Consumer medicine information

Afinitor

Everolimus

BRAND INFORMATION

Brand name

Afinitor

Active ingredient

Everolimus

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Afinitor.

SUMMARY CMI

AFINITOR®

Consumer Medicine Information (CMI) summary

The full CMI on the next page has more details. If you are worried about using this medicine, speak to your doctor or pharmacist.

1. Why am I using Afinitor?

Afinitor contains the active ingredient everolimus. Afinitor is used to treat various types of cancer by slowing the growth of cancer-causing cells.

For more information, see Section 1. Why am I using Afinitor? in the full CMI.

2. What should I know before I use Afinitor?

Do not use if you have ever had an allergic reaction to Afinitor or any of the ingredients listed at the end of the CMI.

Talk to your doctor if you have any other medical conditions, take any other medicines, or are pregnant or plan to become pregnant or are breastfeeding.

For more information, see Section 2. What should I know before I use Afinitor? in the full CMI.

3. What if I am taking other medicines?

Some medicines may interfere with Afinitor and affect how it works.

A list of these medicines is in Section 3. What if I am taking other medicines? in the full CMI.

4. How do I use Afinitor?

  • Your doctor will tell you the dose of Afinitor that you should take.

More instructions can be found in Section 4. How do I use Afinitor? in the full CMI.

5. What should I know while using Afinitor?

Things you should do
  • Remind any doctor, dentist or pharmacist you visit that you are using Afinitor.
  • Avoid becoming pregnant while using Afinitor and for up to 8 weeks after you stop using it.
Things you should not do
  • Do not stop using this medicine suddenly.
  • Do not take Afinitor to treat any other complaints unless your doctor tells you to.
  • Do not give your medicine to anyone else, even if they have the same condition as you.
Driving or using machines
  • It is not known if Afinitor will influence your ability to drive and use machines.
Drinking alcohol
  • There are no known interactions between Afinitor and alcohol.
Looking after your medicine
  • Store below 30°C in the original packaging. Store it in a cool dry place away from moisture, heat or sunlight.
  • Keep out of reach of children.

For more information, see Section 5. What should I know while using Afinitor? in the full CMI.

6. Are there any side effects?

Common side effects include infections, rash, feeling weak or tired, diarrhoea, swelling of arms, hands, feet, ankles, face or other parts of the body, abdominal pain, nausea, fever, cough, headache, decreased appetite. For more information, including what to do if you have any side effects, see Section 6. Are there any side effects? in the full CMI.



FULL CMI

AFINITOR®

Active ingredient(s): everolimus

Consumer Medicine Information (CMI)

This leaflet provides important information about using Afinitor. You should also speak to your doctor or pharmacist if you would like further information or if you have any concerns or questions about using Afinitor.

Where to find information in this leaflet:

1. Why am I using Afinitor?
2. What should I know before I use Afinitor?
3. What if I am taking other medicines?
4. How do I use Afinitor?
5. What should I know while using Afinitor?
6. Are there any side effects?
7. Product details

1. Why am I using Afinitor?

Afinitor contains the active ingredient everolimus. Afinitor is classed as an inhibitor targeting mTOR (mammalian target of rapamycin). Afinitor is used to treat various types of cancer by slowing the growth of cancer-causing cells.

Afinitor is used in the treatment of:

  • Renal cell carcinoma, a type of kidney cancer
    Afinitor stops the cancer from making new cells and cuts off the blood supply. This slows the growth and spread of the cancer.
  • Neuroendocrine tumours (NETs)
    Afinitor is used to control the growth of these tumours located in the stomach and intestine, lung or pancreas.
  • Tuberous sclerosis complex (TSC) with angiomyolipoma of the kidney not requiring immediate surgery
    Afinitor may reduce the size of the tumour that is associated with a genetic disorder called TSC. This may lower the risk of the tumour(s) causing bleeding complications and may help to preserve kidney function.
  • TSC with subependymal giant cell astrocytoma (sometimes called 'SEGA'), not requiring immediate surgery
    Afinitor reduces the size of brain tumours (SEGA) that are caused by a genetic disorder called tuberous sclerosis. This may stop the tumours from causing problems as they grow, such as hydrocephalus (excessive accumulation of fluid within the brain).
  • TSC with seizures in patients 2 years and older
    Afinitor may reduce the frequency of seizures in patients with a genetic disorder called TSC.
  • Hormone receptor-positive, HER2 negative advanced breast cancer in postmenopausal women
    Growth of this type of breast cancer is stimulated by oestrogens which are female sex hormones. Oestrogen inhibitors such as letrozole, anastrozole and exemestane reduce the amount of oestrogen and can slow the growth of breast cancers. After failure of letrozole or anastrozole, exemestane is used in combination with Afinitor to prevent the breast cancer cells from becoming resistant to the exemestane. It is only used in patients whose tumour has tested negative to HER2.

2. What should I know before I use Afinitor?

Warnings

Do not use Afinitor if:

  • you are allergic to everolimus, or any of the ingredients listed at the end of this leaflet. Always check the ingredients to make sure you can use this medicine
  • you have an allergy to everolimus-related medicines such as Rapamune, which contains the active ingredient sirolimus.

Some of the symptoms of an allergic reaction may include shortness of breath, wheezing or difficulty breathing; swelling of the face, lips, tongue or other parts of the body; rash, itching or hives on the skin.

Check with your doctor if you:

  • have or have had problems with your liver; It may be necessary to modify your dose of Afinitor
  • have or have had diabetes or high levels of blood sugar
  • have previously had Hepatitis B
  • have received or about to receive radiation treatment
  • have lactose intolerance
  • have allergies to any other medicines, foods, preservatives or dyes
  • have had or about to have recent surgery, or have an unhealed wound following surgery
  • have any type of infection; it is important to treat your infection before starting Afinitor
  • are scheduled to receive any vaccine
  • have any other medical conditions
  • take any medicines for any other condition.

During treatment, you may be at risk of developing certain side effects. It is important you understand these risks and how to monitor for them. See additional information under Section 6. Are there any side effects?

Pregnancy and breastfeeding

Check with your doctor if you are pregnant or intend to become pregnant.

Afinitor is not recommended for use during pregnancy.

Talk to your doctor if you are breastfeeding or intend to breastfeed.

Breastfeeding is not recommended while you are taking Afinitor and for two weeks after the last dose of Afinitor. It is not known whether Afinitor passes into breast milk and could affect your baby.

Contraception

To avoid becoming pregnant, you should use effective contraception while using Afinitor and for up to 8 weeks after you stop using it.

Children and adolescents

Afinitor can be used in children or adolescents with normal liver function for the treatment of:

  • TSC with SEGA (starting at 1 year of age)
  • TSC with seizures SEGA (starting at 2 years of age).

Afinitor is not to be used in children or adolescents for the treatment of cancer, or TSC with angiomyolipoma of the kidney.

3. What if I am taking other medicines?

Tell your doctor or pharmacist if you are taking any other medicines, including any medicines, vitamins or supplements that you buy without a prescription from your pharmacy, supermarket or health food shop.

Some medicines may interfere with Afinitor and affect how it works.

  • Antibiotics such as rifampicin, rifabutin, clarithromycin and erythromycin
  • Antifungal medicines such as ketoconazole, voriconazole, fluconazole and itraconazole
  • Medicines for high blood pressure or heart problems such as diltiazem and verapamil
  • Medicines used to treat high blood pressure or other heart problems, known as ACE inhibitors
  • Medicines used to treat HIV/AIDS such as ritonavir, amprenavir, fosamprenavir, efavirenz and nevirapine
  • Medicines for epilepsy such as carbamazepine, phenobarbitone and phenytoin. If you are taking a medicine to control seizures, any change in the dose of your medication may require a change in your Afinitor dose
  • Cannabidiol used to treat epilepsy and chronic pain, and to improve symptoms related to muscle stiffness and spasms in multiple sclerosis
  • St John's wort, a herbal product used to treat depression and other conditions
  • Drugs used to stop the body from rejecting organ transplants such as ciclosporin
  • Medicines used to prevent vomiting such as aprepitant
  • Midazolam, a medicine used to treat acute seizures, or used as a sedative before or during surgery or a medical procedure.

Check with your doctor or pharmacist if you are not sure about what medicines, vitamins or supplements you are taking and if these affect Afinitor.

Vaccines - tell your doctor if you need to get a vaccination. Some vaccines may be less effective if given while taking Afinitor.

4. How do I use Afinitor?

Afinitor is available as tablets and dispersible tablets. The tablets can be used for the various cancers, TSC with SEGA, and TSC with kidney angiomyolipoma. It is not recommended for use in TSC with seizures. The dispersible tablets can be used for TSC with SEGA and TSC with seizures.

How much to take

Your doctor will tell you how many Afinitor tablets or dispersible tablets to take. The dose will depend on the condition you are being treated for and your individual treatment needs.

When to take Afinitor

  • Take Afinitor once a day, at the same time each day
  • It is best to take Afinitor in the morning, either consistently with or without food
  • Do not drink grapefruit juice or eat grapefruit, star fruit or Seville oranges while taking Afinitor. These foods can stop Afinitor from working properly.

How to take Afinitor

Afinitor Tablets

Swallow the tablets whole with a glass of water. Do not chew or crush the tablets.

If you cannot swallow Afinitor tablets whole, you can stir the tablet into a glass of water:

  • Put the required number of tablets into a glass containing approximately 30 mL of water
  • Gently stir until the tablets break apart (approximately 7 minutes) then drink immediately
  • Rinse the glass with the same amount of water (approximately 30 mL) and drink the contents to make sure that you get the full dose of Afinitor.

Afinitor Dispersible Tablets

Afinitor Dispersible Tablets must be made into a suspension in water first. Do not use any other liquid. Do not chew, crush, or swallow the Dispersible Tablets whole.

You can prepare the suspension in an oral syringe or in a small drinking glass. The suspension must be taken right away. If you do not take the dose within 60 minutes after it has been prepared, throw away the dose and prepare a new dose of Afinitor Dispersible Tablets.

Oral Syringe

  • Remove the plunger from a 10 mL oral syringe and put the prescribed number of dispersible tablets inside the syringe
  • Re-insert the plunger and push it inward to make contact with the dispersible tablets
  • Pull up about 5 mL of water into the syringe to cover the dispersible tablets. Then pull in about 4 mL of air.
  • Place the filled syringe into a container (tip up) for 3 minutes and allow the tablets to disintegrate
  • Gently turn the oral syringe upside down 5 times immediately prior to taking the medicine
  • Carefully push the plunger to remove the excess air from the syringe and then immediately dispense the full contents of the oral syringe directly into the mouth of the patient so they can drink the medicine
  • After taking the medicine, pull up about 5 mL of water and 4 mL of air into the same syringe and swirl the contents and then put the entire contents of the syringe into the mouth of the patient.

Small drinking glass

  • Add approximately 25 mL (2 tablespoons) of water into a small drinking glass and add the prescribed number of dispersible tablets. Do not add more than 10 mg of Afinitor dispersible tablets to the glass. If you need to take more than 10 mg, prepare another glass
  • Allow the dispersible tablets to disintegrate for 3 minutes
  • Stir the contents of the glass gently with a spoon and immediately drink the full amount
  • Refill the glass with the same amount of water (about 25 mL), stir the contents with the same spoon to suspend remaining particles, and drink the entire content of the glass.

Instructions for use and handling of tablets and dispersible tablets

Caregivers are advised to avoid contact with suspensions of Afinitor tablets or dispersible tablets. Wash hands thoroughly before and after preparing either suspension.

If you forget to use Afinitor

Afinitor should be taken regularly at the same time each day. If you miss your dose at the usual time, take it as soon as you remember, and then take the next tablet as usual.

If it is almost time for your next dose, skip the dose you missed and take your next dose when you are meant to.

Do not take a double dose to make up for the dose you missed.

If you are not sure what to do, ask your doctor or pharmacist.

If you use too much Afinitor

If you think that you have taken too much Afinitor, you may need urgent medical attention.

You should immediately:

  • phone the Poisons Information Centre
    (by calling 13 11 26), or
  • contact your doctor, or
  • go to the Emergency Department at your nearest hospital.

You should do this even if there are no signs of discomfort or poisoning.

5. What should I know while using Afinitor?

Things you should do

  • Keep all of your doctor's appointments so that your progress can be checked
  • Tell your doctor if you plan to receive a vaccine
  • Avoid becoming pregnant while using Afinitor and for up to 8 weeks after you stop using it
  • Tell your doctor if you are about to have surgery, have had recent surgery or if you still have an unhealed wound following surgery.

Call your doctor straight away if you:

  • Experience new or worsening cough, difficulty breathing, chest pain, shortness of breath or wheezing
  • Have a temperature or chills, or another sign of an infection
  • Experience pain or discomfort in the mouth or have open sores in the mouth
  • Experience shortness of breath, nausea, diarrhoea, skin rashes or soreness in the mouth, gums or throat
  • Become pregnant while taking this medicine.

Remind any doctor, dentist or pharmacist you visit that you are using Afinitor.

Things you should not do

  • Do not stop using this medicine suddenly
  • Do not change your dose, or switch between tablets and dispersible tablets unless advised by your doctor
  • Do not take Afinitor to treat any other complaints unless your doctor tells you to
  • Do not give your medicine to anyone else, even if they have the same condition as you.

Driving or using machines

Be careful before you drive or use any machines or tools until you know how Afinitor affects you.

Looking after your medicine

Follow the instructions in the carton on how to take care of your medicine properly.

Keep the tablets or dispersible tablets in the original packet and foils until it is time to take them.

Store below 30°C in the original packaging.

Store it in a cool dry place away from moisture, heat or sunlight; for example, do not store it:

  • in the bathroom or near a sink, or
  • in the car or on window sills.

Keep it where young children cannot reach it.

Getting rid of any unwanted medicine

If you no longer need to use this medicine or it is out of date, take it to any pharmacy for safe disposal.

Do not use this medicine after the expiry date.

