Consumer medicine information

Temozolomide JUNO

Temozolomide

BRAND INFORMATION

Brand name

Temozolomide Juno

Active ingredient

Temozolomide

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Temozolomide JUNO.

SUMMARY CMI

Temozolomide Juno

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 Temozolomide Juno?

Temozolomide Juno contains the active ingredient temozolomide. Temozolomide belongs to a group of medicines called cytotoxic or chemotherapy medicines. Temozolomide works by killing cancer cells and stopping cancer cells from growing and multiplying.

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

2. What should I know before I use Temozolomide Juno?

Do not use if you have ever had an allergic reaction to temozolomide 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 Temozolomide Juno? in the full CMI.

3. What if I am taking other medicines?

Some medicines may interfere with temozolomide 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 Temozolomide Juno?

  • Your doctor has worked out the exact dose of Temozolomide Juno for you according to your individual needs.
  • Each time you start a new treatment cycle, be sure you understand exactly how many capsules of each strength you need to take on each day of dosing.

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

5. What should I know while using Temozolomide Juno?

Things you should do
  • Remind any doctor, dentist or pharmacist you visit that you are using Temozolomide Juno.
  • Tell your doctor if you feel sick or vomit while being treated with Temozolomide Juno.
Things you should not do
  • Do not open the capsules. If a capsule is damaged, avoid contact with your skin, eyes and nose. Avoid inhaling the powder. If you touch the powder or get some in your eyes or nose, wash the area with water.
Driving or using machines
  • Be careful before you drive or use any machines or tools until you know how temozolomide affects you.
  • As with other medicines, temozolomide may make some people feel tired. If this occurs do not drive.
Looking after your medicine
  • Store Temozolomide Juno in a cool, dry place where the temperature stays below 25°C.
  • Keep your capsules in the original sachets or bottles until it is time to take them.
  • Follow the instructions on the pack on how to take care of your medicine properly.

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

6. Are there any side effects?

Like all medicines, temozolomide can cause side effects. Your doctor will discuss these with you and will explain the risks and benefits of using this medicine.

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

Temozolomide Juno

Active ingredient(s): temozolomide

Consumer Medicine Information (CMI)

This leaflet provides important information about using Temozolomide Juno. 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 Temozolomide Juno.

Where to find information in this leaflet:

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

1. Why am I using Temozolomide Juno?

Temozolomide Juno contains the active ingredient temozolomide. Temozolomide belongs to a group of medicines called cytotoxic or chemotherapy medicines.

Temozolomide works by killing cancer cells and stopping cancer cells from growing and multiplying.

Temozolomide is used to treat patients with brain tumors. It is also used to treat adult patients with advanced metastatic malignant melanoma.

Your doctor, however, may prescribe temozolomide for another purpose.

Use in children

Temozolomide Juno capsules are used to treat children 3 years of age and older, with specific forms of brain tumour (glioblastoma multiforme or anaplastic astrocytoma, showing recurrence or progression after standard therapy).

Ask your doctor if you have any questions about why Temozolomide Juno has been prescribed for you.

2. What should I know before I use Temozolomide Juno?

Warnings

Do not use Temozolomide Juno if:

  • You are allergic to temozolomide, dacarbazine (DTIC) or any of the ingredients listed at the end of this leaflet. Some of the symptoms of an allergic reaction may include skin rash, itching or hives, swelling of the face, lips or tongue which may cause difficulty in swallowing or breathing, wheezing or shortness of breath. Always check the ingredients to make sure you can use this medicine.
  • You are pregnant or you or your partner intend to become pregnant (see pregnancy information below).
  • You are breastfeeding (see breastfeeding information below).
  • You have a very low level of white blood cells, red blood cells or platelets (myelosuppression).

Check with your doctor if you:

  • Have allergies to any other medicines, foods, preservatives or dyes.
  • Intend to have children. Temozolomide may cause infertility in men.
  • Vomit frequently. Your doctor may give you medicine to control the vomiting.
  • Are anaemic or have blood clotting problems.
  • Have liver or kidney problems. Temozolomide could cause hepatitis B to become active again, which can be fatal in some cases.
  • 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. Temozolomide may cause birth defects if either the male or female is using it at the time of conception or during pregnancy. Therefore, female patients must have a negative pregnancy test before starting temozolomide. Both male and female patients and their partners should each use some kind of birth control while taking temozolomide and also after the last dose. Female patients should continue to use an effective form of birth control for at least 6 months and male patients to continue for at least 3 months after the final dose. Male patients whose partners are already pregnant should use a condom to minimise exposure of the unborn baby to temozolomide in the sperm. Also, do not donate sperm during and for at least 3 months after the final dose due to the potential effects on sperm.

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

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 be affected by temozolomide, or may affect how well it works. These include other medicines used to treat cancer or any other treatments that may affect your immune system. You may need different amounts of your medicine or you may need to use different medicines. Your doctor will advise you.

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

4. How do I use Temozolomide Juno?

How much to take

Your doctor has worked out the exact dose of Temozolomide Juno for you according to your individual needs. You may be given other medication to take before or after Temozolomide Juno to help stop nausea.

If you are taking Temozolomide Juno in combination treatment with radiation (newly diagnosed patients):

If you are a patient with a newly diagnosed brain tumour, your doctor will start you on a dose of Temozolomide Juno every day for 42 days (up to 49 days) in combination with radiation therapy. This is the first part of the treatment ("concomitant phase") in which you complete the radiation therapy. Your treatment will be interrupted for 4 weeks to give your body a chance to recover.

