- 1. Name of the medicinal product
- 2. Qualitative and quantitative composition
- 3. Pharmaceutical form
- 4. Clinical particulars
- 4.1 Therapeutic indications
- 4.2 Posology and method of administration
- 4.3 Contraindications
- 4.4 Special warnings and precautions for use
- 4.5 Interaction with other medicinal products and other forms of interaction
- 4.6 Fertility, pregnancy and lactation
- 4.7 Effects on ability to drive and use machines
- 4.8 Undesirable effects
- 4.9 Overdose
- 5. Pharmacological properties
- 5.1 Pharmacodynamic properties
- 5.2 Pharmacokinetic properties
- 5.3 Preclinical safety data
- 6. Pharmaceutical particulars
- 6.1 List of excipients
- 6.2 Incompatibilities
- 6.3 Shelf life
- 6.4 Special precautions for storage
- 6.5 Nature and contents of container
- 6.6 Special precautions for disposal and other handling
- 7. Marketing authorisation holder
- 8. Marketing authorisation number(s)
- 9. Date of first authorisation/renewal of the authorisation
- 10. Date of revision of the text
Excipient with known effect:1 vial Torisel 30 mg concentrate contains 474 mg ethanol (anhydrous) 1.8 ml of the diluent provided contains 358 mg ethanol (anhydrous)For the full list of excipients, see section 6.1.
Renal cell carcinomaTorisel is indicated for the first-line treatment of adult patients with advanced renal cell carcinoma (RCC) who have at least three of six prognostic risk factors (see section 5.1).
Mantle cell lymphomaTorisel is indicated for the treatment of adult patients with relapsed and/or refractory mantle cell lymphoma (MCL) (see section 5.1).
For instructions on preparation and to help ensure correct dosing, see section 6.6.
PosologyPatients should be given intravenous diphenhydramine 25 mg to 50 mg (or similar antihistamine) approximately 30 minutes before the start of each dose of temsirolimus (see section 4.4).Treatment with Torisel should continue until the patient is no longer clinically benefiting from therapy or until unacceptable toxicity occurs.
Renal cell carcinomaThe recommended dose of Torisel for advanced renal cell carcinoma administered intravenously is 25 mg infused over a 30- to 60-minute period once a week (see section 6.6 for instructions on dilution, administration and disposal). Management of suspected adverse reactions may require temporary interruption and/or dose reduction of temsirolimus therapy. If a suspected reaction is not manageable with dose delays, then temsirolimus may be reduced by 5 mg/week decrements.
Mantle cell lymphomaThe recommended dosing regimen of Torisel for mantle cell lymphoma is 175 mg, infused over a 30-60 minute period once a week for 3 weeks followed by weekly doses of 75 mg, infused over a 30-60 minute period. The starting dose of 175 mg was associated with a significant incidence of adverse events and required dose reductions/delays in the majority of patients. The contribution of the initial 175 mg doses to the efficacy outcome is currently not known.Management of suspected adverse reactions may require temporary interruption and/or dose reduction of temsirolimus therapy according to the guidelines in the following tables. If a suspected reaction is not manageable with dose delays and/or optimal medical therapy, then the dose of temsirolimus should be reduced according to the dose reduction table below.
Dose reduction levels
|Dose reduction level||Starting dose175 mg||Continuing dosea75 mg|
|-1||75 mg||50 mg|
|-2||50 mg||25 mg|
Temsirolimus dose modifications based on weekly ANC and platelet counts
|ANC||Platelets||Dose of temsirolimus|
|≥1.0 x 109/l||≥50 x 109/l||100% of planned dose|
|<1.0 x 109/l||<50 x 109/l||Holda|
ElderlyNo specific dose adjustment is necessary.
Renal impairmentNo dose adjustment of temsirolimus is recommended in patients with renal impairment. Temsirolimus should be used with caution in patients with severe renal impairment (see section 4.4).
Hepatic impairmentTemsirolimus should be used with caution in patients with hepatic impairment (see section 4.4).No dose adjustment of temsirolimus is recommended for patients with advanced renal cell carcinoma (RCC) and mild to moderate hepatic impairment. For patients with RCC and severe hepatic impairment, the recommended dose for patients who have baseline platelets ≥100 x 109/l is 10 mg intravenous once a week infused over a 30-60 minute period (see section 5.2).
Paediatric populationThere is no relevant use of temsirolimus in the paediatric population for the indication: treatment of renal cell carcinoma and mantle cell lymphoma.Temsirolimus should not be used in the paediatric population for the treatment of neuroblastoma, rhabdomyosarcoma or high-grade glioma, because of efficacy concerns based on the available data (see section 5.1).
Method of administrationTorisel must be administered by intravenous infusion. For instructions on dilution and preparation of the medicinal product before administration, see section 6.6.
Renal cell carcinomaThe recommended dose of Torisel for advanced renal cell carcinoma administered intravenously is 25 mg infused over a 30- to 60-minute period once a week (see section 6.6 for instructions on dilution, administration and disposal).
Mantle cell lymphomaThe recommended dose of Torisel for mantle cell lymphoma is 175 mg, infused over a 30-60 minute period once a week for 3 weeks followed by weekly doses of 75 mg, infused over a 30-60 minute period (see section 6.6 for instructions on dilution, administration and disposal).
Paediatric populationTemsirolimus is not recommended for use in paediatric patients (see sections 4.2, 4.8 and 5.1).
ElderlyBased on the results of a Phase 3 study in renal cell carcinoma, elderly patients (≥65 years of age) may be more likely to experience certain adverse reactions, including oedema, diarrhoea, and pneumonia. Based on the results of a Phase 3 study in mantle cell lymphoma, elderly patients (≥65 years of age) may be more likely to experience certain adverse reactions, including pleural effusion, anxiety, depression, insomnia, dyspnoea, leukopaenia, lymphopaenia, myalgia, arthralgia, taste loss, dizziness, upper respiratory infection, mucositis, and rhinitis.
Renal impairmentTemsirolimus elimination by the kidneys is negligible; studies in patients with varying renal impairment have not been conducted (see sections 4.2 and 5.2). Torisel has not been studied in patients undergoing haemodialysis.
Renal failureRenal failure (including fatal outcomes) has been observed in patients receiving Torisel for advanced renal cell cancer and/or with pre-existing renal insufficiency (see section 4.8).
