Consumer medicine information

Palonosetron Medsurge

Palonosetron

BRAND INFORMATION

Brand name

Palonosetron Medsurge

Active ingredient

Palonosetron

Schedule

SUMMARY CMI

Palonosetron Medsurge

Consumer Medicine Information (CMI) summary

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

1. Why am I taking Palonosetron Medsurge?

Palonosetron Medsurge contains the active ingredient palonosetron hydrochloride. Palonosetron is used in the prevention of nausea and vomiting induced by cytotoxic chemotherapy, prevention of postoperative nausea and vomiting (PONV) for up to 24 hours following surgery.

For more information, see Section 1. Why am I taking Palonosetron Medsurge? in the full CMI.

2. What should I know before I take Palonosetron Medsurge?

Do not take if you have ever had an allergic reaction to Palonosetron Medsurge 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 take Palonosetron Medsurge? in the full CMI.

3. What if I am taking other medicines?

Some medicines may interfere with pomalidomide 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 take Palonosetron Medsurge?

Palonosetron Medsurge is given as an injection into a vein. A doctor or nurse will normally inject it
Your doctor will decide how much of this medicine you will be given and for how long.

More instructions can be found in Section 4. How do I take Palonosetron Medsurge? in the full CMI.

5. What should I know while taking Palonosetron Medsurge?

Things you should do	Tell your doctor if you experience any problems with this medicine. Tell your doctor if you are pregnant or breastfeeding. Tell your doctor if you are taking any other medications.
Driving or using machines	Palonosetron Medsurge may induce dizziness, somnolence or fatigue. If you experience any of these symptoms, do not drive, operate machinery or do anything else that could be dangerous.
Looking after your medicine	Store below 25°C. Protect from light.

For more information, see Section 5. What should I know while taking Palonosetron Medsurge? in the full CMI.

6. Are there any side effects?

The following common side effects may occur. Tell your doctor, nurse or pharmacist if you notice any of the below reactions and they worry you.

Headache
Dizziness
Constipation
Diarrhoea

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

Palonosetron Medsurge

Active ingredient(s): Palonosetron hydrochloride

Consumer Medicine Information (CMI)

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

Where to find information in this leaflet:

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

1. Why am I taking Palonosetron Medsurge?

Palonosetron Medsurge contains the active ingredient palonosetron hydrochloride. Palonosetron is used in the prevention of nausea and vomiting induced by cytotoxic chemotherapy, prevention of postoperative nausea and vomiting (PONV) for up to 24 hours following surgery. Palonosetron belongs to a group of medicines known as serotonin (5-HT3) antagonists.

2. What should I know before I take Palonosetron Medsurge?

Warnings

Do not take Palonosetron Medsurge if:

you are allergic to palonosetron hydrochloride or any of the ingredients listed at the end of this leaflet.
Always check the ingredients to make sure you can use this medicine.

Check with your doctor if you:

are pregnant or think you might be, your doctor will not use this medicine unless it is clearly necessary as it is not known

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.

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

It is not known if this medicine is found in breast milk. You should ask your doctor or pharmacist for advice before using it if you are breast-feeding.

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 affect the way other medicines work. Your doctor or pharmacist will be able to tell you what to do when being given this medicine with other medicines.

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

4. How do I take Palonosetron Medsurge?

How much to take / use

Palonosetron Medsurge is given as an injection into a vein. A doctor or nurse will normally inject it
Your doctor will decide how much of this medicine you will be given and for how long.

When to take / use Palonosetron Medsurge

about 30 minutes before the start of chemotherapy or
right before anaesthesia for surgery.
Palonosetron Medsurge is intended for single use in one patient.

If you take too much Palonosetron Medsurge

As Palonosetron Medsurge is given to you under the supervision of your doctor, it is very unlikely that you will receive too much. However, if you experience any side effects after being given it, tell your doctor immediately.

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 taking Palonosetron Medsurge?

Things you should do

If the medicine starts to upset you or your symptoms become worse, tell your doctor.

Tell any other doctors, dentists, and pharmacists who are treating you that you are being treated with this medicine.

