ستوکسیماب
Cetuximab (Erbitux)
ستوکسیماب

نام ژنریک

Cetuximab

شکل دارویی

اشكال دارويي:


Injection: 2 mg/ml ,50ml

موارد مصرف

موارد و مقدار مصرف


الف) كارسينوماي سر و گردن


بزرگسالان: قبل از تجويز دارو از يك دارو با خاصيت آنتاگونيست H1 به عنوان پيش دارو استفاده شود. دوز mg/m2 400 وريدي در عرض 2 ساعت (حداكثر با سرعت ml/min 5) به عنوان دوز بارگيري و ادامه آن با دوز mg/m2 250 وريدي در عرض يك ساعت به صورت هفتگي به عنوان دوز نگهدارنده.


در صورت استفاده از دارو همراه با پرتو درماني ستوكسيماب يك هفته قبل از شروع پرتو درماني آغاز و در حين پرتو درماني ادامه داده مي‌شود (7-6 هفته). در صورت استفاده به صورت تك درماني در موارد عود يا متاستاز بيماري پس از شكست درمان با پايه پلاتين درمان تا زمان پيشرفت بيماري يا بروز عوارض غيرقابل پذيرش ادامه مي‌يابد.


ب) سرطان متاستاتيك كولون و ركتوم در صورت بيان رسپتور فاكتور رشد اپيدرمال در بيماراني كه ايرينوتكان را تحمل نمي‌كنند يا همراه با ايرينوتكان در بيماران مقاوم به ايرينوتكان


بزرگسالان: همراه با ايرينوتكان يا به تنهائي دوز mg/m2 400 وريدي در عرض 2 ساعت (حداكثر با سرعت ml/min 5) به عنوان دوز بارگيري و ادامه آن با دوز mg/m2 250 وريدي در عرض يك ساعت به صورت هفتگي به عنوان دوز نگهدارنده. استفاده از يك داروي با خاصيت آنتاگونيست H1 (مثل 50 ميلي‌گرم ديفن‌هيدرامين وريدي) به عنوان پيش دارو توصيه مي‌شود.


تنظيم دوز: در صورت بروز موارد ملايم تا متوسط (درجه 1 يا 2) واكنش انفوزيون در بيمار سرعت تزريق را 50 درصد كاهش دهيد. در صورت بروز موارد شديد (درجة 3 يا 4) واكنش انفوزيون تزريق دارو بايد قطع شود. در صورت بروز سميت پوستي ملايم تا متوسط نياز به تنظيم دوز وجود ندارد. در صورت بروز بثورات جلدي به شكل آكنه مطابق راهنماي زير عمل شود.


بروز اولين رتبه: انفوزيون را 1 تا 2 هفته به تعويق بياندازيد. در صورت بهبودي دارو با دوز mg/m2 250 شروع شود. در صورت عدم بهبودي تجويز دارو متوقف شود.


بروز دومين رتبه: انفوزيون را 1 تا 2 هفته به تعويق بياندازيد. در صورت بهبودي دارو با دوز mg/m2 200 شروع شود. در صورت عدم بهبودي تجويز دارو متوقف شود.


بروز سومين رتبه: انفوزيون را 1 تا 2 هفته به تعويق بياندازيد. در صورت بهبودي دارو با دوز mg/m2 150 شروع شود. در صورت عدم بهبودي تجويز دارو متوقف شود.


بروز چهارمين رتبه: تجويز دارو متوقف شود.


موارد منع مصرف

موارد منع مصرف و احتياط


موارد احتياط: سابقه حساسيت به ستوكسيماب، مواد افزودني شكل داروئي و پروتئين‌هاي موشي، همراه مصرف همزمان با پرتو درماني در بيماران با سابقة بيماري عروق كروز، آريتمي و نارسائي قلبي.


عوارض جانبی دارو

عوارض جانبي


اعصاب مرکزي: ضعف، افسردگي، تب، سردرد، بي‌خوابي، درد.


قلبي ـ عروقي: ادم، ايست قلبي ـ تنفسي.


چشم: كنژكتيويت.


دستگاه گوارش: درد شكم، بي‌اشتهائي، يبوست، اسهال، سوءهاضمه، تهوع، التهاب زبان، استفراغ، موكوزيت، خشكي دهان، اختلال بلع.


ادراري ـ تناسلي: نارسائي حاد كليه.


خون: آنمي، لكوپني.


متابوليك: دهيدراتاسيون، كاهش وزن.


عضلاني ـ اسكلتي: درد كمر


تنفسي: سرفه، تنگي نفس، آمبولي ريوي.


پوست: بثورات جلدي شبه آكنه، ريزش مو، اختلال ناخن، خارش، درماتيت ناشي از پرتو درماني.


ساير عوارض: عفونت،‌ سپسيس، واكنش ناشي از انفوزيون.


مسموميت و درمان


موردي از مسموميت گزارش نشده است.


موارد قابل توجه

-

تداخل دارویی

تداخل دارويي


در صورت قرارگيري در معرض نور خورشيد احتمال تشديد واكنش‌هاي پوستي وجود دارد.

مکانیزم اثر

تداخل دارويي


در صورت قرارگيري در معرض نور خورشيد احتمال تشديد واكنش‌هاي پوستي وجود دارد.

فارماكوكینتیك

فارماكوكينتيك


جذب: دارو به صورت وريدي تجويز مي‌شود.


پخش: دارو در بسياري از بافتهاي اپيتليال نرمال مثل پوست و فوليكول‌هاي مو و بافتهاي سرطاني توزيع مي‌يابد. به نظر مي‌رسد توزيع غير وابسته به دوز بوده و در حدود L/m2 3-2 باشد.


متابوليسم: اطلاعاتي موجود نمي‌باشد.


دفع: نيمه‌ عمر دارو حدود 114 ساعت است.


سایر اطلاعات

طبقه‌بندي فارماكولوژيك: آنتي‌بادي مونوكلونال موشي ـ انساني نوتركيب


طبقه‌بندي درماني: آنتاگونيست رسپتور فاكتور رشد اپيدرمال


طبقه‌بندي مصرف در بارداري: رده C


نام‌هاي تجاري: Erbitux


ملاحظات اختصاصي


1- بيماراني كه به طور همزمان نياز به پرتو درماني دارند بايد از نظر الكتروليت‌ها مورد پايش قرار گيرند. به خصوص منيزيم، پتاسيم و كلسيم در حين درمان و پس از درمان.


2- قبل از درمان 50 ميلي‌گرم ديفن‌هيدرامين به منظور پيش درمان بايد استفاده شود.


توجه: در حين كارآزمائيهاي باليني، استفاده از تست دوز 20 ميلي‌گرم قبل از دوز بارگيري نمي‌تواند باعث شناسائي بيماران با احتمال بالاي واكنش‌هاي حساسيتي شديد شود.


3- محلول بايد بدون رنگ و شفاف باشد. احتمال وجود مقادير اندكي از ذرات در محلول وجود دارد. از رقيق سازي و تكان دادن محلول خودداري شود.


4- دارو مي‌تواند از طريق پمپ انفوزيون يا پمپ سرنگ استفاده شود.


توجه: از تزريق سريع وريدي اجتناب شود.


5- دارو بايد از طريق فيلترهاي 22/0 ميكرومتر و با اتصال كم پروتئيني تزريق شود. پس از تزريق مسير انفوزيون توسط نرمال‌سالين شستشو شود. از رقيق سازي توسط ساير محلولها و تزريق دارو با سرعت بيش از ml/min 5 خودداري شود.