You will then start the next phase of treatment ("adjuvant phase"). and your Temozolomide Juno dose will change. In this phase, there are up to 6 treatment cycles. Each treatment cycle lasts 28 days. You will take your new dose of Temozolomide Juno capsules once daily for the first five days ("dosing days") of each cycle, followed by 23 days without Temozolomide Juno; this adds up to a 28 day treatment cycle. After day 28, the next cycle will begin, in which you will again take this medicine once daily for five days followed by 23 days without Temozolomide Juno.

Before each new treatment cycle begins, your blood will be tested to determine if the Temozolomide Juno dose needs to be adjusted.

If you are taking Temozolomide Juno alone (patients treated for recurrent brain tumour):

Take the dose the doctor has prescribed once a day for five days.

Depending on your response to Temozolomide Juno, a new treatment cycle will begin each 28 days. You will then take this medicine again once daily for five days.

Before each new treatment cycle, your blood will be tested to see if the dose needs to be changed.

How to take Temozolomide Juno

Swallow the capsules whole with a glass of water. Do not open or chew the capsules.

Each time you start a new treatment cycle, be sure you understand exactly how many capsules of each strength you need to take on each day of dosing.

Temozolomide Juno comes in different strength capsules (shown on the outer label in ‘mg’). Each strength is a different colour. Depending on the dose of Temozolomide Juno that your doctor prescribes, you may have to take several capsules on each dosing day of the treatment cycle.

Be sure you understand exactly how many capsules you need to take of each strength.

Ask your doctor or pharmacist to write down the number of each strength (include colour) that you need to take on each dosing day.

Be sure you know exactly which days are your dosing days.

Be sure you review the dose with your health care provider each time you start a new cycle.

Sometimes the dose or the mix of capsules you need to take will be different from the last cycle.

Once you take the medicine home, if you are confused or unsure about how to take your dose, call for re-instruction before beginning the treatment cycle.

Errors in how you take this medicine may have serious health consequences.

When to take Temozolomide Juno

Take Temozolomide Juno without food at least one hour before a meal.

It is good practice to take it at about the same time each day.

If vomiting occurs after you take your capsules, do not take another dose that day.

How long to take it for

Keep taking Temozolomide Juno exactly as your doctor recommends.

Your doctor will tell you when your treatment should be stopped.

If you forget to use Temozolomide Juno

Temozolomide Juno should be used regularly at the same time each day. If you miss your dose at the usual time, take the missed dose as soon as possible during the same day. If a full day has gone by, check with your doctor.

Do not double the next dose unless your doctor tells you to do so.

If you use too much Temozolomide Juno

If you think that you have used too much temozolomide, 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 Temozolomide Juno?

Things you should do

Tell all doctors, dentists and pharmacists who are treating you that you are taking Temozolomide Juno.

Tell your doctor if you feel sick or vomit while being treated with Temozolomide Juno.

Your doctor may give you another medicine to help with this.

Tell your doctor if you become unusually pale or tired, get blood clotting problems or frequent infections while being treated with Temozolomide Juno.

These could be caused by a low level of red blood cells, platelets or white blood cells in the blood. This is more common in patients over 70 years of age. Your doctor may need to change your dose of Temozolomide Juno.

Tell your doctor immediately if you or your partner becomes pregnant while taking Temozolomide Juno.

Be sure to keep all your doctor's appointments so your progress can be checked.

Your doctor may need to do some blood and other tests from time to time to check on your progress and detect any unwanted side effects.

Keep follow-up appointments with your doctor.

It is important to have your follow-up doses of Temozolomide Juno at the appropriate times to get the best effects from your treatment.

If you are about to be started on any new medicine, tell your doctor, dentist or pharmacist that you are being treated with Temozolomide Juno.

Things you should not do

Do not open the capsules. If a capsule is damaged, avoid contact with your skin, eyes and nose. Avoid inhaling the powder. If you touch the powder or get some in your eyes or nose, wash the area with water.

Do not use Temozolomide Juno to treat any other conditions unless your doctor tells you to.

Do not give Temozolomide Juno 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 temozolomide affects you.

As with other medicines, temozolomide may make some people feel tired. If this occurs, do not drive.

Drinking alcohol

Tell your doctor if you drink alcohol.

Alcohol may make some side effects worse.

Looking after your medicine

  • Keep your capsules in the original sachets or bottles until it is time to take them.
  • Keep your capsules in a cool, dry place where the temperature stays below 25°C.

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

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.

When to discard your medicine (as relevant)

  • Do not use Temozolomide Juno after the expiry date printed on the pack.
  • Do not use Temozolomide Juno if the packaging shows signs of tampering.

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.

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
  • nausea, vomiting, feeling unwell
  • tiredness, sleepiness
  • constipation
  • headache
  • loss of appetite or weight
  • diarrhoea
  • fever or high temperature
  • rash, hair loss, itching
  • dizziness, weakness
  • general body pain
  • stomach pain, indigestion
  • different taste sensation
  • mouth ulcers
  • coughing
  • sleeplessness
Speak to your doctor if you have any of these less serious side effects and they worry you.

Serious side effects

Serious side effectsWhat to do
  • shortness of breath
  • tingling or numbness in hands or feet
  • bruising, bleeding or being unusually pale or tired. This could be caused by a low level of platelets or red blood cells in the blood.
  • new or recurring cytomegalovirus infection and return of hepatitis B
  • symptoms of diabetes, such as passing large amount of urine and constant thirst
  • symptoms such as fever, headache, personality change, seizures, and/or vomiting which could be associated with a brain infection caused by herpes virus.
  • shivering that is associated with chills and fever. This could be sign of an infection caused by a low level of white blood cells in the blood.
  • development of red or purple spots under the skin
These last two side effects may take some time to occur. Therefore, even after you have finished your treatment with temozolomide, you should tell your doctor immediately if you notice these side effects.		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.

