 54 months (from date of randomisation to data cut-off), with a total of 83 months between the first patient randomised and the cut-off date.

The primary endpoint of the study was recurrence-free survival (RFS), defined as the time from date of randomisation to the date of recurrence or death from any cause.

Thirty-six (36) months of imatinib treatment significantly prolonged RFS compared to 12 months of imatinib treatment (with overall Hazard Ratio (HR) = 0.46 [0.32, 0.65], p<0.0001) (Table 8, Figure 1).

In addition, thirty-six (36) months of imatinib treatment significantly prolonged overall survival (OS) compared to 12 months of imatinib treatment (HR = 0.45 [0.22, 0.89], p=0.0187) (Table 8, Figure 2).

Longer duration of the treatment (> 36 months) may delay the onset of further recurrences; however the impact of this finding on the overall survival remains unknown.

The total number of deaths were 25 for the 12-month treatment arm and 12 for the 36-month treatment arm.

Treatment with imatinib for 36 months was superior to treatment for 12 months in the ITT analysis, i.e. including the entire study population. In a planned subgroup analysis by mutation type, the HR for RFS for 36 months of treatment for patients with mutations of exon 11 was 0.35 [95% CI: 0.22, 0.56]. No conclusions can be drawn for other less common mutation subgroups due to the low number of observed events.

Table 9 12-month and 36-month imatinib treatment (SSGXVIII/AIO Trial)

There are no controlled trials in paediatric patients with c-Kit positive GIST. Seventeen (17) patients with

GIST (with or without Kit and PDGFR mutations) were reported in 7 publications. The age of these patients ranged from 8 to 18 years and imatinib was given in both adjuvant and metastatic settings at doses ranging from 300 to 800 mg daily. The majority of paediatric patients treated for GIST lacked data confirming c-kit or PDGFR mutations which may have led to mixed clinical outcomes.

Clinical studies in DFSP

One phase II, open label, multicentre clinical trial (study B2225) was conducted including 12 patients with DFSP treated with imatinib 800 mg daily. The age of the DFSP patients ranged from 23 to 75 years; DFSP was metastatic, locally recurrent following initial resective surgery and not considered amenable to further resective surgery at the time of study entry. The primary evidence of efficacy was based on objective response rates. Out of the 12 patients enrolled, 9 responded, one completely and 8 partially. Three of the partial responders were subsequently rendered disease free by surgery. The median duration of therapy in study B2225 was 6.2 months, with a maximum duration of 24.3 months. A further 6 DFSP patients treated with imatinib were reported in 5 published case reports, their ages ranging from 18 months to 49 years.

The adult patients reported in the published literature were treated with either 400 mg (4 cases) or 800 mg (1 case) imatinib daily. 5 patients responded, 3 completely and 2 partially. The median duration of therapy

Probability of overall survival in the published literature ranged between 4 weeks and more than 20 months. The translocation t(17:22)[(q22:q13)], or its gene product, was present in nearly all responders to imatinib treatment.

There are no controlled trials in paediatric patients with DFSP. Five (5) patients with DFSP and PDGFR gene re-arrangements were reported in 3 publications. The age of these patients ranged from newborn to

14 years and imatinib was given at dose 50 mg daily or doses ranging from 400 to 520 mg/m2 daily. All patients achieved partial and/or complete response.

Pharmacokinetics of imatinib

The pharmacokinetics of imatinib have been evaluated over a dosage range of 25 to 1,000 mg. Plasma pharmacokinetic profiles were analysed on day 1 and on either day 7 or day 28, by which time plasma concentrations had reached steady state.

Absorption

Mean absolute bioavailability for imatinib is 98%. There was high between- patient variability in plasma imatinib AUC levels after an oral dose. When given with a high-fat meal, the rate of absorption of imatinib was minimally reduced (11% decrease in Cmax and prolongation of tmax by 1.5 h), with a small reduction in AUC (7.4%) compared to fasting conditions. The effect of prior gastrointestinal surgery on drug absorption has not been investigated.