6. Are there any side effects?

All medicines can have side effects. If you do experience any side effects, most of them are minor and temporary. However, some side effects may need medical attention.

See the information below and, if you need to, ask your doctor or pharmacist if you have any further questions about side effects.

Less serious side effects

Less serious side effectsWhat to do
Mouth, stomach, bowel problems:
  • Sore mouth or throat, cold sores or mouth ulcers
  • Nausea, vomiting, diarrhoea, constipation, tummy pain, excess gas
  • Dry mouth, difficulty swallowing
  • Loss of appetite, change in or loss of taste, weight loss
  • Cloudy urine, pain when urinating, wanting to urinate more often
General problems:
  • Feeling thirsty
  • Fatigue or unusual weakness
  • Trouble sleeping
  • Headache, dizziness
  • Ear ache
  • Runny nose, cough
  • Fever
  • Nose bleeds
  • Irregular, absent or heavy menstrual periods in females
  • Joint pain
  • Poor wound healing
  • Swelling of hands, feet or limbs due to fluid retention
Skin problems:
  • Bleeding or bruising more easily than normal
  • Small, solid pink or red bumps on the skin
  • Dry or red skin, rash
  • Nail disorders
  • Rash and pain on the palms of your hands or soles of your feet
  • Pimples
Speak to your doctor if you have any of these less serious side effects and they worry you.
If these side effects become severe, tell your doctor, pharmacist or healthcare provider

Serious side effects

Serious side effectsWhat to do
Symptoms of an allergic reaction or infection such as:
  • Shortness of breath, wheezing or difficulty breathing; swelling of the face, lips, tongue or other parts of the body; rash, itching or hives on the skin
  • Fever, chills, sore throat, aching joints and inflammation, swollen glands, cough, or any other signs of infection such as infection of a cut or scratch
  • Painful skin rash with small fluid-filled blisters in a limited area on one side of the body (left or right), often in a stripe (herpes zoster)
Lung or heart problems such as:
  • Coughing, breathing problems, rapid breath or shortness of breath
  • Sudden onset of shortness of breath, chest pain or coughing up blood
Other problems:
  • Difficulty breathing, nausea, diarrhoea, soreness in the mouth, gums or throat, skin rashes or redness at site of radiation therapy
  • Symptoms of hepatitis B such as fever, skin rash, joint pain, inflammation, fatigue, loss of appetite, nausea, jaundice (yellowing of the skin), pain in the upper right abdomen, pale stool or dark urine
  • Swelling and/or pain in one of your legs, usually your calf, (redness or warm skin in the affected area)
  • Swelling, feeling of heaviness or tightness, pain, limited movement of body parts which could be a sign of fluid build-up and a problem with your lymphatic system
  • Vomiting blood, blood in your faeces
  • Signs of anger, easily irritated
Call your doctor straight away, or go straight to the Emergency Department at your nearest hospital if you notice any of these serious side effects.

Tell your doctor or pharmacist if you notice anything else that may be making you feel unwell.

Other side effects not listed here may occur in some people. Some of these side effects can only be found by laboratory testing (for example, high levels of cholesterol, lipids, or sugar in the blood).

Reporting side effects

After you have received medical advice for any side effects you experience, you can report side effects to the Therapeutic Goods Administration online at www.tga.gov.au/reporting-problems. By reporting side effects, you can help provide more information on the safety of this medicine.

Always make sure you speak to your doctor or pharmacist before you decide to stop taking any of your medicines.

7. Product details

This medicine is only available with a doctor's prescription.

What Afinitor contains

Active ingredient
(main ingredient)		everolimus
Other ingredients
(inactive ingredients)

Afinitor Tablets

  • butylated hydroxytoluene
  • magnesium stearate
  • lactose monohydrate
  • hypromellose
  • crospovidone
  • lactose

Afinitor Dispersible Tablets

  • butylated hydroxytoluene
  • magnesium stearate
  • lactose monohydrate
  • hypromellose
  • crospovidone
  • mannitol
  • microcrystalline cellulose
  • colloidal anhydrous silica
Potential allergensLactose

Do not take this medicine if you are allergic to any of these ingredients.

What Afinitor looks like

Afinitor Tablets

Afinitor tablets are available in three different strengths, supplied in packs of 30 tablets:

  • Afinitor 2.5 mg tablets are white to yellowish and elongated with no score, with "LCL" on one side and "NVR" on the other (AUST R 177648)
  • Afinitor 5 mg tablets are white to yellowish and elongated with no score, with "5" on one side and "NVR" on the other (AUST R 154661)
  • Afinitor 10 mg tablets are white to yellowish and elongated with no score, with "UHE" on one side and "NVR" on the other (AUST R 154663)

Afinitor Dispersible Tablets

Afinitor dispersible tablets are available in three different strengths, supplied in packs of 30 tablets:

  • Afinitor 2 mg dispersible tablets are white to slightly yellowish, round, flat tablets with a bevelled edge and no score, with "D2" on one side and "NVR" on the other (AUST R 200203)
  • Afinitor 3 mg dispersible tablets are white to slightly yellowish, round, flat tablets with a bevelled edge and no score, with "D3" on one side and "NVR" on the other (AUST R 200204)
  • Afinitor 5 mg dispersible tablets are white to slightly yellowish, round, flat tablets with a bevelled edge and no score, with "D5" on one side and "NVR" on the other (AUST R 200205)

Who distributes Afinitor

Afinitor is supplied in Australia by:

Novartis Pharmaceuticals Australia Pty Limited
ABN 18 004 244 160
54 Waterloo Road
Macquarie Park NSW 2113
Telephone 1 800 671 203
Website: www.novartis.com.au

This leaflet was prepared in March 2024.

(afi150324c.doc) based on PI (afi150324i.doc)

Published by MIMS May 2024

BRAND INFORMATION

Brand name

Afinitor

Active ingredient

Everolimus

Schedule

S4

 

1 Name of Medicine

Everolimus.

2 Qualitative and Quantitative Composition

Each Afinitor tablet contains either 2.5 mg, 5 mg or 10 mg everolimus.
Each Afinitor dispersible tablet contains either 2 mg, 3 mg or 5 mg everolimus.

Excipients with known effect.

Tablets only - contains sugars as lactose.
For the full list of excipients, see Section 6.1 List of Excipients.

3 Pharmaceutical Form

2.5 mg tablet.

White to slightly yellowish, elongated tablet with a bevelled edge and no score engraved with "LCL" on one side and "NVR" on the other.

5 mg tablet.

White to slightly yellowish, elongated tablet with a bevelled edge and no score engraved with "5" on one side and "NVR" on the other.

10 mg tablet.

White to slightly yellowish, elongated tablet with a bevelled edge and no score engraved with "UHE" on one side and "NVR" on the other.

2 mg dispersible tablet.

White to slightly yellowish, round, flat tablets with a bevelled edge and no score. The tablets are engraved with "D2" on one side and "NVR" on the other.

3 mg dispersible tablet.

White to slightly yellowish, round, flat tablets with a bevelled edge and no score. The tablets are engraved with "D3" on one side and "NVR" on the other.

5 mg dispersible tablet.

White to slightly yellowish, round, flat tablets with a bevelled edge and no score. The tablets are engraved with "D5" on one side and "NVR" on the other.

4 Clinical Particulars

4.1 Therapeutic Indications

Afinitor is indicated for the:
Treatment of postmenopausal women with hormone receptor-positive, HER2 negative advanced breast cancer in combination with exemestane after failure of treatment with letrozole or anastrozole.
Treatment of progressive, unresectable or metastatic, well or moderately differentiated neuroendocrine tumours (NETs) of pancreatic origin.
Treatment of progressive, unresectable or metastatic, well-differentiated, non-functional neuroendocrine tumours (NET) of gastrointestinal or lung origin in adults.
Treatment of advanced renal cell carcinoma after failure of treatment with sorafenib or sunitinib.
Treatment of subependymal giant cell astrocytoma (SEGA) associated with tuberous sclerosis complex (TSC) who require therapeutic intervention but are not candidates for curative surgical resection.
Treatment of patients with tuberous sclerosis complex (TSC) who have renal angiomyolipoma not requiring immediate surgery.
Adjunctive treatment of patients aged 2 years and older with TSC and associated refractory seizures.

4.2 Dose and Method of Administration

Treatment with Afinitor should be initiated by a physician experienced in the use of anticancer therapies or in the treatment of patients with TSC.
Afinitor should be administered orally once daily at the same time every day (preferably in the morning), either consistently with or consistently without food (see Section 5.2 Pharmacokinetic Properties). Afinitor is available in two formulations: tablets (Afinitor tablets) and dispersible tablets (Afinitor dispersible tablets).
Afinitor tablets may be used in all oncology indications and in the TSC with SEGA and TSC with renal angiomyolipoma indications. Afinitor tablets have not been studied and are not recommended for use in patients with TSC and refractory seizures.
Afinitor dispersible tablets may be used for the treatment of patients with TSC who have SEGA and patients with TSC and refractory seizures in conjunction with therapeutic drug monitoring (see Section 4.2 Dose and Method of Administration, Therapeutic drug monitoring).
If a dose is missed, the patient should take the next dose at the next scheduled time. Patients should not take two doses to make up for the one that they missed.
Treatment should continue as long as clinical benefit is observed or until unacceptable toxicity occurs.

Afinitor tablets.

Afinitor tablets should be swallowed whole with a glass of water. The tablets should not be chewed or crushed.
For patients with TSC who have SEGA and are unable to swallow tablets whole, Afinitor tablets can be dispersed completely in a glass of water (containing approximately 30 mL) by gently stirring until the tablet(s) is fully disintegrated (approximately 7 minutes), immediately prior to drinking. The glass should be rinsed with the same volume of water and the rinse completely swallowed to ensure the entire dose is administered.

Afinitor dispersible tablets.

Afinitor dispersible tablets are to be taken as a suspension only and should not be swallowed whole, chewed, or crushed. The suspension can be prepared in an oral syringe or in a small drinking glass. Care should be taken to ensure the entire dose is administered.
Administer the suspension immediately after preparation. Discard the suspension if not administered within 60 minutes of preparation. Prepare the suspension in water only.

Using an oral syringe.

Place the prescribed dose of Afinitor dispersible tablets into a 10 mL syringe. Do not exceed a total of 10 mg per syringe. If higher doses are required, prepare an additional syringe. Do not break or crush tablets.
Draw approximately 5 mL of water and 4 mL of air into the syringe.
Place the filled syringe into a container (tip up) for 3 minutes, until the Afinitor dispersible tablets are in suspension.
Gently invert the syringe 5 times immediately prior to administration.
After administration of the prepared suspension, draw approximately 5 mL of water and 4 mL of air into the same syringe, and swirl the contents to suspend remaining particles. Administer the entire contents of the syringe.

Using a small drinking glass.

Place the prescribed dose of Afinitor dispersible tablets into a small drinking glass (maximum size 100 mL) containing approximately 25 mL of water. Do not exceed a total of 10 mg of Afinitor dispersible tablets per glass. If higher doses are required, prepare an additional glass. Do not break or crush tablets.
Allow 3 minutes for suspension to occur.
Stir the contents gently with a spoon, immediately prior to drinking.
After administration of the prepared suspension, add 25 mL of water and stir with the same spoon to re-suspend remaining particles. Administer the entire contents of the glass.

Switching dosage forms.

The two dosage forms (Afinitor tablets and Afinitor dispersible tablets) are not interchangeable. Do not combine the two dosage forms to achieve the desired dose. Consistently use the same dosage form, as appropriate for the indication being treated.
When switching dosage forms, the dose should be adjusted to the closest milligram strength of the new dosage form and the everolimus trough concentration should be assessed approximately 2 weeks later (see Section 4.2 Dose and Method of Administration, Therapeutic drug monitoring).

Adults.

Dosing in hormone receptor positive advanced breast cancer, advanced neuroendocrine tumours, advanced renal cell carcinoma, and TSC with renal angiomyolipoma.

The recommended dose of Afinitor is 10 mg to be taken once daily.

BSA based dosing in TSC with SEGA and TSC with refractory seizures.

Individualise dosing based on the body surface area (BSA, in m2) using the Dubois formula, where weight (W) is in kilograms and height (H) is in centimetres (see Equation 1).

Starting dose and target trough concentrations in TSC with SEGA.

The recommended starting dose of Afinitor for treatment of patients with TSC who have SEGA is 4.5 mg/m2, rounded to the nearest strength of Afinitor tablets or Afinitor dispersible tablets. Different strengths of Afinitor tablets can be combined to attain the desired dose. Likewise, different strengths of Afinitor dispersible tablets can be combined to attain the desired dose. The two dosage forms should not be combined to achieve the desired dose.
Dosing should be titrated to attain trough concentrations of 3 to 15 nanogram/mL.

Starting dose and target trough concentrations in TSC with refractory seizures.

The recommended starting daily dose for Afinitor dispersible tablets for the treatment of patients with seizures is shown in Table 1. The starting dose should be rounded to the nearest available strength of Afinitor dispersible tablets. Different strengths of Afinitor dispersible tablets can be combined to attain the desired dose. Dosing should be titrated to attain trough concentrations of 5 to 15 nanogram/mL.

Dose monitoring.

Therapeutic drug monitoring of everolimus blood concentrations is required for patients with TSC who have SEGA or patients with TSC and seizures (see Section 4.2 Dose and Method of Administration, Therapeutic drug monitoring). Everolimus whole blood trough concentrations should be assessed approximately 1 to 2 weeks after commencing treatment or any change in dose.

Titration.

Individualized dosing should be titrated by increasing the dose by increments of 1 to 4 mg to attain the target trough concentration for optimal clinical response. Efficacy, safety, concomitant medication, and the current trough concentration should be considered when planning for dose titration. Individualized dose titration can be based on simple proportion (see Equation 2):
For example, a patient's current dose based on BSA is 4 mg with a steady state concentration of 4 nanogram/mL. In order to achieve a target concentration above the lower Cmin limit of 5 nanogram/mL, e.g. 8 nanogram/mL, the new everolimus dose would be 8 mg (an increase of 4 mg to the current daily dose). The trough concentration should then be assessed 1 to 2 weeks after this change in dose.