Tell your doctor if you become pregnant during treatment with this medicine.

Driving or using machines

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

Palonosetron Medsurge may induce dizziness, somnolence or fatigue. If you experience any of these symptoms, do not drive, operate machinery or do anything else that could be dangerous.

Looking after your medicine

Store below 25°C.
Store in the original container.
Keep the container in the outer carton to protect from light.

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 take 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 effects	What to do
Headache Dizziness Constipation Diarrhoea	Tell your doctor, nurse or pharmacist if you notice any of the Less serious side effects reactions and they worry you.

Serious side effects

Serious side effects	What to do
Loss of appetite Anxiety or euphoria Sleep disturbances Change of sensation in your limbs Visual or hearing disturbances Motion sickness Change in heart rate Prominent or discoloured veins Hiccups, flatulence or dry mouth Upset stomach or stomach pain Rash Joint pain Difficulty passing water Weakness or tiredness Fever or a flu-like illness	You should tell your doctor if you notice any of the 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.

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 Palonosetron Medsurge contains

Active ingredient (main ingredient)	Palonosetron hydrochloride
Other ingredients (inactive ingredients)	mannitol, disodium edetate, citric acid monohydrate, sodium citrate dihydrate, sodium hydroxide and/or hydrochloric acid water for injections.
Potential allergens	none

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

What Palonosetron Medsurge looks like

Palonosetron Medsurge is a colourless solution, supplied in a pack of one glass vial, which contains 5 mL of the solution. (Aust R 391571).

Who distributes Palonosetron Medsurge

Medsurge Pharma Pty Ltd
Unit 1&2, 6-7 Gilda Court
Mulgrave, Victoria 3170

Marketed and Distributed by Medsurge Healthcare.

Telephone: 1300 788 261
Website: medsurgehc.com

This leaflet was prepared in November 2023

Published by MIMS March 2024

BRAND INFORMATION

Brand name

Palonosetron Medsurge

Active ingredient

Palonosetron

Schedule

1 Name of Medicine

Palonosetron (as hydrochloride).

2 Qualitative and Quantitative Composition

Palonosetron Medsurge injection is a sterile, clear, colourless, non-pyrogenic, isotonic, buffered solution for intravenous administration.
Palonosetron Medsurge injection is available as 5 mL single use vial.
Each 5 mL vial of Palonosetron Medsurge injection contains 250 microgram equivalent palonosetron base as hydrochloride.
For the full list of excipients, see Section 6.1 List of Excipients.

3 Pharmaceutical Form

Palonosetron Medsurge solution for injection is a clear, essentially colourless solution in a clear glass vial.

4 Clinical Particulars

4.1 Therapeutic Indications

Palonosetron Medsurge is indicated for:
prevention of nausea and vomiting induced by cytotoxic chemotherapy;
prevention of postoperative nausea and vomiting (PONV) for up to 24 hours following surgery.

4.2 Dose and Method of Administration

Dosage for adults - chemotherapy induced nausea and vomiting (CINV).

The recommended dosage of palonosetron is 250 microgram administered as a single dose approximately 30 minutes before the start of chemotherapy.
Drug accumulation was observed in subjects administered palonosetron on consecutive days or once every two days for three doses (see Section 5.2 Pharmacokinetic Properties). Safety and efficacy data available regarding repeated dosing of palonosetron within a course of multi-day chemotherapy are limited (see Section 5.1 Pharmacodynamic Properties, Clinical trials).

Dosage for adults - postoperative nausea and vomiting (PONV).

The recommended dosage of palonosetron is 75 microgram administered as single dose immediately before induction of anaesthesia.

Use in geriatric patients and in patients with impaired renal or hepatic function.

No dosage adjustment is recommended.

Dosage for paediatric patients.

A recommended intravenous dosage has not been established for paediatric patients.

Administration - chemotherapy induced nausea and vomiting (CINV).

Palonosetron should only be used before chemotherapy administration. Palonosetron is to be infused intravenously over 30 seconds.

