Qarziba is indicated for the treatment of high-risk neuroblastoma in patients aged 12 months and above, who have previously received induction chemotherapy and achieved at least a partial response, followed by myeloablative therapy and stem cell transplantation, as well as patients with history of relapsed or refractory neuroblastoma, with or without residual disease. Prior to the treatment of relapsed neuroblastoma, any actively progressing disease should be stabilised by other suitable measures.

In patients with a history of relapsed/refractory disease and in patients who have not achieved a complete response after first line therapy, Qarziba should be combined with interleukin-2 (IL-2).

Qarziba is restricted to hospital-use only and must be administered under the supervision of a physician experienced in the use of oncological therapies. It must be administered by a healthcare professional prepared to manage severe allergic reactions including anaphylaxis in an environment where full resuscitation services are immediately available.

Posology

Treatment with Qarziba consists of 5 consecutive courses, each course comprising 35 days. The individual dose is determined based on the body surface area and should be a total of 100 mg/m² per course.

Two modes of administration are possible:

• a continuous infusion over the first 10 days of each course (a total of 240 hours) at the daily dose of 10 mg/m²

• or five daily infusions of 20 mg/m² administered over 8 hours, on the first 5 days of each course

When IL-2 is combined with Qarziba, it should be administered as subcutaneous injections of 6× 10⁶ IU/m²/day, for 2 periods of 5 consecutive days, resulting in an overall dose of 60× 10⁶ IU/m² per course. The first 5-day course should start 7 days prior to the first infusion of dinutuximab beta and the second 5-day course should start concurrently with dinutuximab beta infusion (days 1 to 5 of each dinutuximab beta course).

Prior to starting each treatment course, the following clinical parameters should be evaluated and treatment should be delayed until these values are reached:

• pulse oximetry > 94% on room air

• adequate bone marrow function: absolute neutrophil count ≥ 500/µ L, platelet count ≥ 20,000/µ L, haemoglobin > 8.0 g/dL

• adequate liver function: alanine aminotransferase (ALT)/ aspartate aminotransferase (AST) < 5 times upper limit of normal (ULN)

• adequate renal function: creatinine clearance or glomerular filtration rate (GRF) > 60 mL/min/1.73 m²

Dose modification of dinutuximab beta

Based on the physician's evaluation of the severity of adverse drug reactions to dinutuximab beta, patients may undergo a dose reduction of 50% or a temporary interruption of the infusion. As a consequence, either the infusion period is prolonged or, if tolerated by the patient, the infusion rate may be increased up to 3 mL/h (continuous infusion), in order to administer the total dose.

Recommended dose modifications for dinutuximab beta

Treatment with dinutuximab beta should be permanently discontinued if the following toxicities occur:

• grade 3 or 4 anaphylaxis

• prolonged grade 2 peripheral motor neuropathy

• grade 3 peripheral neuropathy

• grade 3 vision eye toxicity

• grade 4 hyponatremia (< 120 mEq/L) despite appropriate fluid management

• recurrent or grade 4 capillary leak syndrome (requires ventilator support)

• severe central neurotoxicity that includes grade 3 or 4 with substantial prolonged neurological deficit without any detectable reason, recurrent grade 1-3 neurotoxicity, and permanent neurological deficit

• all grades of posterior reversible encephalopathy syndrome and transverse myelitis

Renal and hepatic impairment

There are no data in patients with renal and hepatic impairment (see section 5.2).

Paediatric population

The safety and efficacy of Qarziba in children aged less than 12 months have not yet been established. No data are available.

Method of administration

Qarziba is for intravenous infusion. The solution should be administered via a peripheral or central intravenous line. Other intravenously co-administered agents should be delivered via a separate infusion line (see section 6.6).

For continuous infusions, the solution is administered at a rate of 2 mL per hour (48 mL per day) using an infusion pump.

For 8-hour daily infusions, the solution is administered at a rate of approximately 13 mL per hour.