Distribution

At clinically relevant concentrations of imatinib, binding to plasma proteins was approximately 95% on the basis of in vitro experiments, mostly to albumin and alpha-acid-glycoprotein, with little binding to lipoprotein.

Biotransformation

The main circulating metabolite in humans is the N-demethylated piperazine derivative, which shows similar in vitro potency to the parent. The plasma AUC for this metabolite was found to be only 16% of the AUC for imatinib. The plasma protein binding of the N-demethylated metabolite is similar to that of the parent compound.

Imatinib and the N-demethyl metabolite together accounted for about 65% of the circulating radioactivity (AUC(0-48h)). The remaining circulating radioactivity consisted of a number of minor metabolites.

The in vitro results showed that CYP3A4 was the major human P450 enzyme catalysing the biotransformation of imatinib. Of a panel of potential comedications (acetaminophen, aciclovir,

allopurinol, amphotericin, cytarabine, erythromycin, fluconazole, hydroxyurea, norfloxacin, penicillin V) only erythromycin (IC50 50 μM) and fluconazole (IC50 118 μM) showed inhibition of imatinib metabolism which could have clinical relevance.

Imatinib was shown in vitro to be a competitive inhibitor of marker substrates for CYP2C9, CYP2D6 and CYP3A4/5. Ki values in human liver microsomes were 27, 7.5 and 7.9 μmol/l, respectively. Maximal plasma concentrations of imatinib in patients are 2–4 μmol/l, consequently an inhibition of CYP2D6 and/or CYP3A4/5-mediated metabolism of co-administered drugs is possible. Imatinib did not interfere with the biotransformation of 5-fluorouracil, but it inhibited paclitaxel metabolism as a result of competitive inhibition of CYP2C8 (Ki = 34.7 μM). This Ki value is far higher than the expected plasma levels of imatinib in patients, consequently no interaction is expected upon co-administration of either 5- fluorouracil or paclitaxel and imatinib.

Elimination

Based on the recovery of compound(s) after an oral 14C-labelled dose of imatinib, approximately 81% of the dose was recovered within 7 days in faeces (68% of dose) and urine (13% of dose). Unchanged imatinib accounted for 25% of the dose (5% urine, 20% faeces), the remainder being metabolites.

Plasma pharmacokinetics

Following oral administration in healthy volunteers, the t½ was approximately 18 h, suggesting that oncedaily dosing is appropriate. The increase in mean AUC with increasing dose was linear and dose proportional in the range of 25–1,000 mg imatinib after oral administration. There was no change in the kinetics of imatinib on repeated dosing, and accumulation was 1.5–2.5-fold at steady state when dosed once daily.

Pharmacokinetics in GIST patients

In patients with GIST steady-state exposure was 1.5-fold higher than that observed for CML patients for the same dosage (400 mg daily). Based on preliminary population pharmacokinetic analysis in GIST patients, there were three variables (albumin, WBC and bilirubin) found to have a statistically significant relationship with imatinib pharmacokinetics. Decreased values of albumin caused a reduced clearance

(CL/f); and higher levels of WBC led to a reduction of CL/f. However, these associations are not sufficiently pronounced to warrant dose adjustment. In this patient population, the presence of hepatic metastases could potentially lead to hepatic insufficiency and reduced metabolism.

Population pharmacokinetics

Based on population pharmacokinetic analysis in CML patients, there was a small effect of age on the volume of distribution (12% increase in patients > 65 years old). This change is not thought to be clinically significant. The effect of bodyweight on the clearance of imatinib is such that for a patient weighing 50 kg the mean clearance is expected to be 8.5 l/h, while for a patient weighing 100 kg the clearance will rise to 11.8 l/h. These changes are not considered sufficient to warrant dose adjustment based on kg bodyweight. There is no effect of gender on the kinetics of imatinib.