Hepatic impairmentCaution should be used when treating patients with hepatic impairment.Temsirolimus is cleared predominantly by the liver. In an open-label, dose-escalation Phase 1 study in 110 subjects with advanced malignancies and either normal or impaired hepatic function, concentrations of temsirolimus and its metabolite sirolimus were increased in patients with elevated aspartate aminotransferase (AST) or bilirubin levels. Assessment of AST and bilirubin levels is recommended before initiation of temsirolimus and periodically after.An increased rate of fatal events was observed in patients with moderate and severe hepatic impairment. The fatal events included those due to progression of disease; however a causal relationship cannot be excluded.Based on the Phase 1 study, no dose adjustment of temsirolimus is recommended for RCC patients with baseline platelet counts ≥100 x109/l and mild to moderate hepatic impairment (total bilirubin up to 3 times upper limit of normal [ULN] with any abnormality of AST, or as defined by Child-Pugh Class A or B). For patients with RCC and severe hepatic impairment (total bilirubin >3 times ULN with any abnormality of AST, or as defined by Child-Pugh Class C), the recommended dose for patients who have baseline platelets ≥100 x 109/l is 10 mg intravenous once a week infused over a 30-60 minute period (see section 4.2).
Intracerebral bleedingPatients with central nervous system (CNS) tumours (primary CNS tumours or metastases) and/or receiving anticoagulation therapy may be at an increased risk of developing intracerebral bleeding (including fatal outcomes) while receiving therapy with temsirolimus.
Thrombocytopaenia, neutropaenia and anaemiaGrades 3 and 4 thrombocytopaenia and/or neutropaenia have been observed in the MCL clinical trial (see section 4.8). Patients on temsirolimus who develop thrombocytopaenia may be at increased risk of bleeding events, including epistaxis (see section 4.8). Patients on temsirolimus with baseline neutropaenia may be at risk of developing febrile neutropaenia. Cases of anaemia have been reported in RCC and MCL (see section 4.8). Monitoring of complete blood count is recommended prior to initiating temsirolimus therapy and periodically thereafter.
InfectionsPatients may be immunosuppressed and should be carefully observed for the occurrence of infections, including opportunistic infections. Among patients receiving 175 mg/week for the treatment of MCL, infections (including Grade 3 and 4 infections) were substantially increased compared to lower doses and compared to conventional chemotherapy. Cases of Pneumocystis jiroveci pneumonia (PCP) some with fatal outcomes, have been reported in patients who received temsirolimus, many of whom also received corticosteroids or other immunosuppressive agents. Prophylaxis of PCP should be considered for patients who require concomitant use of corticosteroids or other immunosuppressive agents based upon current standard of care.
CataractsCataracts have been observed in some patients who received the combination of temsirolimus and interferon-α (IFN-α).
Hypersensitivity/infusion reactionsHypersensitivity/infusion reactions (including some life-threatening and rare fatal reactions), including and not limited to flushing, chest pain, dyspnoea, hypotension, apnoea, loss of consciousness, hypersensitivity and anaphylaxis, have been associated with the administration of temsirolimus (see section 4.8). These reactions can occur very early in the first infusion, but may also occur with subsequent infusions. Patients should be monitored early during the infusion and appropriate supportive care should be available. Torisel infusion should be interrupted in all patients with severe infusion reactions and appropriate medical therapy administered. A benefit-risk assessment should be done prior to the continuation of temsirolimus therapy in patients with severe or life-threatening reactions.If a patient develops a hypersensitivity reaction during the Torisel infusion, despite the premedication, the infusion must be stopped and the patient observed for at least 30 to 60 minutes (depending on the severity of the reaction). At the discretion of the physician, treatment may be resumed after the administration of an H1-receptor antagonist (diphenhydramine or similar antihistamine) and a H2-receptor antagonist (intravenous famotidine 20 mg or intravenous ranitidine 50 mg) approximately 30 minutes before restarting the Torisel infusion. Administration of corticosteroids may be considered; however, the efficacy of corticosteroid treatment in this setting has not been established. The infusion may then be resumed at a slower rate (up to 60 minutes) and should be completed within six hours from the time that Torisel is first added to sodium chloride 9 mg/ml (0.9%) solution for injection. Because it is recommended that an H1 antihistamine be administered to patients before the start of the intravenous temsirolimus infusion, Torisel should be used with caution in patients with known hypersensitivity to the antihistamine or in patients who cannot receive the antihistamine for other medical reasons. Hypersensitivity reactions, including anaphylactic/anaphylactoid reactions, angioedema, exfoliative dermatitis and hypersensitivity vasculitis, have been associated with the oral administration of sirolimus.
Hyperglycaemia/glucose intolerance/diabetes mellitusPatients should be advised that treatment with Torisel may be associated with an increase in blood glucose levels in diabetic and non-diabetic patients. In the RCC Clinical Trial, a Phase 3 clinical trial for renal cell carcinoma, 26% of patients reported hyperglycaemia as an adverse event. In the MCL Clinical Trial, a Phase 3 clinical trial for mantle cell lymphoma, 11% of patients reported hyperglycaemia as an adverse event. This may result in the need for an increase in the dose of, or initiation of, insulin and/or hypoglycaemic agent therapy. Patients should be advised to report excessive thirst or any increase in the volume or frequency of urination.
Interstitial lung diseaseThere have been cases of non-specific interstitial pneumonitis, including fatal reports, occurring in patients who received weekly intravenous Torisel. Some patients were asymptomatic or had minimal symptoms with pneumonitis detected on computed tomography scan or chest radiograph. Others presented with symptoms such as dyspnoea, cough, and fever. Some patients required discontinuation of Torisel or treatment with corticosteroids and/or antibiotics, while some patients continued treatment without additional intervention. It is recommended that patients undergo baseline radiographic assessment by lung computed tomography scan or chest radiograph prior to the initiation of Torisel therapy. Periodical follow-up assessments may be considered. It is recommended that patients be followed closely for occurrence of clinical respiratory symptoms and patients should be advised to report promptly any new or worsening respiratory symptoms. If clinically significant respiratory symptoms develop, consider withholding Torisel administration until after recovery of symptoms and improvement of radiographic findings related to pneumonitis. Opportunistic infections such as PCP should be considered in the differential diagnosis. Empiric treatment with corticosteroids and/or antibiotics may be considered. For patients who require use of corticosteroids, prophylaxis of PCP should be considered based upon current standard of care.
HyperlipaemiaThe use of Torisel was associated with increases in serum triglycerides and cholesterol. In the RCC Clinical Trial 1, hyperlipaemia was reported as an adverse event in 27% of patients. In the MCL Clinical Trial, hyperlipaemia was reported as an adverse event in 9.3% of patients. This may require initiation, or increase, in the dose of lipid-lowering agents. Serum cholesterol and triglycerides should be tested before and during treatment with Torisel. The known association of temsirolimus with hyperlipaemia may predispose to myocardial infarction.