Pre-medication should always be considered before starting each infusion (see section 4.4).

For instructions on dilution of the medicinal product before administration, see section 6.6.

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

Acute grade 3 or 4, or extensive chronic graft-versus-host disease (GvHD)

Traceability

In order to improve the traceability of biological medicinal products, the name and the batch number of the administered product should be clearly recorded.

Pain

Neuropathic pain usually occurs at the beginning of the treatment and premedication with analgesics, including intravenous opioids, prior to each infusion of dinutuximab beta is required. A triple therapy, including nonopioid analgesics (according to WHO guidelines), gabapentin and opioids, is recommended for pain treatment. The individual dose may vary widely.

Nonopioid analgesics

Nonopioid analgesics should be used permanently during the treatment, e.g. paracetamol or ibuprofen.

Gabapentin

The patient should be primed with 10 mg/kg/day, starting 3 days prior to dinutuximab beta infusion. The daily dose of gabapentin is increased to 2× 10 mg/kg/day orally, the next day and to 3× 10 mg/kg/day orally, the day before the onset of dinutuximab beta infusion and thereafter. The maximum single dose of gabapentin is 300 mg. This dosing schedule should be maintained for as long as required by the patient.

Oral gabapentin should be tapered off after weaning off intravenous morphine infusion, at the latest after dinutuximab beta infusion therapy has stopped.

Opioids

Treatment with opioids is standard with dinutuximab beta. The first infusion day and course usually requires a higher dose than subsequent days and courses.

• Before initiation of a continuous intravenous morphine infusion, a bolus infusion of 0.02 to 0.05 mg/kg/hour morphine should be started 2 hours before dinutuximab beta infusion.

• Subsequently, a dosing rate of 0.03 mg/kg/hour is recommended concomitantly with dinutuximab beta infusion.

• With daily infusions of dinutuximab beta, morphine infusion should be continued at a decreased rate (e.g. 0.01 mg/kg/h) for 4 hours after the end of dinutuximab beta infusion.

• With continuous infusion, in response to the patient's pain perception, it may be possible to wean off morphine over 5 days by progressively decreasing its dosing rate (e.g. to 0.02 mg/kg/hour, 0.01 mg/kg/hour, 0.005 mg/kg/hour).

• If continous morphine infusion is required for more than 5 days, treatment should be gradually reduced by 20% per day after the last day of dinutuximab beta infusion.

After weaning off intravenous morphine, in case of severe neuropathic pain, oral morphine sulphate (0.2 to 0.4 mg/kg every 4 to 6 hours) can be administered on demand. For moderate neuropathic pain, oral tramodol may be administered.

Hypersensitivity reactions

Severe infusion-related reactions, including cytokine release syndrome (CRS), anaphylactic and hypersensitivity reactions, may occur despite the use of premedication. Occurrence of a severe infusion related reaction (including CRS) requires immediate discontinuation of dinutuximab beta therapy and may necessitate emergency treatment.

Cytokine release syndrome frequently manifests itself within minutes to hours of initiating the first infusion and is characterised by systemic symptoms such as fever, hypotension and urticaria.

Anaphylactic reactions may occur as early as within a few minutes of the first infusion with dinutuximab beta and are commonly associated with bronchospasm and urticaria.

Premedication

Antihistamine premedication (e.g. diphenhydramine) should be administered by intravenous injection approximately 20 minutes before starting each dinutuximab beta infusion. It is recommended that antihistamine administration be repeated every 4 to 6 hours as required during dinutuximab infusion.

Patients should be closely monitored for anaphylaxis and allergic reactions, particularly during the first and second treatment course.

Treatment of hypersensitivity reactions

Intravenous antihistamine, epinephrine (adrenaline) and prednisolone for intravenous administration should be immediately available at the bedside during administration of dinutuximab beta to manage life-threatening allergic reactions. It is recommended that treatment for such reactions include prednisolone administered by intravenous bolus, and epinephrine administered by intravenous bolus every 3 to 5 minutes as necessary, according to clinical response. In case of bronchial and/or pulmonary hypersensitivity reaction, inhalation with epinephrine (adrenaline) is recommended and should be repeated every 2 hours, according to clinical response.