6- تا يك ساعت پس از تزريق بيماران از نظر احتمال بروز واكنش‌هاي ناشي از انفوزيون بايد مورد بررسي قرار گيرند.


توجه: واكنش‌هاي انفوزيون شديد شامل انسداد حاد راههاي هوائي، كهير و افت فشارخون بوده ولي هميشه با تزريق اول بروز نمي‌كنند. در صورت بروز واكنش انفوزيون شديد، تزريق دارو متوقف و درمان علامتي انجام شود.


7- به منظور درمان موارد واكنش‌هاي ناشي از انفوزيون اپي‌نفرين، كورتيكوستروئيدها، آنتي‌هيستامين وريدي، برونكوديلاتورها و اكسيژن بايد موجود باشد.


8- در صورت بروز موارد ملايم تا متوسط واكنش‌هاي ناشي از انفوزيون سرعت انفوزيون كاهش يافته و از آنتي‌هيستامين در موارد بعدي انفوزيون استفاده شود.


9- بيمار بايد از نظر بروز حاد يا تشديد علائم ريوي مورد بررسي قرار گيرد. در صورت اطمينان از بروز بيماري بافت همبند ريوي از ادامه تجويز دارو خودداري شود.


10- در دو هفته اول درمان بيمار بايد از نظر سميت پوستي و اثرات
التهابي و عفونت مورد بررسي باشد. در صورت نياز از آنتي‌بيوتيك‌هاي موضعي و دهان استفاده شده ولي از كاربرد استروئيدهاي موضعي خودداري شود.


11- ويال‌هاي دارو در دماي 8-2 درجه سانتي‌گراد نگهداري شوند. از يخ‌زدگي دارو جلوگيري كنيد.


نكات قابل توصيه به بيمار


1- به بيمار توصيه نمائيد هرگونه ديسترس تنفسي و خارش را در زمان انفوزيون گزارش نمايد.


2- بيمار را نسبت به اهميت گزارش عوارض ناخواسته آگاه نمائيد.


3- به بيمار بگوئيد واكنش‌هاي پوستي معمولاً در 2 هفته اول درمان بروز مي‌نمايد.


4- به بيمار توصيه نمائيد از در معرض قرار گيري طولاني و بدون حفاظت در مقابل نور آفتاب خودداري نمايد. بيمار را در رابطه با استفاده از فرآورده‌هاي ضد آفتاب استفاده از پوشش مناسب در زمان درمان آموزش دهيد.


مصرف در كودكان: اثربخشي و ايمني مصرف دارو در كودكان به اثبات نرسيده است.


مصرف در شيردهي: ترشح دارو در شير مشخص نيست. بيمار را نسبت به ضرورت توقف شيردهي در زمان درمان و تا 60 روز پس از خاتمه درمان آگاه نمائيد.


مصرف در بارداري: خطر جنيني ناشي از مصرف دارو مشخص نيست. با بيمار در رابطه با احتمال بروز خطر قبل از شروع درمان بحث نمائيد.


اثر بر آزمايشهاي تشخيصي


دارو ممكن است باعث افزايش سطوح BUN و كراتي‌نين و كاهش هموگلوبين، هماتوكريت و شمارش WBC شود.


Cetuximab (Erbitux)

ERBITUX®
(cetuximab)

WARNING

SERIOUS INFUSION REACTIONS and CARDIOPULMONARY ARREST

Infusion Reactions: Serious infusion reactions occurred with the administration of Erbitux in approximately 3% of patients in clinical trials, with fatal outcome reported in less than 1 in 1000. [See WARNINGS AND PRECAUTIONS, ADVERSE REACTIONS.] Immediately interrupt and permanently discontinue Erbitux infusion for serious infusion reactions. [See DOSAGE AND ADMINISTRATION, WARNINGS AND PRECAUTIONS]

Cardiopulmonary Arrest: Cardiopulmonary arrest and/or sudden death occurred in 2% of patients with squamous cell carcinoma of the head and neck treated with Erbitux and radiation therapy in Study 1 and in 3% of patients with squamous cell carcinoma of the head and neck treated with European Union (EU)-approved cetuximab in combination with platinum-based therapy with 5-fluorouracil (5-FU)in Study 2. Closely monitor serum electrolytes, including serum magnesium, potassium, and calcium, during and after Erbitux administration. [See WARNINGS AND PRECAUTIONS, Clinical Studies]

DRUG DESCRIPTION

Erbitux (cetuximab) is a recombinant, human/mouse chimeric monoclonal antibody that binds specifically to the extracellular domain of the human epidermal growth factor receptor (EGFR). Cetuximab is composed of the Fv regions of a murine anti-EGFR antibody with human IgG1 heavy and kappa light chain constant regions and has an approximate molecular weight of 152 kDa. Cetuximab is produced in mammalian (murine myeloma) cell culture.

Erbitux is a sterile, clear, colorless liquid of pH 7.0 to 7.4, which may contain a small amount of easily visible, white, amorphous cetuximab particulates. Erbitux is supplied at a concentration of 2 mg/mL in either 100 mg (50 mL) or 200 mg (100 mL), single-use vials. Cetuximab is formulated in a solution with no preservatives, which contains 8.48 mg/mL sodium chloride, 1.88 mg/mL sodium phosphate dibasic heptahydrate, 0.41 mg/mL sodium phosphate monobasic monohydrate, and Water for Injection, USP.

What are the possible side effects of cetuximab (Erbitux)?

Some people receiving a cetuximab injection have had a reaction to the infusion (when the medicine is injected into the vein). Tell your caregiver right away if you feel short of breath, weak or dizzy, nauseated, itchy, or have wheezing, noisy breathing, or a hoarse voice during the injection.

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Call your doctor at once if you have any of these serious side effects:

  • an acne-like skin rash or any severe skin...

Read All Potential Side Effects and See Pictures of Erbitux »

What are the precautions when taking cetuximab (Erbitux)?

Before receiving cetuximab, tell your doctor or pharmacist if you are allergic to it or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.

Before using this medication, tell your doctor or pharmacist your medical history, especially of: lung disease, radiation therapy, heart disease (e.g., coronary artery disease, congestive heart failure, arrhythmias).

This medication may make you drowsy. Do not drive, use machinery, or do any activity that requires alertness until you are sure you can perform such activities safely. Limit alcoholic beverages.

Sunlight may worsen any skin reactions that may occur while you are using this drug. Avoid prolonged...

Read All Potential Precautions of Erbitux »

Last reviewed on RxList: 7/12/2012
This monograph has been modified to include the generic and brand name in many instances.

INDICATIONS

Squamous Cell Carcinoma of the Head and Neck (SCCHN)

Erbitux is indicated in combination with radiation therapy for the initial treatment of locally or regionally advanced squamous cell carcinoma of the head and neck. [See Clinical Studies]

Erbitux is indicated in combination with platinum-based therapy with 5-FU for the first- line treatment of patients with recurrent locoregional disease or metastatic squamous cell carcinoma of the head and neck. [See Clinical Studies]

Erbitux, as a single agent, is indicated for the treatment of patients with recurrent or metastatic squamous cell carcinoma of the head and neck for whom prior platinum-based therapy has failed. [See Clinical Studies.]