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 Temozolomide Juno contains

Active ingredient
(main ingredient)		Temozolomide
Other ingredients
(inactive ingredients)
  • lactose
  • colloidal anhydrous silica
  • sodium starch glycollate
  • tartaric acid
  • stearic acid
  • gelatin
  • purified water
  • titanium dioxide
  • indigo carmine CI73015 (5 mg and 140 mg capsules only)
  • iron oxide yellow (5 mg, 20 mg and 180 mg capsules only)
  • iron oxide red (100 mg and 180 mg capsules only)
  • TekPrint SW-9008 black ink, (ARTG 2328).

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

Temozolomide Juno does not contain sucrose, gluten, tartrazine or other azo dyes.

What Temozolomide Juno looks like

Temozolomide Juno capsules come in the following strengths:

  • 5 mg – green and white capsule printed with “TMZ” and “5” in black
  • 20 mg – yellow and white capsule printed with “TMZ” and “20” in black
  • 100 mg – pink and white capsule printed with “TMZ” and “100” in black
  • 140 mg – blue and white capsule printed with “TMZ” and “140” in black
  • 180 mg – maroon and white capsule printed with “TMZ” and “180” in black
  • 250 mg – white capsule printed with “TMZ” and “250” in black.

Sachet Pack: Each sachet contains 1 capsule. There are 5 sachets or 20 sachets in a pack.

Bottle Pack: Each bottle contains 5 capsules or 20 capsules.

Australian registration numbers (sachets):

  • Temozolomide Juno 5 - AUST R206042
  • Temozolomide Juno 20 - AUST R206043
  • Temozolomide Juno 100 - AUSTR 206044
  • Temozolomide Juno 140 - AUSTR 206215
  • Temozolomide Juno 180 - AUSTR 206045
  • Temozolomide Juno 250 - AUSTR 206046.

Australian registration numbers (bottles):

  • Temozolomide Juno 5 - AUST R354885
  • Temozolomide Juno 20 - AUST R354886
  • Temozolomide Juno 100 - AUSTR 354887
  • Temozolomide Juno 140 - AUSTR 354890
  • Temozolomide Juno 180 - AUSTR 354888
  • Temozolomide Juno 250 - AUSTR 354889.

Who distributes Temozolomide Juno

Juno Pharmaceuticals Pty Ltd
15-17 Chapel Street
Cremorne VIC 3121
www.junopharm.com.au

This leaflet was prepared in October 2024.

Published by MIMS December 2024

BRAND INFORMATION

Brand name

Temozolomide Juno

Active ingredient

Temozolomide

Schedule

S4

 

1 Name of Medicine

Temozolomide.

2 Qualitative and Quantitative Composition

Temozolomide Juno capsules come in 6 strengths and contain 5 mg, 20 mg, 100 mg, 140 mg, 180 mg or 250 mg of temozolomide.

List of excipients with known effect.

Contains sugars as lactose. For the full list of excipients, see Section 6.1 List of Excipients.

3 Pharmaceutical Form

Temozolomide Juno (temozolomide) 5 mg.

Green and white hard capsules, printed in black ink with "TMZ" on the cap and "5" on the body.

Temozolomide Juno (temozolomide) 20 mg.

Yellow and white hard capsules, printed in black ink with "TMZ" on the cap and "20" on the body.

Temozolomide Juno (temozolomide) 100 mg.

Pink and white hard capsules, printed in black ink with "TMZ" on the cap and "100" on the body.

Temozolomide Juno (temozolomide) 140 mg.

Blue and white hard capsules, printed in black ink with "TMZ" on the cap and "140" on the body.

Temozolomide Juno (temozolomide) 180 mg.

Maroon and white hard capsules, printed in black ink with "TMZ" on the cap and "180" on the body.

Temozolomide Juno (temozolomide) 250 mg.

White hard capsules, printed in black ink with "TMZ" on the cap and "250" on the body.

4 Clinical Particulars

4.1 Therapeutic Indications

Treatment of newly diagnosed glioblastoma multiforme concomitantly with radiotherapy and then as adjuvant treatment.
Treatment of recurrence of anaplastic astrocytoma and glioblastoma multiforme following standard therapy.
Temozolomide Juno is also indicated as a first-line treatment for patients with advanced metastatic malignant melanoma.

4.2 Dose and Method of Administration

Antiemetic therapy may be administered prior to or following administration of temozolomide.
Temozolomide should be administered in the fasting state at least one hour before a meal. If vomiting occurs after the dose is administered, a second dose should not be administered that day. Temozolomide capsules must not be opened or chewed, but are to be swallowed whole with a glass of water. If a capsule becomes damaged, avoid contact of the powder contents with skin or mucous membrane.

Adult patients with newly diagnosed glioblastoma multiforme.

Concomitant phase.

Temozolomide is administered orally at 75 mg/m2 daily for 42 days concomitant with focal radiotherapy (60 Gy administered in 30 fractions) followed by adjuvant temozolomide for six cycles. No dose reductions are recommended, however, dose interruptions may occur based on patient tolerance. The temozolomide dose can be continued throughout the 42 day concomitant period up to 49 days (if needed due to radiotherapy interruption) if all of the following conditions are met: ANC greater than or equal to 1.5 x 109/L, thrombocyte count greater than or equal to 100 x 109/L, common toxicity criteria (CTC) nonhaematological toxicity less than or equal to grade 1 (except for alopecia, nausea and vomiting). During treatment a complete blood count should be obtained weekly. Temozolomide dosing should be interrupted or discontinued during concomitant phase according to the haematological and nonhaematological toxicity criteria as noted in Table 1.

Adjuvant phase.