Capillary leak syndrome (CLS)

CLS is characterised by a loss of vascular tone and extravasation of plasma proteins and fluid into the extravascular space. CLS usually develops within hours after initiation of treatment, while clinical symptoms (i.e. hypotension, tachycardia) are reported to occur after 2 to 12 hours. Careful monitoring of circulatory and respiratory function is required.

Neurological disorders of the eye

Eye disorders may occur as dinutuximab beta binds to optic nerve cells. No dose modification is necessary in the case of an impaired visual accommodation that is correctable with eye glasses, as long as this is judged to be tolerable.

Treatment must be interrupted in patients who experience Grade 3 vision toxicity (i.e. subtotal vision loss per toxicity scale). In case of any eye problems, patients should be referred promptly to an ophtalmology specialist.

Peripheral neuropathy

Occasional occurrences of peripheral neuropathy have been reported with Qarziba. Cases of motor or sensory neuropathy lasting more than 4 days must be evaluated and non-inflammatory causes, such as disease progression, infections, metabolic syndromes and concomitant medication, should be excluded.

Treatment should be permanently discontinued in patients experiencing any objective prolonged weakness attributable to dinutuximab beta administration. For patients with moderate (Grade 2) neuropathy (motor with or without sensory), treatment should be interrupted and may be resumed after neurologic symptoms resolve.

Central neurotoxicity

Central neurotoxicity has been reported following treatment with Qarziba. If central neurotoxicity occurs the infusion should be interrupted immediately and the patient treated symptomatically, other influencing factors such as active infection, metastatic spread of neuroblastoma to CNS, neurotoxic concomitant medications should be ruled out.

Treatment with dinutuximab beta should be permanently discontinued following the occurrence of severe neurotoxicity that includes grade 3 or 4 central neurotoxicity with substantial prolonged neurological deficit without any detectable reason, recurrent grade 1-3 neurotoxicity and/or permanent neurological deficit and all grades of posterior reversible encephalopathy syndrome and transverse myelitis.

Systemic infections

Patients are likely to be immunocompromised as a result of prior therapies. As they typically have a central venous catheter in situ, they are at risk of developing systemic infection. Patients should have no evidence of systemic infection and any identified infection should be under control before starting therapy.

Haematologic toxicities

Occurrence of haematologic toxicities has been reported with Qarziba, such as erythropenia, thrombocytopenia or neutropenia. Grade 4 haematologic toxicities, improving to at least Grade 2 or baseline values by start of next treatment course, do not require dose modification.

Laboratory abnormalities

Regulatory monitoring of liver function and electrolytes is recommended.

No interaction studies have been performed. A risk for indirect reduction of CYP activity due to higher TNF-α and IL-6 levels and, therefore, interactions with concomitantly used medicinal products, cannot be excluded.

Corticosteroids

Due to their immunosuppressive activity, concomitant treatment with corticosteroids is not recommended within 2 weeks prior to the first treatment course until 1 week after the last treatment course with dinutuximab beta, except for life-threatening conditions.

Vaccinations

Vaccinations should be avoided during administration of dinutuximab beta until 10 weeks after the last treatment course, due to immune stimulation through dinutuximab beta and possible risk for rare neurological toxicities.

Intravenous immunoglobulin

Concomitant use of intravenous immunoglobulins is not recommended as they may interfere with dinutuximab beta-dependent cellular cytotoxicity.

Pregnancy

There are no data on pregnant women. No animal data are available on teratogenicity or embryotoxicity. Dinutuximab beta target (GD2) is expressed on neuronal tissues, especially during embryofetal development, and may cross the placenta; therefore, Qarziba may cause fetal harm when administered to pregnant women.

Qarziba should not be used during pregnancy.