Pharmacokinetics in children

As in adult patients, imatinib was rapidly absorbed after oral administration in paediatric patients in both phase I and phase II studies. Dosing in children at 260 and 340 mg/m2/day achieved the same exposure, respectively, as doses of 400 mg and 600 mg in adult patients. The comparison of AUC(0-24) on day 8 and day 1 at the 340 mg/m2/day dose level revealed a 1.7-fold drug accumulation after repeated once-daily dosing.

Based on pooled population pharmacokinetic analysis in paediatric patients with haematological disorders (CML, Ph+ALL, or other haematological disorders treated with imatinib), clearance of imatinib increases with increasing body surface area (BSA). After correcting for the BSA effect, other demographics such as age, body weight and body mass index did not have clinically significant effects on the exposure of

imatinib. The analysis confirmed that exposure of imatinib in paediatric patients receiving 260 mg/m2 once daily (not exceeding 400 mg once daily) or 340 mg/m2 once daily (not exceeding 600 mg once daily) were similar to those in adult patients who received imatinib 400 mg or 600 mg once daily.

Organ function impairment

Imatinib and its metabolites are not excreted via the kidney to a significant extent. Patients with mild and moderate impairment of renal function appear to have a higher plasma exposure than patients with normal renal function. The increase is approximately 1.5- to 2-fold, corresponding to a 1.5-fold elevation of plasma AGP, to which imatinib binds strongly. The free drug clearance of imatinib is probably similar between patients with renal impairment and those with normal renal function, since renal excretion represents only a minor elimination pathway for imatinib (see sections 4.2 and 4.4).

Although the results of pharmacokinetic analysis showed that there is considerable inter-subject variation, the mean exposure to imatinib did not increase in patients with varying degrees of liver dysfunction as compared to patients with normal liver function (see sections 4.2, 4.4 and 4.8).

The preclinical safety profile of imatinib was assessed in rats, dogs, monkeys and rabbits.

Multiple dose toxicity studies revealed mild to moderate haematological changes in rats, dogs and monkeys, accompanied by bone marrow changes in rats and dogs.

The liver was a target organ in rats and dogs. Mild to moderate increases in transaminases and slight decreases in cholesterol, triglycerides, total protein and albumin levels were observed in both species. No histopathological changes were seen in rat liver. Severe liver toxicity was observed in dogs treated for 2 weeks, with elevated liver enzymes, hepatocellular necrosis, bile duct necrosis, and bile duct hyperplasia.

Renal toxicity was observed in monkeys treated for 2 weeks, with focal mineralisation and dilation of the renal tubules and tubular nephrosis. Increased blood urea nitrogen (BUN) and creatinine were observed in several of these animals. In rats, hyperplasia of the transitional epithelium in the renal papilla and in the urinary bladder was observed at doses ≥ 6 mg/kg in the 13-week study, without changes in serum or urinary parameters. An increased rate of opportunistic infections was observed with chronic imatinib treatment.

In a 39-week monkey study, no NOAEL (no observed adverse effect level) was established at the lowest dose of 15 mg/kg, approximately one-third the maximum human dose of 800 mg based on body surface.

Treatment resulted in worsening of normally suppressed malarial infections in these animals.

Imatinib was not considered genotoxic when tested in an in vitro bacterial cell assay (Ames test), an in vitro mammalian cell assay (mouse lymphoma) and an in vivo rat micronucleus test. Positive genotoxic effects were obtained for imatinib in an in vitro mammalian cell assay (Chinese hamster ovary) for clastogenicity (chromosome aberration) in the presence of metabolic activation. Two intermediates of the manufacturing process, which are also present in the final product, are positive for mutagenesis in the Ames assay. One of these intermediates was also positive in the mouse lymphoma assay.