Four weeks after completing the temozolomide + radiotherapy phase, temozolomide is administered for an additional six cycles of adjuvant treatment. Dosage in cycle 1 (adjuvant) is 150 mg/m2 once daily for five days followed by 23 days without treatment. At the start of cycle 2, the dose is escalated to 200 mg/m2 if the CTC nonhaematological toxicity for cycle 1 is grade less than or equal to 2 (except for alopecia, nausea and vomiting), ANC is greater than or equal to 1.5 x 109/L and the thrombocyte count is greater than or equal to 100 x 109/L. If the dose was not escalated at cycle 2, escalation should not be done in subsequent cycles. The dose remains at 200 mg/m2 per day for the first five days of each subsequent cycle except if toxicity occurs. Dose reductions during the adjuvant phase should be applied according to Tables 2 and 3.
During treatment a complete blood count should be obtained on day 22 (21 days after the first dose of temozolomide). The temozolomide dose should be reduced or discontinued according to Table 3.

Adults with recurrent glioblastoma multiforme or anaplastic astrocytoma.

In recurrent adult patients previously untreated with chemotherapy, temozolomide is administered orally at a dose of 200 mg/m2 once daily for five days per 28 day cycle. For those previously treated with chemotherapy, the initial dose is 150 mg/m2 once daily, to be increased in the second cycle to 200 mg/m2 daily providing the ANC is greater than or equal to 1.5 x 109/L and the platelet count is greater than or equal to 100 x 109/L on day 1 of the next cycle.
Dose modification for temozolomide should be based on toxicities according to nadir ANC or platelet counts.

Adults with metastatic malignant melanoma.

For patients with metastatic malignant melanoma, the recommended dose is 200 mg/m2 once daily for five days per 28 day cycle.

Paediatric patients with recurrent glioblastoma multiforme or anaplastic astrocytoma.

In patients 3 years of age or older, temozolomide is administered orally at a dose of 200 mg/m2 once daily for five days per 28 day cycle. Paediatric patients previously treated with chemotherapy or craniospinal irradiation should receive an initial dose of 150 mg/m2 once daily for five days, with escalation to 200 mg/m2 once daily at the next cycle if there is no toxicity.
The efficacy of temozolomide for the treatment of recurrent glioblastoma multiforme in patients who received the drug as concomitant/adjuvant treatment has not been established.
In patients with recurrent glioblastoma multiforme/anaplastic astrocytoma or metastatic melanoma, can be continued until disease progression or for a maximum of two years.

4.3 Contraindications

History of hypersensitivity reaction to components of temozolomide or to DTIC.
Use during pregnancy and in women who intend to become pregnant (see Section 4.6 Fertility, Pregnancy and Lactation).
Must not be used by breastfeeding women (see Section 4.6 Fertility, Pregnancy and Lactation).
Severe myelosuppression.

4.4 Special Warnings and Precautions for Use

Pneumocystis carinii pneumonia.

Patients who received concomitant temozolomide and radiotherapy in a pilot trial for the prolonged 42 day schedule were shown to be at particular risk for developing Pneumocystis carinii pneumonia (PCP).
Thus, prophylaxis against PCP is required for all patients receiving concomitant temozolomide and radiotherapy for the 42 day regimen (with a maximum of 49 days) regardless of lymphocyte count. If lymphocytopenia occurs PCP prophylaxis should continue to a lymphocyte count less than or equal to grade 1.
There may be a higher occurrence of PCP when temozolomide is administered during a longer dosing regimen. However, all patients receiving temozolomide, particularly patients receiving steroids, should be observed closely for the development of PCP regardless of the regimen.

Hepatotoxicity.

Hepatic injury, including fatal hepatic failure, has been reported very rarely in patients treated with temozolomide. Baseline liver function tests should be performed prior to treatment initiation. If abnormal, physicians should assess the benefit/risk prior to initiating temozolomide including the potential for fatal hepatic failure. For patients on a 42 day treatment cycle liver function tests should be repeated midway during this cycle. For all patients, liver function tests should be checked after each treatment cycle. For patients with significant liver function abnormalities, physicians should assess the benefit/risk of continuing treatment. Liver toxicity may occur several weeks or more after the last treatment with temozolomide.

HBV reactivation.

Hepatitis due to hepatitis B virus (HBV) reactivation, in some cases resulting in death, has been reported. Patients should be screened for HBV infection before treatment initiation. Patients with evidence of prior HBV infection should be monitored for clinical and laboratory signs of hepatitis or HBV reactivation during and for several months following treatment with temozolomide. Therapy should be discontinued for patients with evidence of active hepatitis B infection.

Antiemetic therapy.

Nausea and vomiting are very commonly associated with temozolomide and guidelines are provided as follows.

Patients with newly diagnosed glioblastoma multiforme.

Antiemetic prophylaxis is recommended prior to the initial dose of concomitant temozolomide.
Antiemetic prophylaxis is strongly recommended during the adjuvant phase.

Patients with recurrent glioma.

Patients who have experienced severe (grade 3 or 4) vomiting in previous treatment cycles may require antiemetic therapy.

All patients.

Keep this medication out of the reach of children.

Myelosuppression.

Temozolomide causes myelosuppression. Patients treated with temozolomide may also experience prolonged pancytopenia. This may result in aplastic anaemia, which in some cases has resulted in a fatal outcome. In some cases, exposure to concomitant medications associated with aplastic anaemia, including carbamazepine, phenytoin and sulfamethoxazole/trimethoprim complicates assessment. Prior to dosing, the following laboratory parameters must be met: absolute neutrophil count (ANC) of > 1.5 x 109/L and platelets of > 100 x 109/L. During cyclical treatment a complete blood count must be obtained on day 22 (21 days after the first dose) or within 48 hours of that day, and weekly until ANC is above 1.5 x 109/L and platelet count exceeds 100 x 109/L. If ANC falls to < 1.0 x 109/L or the platelet count is < 50 x 109/L during any cycle, the next cycle should be reduced one dose level. Dose levels include 100, 150 and 200 mg/m2. The lowest recommended dose is 100 mg/m2.