Breast-feeding

There are no data on lactating women. It is unknown whether dinutuximab beta is excreted in human milk. Breast-feeding should be discontinued during treatment with Qarziba and for 6 months after the last dose.

Fertility

The effects of dinutuximab beta on fertility in humans are unknown. In animals, dedicated fertility studies have not been conducted, but no adverse effects on reproductive organs were observed in toxicity studies performed in Guinea pig and cynomolgous monkey.

Qarziba should not be used in women of childbearing potential not using contraception. It is recommended that women of childbearing potential use contraception for 6 months after discontinuation of treatment with dinutuximab beta.

Dinutuximab beta has major influence on the ability to drive and use machines. Patients should not use or drive machines during treatment with dinutuximab beta.

Summary of the safety profile

The safety of dinutuximab beta has been evaluated in 628 patients with high-risk and relapsed/refractory neuroblastoma, who received it as a continuous infusion (212) or as repeated daily infusions (416). It was combined with 13-cis retinoic in most patients and with IL-2 in 307 patients.

The most common adverse reactions were pyrexia (88%) and pain (77%) that occurred despite analgesic treatment. Other frequent adverse reactions were hypersensitivity (74.1%), vomiting (57%), diarrhoea (51%), capillary leak syndrome (40%), Anaemia (72.3%), neutropenia (52%), thrombocytopenia (49.6%) and hypotension (42.2%).

Tabulated list of adverse reactions

Adverse reactions reported in clinical trials are listed by system organ class and by frequency and summarised in the table below. These adverse reactions are presented by MedDRA system organ class and frequency. Frequency categories are defined as: very common (≥ 1/10), common (≥ 1/100 to < 1/10) and uncommon (≥ 1/1,000 to < 1/100). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness. The type of adverse reactions seen in the post-marketing setting is consistent with the reactions seen in clinical trials.

*includes abdominal pain, pain in extremity, oropharyngeal pain, and Back pain reported in >10% of patients. In addition, other common pain types reported were arthralgia, injection site pain, musculoskeletal pain, bone pain, chest pain, and neck pain.

Description of selected adverse reactions

Hypersensitivity

The most frequent hypersensitivity reactions included hypotension (42.2%), urticaria (15%) and bronchospasm (5.3%). Cytokine release syndrome was also reported in 32% of the patients. Serious anaphylactic reactions occurred in 3.5% of the patients.

Pain

Pain typically occurs during the first infusion of dinutuximab beta and decreases over the treatment courses. Most commonly, patients reported abdominal pain, pain in the extremities, back pain, chest pain, or arthralgia.

Capillary leak syndrome (CLS)

Overall, 10% of CLS were severe (grade 3-4) and their frequency decreased over the treatment courses.

Eye problems

These included impaired visual accommodation that is correctable with eye glasses, as well as mydriasis (10.7%), periorbital oedema and eyelid oedema (7.1%), blurred vision (3%) or photophobia (3%), which were usually reversible after treatment discontinuation. Severe eye disorders were also reported including ophthalmoplegia (2%) and optic atrophy.

Peripheral neuropathy

Both motor and sensory peripheral neuropathies have been reported, overall in 9% of the patients. Most events were of grade 1-2 and resolved.

Central Neurotoxicity

Reports of central neurotoxicity and severe neurotoxicity have been received including posterior reversible encephalopathy syndrome (0.7%) and seizures (1.7%).

Safety profile with and without IL-2

The combination of Qarziba with IL-2 increases the risk of adverse drug reactions compared to Qarziba without IL-2, especially for pyrexia (92% vs. 79%), CLS (50% vs. 25%), pain related to dinutuximab beta (75% vs. 63%), hypotension (43% vs. 26%), and peripheral neuropathy (14% vs. 7%), respectively.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme Website: https://yellowcard.mhra.gov.uk/ or search for MHRA Yellow Card in the Google Play or Apple App Store.

No cases of dinutuximab beta overdose have been reported.