Administration - postoperative nausea and vomiting (PONV).

Palonosetron should be administered as single dose immediately before induction of anaesthesia.
It is to be infused intravenously over 10 seconds.

Instructions for use/ handling.

This medicinal product must not be mixed with other medicinal products.
Flush the infusion line with normal saline before and after administration of palonosetron.
Contains no antimicrobial agent. Palonosetron Medsurge solution for injection is for single use in one patient only. Discard any residue.

4.3 Contraindications

Palonosetron is contraindicated in patients known to have hypersensitivity to the drug or any of its components.

4.4 Special Warnings and Precautions for Use

General.

Hypersensitivity reactions may occur in patients who have exhibited hypersensitivity to other selective 5-HT₃ receptor antagonists. Palonosetron should not be used to prevent or treat nausea and vomiting in the days following chemotherapy if not associated with another chemotherapy administration.
There have been reports of serotonin syndrome with the use of 5-HT₃ antagonists either alone or in combination with other serotonergic drugs including selective serotonin reuptake inhibitors (SSRI) and serotonin noradrenaline reuptake inhibitors (SNRIs).
As palonosetron may increase large bowel transit time, patients with a history of constipation or signs of subacute intestinal obstruction should be monitored following administration.

Cardiac conduction.

At all dose levels tested, palonosetron did not induce clinically relevant prolongation of the QTc interval. A specific thorough QT/QTc study was conducted in healthy volunteers for definitive data demonstrating the effect of palonosetron on QT/QTc (see Section 5.1 Pharmacodynamic Properties). However, as for the other 5-HT₃ antagonists, caution should be exercised in the concomitant use of palonosetron with medicinal products that increase the QT interval or in patients who have or are likely to develop prolongation of the QT interval.

Special populations.

Intravenous palonosetron pharmacokinetics was characterized in twenty-four healthy Japanese subjects over the dose range of 3-90 microgram/kg. Total body clearance was 25% higher in Japanese subjects compared to Whites; however, no dose adjustment is required. The pharmacokinetics of palonosetron in Blacks has not been adequately characterised.

Use in hepatic impairment.

Hepatic impairment does not significantly affect total body clearance of palonosetron compared to the healthy subjects. Dosage adjustment is not necessary in patients with any degree of hepatic impairment.

Use in renal impairment.

Mild to moderate renal impairment does not significantly affect palonosetron pharmacokinetic parameters. Total systemic exposure increased by approximately 28% in severe renal impairment relative to healthy subjects. Dosage adjustment is not necessary in patients with any degree of renal impairment.

Use in the elderly.

Population pharmacokinetic analysis and clinical safety and efficacy data did not reveal any differences between cancer patients ≥ 65 years of age and younger patients (18 to 64 years). No dose adjustment is required for these patients.

Paediatric use.

There are no data on efficacy and safety in patients below 18 years.

Effects on laboratory tests.

No data available.

4.5 Interactions with Other Medicines and Other Forms of Interactions

Palonosetron is eliminated from the body through both renal excretion and metabolic pathways with the latter mediated via multiple CYP enzymes. Further in vitro studies indicated that palonosetron is not an inhibitor of CYP1A2, CYP2A6, CYP2B6, CYP2C9, CPY2D6, CYP2E1 and CYP3A4/5 (CYP2C19 was not investigated) nor does it induce the activity of CYP1A2, CYP2D6, or CYP3A4/5. Therefore, the potential for clinically significant drug interactions with palonosetron appears to be low.
A study in healthy volunteers involving the co-administration of single IV doses of palonosetron (250 microgram) and dexamethasone (20 mg) demonstrated no significant interaction.
In a study in healthy volunteers involving the co-administration of a single dose of IV palonosetron (250 microgram) on Day 1 with single doses of aprepitant (125 mg/ 80 mg/ 80 mg) on Days 1, 2 and 3, the pharmacokinetics of palonosetron were not significantly altered (C_max: 15% increase, AUC: no change). A study in healthy volunteers involving single-dose IV palonosetron (0.75 mg) and steady state oral metoclopramide (10 mg four times daily) demonstrated no significant pharmacokinetic interaction.
In controlled clinical trials, palonosetron injection has been safely administered with corticosteroids, analgesics, antiemetics/ antinauseants, antispasmodics and anticholinergic agents.
Palonosetron did not inhibit the antitumor activity of the five chemotherapeutic agents tested (cisplatin, cyclophosphamide, cytarabine, doxorubicin and mitomycin C) in murine tumor models.
There have been reports of serotonin syndrome following concomitant use of 5-HT₃ antagonists and other serotonergic drugs (including SSRIs and SNRIs).