Long-term dose monitoring.

For patients with TSC who have SEGA, evaluate SEGA volume approximately 3 months after commencing Afinitor therapy, with subsequent dose adjustments taking into consideration changes in SEGA volume, corresponding trough concentration, and tolerability (see Section 5 Pharmacological Properties).
For patients with TSC who have SEGA and patients with TSC and seizures, once a stable desired dose is attained, monitor trough concentrations every 3 to 6 months in patients with changing body surface area or every 6 to 12 months in patients with stable body surface area for the duration of treatment.

Dose modifications due to adverse drug reactions.

Management of severe or intolerable adverse drug reactions (ADRs) may require temporary dose interruption (with or without dose reduction) or discontinuation of Afinitor therapy (see Section 4.4 Special Warnings and Precautions for Use). If dose reduction is required, the suggested dose is approximately 50% lower than the daily dose previously administered. For dose reductions below the lowest available tablet strength, alternate day dosing should be considered.
Table 2 summarizes recommendations for dose interruption, reduction, or discontinuation of Afinitor in the management of ADRs. General management recommendations are also provided as applicable. Clinical judgment of the treating physician should guide the management plan of each patient based on individual benefit/risk assessment.
Moderate CYP3A4 or Pgp inhibitors. Use caution when administering Afinitor in combination with moderate CYP3A4 or Pgp inhibitors. If patients require co-administration of a moderate CYP3A4 or Pgp inhibitor, reduce the Afinitor daily dose by approximately 50%. Further dose reduction may be required to manage adverse drug reactions. For dose reductions below the lowest available strength, alternate day dosing should be considered (see Section 4.4 Special Warnings and Precautions for Use).

Hormone receptor-positive advanced breast cancer, advanced neuroendocrine tumours, advanced renal cell carcinoma, and TSC with renal angiomyolipoma.

If the moderate CYP3A4/PgP inhibitor is discontinued, consider a washout period of at least 2 to 3 days (average for most commonly used moderate inhibitors) before the Afinitor dose is increased. The Afinitor dose should be returned to the dose used prior to initiation of the moderate CYP3A4/PgP inhibitor (see Section 4.4 Special Warnings and Precautions for Use).

TSC with SEGA.

Everolimus trough concentrations should be assessed approximately 1 to 2 weeks after the addition of a moderate CYP3A4 or PgP inhibitor. If the inhibitor is discontinued the Afinitor dose should be returned to the dose used prior to initiation of the inhibitor and the everolimus trough concentration should be re-assessed approximately 2 weeks later (see Section 4.4 Special Warnings and Precautions for Use; Section 4.2 Dose and Method of Administration, Therapeutic drug monitoring).
Strong CYP3A4 inducers. Avoid the use of concomitant strong CYP3A4 inducers.

Hormone receptor-positive advanced breast cancer, advanced neuroendocrine tumours, advanced renal cell carcinoma, and TSC with renal angiomyolipoma.

If patients require coadministration of a strong CYP3A4 inducer, consider doubling the daily dose of Afinitor (based on pharmacokinetic data), using increments of 5 mg or less. This dose of Afinitor is predicted to adjust the AUC to the range observed without inducers. However, there are no clinical data with this dose adjustment in patients receiving strong CYP3A4 inducers. If the strong inducer is discontinued, consider a washout period of at least 3 to 5 days (reasonable time for significant enzyme deinduction), before the Afinitor dose is returned to the dose used prior to initiation of the strong CYP3A4 inducer (see Section 4.4 Special Warnings and Precautions for Use).

TSC with SEGA and TSC with refractory seizures.

Patients with SEGA receiving concomitant strong CYP3A4 inducers (e.g. the enzyme inducing antiepileptic drugs carbamazepine, phenobarbital (phenobarbitone), and phenytoin) at the start of treatment may require an increased Afinitor dose to attain trough concentrations of 3 to 15 nanogram/mL. Double the daily dose of Afinitor and assess tolerability. Assess the everolimus trough level approximately two weeks after doubling the dose. Further adjust the dose by increments of 1 to 4 mg as necessary to maintain the target trough concentration.
Patients with seizures receiving concomitant strong CYP3A4 inducers (e.g. enzyme inducing antiepileptic drugs carbamazepine, phenobarbital (phenobarbitone), and phenytoin) require an increased starting dose to attain trough concentrations of 5 to 15 nanogram/mL (see recommendations outlined in Table 1). Further adjust the dose by increments of 1 to 4 mg as necessary to maintain the target trough concentration.
The addition of another concomitant strong CYP3A4 inducer may not require additional dose adjustment. Assess the everolimus trough level two weeks after initiating the additional inducer. Adjust the dose in 1 to 4 mg increments as necessary to maintain the target trough concentration.
Discontinuation of one of multiple strong CYP3A4 inducers may not require additional dose adjustment. Assess the everolimus trough level two weeks after discontinuation of one of multiple strong CYP3A4 inducers. If all strong inducer are discontinued, consider a washout period of at least 3 to 5 days (reasonable time for significant enzyme de-induction) before the Afinitor dose is returned to the dose used prior to initiation of the strong CYP3A4 inducer. Assess the everolimus trough concentration approximately two weeks later (see Section 4.2 Dose and Method of Administration, Therapeutic drug monitoring; Section 4.4 Special Warnings and Precautions for Use; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

Therapeutic drug monitoring.

Therapeutic drug monitoring of everolimus blood concentrations is required for patients treated for TSC with SEGA or refractory seizures using a validated bioanalytical LC/MS method. When possible, use the same assay and laboratory for therapeutic drug monitoring throughout treatment.
Trough concentrations should be assessed approximately 1 to 2 weeks after the initial dose, after any change in dosage form, after an initiation or change in co-administration of CYP3A4/Pgp inhibitors (see Section 4.4 Special Warnings and Precautions for Use) or after any change in hepatic (Child-Pugh) status. Trough concentrations should be assessed approximately 2 weeks after initiation or change in co-administration of CYP3A4/Pgp inducers (see Section 4.4 Special Warnings and Precautions for Use; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions). Dosing should be titrated with the objective of attaining everolimus trough concentrations of 3 to 15 nanogram/mL for patients with TSC who have SEGA and 5 to 15 nanogram/mL for patients with TSC and refractory seizures, subject to tolerability (see Section 5.2 Pharmacokinetic Properties). The dose may be increased to attain a higher trough concentration within the target range to obtain optimal efficacy, subject to tolerability.

Special populations.

Paediatric population. Afinitor is not recommended for use in paediatric cancer patients.
Afinitor is not recommended for use in paediatric patients with TSC who have renal angiomyolipoma.
Afinitor has not been studied in paediatric patients < 1 year of age with TSC who have SEGA.
Afinitor has not been studied in paediatric patients < 2 years of age with TSC and refractory seizures.
Dosing recommendations for paediatric patients with TSC who have SEGA are consistent with those for the corresponding adult population with the exception of those patients with hepatic impairment.
Dosing recommendations for paediatric patients with TSC and refractory seizures are consistent with those for the corresponding adult population with the exception of the starting dose for patients < 6 years of age.
Afinitor is not recommended for patients < 18 years of age with hepatic impairment and TSC with SEGA or TSC with seizures.
Elderly patients (65 years of age or older). No dosage adjustment is required (see Section 5.2 Pharmacokinetic Properties).
Renal impairment. No dosage adjustment is required (see Section 5.2 Pharmacokinetic Properties).
Hepatic impairment.

Hormone receptor positive advanced breast cancer, advanced neuroendocrine tumours and, advanced renal cell carcinoma, and TSC with renal angiomyolipoma.

Mild hepatic impairment (Child-Pugh A): the recommended dose is 7.5 mg daily.
Moderate hepatic impairment (Child-Pugh B): the recommended dose is 2.5 mg daily.
Severe hepatic impairment (Child-Pugh C): not recommended. If the desired benefit outweighs the risk, a dose of 2.5 mg daily must not be exceeded.
Dose adjustments should be made if a patient's hepatic (Child-Pugh) status changes during treatment.

TSC with SEGA and TSC with refractory seizures.

Patients ≥ 18 years of age. Mild hepatic impairment (Child-Pugh A): 75% of the dose calculated based on BSA (rounded to the nearest strength).
Moderate hepatic impairment (Child-Pugh B): 25% of the dose calculated based on BSA (rounded to the nearest strength).
Severe hepatic impairment (Child-Pugh C): not recommended. If the desired benefit outweighs the risk, 25% of the dose calculated based on BSA (rounded to the nearest strength) must not be exceeded.
Everolimus whole blood trough concentrations should be assessed approximately 1 to 2 weeks after commencing treatment or after any change in hepatic (Child-Pugh) status. For patients with SEGA, dosing should be titrated to attain trough concentrations of 3 to 15 nanogram/mL (see Section 4.2 Dose and Method of Administration, Therapeutic drug monitoring).
For patients with seizures, dosing should be titrated to attain trough concentrations of 5 to 15 nanogram/mL (see Section 4.2 Dose and Method of Administration, Therapeutic drug monitoring). Dose adjustments should be made if a patient's hepatic (Child-Pugh) status changes during treatment (see Section 5.2 Pharmacokinetic Properties).
Patients < 18 years of age. Afinitor is not recommended for patients < 18 years of age with TSC with SEGA or seizures and hepatic impairment.

4.3 Contraindications

Afinitor is contraindicated in patients with hypersensitivity to the active substance, to other rapamycin derivatives or to any of the excipients (see Section 4.4 Special Warnings and Precautions for Use).

4.4 Special Warnings and Precautions for Use

Non-infectious pneumonitis.

Non-infectious pneumonitis is a class effect of rapamycin derivatives. Cases of non-infectious pneumonitis (including interstitial lung disease) have also been described in patients taking Afinitor (see Section 4.8 Adverse Effects (Undesirable Effects)). Some of these have been severe and on rare occasions, a fatal outcome was observed. A diagnosis of non-infectious pneumonitis should be considered in patients presenting with non-specific respiratory signs and symptoms such as hypoxia, pleural effusion, cough or dyspnoea, and in whom infectious, neoplastic and other non-medicinal causes have been excluded by means of appropriate investigations. Opportunistic infections such as Pneumocystis jirovecii pneumonia (PJP) should be ruled out in the differential diagnosis of noninfectious pneumonitis (see Section 4.4 Special Warnings and Precautions for Use, Infections).
Patients should be advised to report promptly any new or worsening respiratory symptoms.
Patients who develop radiological changes suggestive of non-infectious pneumonitis and have few or no symptoms may continue Afinitor therapy without dose alteration. If symptoms are moderate (grade 2), consideration should be given to interruption of therapy until symptoms improve. The use of corticosteroids may be indicated:
In patients with hormone receptor-positive advanced breast cancer, advanced neuroendocrine tumours or advanced renal cell carcinoma, Afinitor may be reintroduced at 5 mg daily.
In patients with SEGA, Afinitor may be reintroduced at a daily dose approximately 50% lower than the dose previously administered.
For cases where symptoms of non-infectious pneumonitis are severe (grade 3 or 4), Afinitor therapy should be discontinued and the use of corticosteroids may be indicated until clinical symptoms resolve. For cases of grade 3 non-infectious pneumonitis:
In patients with hormone receptor-positive advanced breast cancer, advanced neuroendocrine tumours or advanced renal cell carcinoma, therapy with Afinitor may be reinitiated at a reduced dose of 5 mg daily depending on the individual clinical circumstances.
In patients with SEGA, therapy with Afinitor may be re-initiated at a daily dose approximately 50% lower than the dose previously administered depending on the individual clinical circumstances.
For patients who require use of corticosteroids for treatment of non-infectious pneumonitis, prophylaxis for Pneumocystis jirovecii pneumonia (PJP) may be considered. The development of pneumonitis has also been reported at a reduced dose (see Section 4.2 Dose and Method of Administration).

Infections.

Afinitor has immunosuppressive properties and may predispose patients to bacterial, fungal, viral or protozoan infections, including infections with opportunistic pathogens (see Section 4.8 Adverse Effects (Undesirable Effects)). Localised and systemic infections, including pneumonia, other bacterial infections, invasive fungal infections, such as aspergillosis, candidiasis or Pneumocystis jirovecii pneumonia (PJP) and viral infections including reactivation of hepatitis B virus, have been described in patients taking Afinitor. Some of these infections have been severe (e.g. leading to sepsis including septic shock, respiratory or hepatic failure) and occasionally have had a fatal outcome in adult and paediatric patients (see Section 4.8 Adverse Effects (Undesirable Effects)). Physicians and patients should be aware of the increased risk of infection with Afinitor. Pre-existing infections should be treated appropriately and should have resolved fully before starting treatment with Afinitor. While taking Afinitor, be vigilant for symptoms and signs of infection; if a diagnosis of infection is made, institute appropriate treatment promptly and consider interruption or discontinuation of Afinitor.
If a diagnosis of invasive systemic fungal infection is made, Afinitor should be promptly and permanently discontinued and the patient treated with appropriate antifungal therapy.
Cases of Pneumocystis jirovecii pneumonia (PJP), some with fatal outcome, have been reported in patients who received everolimus. PJP may be associated with concomitant use of corticosteroids or other immunosuppressive agents. Prophylaxis for PJP should be considered when concomitant use of corticosteroids or other immunosuppressive agents are required.

Impaired wound healing.

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

Radiation therapy complications.

Severe radiation reactions (including radiation esophagitis, radiation pneumonitis and radiation skin injury) have been reported when everolimus was used during, or shortly after radiation therapy. Caution should therefore be exercised for patients using everolimus in close temporal relationship with radiation therapy.
Additionally, radiation recall syndrome has been reported in patients on everolimus who have received prior radiotherapy.

Hypersensitivity.

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

Angioedema with concomitant use of angiotensin-converting enzyme (ACE) inhibitors.