In the case of overdose, patients should be carefully observed for signs or symptoms of adverse reactions and supportive care administered, as appropriate.

Pharmacotherapeutic group: Antineoplastic agents, monoclonal antibodies, ATC code: L01FX06

Mechanism of action

Dinutuximab beta is a chimeric monoclonal IgG1 antibody that is specifically directed against the carbohydrate moiety of disialoganglioside 2 (GD2), which is overexpressed on neuroblastoma cells.

Pharmacodynamic effects

Dinutuximab beta has been shown in vitro to bind to neuroblastoma cell lines known to express GD2 and to induce both complement dependent cytoxicity (CDC) and antibody dependent cell-mediated cytoxicity (ADCC). In the presence of human effector cells, including peripheral blood nuclear cells and granulocytes from normal human donors, dinutuximab beta was found to mediate the lysis of human neuroblastoma and melanoma cell lines in a dose-dependent manner. Additionally, in vivo studies demonstrated that dinutuximab beta could suppress liver metastasis in a syngeneic liver metastasis mouse model.

Neurotoxicity associated to dinutuximab beta is likely due to the induction of mechanical allodynia that may be mediated by the reactivity of dinutuximab beta with the GD2 antigen located on the surface of peripheral nerve fibres and myelin.

Clinical efficacy

The efficacy of dinutuximab beta has been evaluated in a randomised controlled trial comparing the administration of dinutuximab beta with or without IL-2 in the first-line treatment of patients with high-risk neuroblastoma and in two single-arm studies in the relapsed/refractory setting.

Relapsed and refractory patients

In a compassionate use programme (study 1), 54 patients received 10 mg/m²/day dinutuximab beta given by continuous 10-day intravenous infusion in a 5-week treatment course, concurrently with subcutaneous IL-2 (6× 10⁶ IU/m²/day given on days 1-5 and 8-12 of each course) and followed by oral 13-cis-RA treatment (160 mg/m²/day for 14 days per course). The same treatment regimen was used in a Phase II study (study 2), which enrolled 44 patients.

Overall, these 98 patients had primary refractory neuroblastoma (40) or relapsed neuroblastoma (49) with an additional 9 patients enrolled after first-line therapy. These were 61 boys and 37 girls, aged 1 to 26 years (median 5 years). Most had an initial diagnosis of INSS stage 4 disease without MYCN amplification (16% of the subjects had MYCN amplified tumours and in 14% this information was missing). Most patients with relapsed disease were enrolled after their first relapse and the median time from diagnosis to first relapse was about 14 months. Treatment of disease before immunotherapy included intensive chemotherapy regimen followed by autologous stem cell transplantation (ASCT), radiotherapy, and surgery. At baseline, 72 patients had measurable disease and 26 patients had no detectable disease.

Survival rates (event-free survival, overall survival) are presented by type of disease in Table 1. The overall response rate (complete response plus partial response) in patients with evidence of disease at baseline was 36% (95% confidence interval [25; 48]) and was more favourable in patients with refractory disease (41% [23; 57]) than in patients with relapsed disease (29% [15; 46]).

Table 1: Event-free survival (EFS) and overall survival (OS) rates in relapsed and refractory patients

First-line patients who received autologous stem cell transplantation

In study 3, patients with high-risk neuroblastoma were enrolled after they had received induction chemotherapy and achieved at least a partial response, then myeloablative therapy and stem cell transplantation. Patients with progressive disease were excluded. Dinutuximab beta was administered at a dose of 20 mg/m²/day on 5 consecutive days, given by 8-hour intravenous infusion in a 5-week treatment course, and was combined with 13-cis-RA and with or without additional subcutaneous IL-2 at the same posologies as in the previous studies.

A total of 370 patients were randomised and received treatment. These included 64% male and 36% female patients with a median age of 3 years (0.6 to 20); 89% had a tumour INSS stage 4 and MYCN amplification was reported in 44% of the cases. The primary efficacy endpoint was 3-year EFS and secondary endpoint was OS. EFS and OS rates are presented in Tables 2 and 3 according to the evidence of disease at baseline.