In a study of fertility, in male rats dosed for 70 days prior to mating, testicular and epididymal weights and percent motile sperm were decreased at 60 mg/kg, approximately equal to the maximum clinical dose of 800 mg/day, based on body surface area. This was not seen at doses ≤ 20 mg/kg. A slight to moderate reduction in spermatogenesis was also observed in the dog at oral doses ≥ 30 mg/kg. When female rats were dosed 14 days prior to mating and through to gestational day 6, there was no effect on mating or on number of pregnant females. At a dose of 60 mg/kg, female rats had significant post-implantation foetal loss and a reduced number of live foetuses. This was not seen at doses ≤ 20 mg/kg.

In an oral pre- and postnatal development study in rats, red vaginal discharge was noted in the 45 mg/kg/day group on either day 14 or day 15 of gestation. At the same dose, the number of stillborn pups as well as those dying between postpartum days 0 and 4 was increased. In the F1 offspring, at the same dose level, mean body weights were reduced from birth until terminal sacrifice and the number of litters achieving criterion for preputial separation was slightly decreased. F1 fertility was not affected, while an increased number of resorptions and a decreased number of viable foetuses was noted at 45 mg/kg/day.

The no observed effect level (NOEL) for both the maternal animals and the F1 generation was 15 mg/kg/day (one quarter of the maximum human dose of 800 mg).

Imatinib was teratogenic in rats when administered during organogenesis at doses ≥ 100 mg/kg, approximately equal to the maximum clinical dose of 800 mg/day, based on body surface area.

Teratogenic effects included exencephaly or encephalocele, absent/reduced frontal and absent parietal bones. These effects were not seen at doses ≤ 30 mg/kg.

In the 2-year rat carcinogenicity study administration of imatinib at 15, 30 and 60 mg/kg/day resulted in a statistically significant reduction in the longevity of males at 60 mg/kg/day and females at 30 mg/kg/day. Histopathological examination of decedents revealed cardiomyopathy (both sexes), chronic progressive nephropathy (females) and preputial gland papilloma as principal causes of death or reasons for sacrifice. Target organs for neoplastic changes were the kidneys, urinary bladder, urethra, preputial and clitoral gland, small intestine, parathyroid glands, adrenal glands and non-glandular stomach.

Papilloma/carcinoma of the preputial/clitoral gland were noted from 30 mg/kg/day onwards, representing approximately 0.5 or 0.3 times the human daily exposure (based on AUC) at 400 mg/day or 800 mg/day, respectively, and 0.4 times the daily exposure in children (based on AUC) at 340 mg/m2/day. The no observed effect level (NOEL) was 15 mg/kg/day. The renal adenoma/carcinoma, the urinary bladder and urethra papilloma, the small intestine adenocarcinomas, the parathyroid glands adenomas, the benign and malignant medullary tumours of the adrenal glands and the non-glandular stomach papillomas/carcinomas were noted at 60 mg/kg/day, representing approximately 1.7 or 1 times the human daily exposure (based

on AUC) at 400 mg/day or 800 mg/day, respectively, and 1.2 times the daily exposure in children (based on AUC) at 340 mg/m2/day. The no observed effect level (NOEL) was 30 mg/kg/day.

The mechanism and relevance of these findings in the rat carcinogenicity study for humans are not yet clarified.

Non-neoplastic lesions not identified in earlier preclinical studies were the cardiovascular system, pancreas, endocrine organs and teeth. The most important changes included cardiac hypertrophy and dilatation, leading to signs of cardiac insufficiency in some animals.

Capsule filling

Crospovidone (type A)

Lactose monohydrate

Magnesium stearate

Capsule shell

Gelatin

Yellow iron oxide (E172)

Titanium dioxide (E171)

Red iron oxide (E172)

Not applicable.

Do not store above 30⁰C .

Blister consisting of PA-Aluminium/PVC//Aluminium.

Packs containing 30, 60, 100, 120 or 180 capsules, hard.

Not all pack sizes may be marketed.

Any unused medicinal product or waste material should be disposed of in accordance with local

requirements.