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

Palonosetron at oral doses of up to 60 mg/kg/day (> 170 times the recommended human intravenous dose based on estimated plasma AUC) was found to have no effect on fertility and reproductive performance of male and female rats. Oral doses of 60 and 120 mg/kg/day given to male rats for 2 months prior to mating associated with complete infertility at the 120 mg/kg/day dose. Testicular degeneration was confirmed in a 3 month general toxicity study at oral doses of 60 and 120 mg/kg/day. An IV dose of up to 10 mg/kg/day (> 250 times the recommended human intravenous dose based on plasma AUC) had no effect on male fertility and reproductive performance.
(Category B1)
Palonosetron had no effect on foetal development at oral doses of up to 18 mg/kg/day in rats and 90 mg/kg/day in rabbits. At 60 and 120 mg/kg/day in rats, foetal weight was reduced.
Palonosetron did not cause foetal abnormalities at these dose levels. However, palonosetron had toxic effects on the dams at 120 mg/kg in rats and 90 mg/kg/day in rabbits.
Because animal reproduction studies are not always predictive of human response, palonosetron should not be used during pregnancy unless it is considered essential.
It is not known whether palonosetron is excreted in human milk, but some other drugs of the same class are known to be excreted in rat milk. Because of the potential for serious adverse reactions in nursing infants, a decision should be made whether to discontinue breastfeeding or to discontinue the drug, taking into account the importance of the drug to the mother.

4.7 Effects on Ability to Drive and Use Machines

No studies on the effects on the ability to drive and use machines have been performed. Since palonosetron may induce dizziness, somnolence or fatigue, patients should be cautioned when driving or operating machines.

4.8 Adverse Effects (Undesirable Effects)

Chemotherapy-induced nausea and vomiting (CINV) in adults.

In clinical trials for the prevention of nausea and vomiting induced by moderately or highly emetogenic chemotherapy, 1374 adult patients received palonosetron. Adverse reactions were similar in frequency and severity with palonosetron and ondansetron or dolasetron. Following is a listing of all adverse reactions reported by ≥ 2% of patients in these trials (Table 1).

In other studies, 2 subjects experienced severe constipation following a single palonosetron dose of approximately 0.75 mg, three times the recommended dose. One patient received a 10 microgram/kg oral dose in a post-operative nausea and vomiting study and one healthy subject received a 0.75 mg IV dose in a pharmacokinetic study.
In clinical trials, the following infrequently reported adverse reactions, assessed by investigators as treatment-related or causality unknown, occurred following administration of palonosetron to adult patients receiving concomitant cancer chemotherapy:

Cardiovascular.

1%: non-sustained tachycardia, bradycardia, hypotension, < 1%: hypertension, myocardial ischemia, extrasystoles, sinus tachycardia, sinus arrhythmia, supraventricular extrasystoles and QT prolongation. In many cases, the relationship to palonosetron was unclear.

Dermatological.

< 1%: allergic dermatitis, pruritic rash.

Hearing and vision.

< 1%: motion sickness, tinnitus, eye irritation and amblyopia.

Gastrointestinal system.

1%: diarrhoea, < 1%: dyspepsia, upper abdominal pain, dry mouth, hiccups and flatulence.

General.

1%: weakness, asthenia < 1%: fatigue, fever, hot flash, flu-like syndrome.

Liver.

< 1%: transient, asymptomatic increases in AST and/or ALT and bilirubin. These changes occurred predominantly in patients receiving highly emetogenic chemotherapy.