For patients without evidence of disease at baseline, addition of IL-2 did not improve EFS and OS.

Table 2: Event-free survival (EFS) and overall survival (OS) rates [95% confidence interval] in patients without evidence of disease at baseline (complete response to initial treatment)

Table 3: Event-free survival (EFS) and overall survival (OS) rates [95% confidence interval] in patients with evidence of disease at baseline (no complete response to initial treatment)

Immunogenicity

In 3 clinical studies the appearance of ADA was 57.1% (112/196) in subjects being classed as ADA positive on the basis of having at least one measurable ADA response over the course of treatment. Neutralising antibody activity was observed in 63.5% (54/85) of the ADA-positive subjects in 2 studies. There was an overall trend of lower dinutuximab beta concentration with increasing ADA titre, (low, medium and high). In 16.8% of subjects (33/196) with a high ADA titre, the reduction in dinutuximab beta concentration impacted on pharmacodynamic responses. Based on the available data it is not possible to determine a quantitative association between ADA titre and impact on efficacy.

No clear associations between ADA response and relevant Selected Safety Events were observed.

From an efficacy and safety perspective, there is no rationale for adjusting or stopping treatment on the basis of measured ADA responses.

Dinutuximab beta has been investigated using short-term infusions (STI - five days of eight-hour infusions at 20 mg/m²/day) and long-term infusions (LTI - ten days of continuous infusion at 100 mg/m²).

Absorption

Dinutuximab beta is administered as an intravenous infusion. The maximum concentration (mean (± SD)) at the end of the long-term infusion was 11.2 (± 3.3) mg/L. Other routes of administration have not been investigated.

Distribution

The population mean (± SD) estimate for the central volume of distribution was 2.04 (± 1.05) L and for the peripheral volume of distribution 2.65 (± 1.01) L.

Biotransformation

The metabolism of dinutuximab beta has not been investigated. As a protein, dinutuximab beta is expected to be metabolised to small peptides and individual amino acids by ubiquitous proteolytic enzymes.

Elimination

The clearance after the LTI was 0.72 (± 0.24) L/d/m2. The accumulation ratio for C_max was 1.13 (± 0.54) after 5 LTI courses (mean (± SD)). The apparent terminal elimination t_1/2 was 8.7 (± 2.6) days (mean (± SD)). The clearance of dinutuximab beta increased in the presence of high anti-drug antibody titres regardless of neutralising activity (See Immunogenicity in Section 5.1).

Linearity/non-linearity

Variations in dose of the first infusion in Study 2 revealed a dose-proportional increase in exposure (AUC∞ ) up to the recommended dose of 100 mg/m² per course for 10 days.

Specific populations

The age of patients ranged from 1 to 27 years (median 6 years). Body weight ranged from 9 to 75 kg (median 18.5 kg) and body-surface area ranged from 0.44 to 1.94 m² (median 0.75 m²). A two-compartment population-PK model with first-order elimination from the central compartment was developed using the data from 224 patients in four studies (STI 30 patients, LTI 194 patients). Volume and clearance parameters increased across the ranges with increasing body size. Body weight and ADA titre were covariates for clearance while body weight, age and IL-2 co-administration were covariates for volume of distribution.

Age

The population pharmacokinetic analyses showed comparable exposure to dinutuximab beta in patients of all ages studied when dosed at 100 mg/m².

Gender

The population pharmacokinetic analysis with 89 female (40%) and 135 male (60%) patients

showed no clinically meaningful effect of gender on dinutuximab beta pharmacokinetics.

Race

Since the PK analysis population was predominantly Caucasian (92.9%) race was not formally examined as a potential PK covariate.

Weight

Dosing on the basis of body surface area provides consistent exposure across populations.