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

Stomatitis.

Stomatitis, including mouth ulceration, and oral mucositis is the most commonly reported adverse drug reaction in patients treated with Afinitor (see Section 4.8 Adverse Effects (Undesirable Effects)). Stomatitis mostly occurs within the first 8 weeks of treatment. If stomatitis occurs, topical treatments are recommended, but alcohol, hydrogen peroxide-, iodine-, or thyme-containing products should be avoided as they may exacerbate the condition (see Section 4.2 Dose and Method of Administration). Antifungal agents should not be used unless fungal infection has been diagnosed (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).
In a single arm study in 92 postmenopausal breast cancer patients, a topical alcohol-free corticosteroid oral solution was administered as a mouthwash during the initial 8 weeks of starting treatment with Afinitor plus exemestane. In this study, a clinically meaningful reduction in the incidence and severity of stomatitis was observed (see Section 4.8 Adverse Effects (Undesirable Effects)).
The study used topical treatment with dexamethasone 0.5 mg/5 mL alcohol-free oral solution (10 mL swished in the mouth for 2 minutes and then spat out, to be repeated 4 times daily for 8 weeks). No food or drink was to be consumed for at least 1 hour after swishing and spitting the dexamethasone oral solution.

Ethnicity.

In Asian patients, with NETs, the reported adverse events of hypertension were 1.95-fold higher (17.6% vs. 9.0%), of pneumonitis 1.88-fold higher (13.2% vs. 7.0%), and of hyperglycaemia 1.59-fold higher (29.4% vs. 18.4%) than in Caucasian patients.

Renal failure events.

Cases of renal failure (including acute renal failure), some with a fatal outcome, have been observed in patients treated with Afinitor. Renal function of patients should be monitored particularly where patients have additional risk factors that may further impair renal function (see Section 4.8 Adverse Effects (Undesirable Effects); Section 4.4 Special Warnings and Precautions for Use, Effects on laboratory tests; Section 4.2 Dose and Method of Administration, Therapeutic drug monitoring).

Functional carcinoid tumours.

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

Prognostic factors in neuroendocrine tumours of gastrointestinal or lung origin.

In patients with non-functional gastrointestinal or lung neuroendocrine tumours and good prognostic baseline factors, e.g. ileum as primary tumour origin and normal chromogranin A values or without bone involvement, an individual benefit-risk assessment should be performed prior to the start of Afinitor therapy. In the subgroup of patients with ileum as primary tumour origin, PFS benefit was uncertain (see Section 5.1 Pharmacodynamic Properties, Clinical trials, RADIANT-4, Figure 6).

Use in hepatic impairment.

Exposure to everolimus was increased in patients with mild (Child-Pugh A), moderate (Child-Pugh B), and severe (Child-Pugh C) hepatic impairment (see Section 4.2 Dose and Method of Administration; Section 4.4 Special Warnings and Precautions for Use).
Afinitor is not recommended for use in patients ≥ 18 years of age with severe hepatic impairment (Child-Pugh C) unless the potential benefit outweighs the risk (see Section 4.2 Dose and Method of Administration; Section 5.2 Pharmacokinetic Properties).
Afinitor is not recommended for use in patients < 18 years of age with TSC who have SEGA or refractory seizures and concomitant hepatic impairment (Child-Pugh A, B or C) (see Section 4.2 Dose and Method of Administration; Section 5 Pharmacological Properties).

Use in the elderly.

In patients over 65 years, with NETs, the reported incidences of dehydration, hypomagnesaemia and pneumonitis was more than 1.4 fold higher than for patients 65 years or younger.

Paediatric use.

There is no indication for use of Afinitor in the paediatric cancer population (see Section 4.2 Dose and Method of Administration) or in paediatric patients with TSC who have renal angiomyolipoma.
Afinitor has not been studied in paediatric patients < 1 year of age with TSC who have SEGA.
Afinitor has not been studied in paediatric patients < 2 years of age with TSC and refractory seizures.
Dosing recommendations for paediatric patients with TSC who have SEGA are consistent with those for the corresponding adult population with the exception of those patients with hepatic impairment.
Afinitor is not recommended for patients < 18 years of age with hepatic impairment and TSC with SEGA or TSC with seizures.
The starting dose for paediatric patients < 6 years of age with TSC and refractory seizures is slightly higher than for adults (see Section 4.2 Dose and Method of Administration).

Effects on laboratory tests.

Renal function.

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

Blood glucose.

Hyperglycaemia has been reported in patients taking Afinitor (see Section 4.8 Adverse Effects (Undesirable Effects)). Monitoring of fasting serum glucose is recommended prior to the start of Afinitor therapy and periodically thereafter. More frequent monitoring is recommended when Afinitor is co-administered with other drugs that may induce hyperglycaemia. The appropriate optimal glycaemic control must be achieved before starting a patient on Afinitor.
Octreotide has been associated with a rise in blood glucose which may increase the hyperglycaemic effect of everolimus.

Blood lipids.

Dyslipidemia (including hypercholesterolemia and hypertriglyceridemia) has been reported in patients taking Afinitor. Monitoring of blood cholesterol and triglycerides prior to the start of Afinitor therapy and periodically thereafter as well as management with appropriate medical therapy is recommended.

Haematological parameters.

Decreased haemoglobin, lymphocytes, neutrophils and platelets have been reported in patients treated with Afinitor (see Section 4.8 Adverse Effects (Undesirable Effects)). Monitoring of complete blood count is recommended prior to the start of Afinitor therapy and periodically thereafter.

4.5 Interactions with Other Medicines and Other Forms of Interactions

Everolimus is a substrate of CYP3A4, and also a substrate and moderate inhibitor of the multidrug efflux pump P-glycoprotein (Pgp). Therefore, absorption and subsequent elimination of everolimus may be influenced by products that affect CYP3A4 and/or Pgp.
In vitro, everolimus is a competitive inhibitor of CYP3A4 and a mixed inhibitor of CYP2D6.

Agents that may increase everolimus blood concentrations.

Everolimus blood concentrations may be increased by substances that inhibit CYP3A4 activity and thus decrease everolimus metabolism.
Everolimus blood concentrations may be increased by inhibitors of Pgp that may decrease the efflux of everolimus from intestinal cells.

Moderate CYP3A4 or Pgp inhibitors.

Concomitant treatment with moderate inhibitors of CYP3A4 including but not limited to erythromycin, verapamil, ciclosporin, fluconazole, diltiazem, amprenavir, fosamprenavir, aprepitant, or posaconazole and Pgp requires caution. If Afinitor must be co-administered with a moderate CYP3A4 or Pgp inhibitor, the patient should be carefully monitored for undesirable effects and the dose reduced if necessary (see Section 4.2 Dose and Method of Administration).
There was an increase in exposure to everolimus in healthy subjects when everolimus was coadministered with:
erythromycin (a moderate CYP3A4 inhibitor and a Pgp inhibitor; Cmax and AUC increased by 2.0 and 4.4-fold, respectively);
verapamil (a moderate CYP3A4 inhibitor and a Pgp inhibitor; Cmax and AUC increased by 2.3 and 3.5-fold, respectively);
ciclosporin (a CYP3A4 substrate and a Pgp inhibitor; Cmax and AUC increased by 1.8 and 2.7-fold, respectively).
Other moderate inhibitors of CYP3A4 and Pgp that may increase everolimus blood concentrations include certain antifungal agents (e.g. fluconazole) and calcium channel blockers (e.g. diltiazem).
Co-administration of cannabidiol with the P-glycoprotein and CYP3A4 substrate everolimus in a healthy volunteer study led to an increase in everolimus exposure of approximately 2.5-fold for both Cmax and AUC. Everolimus and cannabidiol should be co-administered with caution, closely monitoring for side effects. Monitor everolimus whole blood trough concentrations and reduce the everolimus dose as necessary.
Grapefruit, grapefruit juice, star fruit, Seville oranges and other foods that are known to affect cytochrome P450 and Pgp activity should be avoided during treatment.

Strong CYP3A4 or Pgp inhibitors.

Concurrent treatment with strong inhibitors of CYP3A4 or Pgp (including but not limited to ketoconazole, itraconazole, ritonavir and clarithromycin) should be avoided.
There was a significant increase in exposure to everolimus (Cmax and AUC increased by 3.9- and 15.0-fold, respectively) in healthy subjects when everolimus was co-administered with ketoconazole (a strong CYP3A4 inhibitor and Pgp inhibitor). An interaction with topically administered ketoconazole cannot be excluded.

Agents that may decrease everolimus blood concentrations.

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

Strong CYP3A4 inducers.

Concurrent treatment with strong inducers of CYP3A4 or Pgp should be avoided (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions). If Afinitor must be co-administered with a strong CYP3A4 or Pgp inducer (e.g. rifampicin and rifabutin), the patient should be carefully monitored for clinical response. Consider a dose increase of Afinitor when co-administered with strong inducers of CYP3A4 or Pgp if alternative treatment is not possible (see Section 4.2 Dose and Method of Administration).
Exercise caution when Afinitor is taken in combination with orally administered CYP3A4 substrates with a narrow therapeutic index due to the potential for drug interactions. If Afinitor is taken with orally administered CYP3A4 substrates with a narrow therapeutic index, the patient should be monitored for undesirable effects described in the product information of the orally administered CYP3A4 substrate.
Pre-treatment of healthy subjects with multiple doses of rifampicin (a CYP3A4 and Pgp inducer) 600 mg daily for 8 days followed by a single dose of everolimus, increased everolimus oral dose clearance nearly 3-fold and decreased Cmax by 58% and AUC by 63%.
Other strong inducers of CYP3A4 that may increase the metabolism of everolimus and decrease everolimus blood levels include St. John's wort (Hypericum perforatum), corticosteroids (e.g. dexamethasone, prednisone, prednisolone), anticonvulsants (e.g. carbamazepine, phenobarbital (phenobarbitone), phenytoin), and anti HIV agents (e.g. efavirenz, nevirapine).

Agents whose plasma concentration may be altered by everolimus.

Studies in healthy subjects indicate that there are no clinically significant pharmacokinetic interactions between Afinitor and the HMG-CoA reductase inhibitors atorvastatin (a CYP3A4 substrate) and pravastatin (a non-CYP3A4 substrate) and population pharmacokinetic analyses also detected no influence of simvastatin (a CYP3A4 substrate) on the clearance of Afinitor.
In vitro, everolimus competitively inhibited the metabolism of the CYP3A4 substrate ciclosporin and was a mixed inhibitor of the CYP2D6 substrate dextromethorphan. The mean steady-state of everolimus Cmax with an oral dose of 10 mg daily or 70 mg weekly is more than 12- to 36-fold below the Ki-values of the in vitro inhibition. An effect of everolimus on the metabolism of CYP3A4 and CYP2D6 substrates was therefore considered to be unlikely.
A study in healthy subjects demonstrated that co-administration of an oral dose of midazolam with everolimus resulted in a 25% increase in midazolam Cmax and a 30% increase in midazolam AUC(0-inf), whereas the metabolic AUC(0-inf) ratio (1-hydroxy-midazolam/midazolam) and the terminal t1/2 of midazolam were not affected. This suggests that increased exposure to midazolam is due to effects of everolimus in the gastrointestinal system when both drugs are taken at the same time. Therefore, everolimus may affect the bioavailability of orally co-administered drugs which are CYP3A4 substrates. Everolimus is unlikely to affect the exposure of other CYP3A4 substrate drugs which are administered by non-oral routes such as intravenous, subcutaneous, and transdermal administrations.
Everolimus increased pre-dose concentrations of the antiepileptic drugs (AEDs) carbamazepine, clobazam, and the clobazam metabolite N-desmethylclobazam by about 10%. The increase in the pre-dose concentrations of these AEDs may not be clinically significant but dose adjustments for AEDs with a narrow therapeutic index, e.g. carbamazepine, may be considered. Everolimus had no impact on pre-dose concentrations of AEDs that are substrates of CYP3A4 (clonazepam and zonisamide). Everolimus had no impact on the pre-dose concentration of other AEDs, including valproic acid, topiramate, oxcarbazepine, phenobarbital (phenobarbitone) and phenytoin.
Co-administration of everolimus and exemestane increased exemestane Cmin and C2h by 45% and 71%, respectively. However, the corresponding estradiol levels at steady state (4 weeks) were not different between the two treatment arms. No increase in adverse events related to exemestane was observed in patients with hormone receptor-positive advanced breast cancer receiving the combination. The increase in exemestane levels is unlikely to have an impact on efficacy or safety.

Vaccinations.

Immunosuppressants may affect the response to vaccination and vaccination during treatment with Afinitor may therefore be less effective. The use of live vaccines should be avoided during treatment with Afinitor. Examples of live vaccines are: intranasal influenza, measles, mumps, rubella, oral polio, BCG, yellow fever, varicella, and TY21a typhoid vaccines. For paediatric patients with TSC who have SEGA or seizures and that do not require immediate treatment, complete the recommended childhood series of live virus vaccinations prior to the start of therapy according to local treatment guidelines.

Lactose.

Patients with rare hereditary problems of galactose intolerance, Lapp lactose deficiency or glucose-galactose malabsorption should not take this medicinal product.

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

Based on non-clinical findings, male and female fertility may be compromised by treatment with Afinitor.

Animal data.

Testicular atrophy was observed in all animal species tested (mouse, rat, minipigs and monkey) at drug exposures similar to the expected clinical exposure (blood AUC). Everolimus completely impaired male rat fertility at an everolimus dose that resulted in a drug exposure (blood AUC) that was slightly below1 the expected maximum human value. Testicular morphology was affected at 0.5 mg/kg and above, and sperm motility, sperm head count, and plasma testosterone levels were diminished at 5 mg/kg, which is within the range of therapeutic exposure (52 nanogram.hr/mL and 414 nanogram.hr/mL respectively compared to 560 nanogram.hr/mL human exposure at 10 mg/day) and which caused a reduction in male fertility. There was evidence for partial recovery of fertility over a period approximately equivalent to the treatment period. In animal reproductive studies female fertility was not affected. However, oral doses of everolimus in female rats at ≥ 0.1 mg/kg (approximately 4% the AUC0-24h in patients receiving the 10 mg daily dose) resulted in increased incidence of pre-implantation loss.
1At high dose (5 mg/kg/day), AUC0-24 hr = 414.8 nanogram.hr/mL vs human AUC = 560 at 10 mg/day.