Metabolic.

1%: hyperkalaemia, < 1%: electrolyte fluctuations, hypocalcaemia, hyperglycaemia, metabolic acidosis, glycosuria, appetite decrease, anorexia.

Musculoskeletal.

< 1%: arthralgia.

Nervous system.

1%: dizziness, < 1%: somnolence, insomnia, hypersomnia, paresthesia, and peripheral sensory neuropathy.

Psychiatric.

1%: anxiety, < 1%: euphoric mood.

Urinary system.

< 1%: urinary retention.

Vascular.

< 1%: vein discoloration, vein distention.

Post-operative nausea and vomiting (PONV) in adults.

The adverse reactions cited in Table 2 were reported in ≥ 2% of adults receiving I.V. palonosetron 75 microgram immediately before induction of anaesthesia in one phase 2 and two phase 3 randomised placebo-controlled trials. Rates of events between palonosetron and placebo groups were similar. Some events are known to be associated with, or may be exacerbated by, concomitant perioperative and intraoperative medications administered in this surgical population.

In these clinical trials, the following infrequently reported adverse reactions, assessed by investigators as treatment-related or causality unknown, occurred following administration of palonosetron to adult patients receiving concomitant perioperative and intraoperative medications including those associated with anaesthesia:

Cardiovascular.

1%: electrocardiogram QTc prolongation, sinus bradycardia, tachycardia, < 1%: blood pressure decreased, hypotension, hypertension, arrhythmia, ventricular extrasystoles, generalised oedema, ECG T wave amplitude decreased, platelet count decreased. The frequency of these adverse effects did not appear to be different from placebo.

Dermatological.

1%: pruritus.

Gastrointestinal system.

1%: flatulence, < 1%: dry mouth, upper abdominal pain, salivary hypersecretion, dyspepsia, diarrhoea, intestinal hypomotility, anorexia.

General.

< 1%: chills.

Liver.

1%: increases in AST and/or ALT, < 1%: hepatic enzyme increased.

Metabolic.

< 1%: hypokalaemia, anorexia.

Nervous system.

< 1%: dizziness.

Respiratory.

< 1%: hypoventilation, laryngospasm.

Urinary system.

1%: urinary retention.

Post-marketing experience.

In post-marketing reports there have been very rare cases of:
hypersensitivity reactions including anaphylaxis and shock; and
injection site reactions such as burning, induration, discomfort and pain.

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-problem.

4.9 Overdose

There is no known antidote to palonosetron. Overdose should be managed with supportive care. Fifty adult cancer patients were administered palonosetron at a dose of 90 microgram/kg (equivalent to 6 mg fixed dose) as part of a dose ranging study. This is approximately 25 times the recommended dose of 250 microgram. This dose group had a similar incidence of adverse events compared to the other dose groups and no dose response effects were observed. Dialysis studies have not been performed; however, due to the large volume of distribution, dialysis is unlikely to be an effective treatment for palonosetron overdose. A single intravenous dose of palonosetron at 30 mg/kg (947 and 474 times the human dose for rats and mice, respectively, based on body surface area) was lethal to rats and mice. The major signs of toxicity were convulsions, gasping, pallor, cyanosis and collapse.
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.

Palonosetron hydrochloride is an antiemetic and antinauseant agent. It is a selective serotonin subtype 3 (5-HT₃) receptor antagonist with a strong binding affinity for this receptor.

Pharmacodynamics.