Wound healing complicationsThe use of Torisel has been associated with abnormal wound healing; therefore, caution should be exercised with the use of Torisel in the peri-surgical period.
MalignanciesThe possible development of lymphoma and other malignancies, particularly of the skin, may result from immunosuppression. As usual for patients with increased risk for skin cancer, exposure to sunlight and ultraviolet (UV) light should be limited by wearing protective clothing and using a sunscreen with a high protection factor.
Concomitant use of temsirolimus with sunitinibThe combination of temsirolimus and sunitinib resulted in dose-limiting toxicity. Dose-limiting toxicities (Grade 3/4 erythematous maculopapular rash, gout/cellulitis requiring hospitalisation) were observed in 2 out of 3 patients treated in the first cohort of a Phase 1 study at doses of temsirolimus 15 mg intravenous per week and sunitinib 25 mg oral per day (Days 1-28 followed by a 2-week rest) (see section 4.5).
Concomitant use of angiotensin-converting enzyme (ACE) inhibitorsAngioneurotic oedema-type reactions (including delayed reactions occurring two months following initiation of therapy) have been observed in some patients who received temsirolimus and ACE inhibitors concomitantly (see section 4.5).
Agents inducing CYP3A metabolismAgents such as carbamazepine, phenobarbital, phenytoin, rifampicin, and St. John's wort are strong inducers of CYP3A4/5 and may decrease composite exposure of the active moieties, temsirolimus and its metabolite, sirolimus. Therefore, for patients with renal cell carcinoma, continuous administration beyond 5-7 days with agents that have CYP3A4/5 induction potential should be avoided. For patients with mantle cell lymphoma, it is recommended that coadministration of CYP3A4/5 inducers should be avoided due to the higher dose of temsirolimus (see section 4.5).
Agents inhibiting CYP3A metabolismAgents such as protease inhibitors (nelfinavir, ritonavir), antifungals (e.g., itraconazole, ketoconazole, voriconazole), and nefazodone are strong CYP3A4 inhibitors and may increase blood concentrations of the active moieties, temsirolimus and its metabolite, sirolimus. Therefore, concomitant treatment with agents that have strong CYP3A4 inhibition potential should be avoided. Concomitant treatment with moderate CYP3A4 inhibitors (e.g., aprepitant, erythromycin, fluconazole, verapamil, grapefruit juice) should only be administered with caution in patients receiving 25 mg and should be avoided in patients receiving temsirolimus doses higher than 25 mg (see section 4.5). Alternative treatments with agents that do not have CYP3A4 inhibition potential should be considered (see section 4.5).
VaccinationsImmunosuppressants may affect responses to vaccination. During treatment with Torisel, vaccination may be less effective. The use of live vaccines should be avoided during treatment with Torisel. Examples of live vaccines are: measles, mumps, rubella, oral polio, Bacillus Calmette-Guérin (BCG), yellow fever, varicella, and TY21a typhoid vaccines. ExcipientsAfter first dilution of Torisel 30 mg concentrate with 1.8 ml of withdrawn diluent, the concentrate-diluent mixture contains 35% volume ethanol (alcohol), i.e. up to 0.693 g per 25 mg dose of Torisel, equivalent to 17.6 ml beer or 7.3 ml wine per dose. Patients administered the higher dose of 175 mg of Torisel for the initial treatment of MCL may receive up to 4.85 g of ethanol (equivalent to 123 ml beer or 51 ml wine per dose). Harmful for those suffering from alcoholism.To be taken into account in pregnant or breast-feeding women, children and high-risk groups, such as patients with liver disease or epilepsy. The amount of alcohol in this medicinal product may alter the effects of other medicines. The amount of alcohol in this medicinal product may impair your ability to drive or use machines (see section 4.7).
Concomitant use of temsirolimus with sunitinibThe combination of temsirolimus and sunitinib resulted in dose-limiting toxicity. Dose-limiting toxicities (Grade 3/4 erythematous maculopapular rash, gout/cellulitis requiring hospitalisation) were observed in 2 out of 3 patients treated in the first cohort of a Phase 1 study at doses of temsirolimus 15 mg intravenous per week and sunitinib 25 mg oral per day (Days 1-28 followed by a 2-week rest) (see section 4.4).
Concomitant use of angiotensin-converting enzyme (ACE) inhibitorsAngioneurotic oedema-type reactions (including delayed reactions occurring two months following initiation of therapy) have been observed in some patients who received temsirolimus and ACE inhibitors concomitantly (see section 4.4).
Agents inducing CYP3A metabolismCo-administration of temsirolimus with rifampicin, a potent CYP3A4/5 inducer, had no significant effect on temsirolimus maximum concentration (Cmax) and area under the concentration vs. time curve (AUC) after intravenous administration, but decreased sirolimus Cmax by 65% and AUC by 56%, compared to temsirolimus treatment alone. Therefore, concomitant treatment with agents that have CYP3A4/5 induction potential should be avoided (e.g. carbamazepine, phenobarbital, phenytoin, rifampicin, and St. John's wort) (see section 4.4).
Agents inhibiting CYP3A metabolismCo-administration of temsirolimus 5 mg with ketoconazole, a potent CYP3A4 inhibitor, had no significant effect on temsirolimus Cmax or AUC; however, sirolimus AUC increased 3.1-fold, and AUCsum (temsirolimus + sirolimus) increased 2.3-fold compared to temsirolimus alone. The effect on the unbound concentrations of sirolimus has not been determined, but is expected to be larger than the effect on whole-blood concentrations due to the saturable binding to red blood cells. The effect may also be more pronounced at a 25 mg dose. Therefore, substances that are potent inhibitors of CYP3A4 activity (e.g. nelfinavir, ritonavir, itraconazole, ketoconazole, voriconazole, nefazodone) increase sirolimus blood concentrations. Concomitant treatment of Torisel with these agents should be avoided (see section 4.4).Concomitant treatment with moderate CYP3A4 inhibitors (e.g. diltiazem, verapamil, clarithromycin, erythromycin, aprepitant, amiodarone) should only be administered with caution in patients receiving 25 mg and should be avoided in patients receiving temsirolimus doses higher than 25 mg.