Human data.

Both male and female fertility may be compromised by treatment with everolimus.
Menstrual irregularities, secondary amenorrhea and associated luteinizing hormone (LH)/follicle stimulating hormone (FSH) imbalance have been observed in female patients receiving everolimus. Blood levels of FSH and LH increased, blood levels of testosterone decreased, and azoospermia have been observed in male patients receiving everolimus.
(Category C)

Risk summary.

There are no adequate data from the use of everolimus in pregnant women and the potential risk to the fetus is unknown.
Afinitor should not be given to pregnant women unless the potential benefit outweighs the potential risk to the fetus.

Animal data.

Oral doses of everolimus in female rats at ≥ 0.1 mg/kg (approximately 4% the AUC0-24h in patients receiving the 10 mg daily dose) resulted in increased incidence of pre-implantation loss. Everolimus crossed the placenta and was toxic to the conceptus. In rats, everolimus caused embryo/feto-toxicity at systemic exposure below the therapeutic level. This was manifested as mortality and reduced fetal weight. The incidence of skeletal variations and malformations (e.g. sternal cleft) was increased at 0.3 and 0.9 mg/kg. In rabbits, embryotoxicity was evident as an increase in late resorptions that occurred at an oral dose of 0.8 mg/kg (approximately 45% of the AUC0-24h in patients receiving the 10 mg daily dose). In rats, there was no evidence of adverse effects by treating males with everolimus on embryo-fetal parameters.

Human data.

There have been reports of exposure to everolimus during pregnancy, some due to exposure via the mother and some via the father (pregnancy in a female partner of a male patient while under treatment with everolimus). There were no reports of congenital abnormalities.
 It is not known whether everolimus is transferred in human breast milk. There are no reported cases of exposure to everolimus during breast-feeding in humans. However, in animal studies, everolimus and/or its metabolites readily passed into the milk of lactating rats at a concentration 3.5 times higher than in maternal serum based on AUC. Women taking Afinitor should not breast-feed during treatment and for 2 weeks after the last dose.

Females and males of reproductive potential.

Contraception.

Females of reproductive potential should be advised that animal studies have been performed showing Afinitor to be harmful to the developing fetus. Sexually-active females of reproductive potential should use effective contraception (one that results in an annual pregnancy rate < 1% when used correctly) while receiving Afinitor, and for up to 8 weeks after ending treatment. Male patients taking Afinitor should not be prohibited from attempting to father children.

4.7 Effects on Ability to Drive and Use Machines

The effects of this medicine on a person's ability to drive and use machines were not assessed as part of its registration. However, adverse effects of this medicine include fatigue, asthenia and insomnia which could affect the ability to drive or use machines (see Section 4.8 Adverse Effects (Undesirable Effects)).

4.8 Adverse Effects (Undesirable Effects)

Reporting suspected adverse effects.

Reporting suspected adverse reactions after registration 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 at www.tga.gov.au/reporting-problems.

Oncology - summary of the safety profile.

Adverse drug reaction (ADR, suspected to be related to treatment by the investigator) information is based on pooled safety data in patients receiving Afinitor (N = 2672) in randomised, double-blind, placebo or active comparator controlled phase-III and phase-II studies related to the trials which serve as the basis for the approved indications in oncology (see Section 4.1 Therapeutic Indications).
The most common adverse reactions (incidence ≥ 1/10 and suspected to be related to treatment by the investigator) from the pooled safety data of the double-blind treatment portion of each of the phase-III, controlled studies were (in decreasing order): stomatitis, rash, fatigue, diarrhoea, infections, nausea, decreased appetite, anaemia, dysgeusia, pneumonitis, oedema peripheral, hyperglycaemia, asthenia, pruritus, weight decreased, hypercholesterolaemia, epistaxis, vomiting, cough, headache.
The most common grade 3-4 ADRs (incidence ≥ 1/100 to < 1/10 and suspected to be related to treatment by the investigator) were stomatitis, anaemia, hyperglycaemia, fatigue, infections, pneumonitis, diarrhoea, asthenia, thrombocytopenia, neutropenia, dyspnoea, lymphopenia, proteinuria, haemorrhage, hypophosphataemia, rash, hypertension, aspartate aminotransferase (AST) increased, alanine aminotransferase (ALT) increased, pneumonia and diabetes mellitus.

Tabulated summary of adverse drug reactions from clinical trials in oncology.

Table 3 presents the frequency category of ADRs reported in the pooled safety analysis from the double-blind treatment phase of each of the phase-III, controlled studies noted above.
ADRs are listed according to MedDRA system organ class. Within each system organ class, the ADRs are ranked by frequency, with the most frequent reactions first. Within each frequency grouping, ADRs are presented in order of decreasing frequency. In addition, the corresponding frequency category using the following convention (CIOMS III): 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).
Clinically relevant laboratory abnormalities. In the pooled double blind phase III safety database, the following new or worsening clinically relevant laboratory abnormalities were reported with an incidence of ≥ 1/10 (very common, listed in decreasing frequency):

Haematology.

Haemoglobin decreased, lymphocytes decreased, white blood cells decreased, platelets decreased, and neutrophils decreased (or collectively as pancytopenia).

Clinical chemistry.

Glucose (fasting) increased, cholesterol increased, triglycerides increased, AST increased, phosphate decreased, ALT increased, creatinine increased, potassium decreased and albumin decreased.
Most of the observed abnormalities (≥ 1/100) were mild (grade 1) or moderate (grade 2). Grade 3/4 haematology and chemistry abnormalities include:

Haematology.

Lymphocytes decreased, haemoglobin decreased (very common), neutrophils decreased, platelet count decreased, white blood cells decreased (all common).

Clinical chemistry.

Glucose (fasting) increased (very common); phosphate decreased, potassium decreased, AST increased, ALT increased, creatinine increased, cholesterol (total) increased, triglycerides increased, albumin decreased (all common).

Tuberous sclerosis complex (TSC), summary of the safety profile.

Adverse events (irrespective of causality) presented in Table 4 are based on pooled data from patients with TSC receiving Afinitor (N = 404) or placebo (N = 197) in the double-blind treatment phase of the three phase-III, controlled studies (see Section 4.1 Therapeutic Indications). Table 4 presents the most frequent adverse events (incidence ≥ 1/10) from this pooled safety data.
Adverse drug reaction (ADR, assessed as related to treatment by the sponsor) information is based on pooled data from the 3 controlled studies mentioned above but including cumulative data (N = 608, including 408 patients < 18 years of age) from the double-blind plus open-label treatment phases and in addition from one non-randomised, open-label, single-arm phase II study (see Section 4.1 Therapeutic Indications; Table 5):
The most frequent ADRs (incidence ≥ 1/10, assessed as related to treatment by the sponsor) from the pooled safety database are (in decreasing order): stomatitis, pyrexia, nasopharyngitis, diarrhoea, upper respiratory tract infection, vomiting, cough, rash, headache, amenorrhea, acne, pneumonia, urinary tract infection, sinusitis, menstruation irregular, pharyngitis, decreased appetite, fatigue, hypercholesterolemia and hypertension.
The most frequent grade 3/4 adverse reactions (incidence ≥ 1/100 to < 1/10 suspected to be related to treatment by the sponsor) were pneumonia, stomatitis, amenorrhea, neutropenia, pyrexia, menstruation irregular, hypophosphataemia, diarrhoea and cellulitis.

Tabulated summary of adverse drug reactions from clinical trials in TSC.

Table 6 shows the incidence of ADRs based on pooled data in patients receiving everolimus in the TSC studies (including both the double-blind and open-label study and extension periods) covering a median duration of exposure of 18.25 months (with up to 47.1 months in the TSC-SEGA and TSC-Renal angiomyolipoma studies). ADRs are listed according to MedDRA system organ class. 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, ADRs are presented in order of decreasing frequency.
Clinically relevant laboratory abnormalities. In the pooled TSC safety database the following new or worsening clinically relevant laboratory abnormalities reported with an incidence of ≥ 1/10 (very common, listed in decreasing frequency):

Haematology.

Partial thromboplastin time increased, neutrophils decreased, haemoglobin decreased, white blood cells decreased, platelet count decreased, and lymphocytes decreased.

Clinical chemistry.

Cholesterol increased, triglycerides increased, AST increased, ALT increased, phosphate decreased, alkaline phosphatase increased and glucose (fasting) increased.
Most of the laboratory abnormalities were mild (grade 1) or moderate (grade 2). Grade 3/4 haematology and chemistry abnormalities included:

Haematology.

Neutrophils decreased, partial thromboplastin time increased, haemoglobin decreased, (common); lymphocytes decreased, platelet count decreased and white blood cells decreased (uncommon).

Clinical chemistry.

Phosphate decreased, triglycerides increased, alkaline phosphatase increased, ALT increased, AST increased, cholesterol increased, (common); glucose (fasting) increased (uncommon).

Adverse reactions of special interest.

In clinical trials and post-marketing spontaneous reports, everolimus has been associated with serious cases of hepatitis B reactivation, including fatal outcome. Reactivation of infections is an expected event during periods of immunosuppression (see Section 4.4 Special Warnings and Precautions for Use).
In clinical trials and post-marketing spontaneous reports, everolimus has been associated with renal failure events (including fatal outcome) and proteinuria. Monitoring of renal function is recommended (see Section 4.4 Special Warnings and Precautions for Use).
In clinical trials and post-marketing spontaneous reports, everolimus has been associated with cases of amenorrhea (including secondary amenorrhea).
In clinical trials and post-marketing spontaneous reports, everolimus has been associated with Pneumocystis jirovecii pneumonia (PJP), some with fatal outcome (see Section 4.4 Special Warnings and Precautions for Use).
In clinical trials and post-marketing spontaneous reports, angioedema has been reported with and without concomitant use of ACE inhibitors (see Section 4.4 Special Warnings and Precautions for Use).
In a post-marketing single arm study in postmenopausal women with advanced hormone receptor-positive, HER2-negative breast cancer (N = 92), topical treatment with dexamethasone 0.5 mg/5 mL alcohol-free oral solution (10 mL swished in the mouth for 2 minutes and then spat out, to be repeated 4 times daily for 8 weeks) was administered as a mouthwash to patients at the time of initiating treatment with Afinitor (10 mg/day) plus exemestane (25 mg/day) to reduce the incidence and severity of stomatitis. No food or drink was to be consumed for at least 1 hour after swishing and spitting the dexamethasone oral solution. The incidence of grade ≥ 2 stomatitis at 8 weeks was 2.4% (n = 2/85 evaluable patients) which was lower than historically reported at 27.4% (n = 132/482) in the phase III study in this patient population (BOLERO-2). The incidence of grade 1 stomatitis was 18.8% (n = 16/85) and no grade 3 or 4 stomatitis were reported. The overall safety profile in this study was consistent with that established for everolimus in the oncology and TSC settings, with the exception of oral candidiasis which was reported in 2.2% (n = 2/92) of patients in this study compared to 0.2% (n = 1/482) of patients in BOLERO-2.

Special populations.

Paediatric patients (below 18 years).

The safety of Afinitor in paediatric patients with TSC who have SEGA was demonstrated in two clinical trials (EXIST-1 and Study CRAD001C2485) and in paediatric patients with TSC and refractory seizures in one clinical trial (EXIST-3).
The overall type, frequency and severity of ADRs across the age groups evaluated were similar, with the exception of infections, which were reported at a higher frequency and severity in patients below the age of 6 years. A total of 49 out of 137 patients (36%) < 6 years had Grade 3/4 infections, compared to 53 out of 272 patients (19%) 6 to < 18 years and 27 out of 203 patients (13%) ≥ 18 years. Two fatal cases due to infection were reported in patients < 18 years receiving everolimus.

Geriatric patients (65 years of age or older).

In the pooled oncology safety database, 37% of the Afinitor-treated patients were ≥ 65 years of age.
The number of oncology patients with an ADR leading to discontinuation of Afinitor was higher in patients ≥ 65 years of age (20% vs. 13%). The most common ADRs (≥ 1/100) leading to discontinuation were pneumonitis (including interstitial lung disease), stomatitis, fatigue, and dyspnoea.

Post-marketing experience.

The following adverse reactions have been identified during post approval use of Afinitor. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate frequency or establish a causal relationship to drug exposure.

Blood and lymphatic disorders.

Thrombotic microangiopathy.

Injury, poisoning and procedural complications.

Radiation recall syndrome.

4.9 Overdose

In animal studies, everolimus showed a low acute toxic potential. No lethality or severe toxicity was observed in either mice or rats given single oral doses of 2000 mg/kg (limit test).
Reported experience with overdose in humans is very limited. Single doses of up to 70 mg have been given with acceptable acute tolerability.
General supportive measures should be initiated in all cases of overdose.
For information on the management of overdose, contact the Poisons Information Centre on 13 11 26 (Australia).

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Mechanism of action.