K-Ras Mutation-negative, EGFR-expressing Colorectal Cancer

Erbitux is indicated for the treatment of K-Rasmutation-negative (wild-type), epidermal growth factor receptor (EGFR)-expressing, metastatic colorectal cancer (mCRC) as determined by FDA-approved tests for this use [see DOSAGE AND ADMINISTRATION, Clinical Studies, WARNINGS AND PRECAUTIONS].

Limitation of Use: Erbitux is not indicated for treatment of K-Ras mutation-positive colorectal cancer [see WARNINGS AND PRECAUTIONS, Clinical Studies].

DOSAGE AND ADMINISTRATION

Squamous Cell Carcinoma of the Head and Neck

Erbitux in combination with radiation therapy or in combination with platinum-based therapy with 5-FU:

  • The recommended initial dose is 400 mg/m² administered one week prior to initiation of a course of radiation therapy or on the day of initiation of platinum- based therapy with 5-FU as a 120-minute intravenous infusion (maximum infusion rate 10 mg/min). Complete Erbitux administration 1 hour prior to platinum-based therapy with 5-FU.
  • The recommended subsequent weekly dose (all other infusions) is 250 mg/m² infused over 60 minutes (maximum infusion rate 10 mg/min) for the duration of radiation therapy (6-7 weeks) or until disease progression or unacceptable toxicity when administered in combination with platinum-based therapy with 5-FU. Complete Erbitux administration 1 hour prior to radiation therapy or platinum-based therapy with 5-FU.
Erbitux monotherapy
  • The recommended initial dose is 400 mg/m administered as a 120-minute intravenous infusion (maximum infusion rate 10 mg/min).
  • The recommended subsequent weekly dose (all other infusions) is 250 mg/m infused over 60 minutes (maximum infusion rate 10 mg/min) until disease progression or unacceptable toxicity.

Colorectal Cancer

  • Determine K-Ras mutation and EGFR-expression status using FDA-approved tests prior to initiating treatment. Only patients whose tumors are K-Rasmutation- negative (wild-type) should receive Erbitux.
  • The recommended initial dose, either as monotherapy or in combination with irinotecan or FOLFIRI (irinotecan, 5-fluorouracil, leucovorin), is 400 mg/m administered as a 120-minute intravenous infusion (maximum infusion rate 10 mg/min). Complete Erbitux administration 1 hour prior to FOLFIRI.
  • The recommended subsequent weekly dose, either as monotherapy or in combination with irinotecan or FOLFIRI, is 250 mg/m infused over 60 minutes (maximum infusion rate 10 mg/min) until disease progression or unacceptable toxicity. Complete Erbitux administration 1 hour prior to FOLFIRI.

Recommended Premedication

Premedicate with an H1antagonist (eg, 50 mg of diphenhydramine) intravenously 30-60 minutes prior to the first dose; premedication should be administered for subsequent Erbitux doses based upon clinical judgment and presence/severity of prior infusion reactions.

Dose Modifications

Infusion Reactions

Reduce the infusion rate by 50% for NCI CTC Grade 1 or 2 and non-serious NCI CTC Grade 3 infusion reaction.

Immediately and permanently discontinue Erbitux for serious infusion reactions, requiring medical intervention and/or hospitalization. [See WARNINGS AND PRECAUTIONS]

Dermatologic Toxicity

Recommended dose modifications for severe (NCI CTC Grade 3 or 4) acneiform rash are specified in Table 1. [See WARNINGS AND PRECAUTIONS]

Table 1: Erbitux Dose Modification Guidelines for Rash

Severe Acneiform Rash Erbitux Outcome Erbitux Dose Modification
1st occurrence Delay infusion 1 to 2 weeks Improvement No Improvement 2 Continue at 250 mg/m² Discontinue Erbitux
2nd occurrence Delay infusion 1 to 2 weeks Improvement No Improvement Reduce dose to 200 mg/m² Discontinue Erbitux
3rd occurrence Delay infusion 1 to 2 weeks Improvement No Improvement Reduce dose to 150 mg/m² Discontinue Erbitux
4th occurrence Discontinue Erbitux    

Preparation for Administration

Do not administer Erbitux as an intravenous push or bolus.

Administer via infusion pump or syringe pump. Do not exceed an infusion rate of 10 mg/min.

Administer through a low protein binding 0.22-micrometer in-line filter.

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.

The solution should be clear and colorless and may contain a small amount of easily visible, white, amorphous, cetuximab particulates. Do not shake or dilute.

HOW SUPPLIED

Dosage Forms And Strengths

100 mg/50 mL, single-use vial 200 mg/100 mL, single-use vial

Storage And Handling

Erbitux® (cetuximab) is supplied at a concentration of 2 mg/mL as a 100 mg/50 mL, single-use vial or as a 200 mg/100 mL, single-use vial as a sterile, injectable liquid containing no preservatives.

NDC 66733-948-23 100 mg/50 mL, single-use vial, individually packaged in a carton

NDC 66733-958-23 200 mg/100 mL, single-use vial, individually packaged in a carton

Store vials under refrigeration at 2° C to 8° C (36° F to 46° F). Do not freeze. Increased particulate formation may occur at temperatures at or below 0° C. This product contains no preservatives. Preparations of Erbitux in infusion containers are chemically and physically stable for up to 12 hours at 2° C to 8° C (36° F to 46° F) and up to 8 hours at controlled room temperature (20° C to 25° C; 68° F to 77° F). Discard any remaining solution in the infusion container after 8 hours at controlled room temperature or after 12 hours at 2° C to 8° C. Discard any unused portion of the vial.

Manufactured by ImClone LLC a wholly-owned subsidiary of Eli Lilly and Company, Branchburg, NJ 08876 USA. Distributed and marketed by Bristol-Myers Squibb Company, Princeton, NJ 08543 USA Co-marketed by Eli Lilly and Company, Indianapolis, IN 46285 USA. Rev July 2012

Last reviewed on RxList: 7/12/2012
This monograph has been modified to include the generic and brand name in many instances.

SIDE EFFECTS

The following adverse reactions are discussed in greater detail in other sections of the label:

The most common adverse reactions in Erbitux clinical trials (incidence >25%) include cutaneous adverse reactions (including rash, pruritus, and nail changes), headache, diarrhea, and infection.

The most serious adverse reactions with Erbitux are infusion reactions, cardiopulmonary arrest, dermatologic toxicity and radiation dermatitis, sepsis, renal failure, interstitial lung disease, and pulmonary embolus.

Across Studies 1, 3, 5, and 6, Erbitux was discontinued in 3-10% of patients because of adverse reactions.

Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

The data below reflect exposure to Erbitux in 1373 patients with SCCHN or colorectal cancer in randomized Phase 3 (Studies 1 and 5) or Phase 2 (Studies 3 and 6) trials treated at the recommended dose and schedule for medians of 7 to 14 weeks. [See Clinical Studies.]

Infusion reactions: Infusion reactions, which included pyrexia, chills, rigors, dyspnea, bronchospasm, angioedema, urticaria, hypertension, and hypotension occurred in 15-21% of patients across studies. Grades 3 and 4 infusion reactions occurred in 2-5% of patients; infusion reactions were fatal in 1 patient.

Infections: The incidence of infection was variable across studies, ranging from 13-35%. Sepsis occurred in 1-4% of patients.

Renal: Renal failure occurred in 1% of patients with colorectal cancer.

Squamous Cell Carcinoma of the Head and Neck

Erbitux in Combination with Radiation Therapy

Table 2 contains selected adverse reactions in 420 patients receiving radiation therapy either alone or with Erbitux for locally or regionally advanced SCCHN in Study 1. Erbitux was administered at the recommended dose and schedule (400 mg/m initial dose, followed by 250 mg/m weekly). Patients received a median of 8 infusions (range 1-11).