Interaction with medicinal products metabolised by CYP2D6 or CYP3A4/5In 23 healthy subjects the concentration of desipramine, a CYP2D6 substrate, was unaffected when 25 mg of temsirolimus was co-administered. In 36 patients with MCL, including 4 poor metabolisers, the effect of CYP2D6 inhibition after administration of single doses of 175 mg and 75 mg temsirolimus was investigated. Population PK analysis based on sparse sampling indicated no clinically significant interaction effect on AUC and Cmax of the CYP2D6 substrate desipramine. No clinically significant effect is anticipated when temsirolimus is co-administered with agents that are metabolised by CYP2D6. The effect of a 175 or 75 mg temsirolimus dose on CYP3A4/5 substrates has not been studied. However, in vitro studies in human liver microsomes followed by physiologically-based pharmacokinetic modelling indicate that the blood concentrations achieved after a 175 mg dose of temsirolimus most likely leads to relevant inhibition of CYP3A4/5 (see section 5.2). Therefore, caution is advised during concomitant administration of temsirolimus at a dose of 175 mg with medicinal products that are metabolised predominantly via CYP3A4/5 and that have a narrow therapeutic index.
Interactions with medicinal products that are P-glycoprotein substratesIn an in vitro study, temsirolimus inhibited the transport of P-glycoprotein (P-gp) substrates with an IC50 value of 2 µM. In vivo, the effect of P-gp inhibition has not been investigated in a clinical drug-drug interaction study, however, recent preliminary data from a Phase 1 study of combined lenalidomide (dose of 25 mg) and temsirolimus (dose of 20 mg) seem to support the in vitro findings and suggest an increased risk of adverse events. Therefore, when temsirolimus is co-administered with medicinal products which are P-gp substrates (e.g. digoxin, vincristine, colchicine, dabigatran, lenalidomide, and paclitaxel) close monitoring for adverse events related to the co-administered medicinal products should be observed.
Amphiphilic agentsTemsirolimus has been associated with phospholipidosis in rats. Phospholipidosis has not been observed in mice or monkeys treated with temsirolimus, nor has it been documented in patients treated with temsirolimus. Although phospholipidosis has not been shown to be a risk for patients administered temsirolimus, it is possible that combined administration of temsirolimus with other amphiphilic agents such as amiodarone or statins could result in an increased risk of amphiphilic pulmonary toxicity.
Women of childbearing potential/Contraception in males and femalesDue to the unknown risk related to potential exposure during early pregnancy, women of childbearing potential must be advised not to become pregnant while using Torisel. Men with partners of childbearing potential should use medically acceptable contraception while receiving Torisel (see section 5.3).
PregnancyThere are no adequate data from the use of temsirolimus in pregnant women. Studies in animals have shown reproductive toxicity. In reproduction studies in animals, temsirolimus caused embryo/foetotoxicity that was manifested as mortality and reduced foetal weights (with associated delays in skeletal ossification) in rats and rabbits. Teratogenic effects (omphalocele) were seen in rabbits (see section 5.3). The potential risk for humans is unknown. Torisel must not be used during pregnancy, unless the risk for the embryo is justified by the expected benefit for the mother.
Breast-feedingIt is unknown whether temsirolimus is excreted in human breast milk. The excretion of temsirolimus in milk has not been studied in animals. However, sirolimus, the main metabolite of temsirolimus, is excreted in milk of lactating rats. Because of the potential for adverse reactions in breast-fed infants from temsirolimus, breast-feeding should be discontinued during therapy.
FertilityIn male rats, decreased fertility and partly reversible reductions in sperm counts were reported (see section 5.3).
Tabulated list of adverse reactionsAdverse reactions that were reported in RCC and MCL patients in the Phase 3 studies are listed below (Table 1), by system organ class, frequency and grade of severity (NCI-CTCAE). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.Adverse reactions are listed according to the following categories: Very common (≥1/10) Common (≥1/100 to <1/10) Uncommon (≥1/1,000 to <1/100)
|Table 1: Adverse reactions From clinical trials in RCC (study 3066K1-304) and in MCL (study 3066K1-305)|
|System organ class||Frequency||Adverse reactions||All gradesn (%)||Grade 3 & 4 n (%)|
|Infections and infestations||Very common||Bacterial and viral infections (including infection, viral infection, cellulitis, herpes zoster, oral herpes, influenza, herpes simplex, herpes zoster ophthalmic, herpes virus infection, bacterial infection, bronchitis*, abscess, wound infection, post-operative wound infections)||91 (28.3)||18 (5.6)|
|Pneumoniaa (including interstitial pneumonia)||35 (10.9)||16 (5.0)|
|Common||Sepsis* (including septic shock)||5 (1.5)||5 (1.5)|
|Candidiasis (including oral and anal candidiasis) and fungal infection/fungal skin infections||16 (5.0)||0 (0.0)|
|Urinary tract infection (including cystitis)||29 (9.0)||6 (1.9)|
|Upper respiratory tract infection||26 (8.1)||0 (0.0)|
|Pharyngitis||6 (1.9)||0 (0.0)|
|Sinusitis||10 (3.1)||0 (0.0)|
|Rhinitis||7 (2.2)||0 (0.0)|
|Folliculitis||4 (1.2)||0 (0.0)|
|Uncommon||Laryngitis||1 (0.3)||0 (0.0)|
|Blood and lymphatic system disorders||Very common||Neutropaenia||46 (14.3)||30 (9.3)|
|Thrombocytopaenia**||97 (30.2)||56 (17.4)|
|Common||Leukopaenia **||29 (9.0)||10 (3.1)|
|Lymphopaenia||25 (7.8)||16 (5.0)|
|Immune system disorders||Common||Hypersensitivity reactions/drug hypersensitiviy||24 (7.5)||1 (0.3)|
|Metabolism and nutrition disorders||Very common||Hyperglycaemia||63 (19.6)||31 (9.7)|
|Hypercholesterolaemia||60 (18.79)||1 (0.3)|
|Hypertriglyceridaemia||56 (17.4)||8 (2.5)|
|Decreased appetite||107 (33.3)||9 (2.8)|
|Hypokalaemia||44 (13.7)||13 (4.0)|
|Common||Diabetes mellitus||10 (3.1)||2 (0.6)|
|Dehydration||17 (5.3)||8 (2.5)|
|Hypocalcaemia||21 (6.5)||5 (1.6)|
|Hypophosphataemia||26 (8.1)||14 (4.4)|
|Hyperlipidaemia||4 (1.2)||0 (0.0)|
|Psychiatric disorders||Very Common||Insomnia||45 (14.0)||1 (0.3)|