Use in hepatic impairment.

No data are available on the administration of temozolomide in patients with hepatic dysfunction. Based on the pharmacokinetic properties of temozolomide, it is unlikely that dose reductions are required in such patients. However, caution should be exercised when temozolomide is administered to these patients. See Section 4.4 Special Warnings and Precautions for Use, Hepatotoxicity.

Use in renal impairment.

No data are available on the administration of temozolomide in patients with renal dysfunction. Based on the pharmacokinetic properties of temozolomide, it is unlikely that dose reductions are required in such patients. However, caution should be exercised when temozolomide is administered to these patients.

Use in the elderly.

Elderly patients (> 70 years of age) appear to be at increased risk of neutropenia and thrombocytopenia, compared with younger patients.

Paediatric use.

Anaplastic astrocytoma/ glioblastoma multiforme.

There is limited experience in children over the age of 3 years with glioma (see Section 5.1 Pharmacodynamic Properties, Clinical trials). There is no clinical experience with use of temozolomide in children under the age of 3 years.

Melanoma.

There is no clinical experience in patients under 18 years of age.

Effects on laboratory tests.

No data available.

4.5 Interactions with Other Medicines and Other Forms of Interactions

Administration of temozolomide with ranitidine did not result in clinically significant alterations in the extent of absorption of temozolomide. Coadministration of dexamethasone, prochlorperazine, phenytoin, carbamazepine, ondansetron, H2-receptor antagonists or phenobarbitone did not alter the clearance of temozolomide. Coadministration with valproic acid was associated with a small but statistically significant decrease in clearance of temozolomide.
Use of temozolomide in combination with other alkylating agents or O6-alkylguanine-DNA alkyltransferases may increase the likelihood of myelosuppression and general toxicity.

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

Temozolomide is contraindicated in women who intend to become pregnant, and effective contraception should be used by female patients during and for at least 6 months after treatment with temozolomide (see Section 4.3 Contraindications; Section 4.6 Fertility, Pregnancy and Lactation).

Use in men.

Effective contraception should be used by male patients treated with temozolomide as it can have genotoxic effects. Therefore, men being treated with temozolomide are advised not to father a child for at least 3 months after receiving the final dose and to seek advice on cryoconservation of spermatozoa prior to treatment because of the possibility of irreversible impairment in fertility due to therapy with temozolomide. Semen donation is also not advised during treatment and for at least 3 months after the final dose. (see Section 5.3 Preclinical Safety Data; Section 4.6 Fertility, Pregnancy and Lactation).
(Category D)
Cytotoxic agents can produce spontaneous abortion, foetal loss and birth defects. There are no studies in pregnant women. In preclinical studies in rats and rabbits administered 150 mg/m2, (associated with systemic exposure below that anticipated in humans) teratogenicity and/or foetal toxicity were demonstrated. Temozolomide, therefore, should not be administered to pregnant women. If use during pregnancy must be considered, the patient should be apprised of the potential risk to the foetus. Women of childbearing potential should be advised to avoid pregnancy if they are going to receive temozolomide treatment and for six months after discontinuation of therapy.
 It is not known whether temozolomide is excreted in human milk. A peri/postnatal study in rats found that treatment with temozolomide at doses of greater than 25 mg/m2/day decreased pup growth and retarded development. Given its potential adverse effects in the newborn, temozolomide must not be used by breastfeeding women.

4.7 Effects on Ability to Drive and Use Machines

Temozolomide may influence the ability to drive and use machines due to fatigue and somnolence (see Section 4.8 Adverse Effects (Undesirable Effects)).

4.8 Adverse Effects (Undesirable Effects)

Newly diagnosed glioblastoma multiforme.

See Table 4.

Patients with recurrent anaplastic astrocytoma, glioblastoma multiforme or malignant melanoma.

The frequency of adverse drug reactions reported in clinical trials or spontaneously is listed below and classified according to body system. Frequency estimates: Very common (≥ 10%), Common (≥ 1% and < 10%).

Neurological.

Very common: fatigue, headache.
Common: somnolence, asthenia, dizziness, paraesthesia.

Gastrointestinal.

Very common: nausea, vomiting, constipation, anorexia.
Common: diarrhoea, abdominal pain, dyspepsia, taste perversion.

Haematological.

Very common: thrombocytopenia, neutropenia.
Common: anaemia, leucopenia.

Dermatological.

Common: rash, alopecia, pruritus, petechiae.

Respiratory.

Common: dyspnoea.

General.

Common: fever, pain, malaise, weight decrease, rigors.
In clinical trials, the most frequently occurring undesirable effects were gastrointestinal disturbances, specifically nausea (43%) and vomiting (36%). These effects were usually grade 1 or 2 (mild to moderate in severity) and were either self limiting or readily controlled with standard antiemetic therapy. The incidence of severe nausea and vomiting was 4%. Severe myelosuppression, predominantly thrombocytopenia, was dose limiting and occurred in 7% of all patients. Anaemia was reported in 5% of patients. Severe neutropenia and leucopenia occurred in 3 and 2% of patients, respectively.
In children, the incidence of the more common adverse events (nausea, vomiting, various CNS events and those of haematological origin) are consistent with the results from studies in adults as well as the underlying disease.

Myelosuppression.