Everolimus is an inhibitor targeting mTOR (mammalian target of rapamycin), or more specifically, mTORC1 (mammalian 'target of rapamycin' complex 1). It exerts its activity through high affinity interaction with the intracellular receptor protein FKBP12. The FKBP12/everolimus complex binds to mTORC1, inhibiting its signaling capacity. mTOR is a key serine-threonine kinase playing a central role in the regulation of cell growth, proliferation and survival. The regulation of mTORC1 signaling is complex, being modulated by mitogens, growth factors, energy and nutrient availability. mTORC1 is an essential regulator of global protein synthesis downstream on the PI3K/AKT pathway, which is dysregulated in the majority of human cancers as well as genetic diseases such as TSC.
mTORC1 signaling is effected through modulation of the phosphorylation of downstream effectors, the best characterized of which are the translational regulators S6 ribosomal protein kinase (S6K1) and eukaryotic initiation factor 4E-binding protein (4E-BP). Disruption of S6K1 and 4E-BP1 function, as a consequence of mTORC1 inhibition, interferes with the translation of mRNAs encoding pivotal proteins involved in cell cycle regulation, glycolysis and adaptation to low oxygen conditions (hypoxia). This inhibits tumour growth and expression of hypoxia-inducible factors (e.g. HIF-1 transcription factors); the latter resulting in reduced expression of factors involved in the potentiation of tumour angiogenic processes (e.g. the vascular endothelial growth factor (VEGF) in multiple tumours such as RCC and angiomyolipoma). Two primary regulators of mTORC1 signaling are the oncogene suppressors tuberin-sclerosis complexes 1 and 2 (TSC1, TSC2). Loss or inactivation of either TSC1 or TSC2 leads to elevated rheb-GTP levels, a ras family GTPase, which interacts with the mTORC1 complex to cause its activation. mTORC1 activation leads to a downstream kinase signaling cascade, including activation of the S6K1. A substrate of mTOR complex 1 (mTORC1), S6K1 phosphorylates the estrogen receptor, which is responsible for ligand-independent receptor activation.
Everolimus is an inhibitor of the growth and proliferation of tumour cells, endothelial cells, fibroblasts and blood vessel-associated smooth muscle cells. Consistent with the central regulatory role of mTORC1, everolimus has been shown to reduce tumour cell proliferation, glycolysis and angiogenesis in solid tumours in vivo, and thus provides two independent mechanisms for inhibiting tumour growth: direct antitumour cell activity and inhibition of the tumour stromal compartment.
Clinical trial results did not show an impact of Afinitor on growth and pubertal development.
Constitutive activation of the PI3K/Akt/mTOR pathway can contribute to endocrine resistance in breast cancer. In vitro studies show that oestrogen-dependent and HER2+ breast cancer cells are sensitive to the inhibitory effects of everolimus, and that combination of everolimus with Akt, HER2, or aromatase inhibitors synergistically enhances the anti-tumour effect of everolimus.
In tuberous sclerosis syndrome, a genetic disorder, inactivating mutations in either the TSC1 or the TSC2 gene lead to hamartoma formation throughout the body, including seizure and epileptogenesis. The mTOR regulates protein synthesis and multiple downstream cellular functions that may influence neuronal excitability and epileptogenesis. Overactivation of mTOR results in neuronal dysplasia, aberrant axonogenesis and dendrite formation, increased excitatory synaptic currents, reduced myelination, and disruption of the cortical laminar structure causing abnormalities in neuronal development and function. Preclinical studies in models of mTOR dysregulation in the brain demonstrated that treatment with an mTOR inhibitor such as everolimus could prolong survival, suppress seizures, prevent the development of new-onset seizures, and prevent premature death. In summary, everolimus is highly active in this neuronal model of TSC, with benefit apparently attributable to effects on mTORC1 inhibition.

Pharmacodynamic properties/exposure-response relationships.

There was a moderate correlation between the decrease in the phosphorylation of 4E-BP1 (P4E-BP1) in tumour tissue and the average everolimus Cmin at steady state in blood after daily administration of 5 or 10 mg everolimus. Further data suggest that the inhibition of phosphorylation of the S6 kinase is very sensitive to the mTOR inhibition by everolimus. Inhibition of phosphorylation of elF-4G was complete at all Cmin values after the 10 mg daily dose.
In patients with TSC who have SEGA, a model based analysis indicated that a 2-fold Cmin increase led to a 13% (95% CI: -18.2%, -7.5%) tumour size reduction from baseline, which was statistically significant at a 5% level.
In patients with TSC and refractory seizures, a conditional logistic regression analysis for the probability of seizure response vs. Time Normalized (TN)-Cmin stratified by age subgroup indicated that a 2-fold increase in TN-Cmin was associated with a 2.172-fold increase (95% CI: 1.339, 3.524) in the odds for a seizure response. Baseline seizure frequency was also a significant factor in the seizure response (with an odds ratio of 0.978 [95% CI: 0.959, 0.998]).

Clinical trials.