|Common||Depression||16 (5.0)||0 (0.0)|
|Anxiety||28 (8.7)||0 (0.0)|
|Nervous system disorders||Very common||Dysgeusia||55 (17.1)||0 (0.0)|
|Headache||55 (17.1)||2 (0.6)|
|Common||Dizziness||30 (9.3)||1 (0.3)|
|Paresthaesia||21 (6.5)||1 (0.3)|
|Somnolence||8 (2.5)||1 (0.3)|
|Ageusia||6 (1.9)||0 (0.0)|
|Uncommon||Intracranial haemorrhage||1 (0.3)||1 (0.3)|
|Eye disorders||Common||Conjunctivitis (including conjunctivitis, lacrimal disorder)||16 (6.0)||1 (0.3)|
|Uncommon||Eye haemorrhage***||3 (0.9)||0 (0.0)|
|Cardiac disorders||Uncommon||Pericardial effusion||3 (0.9)||1 (0.3)|
|Vascular disorders||Common||Venous thromboembolism (including deep vein thrombosis, venous thrombosis)||7 (2.2)||4 (1.2)|
|Thrombophlebitis||4 (1.2)||0 (0.0)|
|Hypertension||20 (6.2)||3 (0.9)|
|Respiratory, thoracic and mediastinal disorders||Very common||Dyspnoeaa||79 (24.6)||27 (8.4)|
|Epistaxis **||69 (21.5)||1 (0.3)|
|Cough||93 (29)||3 (0.9)|
|Common||Interstitial lung diseasea,****||16 (5.0)||6 (1.9)|
|Pleural effusiona,b||19 (5.9)||9 (2.8)|
|Uncommon||Pulmonary embolisma||2 (0.6)||1 (0.3)|
|Gastrointestinal disorders||Very common||Nausea||109 (34.0)||5 (1.6)|
|Stomatitis||67 (20.9)||3 (0.9)|
|Vomiting||57 (17.8)||4 (1.2)|
|Constipation||56 (17.4)||0 (0.0)|
|Abdominal pain||56 (17.4)||10 (3.1)|
|Common||Gastrointestinal haemorrhage (including anal, rectal, haemorrhoidal, lip, and mouth haemorrhage, gingival bleeding)||16 (5.0)||4 (1.2)|
|Gastritis **||7 (2.1)||2 (0.6)|
|Dysphagia||13 (4.0)||0 (0.0)|
|Abdominal distension||14 (4.4)||1 (0.3)|
|Aphthous stomatitis||15 (4.7)||1 (0.3)|
|Oral pain||9 (2.8)||1 (0.3)|
|Gingivitis||6 (1.9)||0 (0.0)|
|Uncommon||Intestinala/duodenal perforation||2 ( 0.6)||1 (0.3)|
|Skin and subcutaneous tissue disorders||Very common||Rash (including rash, pruritic rash, maculo-papular rash, rash, generalized rash, macular rash, papular rash)||138 (43.0)||16 (5.0)|
|Pruritus (including pruritus generalised)||69 (21.5)||4 (1.2)|
|Dry skin||32 (10.0)||1 (0.3)|
|Common||Dermatitis||6 (1.9)||0 (0.0)|
|Exfoliative rash||5 (1.6)||0 (0.0)|
|Nail disorder||26 (8.1)||0 (0.0)|
|Ecchymosis***||5 (1.6)||0 (0.0)|
|Petechiae***||4 (1.2)||0 (0.0)|
|Musculoskeletal and connective tissue disorders||Very common||Arthralgia||50 (15.6)||2 (0.6)|
|Back pain||53 (16.5)||8 (2.5)|
|Common||Myalgia||19 ( 5.9)||0 (0.0)|
|Renal and urinary disorders||Common||Renal failurea||5 (1.6)||0 (0.0)|
|General disorders and administration site conditions||Very common||Fatigue||133 (41.4)||31 (9.7)|
|Oedema (including generalized oedema, facial oedema, peripheral oedema, scrotal oedema, genital oedema)||122 (38.0)||11 (3.4)|
|Astheniaa||67 (20.9)||16 (5.0)|
|Mucosal inflammation||66 (20.6)||7 (2.2)|
|Pyrexia||91 (28.3)||5 (1.6)|
|Pain||36 (11.2)||7 (2.2)|
|Chills||32 (10.0)||1 (0.3)|
|Chest pain||32 (10.0)||1 (0.3)|
|Uncommon||Impaired wound healing||2 (0.6)||0 (0.0)|
|Investigations||Very common||Blood creatinine increased||35 (10.9)||4 (1.2)|
|Common||Increased aspartate aminotransferase||27 (8.4)||5 (1.6)|
|Common||Increased alanine aminotransferase||17 (5.3)||2 (0.6)|
|Table 2: Adverse reactions reported in post-marketing setting|
|System Organ class||Frequency||Adverse reactions|
|Infections and infestations||Rare||Pneumocystis jiroveci pneumonia|
|Immune system disorders||Not known||Angioneurotic oedema-type reactions|
|Skin and subcutaneous tissue disorders||Not known||Stevens-Johnson syndrome|
|Musculoskeletal and connective tissue disorders||Not known||Rhabdomyolysis|
Post-marketing experienceAngioneurotic oedema-type reactions have been reported in some patients who received temsirolimus and ACE inhibitors concomitantly.Cases of PCP, some with fatal outcomes, have been reported (see section 4.4).
Paediatric populationIn a Phase 1/2 study, 71 patients (59 patients, aged from 1 to 17 years old, and 12 patients, aged 18 to 21 years) were administered temsirolimus at doses ranging from 10 mg/m2 to 150 mg/m2 (see section 5.1). The adverse reactions reported by the highest percentage of patients were haematologic (anaemia, leukopaenia, neutropaenia, and thrombocytopaenia), metabolic (hypercholesterolaemia, hyperlipaemia, hyperglycaemia, increase of serum aspartate amino transferase (AST) and serum alanine aminotransferase (ALT) plasma levels), and digestive (mucositis, stomatitis, nausea, and vomiting).Reporting of suspected adverse reactionsReporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the national reporting system detailed below. United KingdomYellow card system www.mhra.gov.uk/yellowcard. IrelandHPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: firstname.lastname@example.org.
Mechanism of actionTemsirolimus is a selective inhibitor of mTOR (mammalian target of rapamycin). Temsirolimus binds to an intracellular protein (FKBP-12), and the protein/temsirolimus complex binds and inhibits the activity of mTOR that controls cell division. In vitro, at high concentrations (10-20 μM), temsirolimus can bind and inhibit mTOR in the absence of FKBP-12. Biphasic dose response of cell growth inhibition was observed. High concentrations resulted in complete cell growth inhibition in vitro, whereas inhibition mediated by FKBP-12/temsirolimus complex alone resulted in approximately 50% decrease in cell proliferation. Inhibition of mTOR activity results in a G1 growth delay at nanomolar concentrations and growth arrest at micromolar concentrations in treated tumour cells resulting from selective disruption of translation of cell cycle regulatory proteins, such as D-type cyclins, c-myc, and ornithine decarboxylase. When mTOR activity is inhibited, its ability to phosphorylate, and thereby control the activity of protein translation factors (4E-BP1 and S6K, both downstream of mTOR in the P13 kinase/AKT pathway) that control cell division, is blocked. In addition to regulating cell cycle proteins, mTOR can regulate translation of the hypoxia-inducible factors, HIF-1 and HIF-2 alpha. These transcription factors regulate the ability of tumours to adapt to hypoxic microenvironments and to produce the angiogenic factor vascular endothelial growth factor (VEGF). The anti-tumour effect of temsirolimus, therefore, may also in part stem from its ability to depress levels of HIF and VEGF in the tumour or tumour microenvironment, thereby impairing vessel development.