Table 2: Incidence of Selected Adverse Reactions (≥10%) in Patients with Locoregionally Advanced SCCHN

Body System Preferred Term Erbitux plus Radiation
(n=208)
Radiation Therapy Alone
(n=212)
Grades 1-4 Grades 3 and 4 Grades 1-4 Grades 3 and 4
% of Patients
Body as a Whole
Asthenia 56 4 49 5
Fevera 29 1 13 1
Headache 19 <1 8 <1
Infusion Reactionb 15 3 2 0
Infection 13 1 9 1
Chillsa 16 0 5 0
Digestive
Nausea 49 2 37 2
Emesis 29 2 23 4
Diarrhea 19 2 13 1
Dyspepsia 14 0 9 1
Metabolic/Nutritional
Weight Loss 84 11 72 7
Dehydration 25 6 19 8
Alanine Transaminase, highc 43 2 21 1
Aspartate Transaminase, highc 38 1 24 1
Alkaline Phosphatase, highc 33 <1 24 0
Respiratory
Pharyngitis 26 3 19 4
Skin/Appendages
Acneiform Rashd 87 17 10 1
Radiation Dermatitis 86 23 90 18
Application Site Reaction 18 0 12 1
Pruritus 16 0 4 0
a Includes cases also reported as infusion reaction.
bInfusion reaction is defined as any event described at any time during the clinical study as “allergic reaction” or “anaphylactoid reaction”, or any event occurring on the first day of dosing described as “allergic reaction”, “anaphylactoid reaction”, “fever”, “chills”, “chills and fever”, or “dyspnea”.
c Based on laboratory measurements, not on reported adverse reactions, the number of subjects with tested samples varied from 205206 for Erbitux plus Radiation arm; 209210 for Radiation alone.
d Acneiform rash is defined as any event described as “acne”, “rash”, “maculopapular rash”, “pustular rash”, “dry skin”, or “exfoliative dermatitis”.

The incidence and severity of mucositis, stomatitis, and xerostomia were similar in both arms of the study.

Late Radiation Toxicity

The overall incidence of late radiation toxicities (any grade) was higher in Erbitux in combination with radiation therapy compared with radiation therapy alone. The following sites were affected: salivary glands (65% versus 56%), larynx (52% versus 36%), subcutaneous tissue (49% versus 45%), mucous membrane (48% versus 39%), esophagus (44% versus 35%), skin (42% versus 33%). The incidence of Grade 3 or 4 late radiation toxicities was similar between the radiation therapy alone and the Erbitux plus radiation treatment groups.

Study 2: EU-Approved Cetuximab in Combination with Platinum-based Therapy with 5-Fluorouracil

Study 2 used EU-approved cetuximab. Since U.S.-licensed Erbitux provides approximately 22% higher exposure relative to the EU-approved cetuximab, the data provided below may underestimate the incidence and severity of adverse reactions anticipated with Erbitux for this indication. However, the tolerability of the recommended dose is supported by safety data from additional studies of Erbitux [see CLINICAL PHARMACOLOGY].

Table 3 contains selected adverse reactions in 434 patients with recurrent locoregional disease or metastatic SCCHN receiving EU-approved cetuximab in combination with platinum-based therapy with 5-FU or platinum-based therapy with 5-FU alone in Study 2. Cetuximab was administered at 400 mg/m² for the initial dose, followed by 250 mg/m² weekly. Patients received a median of 17 infusions (range 1-89).

Table 3: Incidence of Selected Adverse Reactions (>10%) in Patients with Recurrent Locoregional Disease or Metastatic SCCHN

System Organ Class Preferred Term EU-Approved Cetuximab plus Platinum-based Therapy with 5-FU
(n=219)
Platinum-based Therapy with 5-FU Alone
(n=215)
Grades 1-4 Grades 3 and 4 Grades 1-4 Grades 3 and 4
% of Patients
Eye Disorders
Conjunctivitis 10 0 0 0
Gastrointestinal Disorders
Nausea 54 4 47 4
Diarrhea 26 5 16 1
General Disorders and Administration Site Conditions
Pyrexia 22 0 13 1
Infusion Reactiona 10 2 <1 0
Infections and Infestations
Infectionb 44 11 27 8
Metabolism and Nutrition Disorders
Anorexia 25 5 14 1
Hypocalcemia 12 4 5 1
Hypokalemia 12 7 7 5
Hypomagnesemia 11 5 5 1
Skin and Subcutaneous Tissue Disorders
Acneiform Rashc 70 9 2 0
Rash 28 5 2 0
Acne 22 2 0 0
Dermatitis Acneiform 15 2 0 0
Dry Skin 14 0 <1 0
Alopecia 12 0 7 0
aInfusion reaction defined as any event of “anaphylactic reaction”, “hypersensitivity”, “fever and/or chills”, “dyspnea”, or “pyrexia” on the first day of dosing.
bInfection - this term excludes sepsis-related events which are presented separately.
cAcneiform rash defined as any event described as “acne”, “dermatitis acneiform”, “dry skin”,“exfoliative rash”, “rash”, “rash erythematous”, “rash macular”, “rash papular”, or “rash pustular”.Chemotherapy = cisplatin + 5-fluorouracil or carboplatin + 5-fluorouracil

For cardiac disorders, approximately 9% of subjects in both the EU-approved cetuximab plus chemotherapy and chemotherapy-only treatment arms in Study 2 experienced a cardiac event. The majority of these events occurred in patients who received cisplatin/5-FU, with or without cetuximab as follows: 11% and 12% in patients who received cisplatin/5-FU with or without cetuximab, respectively, and 6% or 4% in patients who received carboplatin/5-FU with or without cetuximab, respectively. In both arms, the incidence of cardiovascular events was higher in the cisplatin with 5-FU containing subgroup. Death attributed to cardiovascular event or sudden death was reported in 3% of the patients in the cetuximab plus platinum-based therapy with 5-FU arm and 2% in the platinum-based chemotherapy with 5-FU alone arm.

Colorectal Cancer

Study 4: EU-Approved Cetuximab in Combination with FOLFIRI

Study 4 used EU-approved cetuximab. U.S.-licensed Erbitux provides approximately 22% higher exposure to cetuximab relative to the EU-approved cetuximab. The data provided below for Study 4 is consistent in incidence and severity of adverse reactions with those seen for Erbitux in this indication. The tolerability of the recommended dose is supported by safety data from additional studies of Erbitux [see CLINICAL PHARMACOLOGY].

Table 4 contains selected adverse reactions in 667 patients with K-Rasmutation-negative (wild-type), EGFR-expressing, metastatic colorectal cancer receiving EU-approved cetuximab plus FOLFIRI or FOLFIRI alone in Study 4 [see WARNINGS AND PRECAUTIONS]. Cetuximab was administered at the recommended dose and schedule (400 mg/m² initial dose, followed by 250 mg/m weekly). Patients received a median of 26 infusions (range 1-224).