Renal impairment

No formal studies have been conducted in patients with renal impairment. Renal function was not a significant covariate in population pharmacokinetic analyses that included patients with normal renal function and mild renal impairment.

Hepatic impairment

No formal studies have been conducted in patients with hepatic impairment. Subjects with ALT >3x ULN had comparable pharmacokinetics as subjects with ALT≤ 3x ULN.

General toxicology

Dinutuximab beta has been administered to male and female juvenile Guinea pigs, as well as male and female young cynomolgus monkeys, as repeat-dose regimens that exceeded the recommended clinical dose. Findings of note included changes (decrease) in thymus weight as well as bone marrow changes (atrophy affecting myeloid and erythroid precursor cell lines). The bone marrow changes were slight to severe and recovered after cessation of dosing. No effects on cardiovascular functions (ECG, blood pressure) were observed in monkeys.

Other

No non-clinical studies to evaluate the potential of dinutuximab beta to cause carcinogenicity, genotoxicity or developmental and reproductive toxicity have been conducted. In the repeat-dose toxicity studies in Guinea pigs and cynomolgus monkeys, no adverse effects of dinutuximab beta were observed on reproductive organs at exposure levels above clinical levels.

Histidine

Sucrose

Polysorbate 20

Water for injections

Hydrochloric acid (for pH adjustment)

This medicinal product must not be mixed with other medicinal products except those mentioned in section 6.6.

Unopened vial

4 years

Diluted solution (solution for infusion)

Chemical and physical in-use stability has been demonstrated for up to 48 hours at 25 ° C (50 mL syringe) and for up to 7 days at 37 ° C (250 mL infusion bag), after cumulative storage in a refrigerator (2 ° C – 8 ° C) for 72 hours (see section 6.6).

From a microbiological point of view, the product should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would not normally be longer than 24 hours at 2 to 8 ° C, unless dilution has taken place in controlled and validated aseptic conditions.

Store in a refrigerator (2 ° C – 8 ° C).

Keep the vial in the outer carton in order to protect from light.

For storage conditions after dilution of the medicinal product, see section 6.3.

Clear Type I glass vial (6 mL) with a halobutyl rubber stopper and aluminium flip-off cap, containing a minimum extractable volume of 4.5 mL concentrate for solution for infusion.

Each carton contains 1 vial.

The solution for infusion must be prepared under aseptic conditions. The solution must not be exposed to direct sunlight or heat.

The patient specific daily dose of Qarziba is calculated based on body surface area (see section 4.2).

Qarziba should be diluted aseptically to the patient specific concentration/dose with sodium chloride 9 mg/mL (0.9%) solution for infusion containing 1% human albumin (e.g. 5 mL of human albumin 20% per 100 mL sodium chloride solution).

For continuous infusions, the solution for infusion can be prepared freshly on a daily basis, or sufficient for up to 5 days of continuous infusion. The daily dose is 10 mg/m². The amount of solution to be infused per day (within a treatment course of 10 consecutive days) should be 48 mL; with 240 mL for a 5-day dose. It is recommended to prepare 50 mL solution in a 50 mL syringe, or 250 mL in an infusion bag suitable for the employed infusion pump, i.e. an overfill of 2 mL (syringe) or 10 mL (infusion bag) to allow for dead volumes of the infusion systems.

For repeated daily 8-hour infusions, the daily dose is 20 mg/m² and the calculated dose should be diluted in 100 mL sodium chloride 9 mg/mL (0.9%) containing 1% human albumin.

The solution for infusion should be administered via a peripheral or central intravenous line. Other intravenously co-administered agents should be delivered via a separate infusion line. The container should be inspected visually for particulates prior to administration. It is recommended that a 0.22 micrometre in-line filter is used during infusion.

For continuous infusions, any medical device suitable for infusion at a rate of 2 mL per hour can be used, e.g. syringe infusion pumps/infusors, electronic ambulatory infusion pumps. Note that elastomeric pumps are not considered suitable in combination with in-line filters.

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