Clinical efficacy and safety
Renal cell carcinomaThe safety and efficacy of Torisel in the treatment of advanced renal cell carcinoma were studied in the following two randomised clinical trials:
RCC Clinical Trial 1RCC Clinical Trial 1 was a Phase 3, multi-centre, 3-arm, randomised, open-label study in previously untreated patients with advanced renal cell carcinoma and with 3 or more of 6 pre-selected prognostic risk factors (less than 1 year from time of initial renal cell carcinoma diagnosis to randomisation, Karnofsky performance status of 60 or 70, haemoglobin less than the lower limit of normal, corrected calcium of greater than 10 mg/dl, lactate dehydrogenase >1.5 times the upper limit of normal, more than 1 metastatic organ site). The primary study endpoint was overall survival (OS). Secondary endpoints included progression-free survival (PFS), objective response rate (ORR), clinical benefit rate, time to treatment failure (TTF), and quality adjusted survival measurement. Patients were stratified for prior nephrectomy status within 3 geographic regions and were randomly assigned (1:1:1) to receive IFN-α alone (n = 207), temsirolimus alone (25 mg weekly; n = 209), or the combination of IFN-α and temsirolimus (n = 210). In RCC Clinical Trial 1, temsirolimus 25 mg was associated with a statistically significant advantage over IFN-α in the primary endpoint of OS at the 2nd pre-specified interim analysis (n = 446 events, p = 0.0078). The temsirolimus arm showed a 49% increase in median OS compared with the IFN-α arm. Temsirolimus also was associated with statistically significant advantages over IFN-α in the secondary endpoints of PFS, TTF, and clinical benefit rate.The combination of temsirolimus 15 mg and IFN-α did not result in a significant increase in overall survival when compared to IFN-α alone at either the interim analysis (median 8.4 vs. 7.3 months, hazard ratio = 0.96, p = 0.6965) or final analysis (median 8.4 vs. 7.3 months, hazard ratio = 0.93, p = 0.4902). Treatment with the combination of temsirolimus and IFN-α resulted in a statistically significant increase in the incidence of certain Grade 3-4 adverse events (weight loss, anaemia, neutropaenia, thrombocytopaenia and mucosal inflammation) when compared to the adverse events observed in the IFN-α or temsirolimus-alone arms.
|Summary of efficacy results in temsirolimus RCC clinical trial 1|
|Parameter||temsirolimus n = 209||IFN-αn = 207||P-valuea||Hazard ratio(95% CI)b|
|Pre-specified interim analysis|
|Median overall survival, Months (95% CI)||10.9 (8.6, 12.7)||7.3 (6.1, 8.8)||0.0078||0.73 (0.58, 0.92)|
|Median overall survival, Months (95% CI)||10.9 (8.6, 12.7)||7.3 (6.1, 8.8)||0.0252||0.78 (0.63, 0.97)|
|Median progression-free survival by independent assessment Months (95% CI)||5.6 (3.9, 7.2)||3.2 (2.2, 4.0)||0.0042||0.74 (0.60, 0.91)|
|Median progression-free survival by investigator assessment Months (95% CI)||3.8 (3.6, 5.2)||1.9 (1.9, 2.2)||0.0028||0.74 (0.60, 0.90)|
|Overall response rate by independent assessment % (95% CI)||9.1 (5.2, 13.0)||5.3 (2.3, 8.4)||0.1361c||NA|
RCC Clinical Trial 2RCC Clinical Trial 2 was a randomised, double-blind, multi-centre, outpatient trial to evaluate the efficacy, safety, and pharmacokinetics of three dose levels of temsirolimus when administered to previously treated patients with advanced renal cell carcinoma. The primary efficacy endpoint was ORR, and OS was also evaluated. One hundred eleven (111) patients were randomly assigned in a 1:1:1 ratio to receive 25 mg, 75 mg, or 250 mg intravenous temsirolimus weekly. In the 25 mg arm (n = 36), all patients had metastatic disease; 4 (11%) had no prior chemo- or immunotherapy; 17 (47%) had one prior treatment, and 15 (42%) had 2 or more prior treatments for renal cell carcinoma. Twenty-seven (27, 75%) had undergone a nephrectomy. Twenty-four (24, 67%) were Eastern Cooperative Oncology Group (ECOG) performance status (PS) = 1, and 12 (33%) were ECOG PS = 0. For patients treated weekly with 25 mg temsirolimus OS was 13.8 months (95% CI: 9.0, 18.7 months); ORR was 5.6% (95% CI: 0.7, 18.7%).
Mantle cell lymphomaThe safety and efficacy of intravenous temsirolimus for the treatment of relapsed and/or refractory mantle cell lymphoma were studied in the following Phase 3 clinical study.
MCL Clinical TrialMCL Clinical Trial is a controlled, randomised, open-label, multicenter, outpatient study comparing 2 different dosing regimens of temsirolimus with an investigator's choice of therapy in patients with relapsed and/or refractory mantle cell lymphoma. Subjects with mantle cell lymphoma (that was confirmed by histology, immunophenotype, and cyclin D1 analysis) who had received 2 to 7 prior therapies that included anthracyclines and alkylating agents, and rituximab (and could include haematopoietic stem cell transplant) and whose disease was relapsed and/or refractory were eligible for the study. Subjects were randomly assigned in a 1:1:1 ratio to receive intravenous temsirolimus 175 mg (3 successive weekly doses) followed by 75 mg weekly (n = 54), intravenous temsirolimus 175 mg (3 successive weekly doses) followed by 25 mg weekly (n=54), or the investigator's choice of single-agent treatment (as specified in the protocol; n = 54). Investigator's choice therapies included: gemcitabine (intravenous: 22 [41.5%]), fludarabine (intravenous: 12 [22.6%] or oral: 2 [3.8%]), chlorambucil (oral: 3 [5.7%]), cladribine (intravenous: 3 [5.7%]), etoposide (intravenous: 3 [5.7%]), cyclophosphamide (oral: 2 [3.8%]), thalidomide (oral: 2 [3.8%]), vinblastine (intravenous: 2 [3.8%]), alemtuzumab (intravenous: 1 [1.9%]), and lenalidomide (oral: 1 [1.9%]). The primary endpoint of the study was PFS, as assessed by an independent radiologist and oncology review. Secondary efficacy endpoints included OS and ORR.The results for the MCL Clinical Trial are summarized in the following table. Temsirolimus 175/75 (temsirolimus 175 mg weekly for 3 weeks followed by 75 mg weekly) led to an improvement in PFS compared with investigator's choice in patients with relapsed and/or refractory mantle cell lymphoma that was statistically significant (hazard ratio = 0.44; p-value = 0.0009). Median PFS of the temsirolimus 175/75 mg group (4.8 months) was prolonged by 2.9 months compared to the investigator's choice group (1.9 months). OS was similar. Temsirolimus also was associated with statistically significant advantages over investigator's choice in the secondary endpoint of ORR. The evaluations of PFS and ORR were based on blinded independent radiologic assessment of tumour response using the International Workshop Criteria.