Hormone receptor positive advanced breast cancer. BOLERO-2 (Study CRAD001Y2301) a randomised, double-blind, multicentre phase III study of Afinitor + exemestane versus placebo + exemestane was conducted in postmenopausal women with oestrogen receptor-positive, HER 2-neu/non-amplified advanced breast cancer (ABC) with recurrence2 or progression3 following prior therapy with letrozole or anastrozole. A total of 724 patients were randomised in a 2:1 ratio to receive either Afinitor (10 mg daily) plus exemestane (25 mg daily) (n = 485) or placebo plus exemestane (25 mg daily) (n = 239). Randomisation was stratified by documented sensitivity to prior hormonal therapy (yes vs. no) and by the presence of visceral metastasis (yes vs. no). Sensitivity to prior hormonal therapy was defined as either (1) documented clinical benefit (complete response [CR], partial response [PR], stable disease ≥ 24 weeks) to at least one prior hormonal therapy in the advanced setting or (2) at least 24 months of adjuvant hormonal therapy prior to recurrence.
2Recurrence while on or within 12 months of end of adjuvant treatment with letrozole or anastrozole.
3Progression while on or within one month of the end of letrozole or anastrozole treatment for ABC.
The primary endpoint for the trial was progression-free survival (PFS) evaluated by Response Evaluation Criteria in Solid Tumours (RECIST), based on the investigators (local radiology) assessment. Supportive PFS analyses were based on an independent central radiology review.
Secondary endpoints included overall survival (OS), Overall Response Rate (ORR), Clinical Benefit Rate (CBR), Safety, change in Quality of Life (QoL) and time to ECOG PS deterioration. Additional endpoints included changes in bone turnover markers at 6 and 12 weeks.
The two treatment groups were generally balanced with respect to the baseline demographics of disease characteristics and history of prior anti-neoplastic usages. The median age of patients was 61 years (range 28 to 93) and 75% were Caucasian.
The median progression-free survival by investigator assessment at the time of the final PFS analysis was 7.8 months and 3.2 months in the Afinitor and placebo arms, respectively. Patients in the placebo + exemestane arm did not cross-over to Afinitor at the time of progression. The median duration of treatment was 29.5 weeks (range 1.0-123.3 weeks) for patients receiving Afinitor + exemestane and 14.1 weeks (range 1.0-101.0 weeks) for the placebo + exemestane group.
The study demonstrated a statistically significant increase in PFS with Afinitor + exemestane compared with placebo + exemestane based on the investigator assessment (see Table 7 and Figure 1). The independent assessment was supportive.
Overall Survival (OS) data are not mature at the time of the interim analysis and no statistically significant treatment-related difference in OS was noted [HR = 0.77 (95% CI: 0.57, 1.04)].
Nine-month PFS rates were 44% of patients receiving Afinitor + exemestane compared with 16% in the placebo + exemestane arm at a median follow-up of 17.7 months.
The estimated PFS treatment effect was supported by planned subgroup analysis of PFS per investigator assessment. For all analysed subgroups, a positive treatment effect was seen with Afinitor + exemestane with an estimated hazard ratio vs. placebo + exemestane ranging from 0.25 to 0.62 (see Figure 2 and Figure 3). Subgroup analyses demonstrated a homogeneous and consistent treatment effect irrespective of sensitivity to prior hormonal therapy and presence of visceral metastasis, and across major demographic and prognostic subgroups.
Clinically or statistically significant differences were not observed between the two treatment arms in terms of time to deterioration of ECOG PS (≥ 1 point) and median times to deterioration (≥ 5%) of QLQ-C30 domain scores.
Advanced neuroendocrine tumours of pancreatic origin. RADIANT-3 (Study CRAD001C2324), a randomised, double-blind, multicentre phase III study of Afinitor plus best supportive care (BSC) versus placebo plus BSC in patients with progressive, unresectable or metastatic, well or moderately differentiated pancreatic neuroendocrine tumours (pNET), demonstrated a statistically significant clinical benefit of Afinitor over placebo by a 2.4-fold prolongation in median progression-free-survival PFS (11.04 months versus 4.6 months), resulting in a 65% risk reduction in PFS (HR 0.35; 95% CI: 0.27, 0.45; one sided p < 0.0001) (see Table 8 and Figure 4).
RADIANT-3 enrolled patients with advanced pNET whose disease had progressed within the prior 12 months, was well or moderately differentiated, and unresectable or metastatic. Patients were stratified by prior cytotoxic chemotherapy (yes/no) and by WHO performance status (0 vs. 1 and 2). Treatment with somatostatin analogs was allowed as part of BSC.
The primary endpoint for the trial was PFS evaluated by RECIST (Response Evaluation Criteria in Solid Tumours, version 1.0) as per investigator radiological review. After documented radiological progression, patients could be unblinded by the investigator: those randomised to placebo were then able to receive open-label Afinitor.
Secondary endpoints include safety, objective response rate ORR (complete response (CR) or partial response (PR)), response duration, and overall survival OS.
In total, 410 patients were randomised 1:1 to receive either Afinitor 10 mg/day (n = 207) or placebo (n = 203). Demographics were well balanced (median age 58 years, 55.4% male, 78.5% Caucasian).
Eighteen-months PFS rates were 34.2% for Afinitor therapy compared to 8.9% for placebo.
The overall survival results are not yet mature and no statistically significant difference in OS was noted (HR = 0.99 (95% CI 0.68 to 1.43) in an updated analysis). Crossover of > 74% of patients from placebo to open-label Afinitor following disease progression likely confounded the detection of any treatment-related difference in OS.
Advanced neuroendocrine tumours of gastrointestinal or lung origin. RADIANT-4 (Study CRAD001T2302), a randomised, double-blind, multicenter phase III study of Afinitor plus best supportive care (BSC) versus placebo plus best supportive care was conducted in patients with advanced well-differentiated (Grade 1 or Grade 2) non-functional neuroendocrine tumours (NET) of gastrointestinal or lung origin without a history of and no active symptoms related to carcinoid syndrome. Randomisation was stratified by prior somatostatin analog (SSA) use, tumour origin and WHO performance status.
The primary endpoint for the study was progression-free survival (PFS) evaluated by Response Evaluation Criteria in Solid Tumours (modified RECIST version 1.0), based on independent radiological assessment. Supportive PFS analysis was based on local investigator review.
Secondary endpoints included overall survival (OS), Overall Response Rate (ORR), Disease Control Rate (DCR = proportion of patients with a best overall response of complete response, partial response or stable disease), Safety, change in Quality of Life (QoL) via FACT-G and time to WHO PS deterioration.
A total of 302 patients were randomised in a 2:1 ratio to receive either everolimus (10 mg daily) (n = 205) or placebo (n = 97). The two treatment groups were generally balanced with respect to the baseline demographics, disease characteristics and history of prior somatostatin analog (SSA) use (approximately 50% of patients had received prior SSA treatment in each arm). The median age of patients was 63 years (range 22 to 86) and 76% were Caucasian. The median duration of blinded treatment was 40.4 weeks for patients receiving Afinitor and 19.6 weeks for those receiving placebo. Patients in the placebo arm did not cross-over to everolimus at the time of progression.
The efficacy results were obtained from the final analysis of PFS after 178 PFS events were observed per independent radiological review.
The study demonstrated a statistically significant clinical benefit of everolimus over placebo by a 2.8-fold prolongation in median PFS (11.01 months versus 3.91 months), resulting in a 52% risk reduction of progression or death (HR 0.48; 95% CI: 0.35, 0.67; one sided stratified log-rank test p-value < 0.001) per independent assessment (see Table 9 and Figure 5).
The analysis of PFS based on local investigator assessment was supportive and showed a 2.6-fold prolongation in median progression-free-survival (14.39 months versus 5.45 months), resulting in a 60% risk reduction of progression or death (HR 0.40; 95% CI: 0.29, 0.55; one-sided stratified log-rank test p-value < 0.001) (see Table 9).
In supportive analyses, positive treatment effect has been observed in all subgroups with the exception of the subgroup of patients with ileum as primary site of tumour origin (Ileum: HR = 1.22 [95% CI: 0.56 to 2.65]; Non-ileum: HR = 0.34 [95% CI: 0.22 to 0.54]; Lung: HR = 0.43 [95% CI: 0.24 to 0.79]) (see Figure 6).
The overall response rate as per independent assessment was 2% in the everolimus arm vs. 1% in the placebo arm. Disease control rate (CR or PR or SD) for everolimus was 82.4% vs. 64.9% in the placebo arm. Tumour reduction was also evident from the corresponding waterfall plot. Results indicate that 63.6% of patients in the everolimus arm experienced tumour shrinkage versus 25.9% for placebo (Figure 7).
The final overall survival (OS) analysis did not show statistically significant difference between those patients who received Afinitor or placebo during the blinded treatment period of the study [HR = 0.90 (95% CI: 0.66 to 1.24)] (Figure 8).
Clinically or statistically significant differences were not observed between the two treatment arms in terms of time to deterioration of WHO PS (HR: 1.02; 95% CI: 0.65, 1.61) and time to deterioration of FACT-G total score (HR: 0.74; 95% CI: 0.50, 1.10).
Advanced renal cell carcinoma. RECORD-1 (CRAD001C2240), a phase III, international, multicentre, randomised, double-blind study comparing Afinitor 10 mg/day and placebo, both in conjunction with best supportive care, was conducted in patients with metastatic renal cell carcinoma whose disease had progressed despite prior treatment with VEGFR-TKI (vascular endothelial growth factor receptor tyrosine kinase inhibitor) therapy (sunitinib, sorafenib, or both sunitinib and sorafenib). Prior therapy with bevacizumab, cytokines and chemotherapy was also permitted. Patients were stratified according to Memorial Sloan-Kettering Cancer Center (MSKCC) prognostic score (favourable- vs. intermediate- vs. poor-risk groups) and prior anticancer therapy (1 vs. 2 prior VEGFR-TKIs).
Progression-free survival, documented using RECIST (Response Evaluation Criteria in Solid Tumours) and assessed via a blinded, independent central review, was the primary endpoint. Secondary endpoints included safety, objective tumour response rate, overall survival, disease related symptoms, and quality of life. After documented radiological progression, patients could be unblinded by the investigator: those randomised to placebo were then able to receive open-label Afinitor 10 mg/day. The Independent Data Monitoring Committee recommended termination of this trial at the time of the second interim analysis as the primary endpoint had been met.
In total, 416 patients were randomised 2:1 to receive Afinitor (n = 277) or placebo (n = 139). Demographics were well balanced (pooled median age 61 years [range 27 to 85], 77% male, 88% Caucasian, 74% one prior VEGFR-TKI therapy.
Results from a planned interim analysis showed that Afinitor was superior to placebo for the primary endpoint of progression-free survival, with a statistically significant 67% reduction in the risk of progression or death (see Table 10 and Figure 9).
Six-month PFS rates were 36% for Afinitor therapy compared with 9% for placebo.
Confirmed objective tumour responses were observed in 5 patients (2%) receiving Afinitor while none were observed in patients receiving placebo. The progression-free survival advantage therefore primarily reflects the population with disease stabilisation (corresponding to 67% of the Afinitor treatment group).
No statistically significant treatment-related difference in overall survival was noted, although there was a trend in favour of Afinitor (HR 0.82; 95% CI: 0.57 to 1.17; p = 0.137). Crossover to open-label Afinitor following disease progression for patients allocated to placebo confounded the detection of any treatment-related difference in overall survival.
Subgroup analyses by age (< 65 years and ≥ 65 years) indicated that the Afinitor treatment effect was consistent.
No difference in health-related quality of life was observed in patients receiving Afinitor compared to placebo patients.
Tuberous sclerosis complex (TSC) with refractory seizures. EXIST-3 (Study CRAD001M2304), a randomised, double-blind, multicenter, three-arm, parallel-group, phase-III study of Afinitor dispersible tablets versus placebo as adjunctive therapy was conducted in TSC patients with refractory seizures. Patients were treated with concomitant and stable dose of 1-3 antiepileptic drug(s) (AEDs) prior to study entry. The study consisted of three phases: an 8-week baseline observation phase; an 18-week double-blind, placebo-controlled core treatment phase (composed of titration and maintenance periods) and an extension phase in which all patients received everolimus.
The primary endpoint was the response rate defined as at least a 50% reduction from baseline in seizure frequency during the maintenance period of the core phase.
The percentage reduction from baseline in seizure frequency during the maintenance period of the core phase was a supporting endpoint.
Secondary endpoints included seizure freedom, proportion of patients with ≥ 25% seizure frequency reduction from baseline, distribution of reduction from baseline in seizure frequency (≤ -25%, > -25% to < 25%; ≥ 25% to < 50%; ≥ 50% to < 75%; ≥ 75% to < 100%; 100%), long-term evaluation of seizure frequency and overall quality-of-life. A total of 366 TSC patients with refractory seizures were randomised in an 1:1.09:1 ratio to Afinitor (n = 117) low trough (LT) range (3 to 7 nanogram/mL), Afinitor (n = 130) high trough (HT) range (9 to 15 nanogram/mL) or placebo (n = 119) added to each patient's concomitant AED therapy. Median age was 10.1 years (range: 2.2-56.3; 28.4% < 6 years, 30.9% 6 to < 12 years, 22.4% 12 to < 18 years and 18.3% > 18 years); 51.9% were male and 64.8% were Caucasian. Median duration of treatment was 18 weeks for all three arms.
At baseline, 19.4% of patients had focal seizures with retained awareness (sensory with electroencephalogram (EEG) or motor), 45.1% had focal seizures with impaired awareness (predominantly non-motor), 69.1% had focal motor seizures, and 1.6% had generalised onset seizures (previously confirmed by EEG). The median baseline seizure frequency across the treatment arms was 35, 38, and 42 seizures per 28 days for the Afinitor LT, Afinitor HT, and placebo groups, respectively. The majority of patients (67%) failed 5 or more AEDs prior to the study and 41.0% and 47.8% of patients were taking 2 and ≥ 3 AEDs during the study.
The study met its primary objective for seizure frequency response rate, as per EMA recommendation, in the two everolimus trough + concomitant AEDs arms over the placebo + concomitant AEDs arm. The response rate, defined as at least 50% reduction from baseline in seizure frequency was 28.2% (95% CI: 20.3, 37.3) in the Afinitor LT arm (p = 0.008), 40.0% (95% CI: 31.5, 49.0) in the Afinitor HT arm (p < 0.001) and 15.1% (95% CI: 9.2, 22.8) in the placebo arm (Figure 10). Odds Ratios vs placebo (95% CIs): Afinitor LT arm 2.21 (1.16, 4.20), Afinitor HT arm 3.93 (2.10, 7.32).
See Table 11.
Percentage reduction from baseline in seizure frequency was a supporting analysis.
The median percentage reduction from baseline in seizure frequency was 29.3% (95% CI: 18.8, 41.9) in the Afinitor LT arm (p = 0.003), 39.6% (95% CI: 35.0, 48.7) in the Afinitor HT arm (p < 0.001) and 14.9% (95% CI: 0.1, 21.7) in the placebo arm.
The seizure free rate (the frequency of seizure-free days per 28 days during the maintenance phase) was 5.1% (95% CI: 1.9, 10.8) and 3.8% (95% CI: 1.3, 8.7) in the Afinitor LT and HT arms, respectively, versus 0.8% (95% CI: 0.0, 4.6) in the placebo arm.
The proportion of patients with at least 25% reduction in seizure frequency was 52.1% (95% CI: 42.7, 61.5) in the Afinitor LT and 70.0% (95% CI: 61.3, 77.7) in the Afinitor HT arms, respectively, versus 37.8% (95% CI: 29.1, 47.2) on placebo.
Higher proportions of responders were evident for all response categories in the everolimus LT and HT arms relative to placebo. Furthermore, approximately twice as many patients in the placebo arm experienced seizure exacerbation relative to the everolimus LT and HT arms.
A homogeneous and consistent everolimus effect was observed across all subgroups evaluated for the primary efficacy endpoints by: age categories (Table 12), gender, race and ethnicity, seizure types, seizures frequency at Baseline, number and name of concomitant AEDs, and TSC features (angiomyolipoma, SEGA, cortical tuber status).
Tuberous sclerosis complex (TSC) with renal angiomyolipoma. EXIST-2 (Study CRAD001M2302), a randomised, double-blind, multicentre phase III study of a once daily oral dose of Afinitor 10 mg versus placebo was conducted in patients with TSC who have angiomyolipoma (n = 113) or sporadic LAM who have angiomyolipoma (n = 5). Patients were randomised in a 2:1 ratio to receive either Afinitor tablets or matching placebo. Presence of at least one angiomyolipoma ≥ 3 cm in longest diameter using CT/MRI (based on local radiology assessment) was required for entry.
The primary efficacy endpoint was angiomyolipoma response rate based on independent central radiology review. The analysis was stratified by use of enzyme-inducing antiepileptic drugs (EIAEDs) at randomisation (yes/no).
Key secondary endpoints included time to angiomyolipoma progression and skin lesion response rate.
A total of 118 patients were randomised, 79 to Afinitor 10 mg daily and 39 to placebo. The two treatment arms were generally well balanced with respect to demographic and baseline disease characteristics and history of prior anti-angiomyolipoma therapies. Median age was 31 years (range: 18 to 61; 46.6% were < 30 years at enrolment), 33.9% were male, and 89.0% were Caucasian. Of the enrolled patients, 83.1% had angiomyolipomas ≥ 4 cm (with 28.8% with angiomyolipomas ≥ 8 cm), 78.0% had bilateral angiomyolipomas, and 39.0% had undergone prior renal embolisation/nephrectomy; 96.6% had skin lesions at baseline and 44.1% had target SEGAs (at least one SEGA ≥ 1 cm in longest diameter). The median duration of blinded study treatment was 48.1 weeks (range 2 to 115) for patients receiving Afinitor and 45.0 weeks (range 9 to 115) for those receiving placebo.
Results showed that Afinitor was superior to placebo for the primary endpoint of best overall angiomyolipoma response (p < 0.0001); the difference observed was both clinically relevant and statistically significant (see footnote 2 in Table 13). Best overall response rate was 41.8% (95% CI: 30.8, 53.4) for the Afinitor arm compared with 0% (95% CI: 0.0, 9.0) for the placebo arm (Table 13).
Patients initially treated with placebo were allowed to cross over to everolimus at the time of angiomyolipoma progression and upon recognition that treatment with everolimus was superior to treatment with placebo. At the time of the final analysis (4 years following the last patient randomisation), the median duration of exposure to everolimus was 204.1 weeks (range 2 to 278). The angiomyolipoma best overall response rate had increased to 58.0% (95% CI: 48.3, 67.3), with a rate of stable disease of 30.4%.
Among patients treated with everolimus during the study, no cases of angiomyolipoma-related nephrectomy and only one case of renal embolisation were reported.
Consistent treatment effects were observed across all subgroups evaluated (i.e. EIAED use vs. EIAED non-use, sex, age, and race) at the primary efficacy analysis (Table 14).
The waterfall plots provide a graphical representation of the reduction in angiomyolipoma volume (Figure 11) at primary analysis; 95.5% of patients in the Afinitor arm experienced angiomyolipoma shrinkage versus 59.4% in the placebo arm.
In the final analysis, reduction in angiomyolipoma volume improved with longer term treatment with Afinitor. At weeks 12, 96 and 192, ≥ 30% reductions in volume were observed in 75.0% (78/104), 80.6% (79/98) and 85.2% (52/61) of the treated patients, respectively. Similarly, at the same timepoints, ≥ 50% reductions in volume were observed in 44.2% (46/104), 63.3% (62/98) and 68.9% (42/61) of the treated patients, respectively.
Afinitor was associated with a clinically relevant and statistically significant prolongation in time to angiomyolipoma progression (HR 0.08; 95% CI: 0.02, 0.37; p < 0.0001) (Figure 12) at the primary analysis. Median time to angiomyolipoma progression was 11.4 months in the placebo arm and was not reached in the Afinitor arm. Progressions were observed in 3.8% (3/79) of patients in the Afinitor arm compared with 20.5% (8/39) in the placebo arm. Estimated progression-free rates at 6 months were 98.4% for the Afinitor arm and 83.4% for the placebo arm. At the final analysis, median time to angiomyolipoma progression was not reached. Angiomyolipoma progressions were observed in 14.3% of the patients (16/112). The estimated angiomyolipoma progression-free rates at 24 months and 48 months were 91.6% (95% CI: 84.0%, 95.7%) and 83.1% (95% CI: 73.4%, 89.5%) respectively (Figure 13).
At the primary analysis, Afinitor demonstrated clinically meaningful and statistically significant improvements in skin lesion response (p = 0.0002), with response rates of 26.0% (20/77) (95% CI: 16.6, 37.2) for the Afinitor arm and 0% (0/37) (95% CI: 0.0, 9.5) for the placebo arm (Table 15). At the final analysis, the skin lesion response rate had increased to 68.2% (73/107) (95% CI: 58.5%, 76.9%) (Table 15), with one patient reporting a confirmed complete clinical skin lesion response and no patients experiencing progressive disease as their best response.
In an exploratory analysis of patients with TSC with angiomyolipoma who also had SEGA, the SEGA response rate (proportion of patients with ≥ 50% reduction from baseline in target lesion volumes in the absence of progression) was 10.3% (4/39) in the everolimus arm at the primary analysis (versus no responses reported in the 13 patients randomised to placebo with a SEGA lesion at baseline) and increased to 48.0% (24/50) at the final analysis.
In EXIST-2, of 34 patients eligible for follow-up after completion of everolimus treatment, 16 were able to be evaluated for efficacy. 12 of 16 evaluable patients evaluated for angiomyolipoma volume for up to 1 year after discontinuation of everolimus, experienced an increase in tumour volume compared to their most recent tumour volume assessment performed before treatment discontinuation; though the angiomyolipoma volume did not exceed that measured at baseline. Two of 16 evaluable patients developed protocol-defined angiomyolipoma progression by virtue of angiomyolipoma-related bleeding (n = 1) and increase in kidney volume (n = 1).
Tuberous sclerosis complex (TSC) with subependymal giant cell astrocytoma (SEGA).

Phase III trial in patients with TSC who have SEGA.