In adult patients myelosuppression was common, with grade 3 or 4 thrombocytopenia and neutropenia observed in 19 and 17% of patients, respectively, treated for glioma and 20 and 22%, respectively, of patients with metastatic melanoma. This led to hospitalisation and/or discontinuation of temozolomide in 8 and 4%, respectively, of patients with glioma and 3 and 1.3%, respectively, of those with melanoma. Myelosuppression was predictable (usually within the first few cycles, with the nadir between day 21 and 28), and recovery was rapid, usually within one to two weeks. No evidence of cumulative myelosuppression was observed. Pancytopenia, leucopenia and anaemia have also been reported. Lymphopenia has also been reported very commonly.
In a population pharmacokinetics analysis of clinical trial experience, there were 101 female and 169 male subjects for whom nadir neutrophil counts were available and 110 female and 174 male subjects for whom nadir platelet counts were available. There were higher rates of grade 4 neutropenia (ANC < 0.5 x 109/L) (12 versus 5%) and thrombocytopenia (< 20 x 109/L) (9 versus 3%), in women versus men in the first cycle of therapy. In a 400 subject recurrent glioma data set, grade 4 neutropenia occurred in 8% of female versus 4% of male subjects and grade 4 thrombocytopenia in 8% of female versus 3% of male subjects in the first cycle of therapy. In a study of 288 subjects with newly diagnosed glioblastoma multiforme, grade 4 neutropenia occurred in 3% of female versus 0% of male subjects and grade 4 thrombocytopenia in 1% of female versus 0% of male subjects in the first cycle of therapy.
In children the incidence of myelosupression was similar to that seen in adults. In the phase II clinical trial, the incidences of grade 4 thrombocytopenia and neutropenia were 16 and 11%, respectively. Myelosupression was usually transient and reversible with cessation of temozolomide treatment.

Postmarketing experience with temozolomide.

During the marketing of temozolomide, allergic reactions, including anaphylaxis, have been reported very rarely. Very rare cases of erythema multiforme, toxic epidermal necrolysis and Stevens-Johnson syndrome have also been observed. Drug reaction with eosinophilia and systemic symptoms has been reported with a frequency of unknown. There have been reported cases of hepatotoxicity including elevations of liver enzymes, hyperbilirubinaemia, cholestasis and hepatitis. Hepatic injury, including fatal hepatic failure, has been reported very rarely (see Section 4.4 Special Warnings and Precautions for Use).
Rarely, cases of opportunistic infections including Pneumocystis carinii pneumonia (PCP) and both primary and reactivated cytomegalovirus (CMV) infection have been reported. Cases of reactivation of hepatitis B infections, including some cases with fatal outcomes have also been reported (see Section 4.4 Special Warnings and Precautions for Use). Cases of herpes simplex encephalitis, including cases with fatal outcomes, have also been reported. Cases of sepsis have also been reported. Cases of interstitial pneumonitis/pneumonitis and pulmonary fibrosis have been reported very rarely. Very rare cases of myelodysplastic syndrome (MDS) and secondary malignancies, including myeloid leukaemia, have also been observed. Prolonged pancytopenia which may result in aplastic anaemia has been reported and in some cases resulted in a fatal outcome. Diabetes insipidus has also been reported.

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 http://www.tga.gov.au/reporting-problems.

4.9 Overdose

Doses of 500, 750, 1,000 and 1,250 mg/m2 (total dose per cycle over five days) have been evaluated clinically in patients. Dose limiting toxicity was haematological and was reported at any dose but is expected to be more severe at higher doses. An overdose of 2,000 mg per day for five days was taken by one patient and the adverse events reported were pancytopenia, pyrexia, multiorgan failure and death.
There are reports of patients who have taken more than five days of treatment (up to 64 days) with adverse events reported including bone marrow suppression, with or without infection, in some cases severe and prolonged and resulting in death. In the event of an overdose, haematological evaluation is needed. Supportive measures should be provided as necessary.
For information on the management of overdose, contact the Poison Information Centre on 13 11 26 (Australia).

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Mechanism of action.

Temozolomide is an imidazotetrazine alkylating agent with antitumour activity. It undergoes rapid chemical conversion in the systemic circulation at physiological pH to the active compound, monomethyl triazeno imidazole carboxamide (MTIC). The cytotoxicity of MTIC is thought to be due primarily to alkylation at the O6 position of guanine with additional alkylation also occurring at the N7 position. Cytotoxic lesions that develop subsequently are thought to involve aberrant repair of the methyl adduct.
Single dose toxicity studies of temozolomide were conducted in mice, rats and dogs. Estimated LD50 doses by the oral route were moderately higher in the rat (approximately 1,900 mg/m2) than in the mouse (approximately 1,000 mg/m2). The minimum lethal dose in dogs was 600 mg/m2. In the single dose studies, clinical signs of toxicity and death were generally delayed, reflecting a delayed toxicity to tissues that normally proliferate more rapidly resulting in general deterioration of organ function; toxicity is consistent with that expected of an alkylating agent.
Temozolomide is rapidly absorbed following oral administration. Systemic exposure at the therapeutic dose level in humans is similar to that of the rat and dog.
Single cycle (five day dosing, 23 days nontreatment), three and six cycle toxicity studies were conducted in rats and dogs. In multiple cycle studies, the primary targets of toxicity included bone marrow, lymphoreticular system, testes and gastrointestinal tract with evidence of toxic effects on the lung, liver, kidney, thyroid gland, urinary bladder, central nervous system (CNS) and retina. Temozolomide appears to be more toxic to rats and dogs than to humans, as the therapeutic dose regimen (200 mg/m2), which has been well tolerated in humans, approximates the minimum lethal dose following multiple doses in both rats and dogs. At this dose level, the plasma area under the curve (AUC) for temozolomide in rats was similar to that anticipated in adult patients and about 60% of that in children; the corresponding value in dogs was about 65 and 40% of that in adult and paediatric patients, respectively. Dose related reductions in leucocytes and platelets appear to be sensitive indicators of toxicity in both rats and dogs. During intervals when dosing is discontinued, significant evidence of recovery from most haematological, biochemical and histopathological changes occurs. However, due to the delayed toxicity of temozolomide, patients should be closely monitored throughout the whole treatment cycle, including the nontreatment period.