Table 4: Incidence of Selected Adverse Reactions Occurring in >10% ofPatients with K-RasMutation-negative (Wild-type) and EGFR-expressing, Metastatic Colorectal Cancera

Body System Preferred Term EU-Approved Cetuximab plus FOLFIRI
(n=317)
FOLFIRI Alone
(n=350)
Grades 1-4b Grades 3 and 4 Grades 1-4 Grades 3 and 4
% of Patients
Blood and Lymphatic System Disorders
Neutropenia 49 31 42 24
Eye Disorders
Conjunctivitis 18 <1 3 0
Gastrointestinal Disorders
Diarrhea 66 16 60 10
Stomatitis 31 3 19 1
Dyspepsia 16 0 9 0
General Disorders and Administration Site Conditions
Infusion-related Reactionc 14 2 <1 0
Pyrexia 26 1 14 1
Infections and Infestations
Paronychia 20 4 <1 0
Investigations
Weight Decreased 15 1 9 1
Metabolism and Nutrition Disorders
Anorexia 30 3 23 2
Skin and Subcutaneous Tissue Disorders
Acne-like Rashd 86 18 13 <1
  Rash 44 9 4 0
  Dermatitis Acneiform 26 5 <1 0
  Dry Skin 22 0 4 0
  Acne 14 2 0 0
  Pruritus 14 0 3 0
Palmar-plantar Erythrodysesthesia Syndrome 19 4 4 <1
Skin Fissures 19 2 1 0
aAdverse reactions occurring in at least 10% of Erbitux combination arm with a frequency at least 5% greater than that seen in the FOLFIRI arm.
b Adverse reactions were graded using the NCI CTC, V 2.0.
c Infusion related reaction is defined as any event meeting the medical concepts of allergy/anaphylaxis at any time during the clinical study or any event occurring on the first day of dosing and meeting the medical concepts of dyspnea and fever or by the following events using MedDRA preferred terms: “acute myocardial infarction”, “angina pectoris”, “angioedema”, “autonomic seizure”, “blood pressure abnormal”, “blood pressure decreased”, “blood pressure increased”, “cardiac failure”, “cardiopulmonary failure”, “cardiovascular insufficiency”, “clonus”, “convulsion”, “coronary no-reflow phenomenon”, “epilepsy”, “hypertension”, “hypertensive crisis”, “hypertensive emergency”, “hypotension”, “infusion related reaction”, “loss of consciousness”, “myocardial infarction”, “myocardial ischaemia”, “prinzmetal angina”, “shock”, “sudden death”, “syncope”, or “systolic hypertension”.
d Acne-like rash is defined by the events using MedDRA preferred terms and included “acne”, “acne pustular”, “butterfly rash”, “dermatitis acneiform”, “drug rash with eosinophilia and systemic symptoms”, “dry skin”, “erythema”, “exfoliative rash”, “folliculitis”, “genital rash”, “mucocutaneous rash”, “pruritus”, “rash”, “rash erythematous”, “rash follicular”, “rash generalized”, “rash macular”, “rash maculopapular”, “rash maculovesicular”, “rash morbilliform”, “rash papular”, “rash papulosquamous”, “rash pruritic”, “rash pustular”, “rash rubelliform”, “rash scarlatiniform”, “rash vesicular”, “skin exfoliation”, “skin hyperpigmentation”, “skin plaque”, “telangiectasia”, or “xerosis”.

Erbitux Monotherapy

Table 5 contains selected adverse reactions in 242 patients with K-Ras mutation-negative (wild-type), EGFR-expressing, metastatic colorectal cancer who received best supportive care (BSC) alone or with Erbitux in Study 5 [see WARNINGS AND PRECAUTIONS]. Erbitux was administered at the recommended dose and schedule (400 mg/m² initial dose, followed by 250 mg/m² weekly). Patients received a median of 17 infusions (range 1-51).

Table 5: Incidence of Selected Adverse Reactions Occurring in >10% of Patients with K-Ras Mutation-negative (Wild-type), EGFR- expressing, Metastatic Colorectal Cancer Treated with Erbitux Monotherapya

Body System Preferred Term Erbitux plus BSC
(n=118)
BSC alone
(n=124)
Grades 1-4b Grades 3 and 4 Grades 1-4 Grades 3 and 4
% of Patients
Dermatology/Skin
Rash/Desquamation 95 16 21 1
Dry Skin 57 0 15 0
Pruritus 47 2 11 0
Other-Dermatology 35 0 7 2
Nail Changes 31 0 4 0
Constitutional Symptoms
Fatigue 91 31 79 29
Fever 25 3 16 0
Infusion Reactionsc 18 3 0 0
Rigors, Chills 16 1 3 0
Pain
Pain-Other 59 18 37 10
Headache 38 2 11 0
Bone Pain 15 4 8 2
Pulmonary
Dyspnea 49 16 44 13
Cough 30 2 19 2
Gastrointestinal
Nausea 64 6 50 6
Constipation 53 3 38 3
Diarrhea 42 2 23 2
Vomiting 40 5 26 5
Stomatitis 32 1 10 0
Other-Gastrointestinal 22 12 16 5
Dehydration 13 5 3 0
Mouth Dryness 12 0 6 0
Taste Disturbance 10 0 5 0
Infection
Infection without neutropenia 38 11 19 5
Musculoskeletal
Arthralgia 14 3 6 0
Neurology
Neuropathy-sensory 45 1 38 2
Insomnia 27 0 13 0
Confusion 18 6 10 2
Anxiety 14 1 5 1
Depression 14 0 5 0
a Adverse reactions occurring in at least 10% of Erbitux plus BSC arm with a frequency at least 5% greater than that seen in the BSC alone arm.
b Adverse reactions were graded using the NCI CTC, V 2.0.
c Infusion reaction is defined as any event (chills, rigors, dyspnea, tachycardia, bronchospasm, chest tightness, swelling, urticaria, hypotension, flushing, rash, hypertension, nausea, angioedema, pain, sweating, tremors, shaking, drug fever, or other hypersensitivity reaction) recorded by the investigator as infusion-related.

Erbitux in Combination with Irinotecan

The most frequently reported adverse reactions in 354 patients treated with Erbitux plus irinotecan in clinical trials were acneiform rash (88%), asthenia/malaise (73%), diarrhea (72%), and nausea (55%). The most common Grades 3-4 adverse reactions included diarrhea (22%), leukopenia (17%), asthenia/malaise (16%), and acneiform rash (14%).

Immunogenicity

As with all therapeutic proteins, there is potential for immunogenicity. Immunogenic responses to cetuximab were assessed using either a double antigen radiometric assay or an ELISA assay. Due to limitations in assay performance and sampling timing, the incidence of antibody development in patients receiving Erbitux has not been adequately determined. Non-neutralizing anti-cetuximab antibodies were detected in 5% (49 of 1001) of evaluable patients without apparent effect on the safety or antitumor activity of Erbitux.

The incidence of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to Erbitux with the incidence of antibodies to other products may be misleading.

Postmarketing Experience

The following adverse reaction has been identified during post-approval use of Erbitux. Because this reaction was reported from a population of uncertain size, it was not always possible to reliably estimate its frequency or establish a causal relationship to drug exposure.

  • Aseptic meningitis

Read the Erbitux (cetuximab) Side Effects Center for a complete guide to possible side effects »

DRUG INTERACTIONS

A drug interaction study was performed in which Erbitux was administered in combination with irinotecan. There was no evidence of any pharmacokinetic interactions between Erbitux and irinotecan.

Last reviewed on RxList: 7/12/2012
This monograph has been modified to include the generic and brand name in many instances.

WARNINGS

Included as part of the PRECAUTIONS section.