EXIST-1 (Study CRAD001M2301), a randomised, double blind, multicentre phase III study of Afinitor versus placebo was conducted in patients with TSC who have SEGA, irrespective of age. The study required the titration of Afinitor from an initial starting dose of 4.5 mg/m2/day, subject to tolerability, with the objective of attaining trough concentrations consistent with the revised 5 to 15 nanogram/mL range. Patients were randomised in a 2:1 ratio to receive either Afinitor or matching placebo. Presence of at least one SEGA lesion ≥ 1.0 cm in longest diameter using MRI (based on local radiology assessment) was required for entry. In addition, serial radiological evidence of SEGA growth, presence of a new SEGA lesion ≥ 1 cm in longest diameter, or new or worsening hydrocephalus was required for entry.
The primary efficacy endpoint was SEGA response rate based on independent central radiology review. The analysis was stratified by use of enzyme inducing antiepileptic drugs (EIAEDs) at randomisation (yes/no).
Key secondary endpoints in hierarchal order of testing included the absolute change in frequency of total seizure events per 24-hour EEG from baseline to Week 24, time to SEGA progression, and skin lesion response rate.
A total of 117 patients were randomised, 78 to Afinitor and 39 to placebo. The two treatment arms were generally well balanced with respect to demographic and baseline disease characteristics and history of prior anti-SEGA therapies. Median age was 9.5 years (range: 0.8 to 26.6; 69.2% were 3 to < 18 years at enrolment; 17.1% were < 3 years at enrolment), 57.3% were male, and 93.2% were Caucasian. Of the enrolled patients, 79.5% had bilateral SEGAs, 42.7% had ≥ 2 target SEGA lesions, 25.6% had inferior growth, 9.4% had evidence of deep parenchymal invasion, 6.8% had radiographic evidence of hydrocephalus, and 6.8% had undergone prior SEGA related surgery; 94.0% had skin lesions at baseline and 37.6% had target renal angiomyolipoma lesions (at least one angiomyolipoma ≥ 1 cm in longest diameter). The median duration of blinded study treatment was 52.2 weeks (range 24 to 89) for patients receiving Afinitor and 46.6 weeks (range 14 to 88) for those receiving placebo.
Results showed that Afinitor was superior to placebo for the primary endpoint of best overall SEGA response (p < 0.0001) (see footnote 2 in Table 16). Response rates were 34.6% (95% CI: 24.2, 46.2) for the Afinitor arm compared with 0% (95% CI: 0.0, 9.0) for the placebo arm (Table 16). In addition, all 8 patients on the Afinitor arm who had radiographic evidence of hydrocephalus at baseline had a decrease in ventricular volume.
Patients initially treated with placebo were allowed to cross over to everolimus at the time of SEGA progression and upon recognition that treatment with everolimus was superior to treatment with placebo. All patients receiving at least one dose of everolimus were followed until drug discontinuation or study completion. At the time of final analysis, the median duration of exposure to everolimus among all such patients was 204.9 weeks (range 8.1 to 253.7). The best overall SEGA response rate had increased to 57.7% (95% CI: 47.9, 67.0) at the final analysis.
No patient required surgical intervention for SEGA during the entire course of the study.
Consistent treatment effects were observed across all subgroups evaluated (i.e. EIAED use vs. EIAED non-use, sex, and age) at the primary analysis (Table 17).
During the double-blind period, reduction of SEGA volume was evident within the initial 12 weeks of treatment with Afinitor: 29.7% (22/74) of patients had ≥ 50% reductions in volume and 73.0% (54/74) of patients had ≥ 30% reductions in volume. Sustained reductions were evident at Week 24, 41.9% (31/74) of patients had ≥ 50% reductions and 78.4% (58/74) of patients had ≥ 30% reductions in SEGA volume.
In the everolimus treated population (N = 111) of the study, including patients who crossed over from the placebo group, tumour response, starting as early as after 12 weeks on everolimus, was sustained at later time points. The proportion of patients achieving at least 50% reductions in SEGA volume was 45.9% (45/98) and 62.1% (41/66) at Weeks 96 and 192 after start of everolimus treatment. Similarly, the proportion of patients achieving at least 30% reductions in SEGA volume was 71.4% (70/98) and 77.3% (51/66) at Weeks 96 and 192 after start of everolimus treatment.
Analysis of the first key secondary endpoint, change in seizure frequency, was inconclusive.
Median time to SEGA progression based on central radiology review was not reached in either treatment arm. Progressions were only observed in the placebo arm (15.4%; unadjusted p = 0.0002) (Figure 14). Estimated progression-free rates at 6 months were 100% for the Afinitor arm and 85.7% for the placebo arm. The long-term follow up of patients randomised to everolimus and patients randomised to placebo who thereafter crossed over to everolimus demonstrated durable responses (Figure 15).
Additional clinical benefits of Afinitor were observed such as reductions in severity of skin lesions and size of renal angiomyolipoma.
At the time of the primary analysis, Afinitor demonstrated clinically meaningful improvements in skin lesion response (unadjusted p = 0.0004), with response rates of 41.7% (95% CI: 30.2, 53.9) for the Afinitor arm and 10.5% (95% CI: 2.9, 24.8) for the placebo arm (Table 18). At the final analysis, the skin lesion response rate increased to 58.1% (95% CI: 48.1, 67.7) (Table 18).
At the time of the primary analysis, angiomyolipoma responses were only observed in the everolimus arm (n/N:16/30; 53.3%; 95% CI: 34.3, 71.7). At the time of final analysis, among the 41 TSC-SEGA patients with an angiomyolipoma lesion(s) present at start of treatment with everolimus, 30 patients (73.2%; 95% CI: 57.1, 85.8) achieved, as their best overall response, at least a 50% reduction in sum of angiomyolipoma volumes. Among the 37 patients with evaluable angiomyolipoma tumour assessments, 35 patients (94.6%) experienced a reduction in the sum of target angiomyolipoma volumes relative to baseline as their best percentage change. Over the entire duration of the study, no new angiomyolipoma lesions were observed, nor were instances of grade 2 or worse bleeding episodes reported.

Phase II trial in patients with TSC who have SEGA.

Study CRAD001C2485, a prospective, open-label, single-arm trial was conducted to evaluate the safety and efficacy of Afinitor in patients with SEGA associated with TSC. Serial radiological evidence of SEGA growth was required for entry.
Change in SEGA volume at the end of the core 6-month treatment phase was assessed via an independent central radiology review, was the primary efficacy endpoint. After the core treatment phase, patients could continue to receive Afinitor treatment as part of an extension treatment phase where SEGA volume was assessed every 6 months.
In total, 28 patients received treatment with Afinitor; median age was 11 years (range 3 to 34), 61% male, 86% Caucasian. Thirteen patients (46%) had a secondary smaller SEGA including 12 patients with SEGA in the contralateral ventricle. Median duration of 67.8 months (range: 4.7 to 83.2 months).
Afinitor was associated with a clinically relevant and statistically significant reduction in primary SEGA volume at 6 months relative to baseline (median reduction of 0.80 cm3; 95% CI: 0.4, 1.2; n = 28; p < 0.001). Tumour shrinkage was most rapid during the initial 3 months of treatment with evidence of a sustained response at subsequent time points (Table 19). At 6 months, 9 out of 28 patients (32%, 95% CI: 16% to 52%) had a ≥ 50% reduction in the tumour volume of their largest SEGA lesion (Table 19).
Three of 4 patients who had prior surgery experienced a ≥ 50% reduction in the tumour volume of their largest SEGA lesion. One of these three patients responded by month 6. No patient developed new lesions, worsening hydrocephalus, increased intracranial pressure, and none required surgical resection or other therapy for SEGA.
Long-term follow-up to a median duration of 67.8 months (range: 4.7 to 83.2 months) demonstrated sustained efficacy with a median reduction in primary SEGA volume per independent central review of 0.50 cm3 at month 60 (range: -0.74 to 9.84 cm3; n = 23).

5.2 Pharmacokinetic Properties

Absorption.

After administration of Afinitor tablets in patients with advanced solid tumours, peak everolimus concentrations are reached 1 to 2 hours after administration of an oral dose of 5 to 70 mg everolimus under fasting conditions or with a light fat-free snack. Cmax is dose-proportional with daily dosing between 5 and 10 mg. AUC shows dose proportionality over the 5 to 70 mg dose range.

Effects of food.

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

Relative bioavailability of dispersible tablets.

The AUC0-∞ of the Afinitor dispersible tablets when administered as a suspension in water was equivalent to that of Afinitor tablets (85% to 91% of that associated with Afinitor tablets). The predicted trough concentrations of everolimus at steady-state after daily administration were similar for both dosage forms. The Cmax of everolimus associated with the Afinitor dispersible tablets was, however, somewhat lower (64% to 80% relative to that associated with Afinitor tablets).

Distribution.

The blood to plasma ratio of everolimus, which is concentration dependent over the range of 5 to 5,000 nanogram/mL, is 17% to 73%. The amount of everolimus confined to the plasma is approximately 20% at blood concentrations observed in cancer patients given 10 mg/day of Afinitor. Plasma protein binding is approximately 74% both in healthy subjects and patients with moderate hepatic impairment.
Following intravenous administration in a rat model, everolimus was shown to cross the blood-brain barrier in a non-linear dose-dependent manner, suggesting saturation of an efflux pump at the blood-brain barrier. Brain penetration of everolimus has also been demonstrated in rats receiving oral doses of everolimus and exposure of everolimus in brain was enhanced by co-administration with ciclosporin.

Metabolism.

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

Excretion.

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

Steady-state pharmacokinetics.

After administration of Afinitor tablets in patients with advanced solid tumours, steady-state AUC0-τ was dose-proportional over the range of 5 to 10 mg with a daily dosing regimen. Steady-state was achieved within two weeks. Cmax is dose proportional between 5 and 10 mg. tmax occurs at 1 to 2 hours post-dose. There was a significant correlation between AUC0-τ and pre-dose trough concentration at steady-state on a daily regimen. Mean elimination half-life is approximately 30 hours.

Special population.

Hepatic impairment.

The safety, tolerability and pharmacokinetics of Afinitor were evaluated in two single oral dose studies of Afinitor tablets in 8 and 34 subjects with impaired hepatic function relative to subjects with normal hepatic function. In one study, the average AUC of everolimus in 8 subjects with moderate hepatic impairment (Child-Pugh class B) was twice that found in 8 subjects with normal hepatic function. In a second study of 34 subjects with different impaired hepatic function compared to normal subjects, there was a 1.6-fold, 3.3-fold, and 3.6-fold increase in exposure (i.e. AUC(0-inf)) for subjects with mild (Child-Pugh A), moderate (Child-Pugh B), and severe (Child-Pugh C) hepatic impairment, respectively. Simulations of multiple dose pharmacokinetics support the dosing recommendations in hepatic impaired subjects based on their Child-Pugh status. Dose adjustment is recommended for patients with hepatic impairment (see Section 4.2 Dose and Method of Administration; Section 4.4 Special Warnings and Precautions for Use).

Renal impairment.

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

Paediatrics.

There is no relevant indication for use of Afinitor in the paediatric cancer population (see Section 4.2 Dose and Method of Administration) or in paediatric patients with TSC who have renal angiomyolipoma. In patients with TSC who have SEGA receiving Afinitor tablets, everolimus Cmin was approximately dose-proportional within the dose range from 1.35 mg/m2 to 14.4 mg/m2.
In patients with TSC who have SEGA receiving Afinitor tablets, the everolimus geometric mean Cmin values normalised to mg/m2 dose in patients aged < 10 years and 10-18 years were statistically lower than those observed in adults (> 18 years of age), suggesting that everolimus clearance was higher in younger patients.
In patients with TSC and refractory seizures receiving Afinitor dispersible tablets, a trend was observed toward lower Cmin normalised to dose (as mg/m2) in younger patients. Median Cmin normalised to mg/m2 dose was lower for the younger age groups, indicating that everolimus clearance (normalised to body surface area) was higher in younger patients.

Elderly.

In a population pharmacokinetic evaluation in cancer patients, no significant influence of age (27-85 years) on oral clearance (CL/F: range 4.8 to 54.5 litres/hour) of everolimus was detected.

Ethnicity.

Asian patients with neuroendocrine tumours (NETs) showed a consistent pattern of reduced clearance, and higher AUC values, with higher Cmin values compared to non-Asian patients (see Section 4.4 Special Warnings and Precautions for Use).
Based on analysis of population pharmacokinetics, oral clearance (CL/F) is, on average, 20% higher in black transplant patients.

5.3 Preclinical Safety Data

Genotoxicity.

Everolimus did not show genotoxicity in in vitro tests for gene mutation (bacteria and mammalian cells), and in an in vitro test and an in vivo mouse micronucleus assay for clastogenic activity.

Carcinogenicity.

Long-term carcinogenicity studies have been carried out in mice and rats and no oncogenic responses were observed. Drug exposures (blood AUC) were up to 4-times4 the expected human value at 10 mg/day in mice, but were less than the expected maximum human value in rats.
4AUC0-24 hr = 2231 nanogram.hr/mL in mice vs. AUC = 560 in human at 10 mg/day.

6 Pharmaceutical Particulars

6.1 List of Excipients

Tablets: butylated hydroxytoluene, magnesium stearate, lactose monohydrate, hypromellose, crospovidone, lactose.
Dispersible tablets: butylated hydroxytoluene, magnesium stearate, lactose monohydrate, hypromellose, crospovidone, mannitol, microcrystalline cellulose, and colloidal anhydrous silica.

6.2 Incompatibilities

Incompatibilities were either not assessed or not identified as part of the registration of this medicine.

6.3 Shelf Life

In Australia, information on the shelf life can be found on the public summary of the ARTG. The expiry date can be found on the packaging.

6.4 Special Precautions for Storage

Store below 30°C in the original packaging. Protect from light and moisture.

6.5 Nature and Contents of Container

2.5 mg tablet: PA/Al/PVC/Al Packs of 10, 30 and 90 tablets.
5 mg tablet: PA/Al/PVC/Al Packs of 30, 50, 60 and 100, 120 tablets.
10 mg tablet: PA/Al/PVC/Al Packs of 30, 50, 60, 100 and 120 tablets.
2 mg dispersible tablet: PA/Al/PVC/Al Packs of 30, 50, 60 and 100, 120 tablets.
3 mg dispersible tablet: PA/Al/PVC/Al Packs of 30, 50, 60 and 100, 120 tablets.
5 mg dispersible tablet: PA/Al/PVC/Al Packs of 30, 50, 60 and 100, 120 tablets.
Not all pack sizes may be marketed.

6.6 Special Precautions for Disposal

In Australia, any unused medicine or waste material should be disposed of by taking to your local pharmacy.

6.7 Physicochemical Properties

Everolimus is a white to faintly yellow powder practically insoluble in water but soluble in organic solvents such as ethanol and methanol.

Chemical structure.

The chemical name is 40-O-(2-hydroxyethyl)-rapamycin or 40-O-(2-hydroxyethyl)-sirolimus. Its molecular formula is C53H83NO14 and its molecular weight is 958.2.
The structural formula of everolimus is:

CAS number.

159351-69-6.

7 Medicine Schedule (Poisons Standard)

Medicine schedule (Poisons Standard) Prescription Only Medicine (Schedule 4).

Summary Table of Changes