Clinical trials.

Newly diagnosed glioblastoma multiforme.

573 patients were randomised to receive either temozolomide (TMZ) + focal radiotherapy (RT) (n=287) or focal RT alone (n=286). Patients in the temozolomide + RT arm received concomitant temozolomide (75 mg/m2) once daily, starting the first day of RT until the last day of RT, for 42 days (with a maximum of 49 days). This was followed by adjuvant temozolomide (150 to 200 mg/m2) on day 1 to 5 of every 28 day cycle for six cycles, starting four weeks after the end of RT. Patients in the control arm received RT only. Pneumocystis carinii pneumonia (PCP) prophylaxis was required during RT and combined temozolomide therapy. PCP prophylaxis was given regardless of lymphocyte count and was continued during RT/TMZ until lymph recovery to less than or equal to grade 1.
The trial excluded patients below 18 years old and greater than 70 years old. Also excluded were patients with a World Health Organization (WHO) PS (performance status) greater than 2 and who had received prior chemotherapy or radiotherapy.
Temozolomide was administered as salvage therapy in the follow-up phase in 161 patients of the 282 (57%) in the RT alone arm and 62 patients of the 277 (22%) in the temozolomide + RT arm. The hazard ratio (HR) for overall survival was 1.59 (95% confidence interval (CI) for HR=1.33 to 1.91) with a log rank p < 0.0001 in favour of the temozolomide arm. The estimated probability of surviving two years or more (26 versus 10%) was higher for the RT + temozolomide arm. The addition of concomitant and adjuvant temozolomide to radiotherapy in the treatment of patients with newly diagnosed GBM demonstrated a statistically significant improved overall survival compared with radiotherapy alone (see Figure 1).

Recurrent glioblastoma multiforme.

Data on clinical efficacy in patients with glioblastoma multiforme (Karnofsky performance status (KPS) greater than or equal to 70), progressive or recurrent after surgery and radiotherapy, were based on two clinical trials. One was a noncomparative trial in 138 patients (29% received prior chemotherapy) and the other was a randomised reference controlled trial of temozolomide and procarbazine in a total of 120 patients (37.5% received prior treatment with nitrosourea based chemotherapy). In both trials, the primary endpoint was progression free survival (PFS) defined by magnetic resonance imaging (MRI) scans or neurological worsening. In the noncomparative trial, the PFS at six months was 19%, the median PFS was 2.1 months and the median overall survival was 5.4 months. The objective response rate based on MRI scans was 8%.
In the randomised trial, the six month PFS was significantly greater for temozolomide (20%, 95% CI: 9 to 30%) than for procarbazine (10%, 95% CI: 2 to 18%) with median PFS of 3.5 and 1.9 months, respectively (log rank, p=0.015). The median survival was 7.7 and 6.1 months for temozolomide and procarbazine, respectively (log rank, p=0.61).
At six months the fraction of surviving patients was significantly higher in the temozolomide arm (66%, 95% CI: 54 to 78%) compared with the procarbazine arm (51%, 95% CI: 38 to 64%). The study has later been completed (225 patients) and results reinforce those of the interim report.

Anaplastic astrocytoma.

In a multicentre, global, prospective phase II trial evaluating the safety and efficacy of temozolomide in the treatment of 162 adult patients with anaplastic astrocytoma at first relapse (60% received prior chemotherapy), the six month PFS was 46%. The median PFS was 5.4 months and median overall survival was 14.6 months. Response rate, based on the central reviewer assessment, was 35% (13 CR and 43 PR) for the intent to treat (ITT) population. Including 43 stable disease responses, the response rate was 61%. The six month event free survival for the ITT population was 44% with a median event free survival of 4.6 months, which was similar to the results for the PFS. For the eligible histology population, the efficacy results were similar. Achieving a radiological objective response or maintaining progression free status was strongly associated with maintained or improved quality of life.

Metastatic melanoma.

The pivotal trial involving 305 adult patients with advanced metastatic melanoma at first presentation of metastatic disease was a large, multicentre, randomised phase III trial comparing the efficacy of temozolomide (156 patients) with the standard treatment, dacarbazine (DTIC, 149 patients). Patients were balanced in regard to demographics and disease characteristics between the two treatment groups. Patients may not have had previous treatment for metastatic melanoma and may not have had brain metastases from melanoma. The primary endpoint was overall survival. PFS and response rate were secondary endpoints.
Median overall survival was longer for patients treated with temozolomide compared to patients treated with DTIC (7.7 versus 6.4 months, respectively, p=0.2). Median PFS was statistically significantly longer with temozolomide compared to DTIC (1.9 versus 1.5 months, respectively, p = 0.012). The overall response rate was 13.5% for temozolomide and 12.1% for DTIC.

Paediatric patients.