PRECAUTIONS

Infusion Reactions

Serious infusion reactions, requiring medical intervention and immediate, permanent discontinuation of Erbitux included rapid onset of airway obstruction (bronchospasm, stridor, hoarseness), hypotension, shock, loss of consciousness, myocardial infarction, and/or cardiac arrest. Severe (NCI CTC Grades 3 and 4) infusion reactions occurred in 2-5% of 1373 patients in Studies 1, 3, 5, and 6 receiving Erbitux, with fatal outcome in 1 patient. [See Clinical Studies]

Approximately 90% of severe infusion reactions occurred with the first infusion despite premedication with antihistamines.

Monitor patients for 1 hour following Erbitux infusions in a setting with resuscitation equipment and other agents necessary to treat anaphylaxis (eg, epinephrine, corticosteroids, intravenous antihistamines, bronchodilators, and oxygen). Monitor longer to confirm resolution of the event in patients requiring treatment for infusion reactions.

Immediately and permanently discontinue Erbitux in patients with serious infusion reactions. [See BOXED WARNING, DOSAGE AND ADMINISTRATION.]

Cardiopulmonary Arrest

Cardiopulmonary arrest and/or sudden death occurred in 4 (2%) of 208 patients treated with radiation therapy and Erbitux as compared to none of 212 patients treated with radiation therapy alone in Study 1. Three patients with prior history of coronary artery disease died at home, with myocardial infarction as the presumed cause of death. One of these patients had arrhythmia and one had congestive heart failure. Death occurred 27, 32, and 43 days after the last dose of Erbitux. One patient with no prior history of coronary artery disease died one day after the last dose of Erbitux. In Study 2, fatal cardiac disorders and/or sudden death occurred in 7 (3%) of 219 patients treated with EU-approved cetuximab and platinum-based therapy with 5-FU as compared to 4 (2%) of 215 patients treated with chemotherapy alone. Five of these 7 patients in the chemotherapy plus cetuximab arm received concomitant cisplatin and 2 patients received concomitant carboplatin. All 4 patients in the chemotherapy-alone arm received cisplatin. Carefully consider use of Erbitux in combination with radiation therapy or platinum- based therapy with 5-FU in head and neck cancer patients with a history of coronary artery disease, congestive heart failure, or arrhythmias in light of these risks. Closely monitor serum electrolytes, including serum magnesium, potassium, and calcium, during and after Erbitux. [See BOXED WARNING.]

Pulmonary Toxicity

Interstitial lung disease (ILD), including 1 fatality, occurred in 4 of 1570 (<0.5%) patients receiving Erbitux in Studies 1, 3, and 6, as well as other studies, in colorectal cancer and head and neck cancer. Interrupt Erbitux for acute onset or worsening of pulmonary symptoms. Permanently discontinue Erbitux for confirmed ILD.

Dermatologic Toxicity

Dermatologic toxicities, including acneiform rash, skin drying and Assuring, paronychial inflammation, infectious sequelae (for example, S. aureus sepsis, abscess formation, cellulitis, blepharitis, conjunctivitis, keratitis/ulcerative keratitis with decreased visual acuity, cheilitis), and hypertrichosis occurred in patients receiving Erbitux therapy. Acneiform rash occurred in 76-88% of 1373 patients receiving Erbitux in Studies 1, 3, 5, and 6. Severe acneiform rash occurred in 1-17% of patients.

Acneiform rash usually developed within the first two weeks of therapy and resolved in a majority of the patients after cessation of treatment, although in nearly half, the event continued beyond 28 days. Monitor patients receiving Erbitux for dermatologic toxicities and infectious sequelae. Instruct patients to limit sun exposure during Erbitux therapy. [See DOSAGE AND ADMINISTRATION.]

Use of Erbitux in Combination With Radiation and Cisplatin

The safety of Erbitux in combination with radiation therapy and cisplatin has not been established. Death and serious cardiotoxicity were observed in a single-arm trial with Erbitux, radiation therapy, and cisplatin (100 mg/m ) in patients with locally advanced SCCHN. Two of 21 patients died, one as a result of pneumonia and one of an unknown cause. Four patients discontinued treatment due to adverse events. Two of these discontinuations were due to cardiac events.

Hypomagnesemia and Electrolyte Abnormalities

In patients evaluated during clinical trials, hypomagnesemia occurred in 55% of 365 patients receiving Erbitux in Study 5 and two other clinical trials in colorectal cancer and head and neck cancer, respectively, and was severe (NCI CTC Grades 3 and 4) in 6-17%.

In Study 2, where EU-approved cetuximab was administered in combination with platinum-based therapy, the addition of cetuximab to cisplatin and 5-FU resulted in an increased incidence of hypomagnesemia (14% vs. 6%) and of Grade 3-4 hypomagnesemia (7% vs. 2%) compared to cisplatin and 5-FU alone. In contrast, the incidences of hypomagnesemia were similar for those who received cetuximab, carboplatin, and 5-FU compared to carboplatin and 5-FU (4% vs. 4%). No patient experienced Grade 3-4 hypomagnesemia in either arm in the carboplatin subgroup.

The onset of hypomagnesemia and accompanying electrolyte abnormalities occurred days to months after initiation of Erbitux. Periodically monitor patients for hypomagnesemia, hypocalcemia, and hypokalemia, during and for at least 8 weeks following the completion of Erbitux. Replete electrolytes as necessary.

K-Ras Testing in Metastatic or Advanced Colorectal Cancer Patients

Determination of K-Ras mutational status in colorectal tumors using an FDA-approved test indicated for this use is necessary for selection of patients for treatment with Erbitux. Erbitux is indicated only for patients with EGFR-expressing K-Ras mutation-negative (wild-type) mCRC. Erbitux is not an effective treatment for patients with colorectal cancer that harbor somatic mutations in codons 12 and 13 (exon 2). Studies 4 and 5, conducted in patients with colorectal cancer, demonstrated a benefit with Erbitux treatment only in the subset of patients whose tumors were K-Ras mutation-negative (wild-type). Erbitux is not effective for the treatment of K-Ras mutation-positive colorectal cancer as determined by an FDA-approved test for this use. [See INDICATIONS AND USAGE, CLINICAL PHARMACOLOGY, Clinical Studies].

Perform the assessment for K-Ras mutation status in colorectal cancer in laboratories with demonstrated proficiency in the specific technology being utilized. Improper assay performance can lead to unreliable test results.

Refer to an FDA-approved test's package insert for instructions on the identification of patients eligible for the treatment of Erbitux.

Epidermal Growth Factor Receptor (EGFR) Expression and Response

Because expression of EGFR has been detected in nearly all SCCHN tumor specimens, patients enrolled in the head and neck cancer clinical studies were not required to have immunohistochemical evidence of EGFR tumor expression prior to study entry.

Patients enrolled in the colorectal cancer clinical studies were required to have immunohistochemical evidence of EGFR tumor expression. Primary tumor or tumor from a metastatic site was tested with the DakoCytomation EGFR pharmDx™ test kit. Specimens were scored based on the percentage of cells expressing EGFR and intensity (barely/faint, weak-to-moderate, and strong). Response rate did not correlate with either the percentage of positive cells or the intensity of EGFR expression.