Cancer chemotherapy may be associated with a high incidence of nausea and vomiting, particularly when certain agents, such as cisplatin, are used. 5-HT₃ receptors are located on the nerve terminals of the vagus in the periphery and centrally in the chemoreceptor trigger zone of the area postrema. It is thought that chemotherapeutic agents produce nausea and vomiting by releasing serotonin from the enterochromaffin cells of the small intestine and that the released serotonin then activates 5-HT₃ receptors located on vagal afferents to initiate the vomiting reflex.
The effect of palonosetron on blood pressure, heart rate, and ECG parameters including QTc were comparable to ondansetron and dolasetron in clinical trials. In non-clinical studies palonosetron possesses the ability to block ion channels involved in ventricular de- and re- polarisation and to prolong action potential duration. The effect of palonosetron on QTc interval was evaluated in a double blind, randomised, parallel, placebo and positive (moxifloxacin) controlled trial in adult men and women. The objective was to evaluate the ECG effects of IV administered palonosetron at single doses of 0.25, 0.75 or 2.25 mg in 221 healthy subjects. The study demonstrated no effect on QT/QTc interval duration as well as any other ECG interval at doses up to 2.25 mg. No clinically significant changes were shown on heart rate, atrioventricular (AV) conduction and cardiac repolarisation.

Clinical trials.

Chemotherapy - induced nausea and vomiting (CINV) in adults.

Single-dose palonosetron administration. Efficacy of single-dose palonosetron injection in preventing nausea and vomiting induced by moderately and highly emetogenic chemotherapy was studied in a phase 2 dose-ranging trial and three phase 3 trials. In the phase 3 trials, the primary efficacy endpoint was complete response rate (no emetic episodes and no rescue medication). Prevention of nausea was assessed as a secondary efficacy endpoint. The safety and efficacy of palonosetron in repeated courses of chemotherapy was also studied.

Moderately emetogenic chemotherapy.

Two Phase 3, double-blind trials involving 1132 patients compared single-dose IV palonosetron with either single-dose IV ondansetron (study 1) or dolasetron (study 2) given 30 minutes prior to moderately emetogenic chemotherapy including carboplatin, cisplatin ≤ 50 mg/m², cyclophosphamide < 1500 mg/m², doxorubicin > 25 mg/m², epirubicin, irinotecan, and methotrexate > 250 mg/m². Concomitant corticosteroids were not administered prophylactically in study 1 and were only used by 4-6% of patients in study 2. The majority of patients in these studies were women (77%), White (65%) and naïve to previous chemotherapy (54%). The mean age was 55 years, (age range 18-97).

Highly emetogenic chemotherapy.

A Phase 2, double-blind, dose-ranging study evaluated the efficacy of single-dose IV palonosetron from 0.3 to 90 microgram/kg (equivalentto < 0.1 mg to 6 mg fixed dose) in 161chemotherapy-naïve adult cancer patients receiving highly-emetogenic chemotherapy (either cisplatin ≥ 70 mg/m² or cyclophosphamide > 1100 mg/m²). Concomitant corticosteroids were not administered prophylactically. Analysis of data from this trial indicates that 250 microgram is the lowest effective dose in preventing acute nausea and vomiting induced by highly emetogenic chemotherapy.
A Phase 3, double-blind trial involving 667 patients compared single-dose IV palonosetron with single-dose IV ondansetron (study 3) given 30 minutes prior to highly emetogenic chemotherapy including cisplatin ≥ 60 mg/m², cyclophosphamide > 1500 mg/m², and dacarbazine. Highly emetogenic chemotherapy was given only for the first day of the chemotherapy cycle. For the remainder of the cycle, low to moderately (max grade 3 of Hesketh scale) emetogenic chemotherapy was allowed. Corticosteroids were co-administered prophylactically before chemotherapy in 67% of patients. Of the 667 patients, 51% were women, 60% White, and 59% naïve to previous chemotherapy. The mean age was 52 years; (age range 18-86).

Efficacy results.

Intent-to-treat analyses are presented. The conclusions of the per protocol analyses were similar.
Palonosetron was non-inferior to the comparators in the prevention of acute vomiting (within 24h) after moderately and highly emetogenic chemotherapy and comparable in the prevention of nausea (Tables 3-5). Efficacy was greater when corticosteroids were administered concomitantly in the highly emetogenic setting. The secondary efficacy endpoint of the study assessed delayed onset (24-120 h) nausea and vomiting, the results are shown below (Tables 3-5).
The comparative efficacy of palonosetron 250 microgram in multiple cycles of chemotherapy has not been demonstrated.