|Summary of efficacy results in temsirolimus MCL clinical trial|
|Parameter||Temsirolimus Concentrate for Injection175/75 mg n = 54||Investigator's Choice (inv choice)n = 54||P-value||Hazard Ratio (97.5% CI)a|
|Median progression-free survivalbMonths (97.5% CI)||4.8 (3.1, 8.1)||1.9 (1.6, 2.5)||0.0009c||0.44 (0.25, 0.78)|
|Objective response rateb% (95% CI)||22.2 (11.1, 33.3)||1.9 (0.0, 5.4)||0.0019d||NA|
|Overall survivalMonths (95% CI)||12.8 (8.6, 22.3)||10.3 (5.8, 15.8)||0.2970c||0.78 (0.49, 1.24)|
|One-year survival rate% (97.5% CI)||0.47 (0.31, 0.61)||0.46 (0.30, 0.60)|
Paediatric populationIn a Phase 1/2 safety and exploratory efficacy study, 71 patients (59 patients, aged from 1 to 17 years, and 12 patients, aged from 18 to 21 years) received temsirolimus as a 60-minute intravenous infusion once weekly in three-week cycles. In Part 1, 14 patients aged from 1 to 17 years with advanced recurrent/refractory solid tumours received temsirolimus at doses ranging from 10 mg/m2 to 150 mg/m2. In Part 2, 45 patients aged from 1 to 17 years with recurrent/relapsed rhabdomyosarcoma, neuroblastoma, or high grade glioma were administered temsirolimus at a weekly dose of 75 mg/m2. Adverse events were generally similar to those observed in adults (see section 4.8).Temsirolimus was found to be ineffective in paediatric patients with neuroblastoma, rhabdomyosarcoma, and high-grade glioma (n = 52). For subjects with neuroblastoma, the objective response rate was 5.3% (95% CI: 0.1%, 26.0%). After 12 weeks of treatment, no response was observed in subjects with rhabdomyosarcoma or high-grade glioma. None of the 3 cohorts met the criterion for advancing to the second stage of the Simon 2-stage design.The European Medicines Agency has waived the obligation to submit the results of studies with Torisel in all subsets of the paediatric population in MCL (see section 4.2 on paediatric use).
AbsorptionFollowing administration of a single 25 mg intravenous dose of temsirolimus in patients with cancer, mean Cmax in whole blood was 585 ng/ml (coefficient of variation [CV] = 14%), and mean AUC in blood was 1627 ngh/ml (CV = 26%). For patients receiving 175 mg weekly for 3 weeks followed by 75 mg weekly, estimated Cmax in whole blood at end of infusion was 2457 ng/ml during Week 1, and 2574 ng/ml during Week 3.
DistributionTemsirolimus exhibits a polyexponential decline in whole blood concentrations, and distribution is attributable to preferential binding to FKBP-12 in blood cells. The mean ±standard deviation, (SD) dissociation constant (Kd) of binding was 5.1± 3.0 ng/ml, denoting the concentration at which 50% of binding sites in blood cells were occupied. Temsirolimus distribution is dose-dependent with mean (10th, 90th percentiles) maximal specific binding in blood cells of 1.4 mg (0.47 to 2.5 mg). Following a single 25 mg temsirolimus intravenous dose, mean steady-state volume of distribution in whole blood of patients with cancer was 172 liters.
MetabolismSirolimus, an equally potent metabolite to temsirolimus, was observed as the principal metabolite in humans following intravenous treatment. During in vitro temsirolimus metabolism studies, sirolimus, seco-temsirolimus and seco-sirolimus were observed; additional metabolic pathways were hydroxylation, reduction and demethylation. Following a single 25 mg intravenous dose in patients with cancer, sirolimus AUC was 2.7-fold that of temsirolimus AUC, due principally to the longer half-life of sirolimus.
EliminationFollowing a single 25 mg intravenous dose of temsirolimus, temsirolimus mean ± SD systemic clearance from whole blood was 11.4 ± 2.4 l/h. Mean half-lives of temsirolimus and sirolimus were 17.7 hours and 73.3 hours, respectively. Following administration of [14C] temsirolimus, excretion was predominantly via the faeces (78%), with renal elimination of active substance and metabolites accounting for 4.6% of the administered dose. Sulfate or glucuronide conjugates were not detected in the human faecal samples, suggesting that sulfation and glucuronidation do not appear to be major pathways involved in the excretion of temsirolimus. Therefore, inhibitors of these metabolic pathways are not expected to affect the elimination of temsirolimus.Model-predicted values for clearance from plasma, after applying a 175 mg dose for 3 weeks, and subsequently 75 mg for 3 weeks, indicate temsirolimus and sirolimus metabolite trough concentrations of approximately 1.2 ng/ml and 10.7 ng/ml, respectively.Temsirolimus and sirolimus were demonstrated to be substrates for P-gp in vitro.
Inhibition of CYP isoformsIn in vitro studies in human liver microsomes, temsirolimus inhibited CYP3A4/5, CYP2D6, CYP2C9 and CYP2C8 catalytic activity with Ki values of 3.1, 1.5, 14 and 27 μM, respectively. IC50 values for inhibition of CYP2B6 and CYP2E1 by temsirolimus were 48 and 100 μM, respectively. Based on a whole blood mean Cmax concentration of 2.6 μM for temsirolimus in MCL patients receiving the 175 mg dose there is a potential for interactions with concomitantly administered medicinal products that are substrates of CYP3A4/5 in patients treated with the 175 mg dose of temsirolimus (see section 4.5). Physiologically-based pharmacokinetic modelling has shown that after four weeks treatment with temsirolimus, the AUC of midazolam can be increased 3-to-4 fold and Cmax around 1.5-fold when midazolam is taken within a few hours after the start of the temsirolimus infusion. However, it is unlikely that whole blood concentrations of temsirolimus after intravenous administration of temsirolimus will inhibit the metabolic clearance of concomitant medicinal products that are substrates of CYP2C9, CYP2C8, CYP2B6 or CYP2E1.