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment of Fertility

Long-term animal studies have not been performed to test cetuximab for carcinogenic potential, and no mutagenic or clastogenic potential of cetuximab was observed in the Salmonella-Escherichia coli (Ames) assay or in the in vivo rat micronucleus test. Menstrual cyclicity was impaired in female cynomolgus monkeys receiving weekly doses of 0.4 to 4 times the human dose of cetuximab (based on total body surface area). Cetuximab-treated animals exhibited increased incidences of irregular or absent cycles, as compared to control animals. These effects were initially noted beginning week 25 of cetuximab treatment and continued through the 6-week recovery period. In this same study, there were no effects of cetuximab treatment on measured male fertility parameters (ie, serum testosterone levels and analysis of sperm counts, viability, and motility) as compared to control male monkeys. It is not known if cetuximab can impair fertility in humans.

Use In Specific Populations

Pregnancy

Pregnancy Category C

There are no adequate and well-controlled studies of Erbitux in pregnant women. Based on animal models, EGFR has been implicated in the control of prenatal development and may be essential for normal organogenesis, proliferation, and differentiation in the developing embryo. Human IgG is known to cross the placental barrier; therefore, Erbitux may be transmitted from the mother to the developing fetus, and has the potential to cause fetal harm when administered to pregnant women. Erbitux should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Pregnant cynomolgus monkeys were treated weekly with 0.4 to 4 times the recommended human dose of cetuximab (based on body surface area) during the period of organogenesis (gestation day [GD] 20-48). Cetuximab was detected in the amniotic fluid and in the serum of embryos from treated dams at GD 49. No fetal malformations or other teratogenic effects occurred in offspring. However, significant increases in embryolethality and abortions occurred at doses of approximately 1.6 to 4 times the recommended human dose of cetuximab (based on total body surface area).

Nursing Mothers

It is not known whether Erbitux is secreted in human milk. IgG antibodies, such as Erbitux, can be excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from Erbitux, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother. If nursing is interrupted, based on the mean half-life of cetuximab [see CLINICAL PHARMACOLOGY], nursing should not be resumed earlier than 60 days following the last dose of Erbitux.

Pediatric Use

The safety and effectiveness of Erbitux in pediatric patients have not been established. The pharmacokinetics of cetuximab, in combination with irinotecan, were evaluated in pediatric patients with refractory solid tumors in an open-label, single-arm, dose-finding study. Erbitux was administered once weekly, at doses up to 250 mg/m², to 27 patients ranging from 1 to 12 years old; and in 19 patients ranging from 13 to 18 years old. No new safety signals were identified in pediatric patients. The pharmacokinetic profiles of cetuximab between the two age groups were similar at the 75 and 150 mg/m² single dose levels. The volume of the distribution appeared to be independent of dose and approximated the vascular space of 2-3 L/m². Following a single dose of 250 mg/m², the geometric mean AUC0-inf (CV%) value was 17.7 mg•h/mL (34%) in the younger age group (1-12 years, n=9) and 13.4 mg•h/mL (38%) in the adolescent group (13-18 years, n=6). The mean half-life of cetuximab was 110 hours (range 69 to 188 hours) for the younger age group, and 82 hours (range 55 to 117 hours) for the adolescent age group.

Geriatric Use

Of the 1662 patients who received Erbitux with irinotecan, FOLFIRI or Erbitux monotherapy in six studies of advanced colorectal cancer, 588 patients were 65 years of age or older. No overall differences in safety or efficacy were observed between these patients and younger patients.

Clinical studies of Erbitux conducted in patients with head and neck cancer did not include sufficient number of subjects aged 65 and over to determine whether they respond differently from younger subjects.

Last reviewed on RxList: 7/12/2012
This monograph has been modified to include the generic and brand name in many instances.

OVERDOSE

The maximum single dose of Erbitux administered is 1000 mg/m² in one patient. No adverse events were reported for this patient.

CONTRAINDICATIONS

None

Last reviewed on RxList: 7/12/2012
This monograph has been modified to include the generic and brand name in many instances.

CLINICAL PHARMACOLOGY

Mechanism of Action

The epidermal growth factor receptor (EGFR, HER1, c-ErbB-1) is a transmembrane glycoprotein that is a member of a subfamily of type I receptor tyrosine kinases including EGFR, HER2, HER3, and HER4. The EGFR is constitutively expressed in many normal epithelial tissues, including the skin and hair follicle. Expression of EGFR is also detected in many human cancers including those of the head and neck, colon, and rectum.

Cetuximab binds specifically to the EGFR on both normal and tumor cells, and competitively inhibits the binding of epidermal growth factor (EGF) and other ligands, such as transforming growth factor-alpha. In vitro assays and in vivo animal studies have shown that binding of cetuximab to the EGFR blocks phosphorylation and activation of receptor-associated kinases, resulting in inhibition of cell growth, induction of apoptosis, and decreased matrix metalloproteinase and vascular endothelial growth factor production. Signal transduction through the EGFR results in activation of wild-type K-Ras protein. However, in cells with activating K-Ras somatic mutations, the mutant K-Ras protein is continuously active and appears independent of EGFR regulation.

In vitro, cetuximab can mediate antibody-dependent cellular cytotoxicity (ADCC) against certain human tumor types. In vitro assays and in vivo animal studies have shown that cetuximab inhibits the growth and survival of tumor cells that express the EGFR. No anti-tumor effects of cetuximab were observed in human tumor xenografts lacking EGFR expression. The addition of cetuximab to radiation therapy or irinotecan in human tumor xenograft models in mice resulted in an increase in anti-tumor effects compared to radiation therapy or chemotherapy alone.

Pharmacodynamics

Effects on Electrocardiogram (ECG)

The effect of cetuximab on QT interval was evaluated in an open-label, single-arm, monotherapy trial in 37 subjects with advanced malignancies who received an initial dose 22 of 400 mg/m , followed by weekly infusions of 250 mg/m for a total of 5 weeks. No large changes in the mean QT interval of >20 ms from baseline were detected in the trial based on Fridericia correction method. A small increase in the mean QTc interval of <10 ms cannot be excluded because of the limitations in the trial design.

Pharmacokinetics

Erbitux administered as monotherapy or in combination with concomitant chemotherapy or radiation therapy exhibits nonlinear pharmacokinetics. The area under the concentration time curve (AUC) increased in a greater than dose proportional manner while clearance of cetuximab decreased from 0.08 to 0.02 L/h/m² as the dose increased from 20 to 200 mg/m², and at doses >200 mg/m², it appeared to plateau. The volume of the distribution for cetuximab appeared to be independent of dose and approximated the vascular space of 2-3 L/m².

Following the recommended dose regimen (400 mg/m² initial dose; 250 mg/m² weekly dose), concentrations of cetuximab reached steady-state levels by the third weekly infusion with mean peak and trough concentrations across studies ranging from 168 to 235 and 41 to 85 ^g/mL, respectively. The mean half-life of cetuximab was approximately 112 hours (range 63-230 hours). The pharmacokinetics of cetuximab were similar in patients with SCCHN and those with colorectal cancer.

Erbitux had an approximately 22% (90% confidence interval; 6%, 38%) higher systemic exposure relative to the EU-approved cetuximab used in Studies 2 and 4 based on a population pharmacokinetic analysis. [See Clinical Studies]

Animal Pharmacology and/or Toxicology

In cynomolgus monkeys, cetuximab, when administered at doses of approximately 0.4 to 4 times the weekly human exposure (based on total body surface area), resulted in dermatologic findings, including inflammation at the injection site and desquamation of the external integument. At the highest dose level, the epithelial mucosa of the nasal passage, esophagus, and tongue were similarly affected, and degenerative changes in the renal tubular epithelium occurred. Deaths due to sepsis were observed in 50% (5/10) of the animals at the highest dose level beginning after approximately 13 weeks of treatment.