Multiple-dose palonosetron administration. Published randomised, controlled studies have not been designed to show, or have not shown, improvement in primary efficacy endpoints related to nausea and vomiting in patient arms given palonosetron daily or on alternate days, relative to single dose use, in the context of multiple day chemotherapy. It has not been clearly established that such repeated dosing provides significant additional benefit compared to a single dose.

Post-operative nausea and vomiting (PONV) in adults.

In one multicentre, randomised, stratified, double-blind, parallel-group, phase 3 clinical study (PALO-04-06), palonosetron was compared with placebo for the prevention of PONV in 546 patients undergoing abdominal and gynaecological surgery. All patients received general anaesthesia. PALO-04-06 was a pivotal study conducted predominantly in the US in the outpatient setting for patients undergoing elective gynaecologic or abdominal laparoscopic surgery and stratified at randomisation for the following risk factors: gender, non-smoking status, history of post-operative nausea and vomiting and/or motion sickness.
In PALO-04-06 patients were randomised to receive palonosetron 25, 50 or 75 microgram or placebo, each given intravenously immediately prior to induction of anaesthesia. The antiemetic activity of palonosetron was evaluated during the 0 to 72 hour time period after surgery.
Of the 138 patients treated with 75 microgram palonosetron in PALO-04-06 and evaluated for efficacy, 96% were women; 66% had a history of PONV or motion sickness; 85% were non-smokers. As for race, 63% were White, 20% were Black, 15% were Hispanic, and 1% were Asian.
The age of patients ranged from 21 to 74 years, with a mean age of 37.9 years. Three patients were greater than 65 years of age.
Co-primary efficacy measures were Complete Response (CR) defined as no emetic episode and no use of rescue medication in the 0-24 and in the 24-72 hours postoperatively.
Secondary efficacy endpoints included:
Complete response (CR) 0-48 and 0-72 hours;
Complete control (CC) defined as CR and no more than mild nausea;
Severity of nausea (none, mild, moderate, severe).
The primary hypothesis in PALO-04-06 was that at least one of the three palonosetron doses was superior to placebo.
Results for complete response in PALO-04-06 for 75 microgram palonosetron versus placebo are described in Table 6.

Palonosetron 75 microgram reduced the severity of nausea compared to placebo. Analyses of other secondary endpoints indicate that palonosetron 75 microgram was numerically better than placebo, however, statistical significance was not formally demonstrated.

5.2 Pharmacokinetic Properties

After intravenous dosing of palonosetron in healthy subjects and cancer patients, an initial decline in plasma concentrations is followed by a slow elimination from the body. Mean maximum plasma concentration (C_max) and area under the concentration-time curve (AUC_0-∞) are generally dose proportional over the dose range of 0.3-90 microgram/kg in healthy subjects and in cancer patients.
Following single IV dose of palonosetron at 3 microgram/kg (or 0.21 mg/70 kg) to six cancer patients, mean (± SD) maximum plasma concentration was estimated to be 5.6 ± 5.5 nanogram/mL and mean AUC was 35.8 ± 20.9 nanogram.hr/mL.
Following intravenous administration of palonosetron 0.25 mg once every other day for 3 doses in 11 testicular cancer patients, the mean (± SD) increase in the initial phase of the plasma concentration-time curve (AUC_{0-2.5 hr}) from Day 1 to Day 5 was 42 ± 34 %; how this finding relates to more conventional measures of systemic exposure is not known.
After intravenous administration of palonosetron 0.25 mg once daily for 3 days in 12 healthy subjects, the mean (± SD) increase in systemic exposure over 24 hours (AUC_{0-24 hr}) from Day 1 to Day 3 was 110 ± 45 %.
Drug accumulation may be greater in the 10% of patients with prolonged elimination half-life.

Distribution.

Palonosetron has a volume of distribution of approximately 8.3 ± 2.5 L/kg. Approximately 62% of palonosetron is bound to plasma proteins.

Metabolism.