Temozolomide capsules have been studied in two open label phase II studies in paediatric patients with advanced recurrent CNS malignancies at a dose of 160 to 200 mg/m2 daily for five days every 28 days. In a phase I trial, 29 patients with recurrent brainstem glioma and 34 patients with recurrent high grade astrocytoma were enrolled. All patients had been previously treated with standard radiation therapy, while 50% of high grade astrocytoma patients and 31% of brainstem glioma patients had previously received chemotherapy. The objective response rate, based on a central review of all subjects deemed to have eligible histologies, (16 brain stem glioma and 26 high grade astrocytoma subjects), was 0% for brain stem glioma subjects although 19% achieved stable disease; responses were documented in 12% of high grade astrocytoma subjects while 15% had stable disease. Based on investigator reviews, three patients with brain stem glioma had a partial response (10%) and an additional 14 patients had stable disease (48%). Eleven patients with high grade astrocytoma had a partial response (32%) and an additional seven patients had stable disease (21%). For all subjects, the median time to progression in the high grade astrocytoma arm was 2.9 months and the median time to progression in the brain stem glioma arm was 2.8 months.
In the phase II open label study, 117/122 patients treated for various recurrent CNS malignancies were evaluable for efficacy with an overall response rate of 5%. Of 23 patients with high grade astrocytomas seven patients (19%) had stable disease after two cycles. Disease progressed thereafter (cycle 3, 4, 5, 6, 7, 8 and 9, respectively); however, one patient had a partial response. In 16 patients with brainstem gliomas, six had stable disease after two cycles, but disease progressed in all patients by the end of the fifth cycle, with no further response.
No clinical trials have been conducted in patients under 18 years of age with malignant melanoma.

5.2 Pharmacokinetic Properties

Absorption.

After oral administration to adult patients, temozolomide is absorbed rapidly with peak concentrations reached as early as 20 minutes post-dose (mean times between 0.5 and 1.5 hours). After oral administration of 14C-labelled temozolomide, mean faecal excretion of 14C over seven days post-dose was 0.8% indicating complete absorption.
Administration of temozolomide with food resulted in a 33% decrease in Cmax, an increase in Tmax from about one to two hours and a 9% decrease in AUC. As it cannot be excluded that the change in Cmax is clinically significant, temozolomide should not be administered with food.

Distribution.

Preclinical data suggest that temozolomide crosses the blood brain barrier rapidly and is present in the cerebrospinal fluid. Plasma concentrations increase in a dose related manner. Plasma clearance, volume of distribution and half-life are independent of dose. Temozolomide demonstrates low protein binding (10 to 20%), and thus is not expected to interact with highly protein bound agents.

Metabolism and excretion.

Following oral administration approximately 5 to 10% of the dose is recovered unchanged in the urine over 24 hours, and the remainder excreted as AIC (4-amino-5-imidazole-carboxamide hydrochloride) or unidentified polar metabolites.
In relation to adults, analysis of population based pharmacokinetics of temozolomide revealed that plasma clearance was independent of age, renal function, hepatic function or tobacco use.
Among paediatric age groups 3 to 12 and > 12 to 16 years, dose normalised Cmax and AUC value were the same. Similarly, clearance, volume of distribution and half-life were not different between the two paediatric age groups. Mean dose normalised AUC was approximately 30% higher in paediatric patients than in adult patients. Volume of distribution and clearance appeared lower in paediatric patients compared to adult patients. Terminal phase half-life was the same in adults and children.
The maximum tolerated dose (MTD) was 1,000 mg/m2 per cycle both in children and in adults.

5.3 Preclinical Safety Data

Genotoxicity.

Temozolomide was genotoxic in assays for gene mutations (Salmonella typhimurium and Escherichia coli) and chromosomal changes (human blood lymphocytes).
Pathological lesions of necrosis, degeneration, hypospermatogenesis and presence of syncytial cells and immature/abnormal spermatozoa in the testes, epididymis and seminal vesicles have been observed in the mouse, rat and dog at systemic exposure levels to temozolomide well within the anticipated human exposure. Decreased ovarian weight was noted in rats at temozolomide exposure comparable to that anticipated clinically. The reversibility of these changes has not been investigated, but no evidence of recovery was noted during the 23 day nontreatment period.

Carcinogenicity.

No long-term carcinogenicity studies have been conducted, but evidence of carcinogenic potential of temozolomide was observed in the three and six cycle studies in rats. Neoplasms observed in the rat studies included mammary carcinoma, keratoacanthoma of the skin, basal cell adenoma and a variety of mesenchymal neoplasms. These neoplasms occurred at systemic exposure to temozolomide less than that anticipated clinically. No tumours or preneoplastic changes were observed in the dog studies of up to six cycles. Considering that temozolomide is a prodrug of the alkylating agent MTIC, its tumorigenic potential is not unexpected and has been observed with other alkylating agents, including those producing MTIC.

6 Pharmaceutical Particulars

6.1 List of Excipients

The capsules also contain lactose, colloidal anhydrous silica, sodium starch glycollate, tartaric acid and stearic acid. The capsule shells contain gelatin, purified water, titanium dioxide, indigo carmine (5 mg, 140 mg capsules only), iron oxide yellow (5 mg, 20 mg, 180 mg capsules only), iron oxide red (100 mg, 180 mg capsules only), and TekPrint SW-9008 Black Ink (ARTG 2328). The capsules are gluten free.

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. Store in original container.

6.5 Nature and Contents of Container

Container type.

Sachets are comprised of a laminated foil (Polyethylene/aluminium/polymer).
Bottles are glass (amber) with a polypropylene child resistant closure.

Pack sizes.

Sachet pack or bottles of 5's and 20's.

Note.

Not all strengths or pack sizes may be marketed.

6.6 Special Precautions for Disposal

In Australia, any unused medicine or waste material should be disposed of in accordance with local requirements.

6.7 Physicochemical Properties

Temozolomide is a white to pale brown/pink, crystalline powder which is odourless or almost odourless and hygroscopic. It is slightly soluble in water (3.1 mg/mL), methanol (4.4 mg/mL) and ethanol (0.6 mg/mL).
The chemical name for temozolomide is 4-methyl-5-oxo- 2,3,4,6,8-pentazabicyclo [4.3.0] nona-2,7,9-triene- 9-carboxamide.

Chemical structure.


CAS number.

85622-93-1.
Molecular formula: C6H6N6.HCl.
Molecular weight: 194.15.

7 Medicine Schedule (Poisons Standard)

Schedule 4 (Prescription Only Medicine).

Summary Table of Changes