Hepatic impairmentTemsirolimus should be used with caution when treating patients with hepatic impairment.Temsirolimus is cleared predominantly by the liver.Temsirolimus and sirolimus pharmacokinetics have been investigated in an open-label, dose-escalation study in 110 patients with advanced malignancies and either normal or impaired hepatic function. For 7 patients with severe hepatic impairment (ODWG, group D) receiving the 10 mg dose of temsirolimus, the mean AUC of temsirolimus was ~1.7-fold higher compared to 7 patients with mild hepatic impairment (ODWG, group B). For patients with severe hepatic impairment, a reduction of the temsirolimus dose to 10 mg is recommended to provide temsirolimus plus sirolimus exposures in blood (mean AUCsum approximately 6510 ng·h/ml; n=7), which approximate to those following the 25 mg dose (mean AUCsum approximately 6580 ng·h/ml; n=6) in patients with normal liver function (see sections 4.2 and 4.4).The AUCsum of temsirolimus and sirolimus on day 8 in patients with mild and moderate hepatic impairment receiving 25 mg temsirolimus was similar to that observed in patients without hepatic impairment receiving 75 mg (mean AUCsum mild: approximately 9770 ng*h/ml, n=13; moderate: approximately 12380 ng*h/ml, n=6; normal approximately 10580 ng*h/ml, n=4).
Gender, weight, race, ageTemsirolimus and sirolimus pharmacokinetics are not significantly affected by gender. No relevant differences in exposure were apparent when data from the Caucasian population was compared with either the Japanese or Black population. In population pharmacokinetic-based data analysis, increased body weight (between 38.6 and 158.9 kg) was associated with a two-fold range of trough concentration of sirolimus in whole blood.Pharmacokinetic data on temsirolimus and sirolimus are available in patients up to age 79 years. Age does not appear to affect temsirolimus and sirolimus pharmacokinetics significantly.
Paediatric populationIn the paediatric population, clearance of temsirolimus was lower and exposure (AUC) was higher than in adults. In contrast, exposure to sirolimus was commensurately reduced in paediatric patients, such that the net exposure as measured by the sum of temsirolimus and sirolimus AUCs (AUCsum) was comparable to that for adults.
Concentrate:Anhydrous ethanol all-rac-α-Tocopherol (E 307) Propylene glycol Anhydrous citric acid (E 330)
Diluent:Polysorbate 80 (E 433)Macrogol 400Anhydrous ethanol
Torisel 30 mg concentrate:Clear glass vial (type 1 glass) with butyl rubber stopper and a plastic flip-top closure sealed with aluminum containing 1.2 ml of concentrate
Diluent:Clear glass vial (type 1 glass) with butyl rubber stopper and a plastic flip-top closure sealed with aluminum containing 2.2 ml of diluent Pack size: 1 vial of concentrate and 1 vial of diluent.
Torisel 30 mg concentrate must be diluted with the supplied diluent before administration in sodium chloride infusion.Note: For mantle cell lymphoma, multiple vials will be required for each dose over 25 mg. Each vial of Torisel must be diluted according to the instructions below. The required amount of concentrate-diluent mixture from each vial must be combined in one syringe for rapid injection into 250 ml of sodium chloride 9 mg/ml (0.9%) solution for injection (see section 4.2).The concentrate-diluent mixture should be inspected visually for particulate matter and discolouration.
Do not use if particulates are present, or if discoloured.In preparing the solution, the following two-step process must be carried out in an aseptic manner according to local standards for handling cytotoxic/cytostatic medicinal products: STEP 1: DILUTION OF TORISEL 30 mg CONCENTRATE WITH THE SUPPLIED DILUENT• Withdraw 1.8 ml of the supplied diluent.• Inject the 1.8 ml of diluent into the vial of Torisel 30 mg concentrate.• Mix the diluent and the concentrate well by inversion of the vial. Sufficient time should be allowed for air bubbles to subside. The solution should be a clear to slightly turbid, colourless to light-yellow to yellow solution, essentially free from visual particulates.One vial of Torisel concentrate contains 30 mg of temsirolimus: when the 1.2 ml concentrate is combined with 1.8 ml of withdrawn diluent, a total volume of 3.0 ml is obtained, and the concentration of temsirolimus will be 10 mg/ml. The concentrate-diluent mixture is stable below 25°C for up to 24 hours.STEP 2: ADMINISTRATION OF CONCENTRATE-DILUENT MIXTURE IN SODIUM CHLORIDE INFUSION• Withdraw the required amount of concentrate-diluent mixture (containing temsirolimus 10 mg/ml) from the vial; i.e., 2.5 ml for a temsirolimus dose of 25 mg.• Inject the withdrawn volume rapidly into 250 ml of sodium chloride 9 mg/ml (0.9%) solution for injection to ensure adequate mixing.The admixture should be mixed by inversion of the bag or bottle, avoiding excessive shaking, as this may cause foaming.The final diluted solution in the bag or bottle should be inspected visually for particulate matter and discolouration prior to administration. The admixture of Torisel in sodium chloride 9 mg/ml (0.9%) solution for injection should be protected from excessive room light and sunlight.
Administration Administration of the final diluted solution should be completed within six hours from the time that Torisel is first added to sodium chloride 9 mg/ml (0.9%) solution for injection. Torisel is infused over a 30 to 60 minute period once a week. The use of an infusion pump is the preferred method of administration to ensure accurate delivery of the medicinal product. Appropriate administration materials must be composed of glass, polyolefin, or polyethylene to avoid excessive loss of medicinal product and to decrease the rate of DEHP extraction. The administration materials must consist of non-DEHP, non-PVC tubing with appropriate filter. An in-line polyethersulfone filter with a pore size of not greater than 5 microns is recommended for administration to avoid the possibility of particles bigger than 5 microns being infused. If the administration set available does not have an in-line filter incorporated, a filter should be added at the end of the set (i.e. an end-filter) before the admixture reaches the vein of the patient. Different end-filters can be used ranging in filter pore size from 0.2 microns up to 5 microns. The use of both an in-line and end-filter is not recommended. Torisel, when diluted, contains polysorbate 80, which is known to increase the rate of DEHP extraction from PVC. This should be considered during the preparation and administration of Torisel following constitution. It is important that the recommendations in section 4.2 be followed closely.
DisposalAny unused medicinal product or waste material should be disposed of in accordance with local requirements.
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