Palonosetron is eliminated by multiple routes with approximately 50% metabolized to form two primary metabolites: N-oxide-palonosetron and 6-S-hydroxy-palonosetron. These metabolites each have less than 1% of the 5-HT₃ receptor antagonist activity of palonosetron. In vitro metabolism studies have suggested that CYP2D6 and to a lesser extent, CYP3A and CYP1A2 are involved in the metabolism of palonosetron. However, clinical pharmacokinetic parameters are not significantly different between poor and extensive metabolizers of CYP2D6 substrates.

Excretion.

After a single intravenous dose of 10 microgram/kg [¹⁴C]-palonosetron, approximately 80% of the dose was recovered within 144 hours in the urine with palonosetron representing approximately 40% of the administered dose. In healthy subjects the total body clearance of palonosetron was 160 ± 35 mL/h/kg and renal clearance was 66.5 ± 18.2 mL/h/kg. Mean terminal elimination half-life is approximately 40 hours.

5.3 Preclinical Safety Data

Genotoxicity.

Palonosetron was not genotoxic in the Ames test, the Chinese hamster ovarian cell (CHO/HGPRT) forward mutation test, the ex vivo hepatocyte unscheduled DNA synthesis test or the mouse micronucleus test. It was, however, positive for clastogenic effects in the CHO cell chromosomal aberration test.

Carcinogenicity.

In a 104-week carcinogenicity study in CD-1 mice, animals were treated with oral doses of palonosetron at 10, 30 and 60 mg/kg/day. Treatment with palonosetron was not tumorigenic. The highest tested dose produced a systemic exposure to palonosetron (plasma AUC) of > 600 times the human exposure at the recommended intravenous dose of 250 microgram.
In a 104-week carcinogenicity study in Sprague-Dawley rats, male and female rats were treated with oral doses of 15, 30 and 60 mg/kg/day and 15, 45 and 90 mg/kg/day, respectively. The lowest and highest doses, respectively, produced a systemic exposure to palonosetron (plasma AUC) of > 25 times and > 500 times the human exposure at the recommended dose.
Treatment with palonosetron produced increased incidences of adrenal benign pheochromocytoma and combined benign and malignant pheochromocytoma in both male and female rats, of pancreatic Islet cell adenoma and combined adenoma and carcinoma of pancreatic acinar cell adenoma and combined adenoma and adenocarcinoma and of pituitary adenoma in male rats. Increased incidences of skin keratocanthomas and tail squamous cell papillomas were also observed, mainly in males. In female rats, palonosetron produced hepatocellular adenoma and combined hepatocellular adenoma and carcinoma, and increased the incidences of thyroid C-cell adenoma and combined adenoma and carcinoma, and of mammary gland adrenocarcinoma

6 Pharmaceutical Particulars

6.1 List of Excipients

Mannitol, disodium edetate, citric acid monohydrate, sodium citrate dihydrate, sodium hydroxide and/or hydrochloric acid, and water for injections.

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 Australian Register of Therapeutic Goods (ARTG). The expiry date can be found on the packaging.

6.4 Special Precautions for Storage

Store below 25°C. Protect from light.

6.5 Nature and Contents of Container

Glass type 1 clear vial.
Palonosetron Medsurge 250 microgram/5 mL solution for injection is sold as a single pack of 1 vial.

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

Palonosetron hydrochloride is a white to off-white crystalline powder. It is freely soluble in water, soluble in propylene glycol, and slightly soluble in ethanol and 2-propanol.
The pH of the solution is 4.5 to 5.5.

Chemical structure.

Chemically, palonosetron hydrochloride is: (3aS)-2-[(S)-1-Azabicyclo[2.2.2]oct-3-yl]- 2,3,3a,4,5,6-hexahydro-1-oxo-1Hbenz[de]isoquinoline hydrochloride. The empirical formula is C₁₉H₂₄N₂O.HCl, with a molecular weight of 332.87. Palonosetron hydrochloride exists as a single isomer.

CAS number.

135729-61-2 palonosetron.
135729-62-3 palonosetron hydrochloride.

7 Medicine Schedule (Poisons Standard)

S4 / Prescription Medicine.

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