Clinical Studies

Studies 2 and 4 were conducted outside the U.S. using an EU-approved cetuximab as the clinical trial material. Erbitux provides approximately 22% higher exposure relative to the EU-approved cetuximab used in Studies 2 and 4; these pharmacokinetic data, together with the results of Studies 2, 4, and other clinical trial data establish the efficacy of Erbitux at the recommended dose in SCCHN and mCRC [see CLINICAL PHARMACOLOGY].

Study 1 was a randomized, multicenter, controlled trial of 424 patients with locally or regionally advanced SCCHN. Patients with Stage III/IV SCCHN of the oropharynx, hypopharynx, or larynx with no prior therapy were randomized (1:1) to receive either Erbitux plus radiation therapy or radiation therapy alone. Stratification factors were Karnofsky performance status (60-80 versus 90-100), nodal stage (N0 versus N+), tumor stage (T1-3 versus T4 using American Joint Committee on Cancer 1998 staging criteria), and radiation therapy fractionation (concomitant boost versus once-daily versus twice- daily). Radiation therapy was administered for 6-7 weeks as once daily, twice daily, or concomitant boost. Erbitux was administered as a 400 mg/m² initial dose beginning one week prior to initiation of radiation therapy, followed by 250 mg/m² weekly administered 1 hour prior to radiation therapy for the duration of radiation therapy (6-7 weeks).

Of the 424 randomized patients, the median age was 57 years, 80% were male, 83% were Caucasian, and 90% had baseline Karnofsky performance status >80. There were 258 patients enrolled in U.S. sites (61%). Sixty percent of patients had oropharyngeal, 25% laryngeal, and 15% hypopharyngeal primary tumors; 28% had AJCC T4 tumor stage. Fifty-six percent of the patients received radiation therapy with concomitant boost, 26% received once-daily regimen, and 18% twice-daily regimen.

The main outcome measure of this trial was duration of locoregional control. Overall survival was also assessed. Results are presented in Table 6.

Table 6: Study 1: Clinical Efficacy in Locoregionally Advanced SCCHN

  Erbitux + Radiation
(n=211)
Radiation Alone
(n=213)
Hazard Ratio (95% CIa) Stratified Log-rank p-value
Locoregional Control
  Median duration (months) 24.4 14.9 0.68
(0.52-0.89)
0.005
Overall Survival
  Median duration (months) 49.0 29.3 0.74
(0.57-0.97)
0.03
a CI = confidence interval

Study 2 was an open-label, randomized, multicenter, controlled trial of 442 patients with recurrent locoregional disease or metastatic SCCHN.

Patients with no prior therapy for recurrent locoregional disease or metastatic SCCHN were randomized (1:1) to receive EU-approved cetuximab plus cisplatin or carboplatin and 5-FU, or cisplatin or carboplatin and 5-FU alone. Choice of cisplatin or carboplatin was at the discretion of the treating physician. Stratification factors were Karnofsky performance status (<80 versus >80) and previous chemotherapy. Cisplatin (100 mg/m², Day 1) or carboplatin (AUC 5, Day 1) plus intravenous 5-FU (1000 mg/m²/day, Days 1-4) were administered every 3 weeks (1 cycle) for a maximum of 6 cycles in the absence of disease progression or unacceptable toxicity. Cetuximab was administered at a 400 mg/m² initial dose, followed by a 250 mg/m² weekly dose in combination with chemotherapy. Patients demonstrating at least stable disease on cetuximab in combination with chemotherapy were to continue cetuximab monotherapy at 250 mg/m² weekly, in the absence of disease progression or unacceptable toxicity after completion of 6 planned courses of platinum-based therapy. For patients where treatment was delayed because of the toxic effects of chemotherapy, weekly cetuximab was continued. If chemotherapy was discontinued for toxicity, cetuximab could be continued as monotherapy until disease progression or unacceptable toxicity.

Of the 442 randomized patients, the median age was 57 years, 90% were male, 98% were Caucasian, and 88% had baseline Karnofsky performance status >80. Thirty-four percent of patients had oropharyngeal, 25% laryngeal, 20% oral cavity, and 14% hypopharyngeal primary tumors. Fifty-three percent of patients had recurrent locoregional disease only and 47% had metastatic disease. Fifty-eight percent had AJCC Stage IV disease and 21% had Stage III disease. Sixty-four percent of patients received cisplatin therapy and 34% received carboplatin as initial therapy. Approximately fifteen percent of the patients in the cisplatin alone arm switched to carboplatin during the treatment period.

The main outcome measure of this trial was overall survival. Results are presented in Table 7 and Figure 1.

Table 7: Study 2: Clinical Efficacy in Recurrent Locoregional Disease or Metastatic SCCHN

  EU-Approved Cetuximab + Platinum-based Therapy + 5-FU
(n=222)
Platinum-based Therapy + 5-FU
(n=220)
Hazard Ratio (95% CIa) Stratified Log-rank p-value
Overall Survival
Median duration (months) 10.1 7.4 0.80 (0.64, 0.98) 0.034
Progression-free Survival
Median duration (months) 5.5 3.3 0.57 (0.46, 0.72) <0.0001
  EU-Approved
Cetuximab + Platinum-based Therapy + 5-FU
(n=222)
Platinum-based Therapy + 5-FU
(n=220)
Odds Ratio (95% CIa) CMHb test p-value
Objective Response Rate 35.6% 19.5% 2.33 (1.50, 3.60) 0.0001
a CI = confidence interval
b CMH = Cochran-Mantel-Haenszel

Figure 1: Kaplan-Meier Curve for Overall Survival in Patients with Recurrent Locoregional Disease or Metastatic Squamous Cell Carcinoma of the Head and Neck

Kaplan-Meier Curve for Overall Survival - Illustration

In exploratory subgroup analyses of Study 2 by initial platinum therapy (cisplatin or carboplatin), for patients (N=284) receiving cetuximab plus cisplatin with 5-FU compared to cisplatin with 5-FU alone, the difference in median overall survival was 3.3 months (10.6 versus 7.3 months, respectively; HR 0.71; 95% CI 0.54, 0.93). The difference in median progression-free survival was 2.1 months (5.6 versus 3.5 months, respectively; HR 0.55; 95% CI 0.41, 0.73). The objective response rate was 39% and 23%, respectively (OR 2.18; 95% CI 1.29, 3.69). For patients (N=149) receiving cetuximab plus carboplatin with 5-FU compared to carboplatin with 5-FU alone, the difference in median overall survival was 1.4 months (9.7 versus 8.3 months; HR 0.99; 95% CI 0.69, 1.43). The difference in median progression-free survival was 1.7 months (4.8 versus 3.1 months, respectively; HR 0.61; 95% CI 0.42, 0.89). The objective response rate was 30% and 15%, respectively (OR 2.45; 95% CI 1.10, 5.46).

Study 3 was a single-arm, multicenter clinical trial in 103 patients with recurrent or metastatic SCCHN. All patients had documented disease progression within 30 days of a platinum-based chemotherapy regimen. Patients received a 20-mg test dose of Erbitux on Day 1, followed by a 400 mg/m² initial dose, and 250 mg/m² weekly until disease progression or unacceptable toxicity.

The median age was 57 years, 82% were male, 100% Caucasian, and 62% had a Karnofsky performance status of >80.

The objective response rate was 13% (95% confidence interval 7%-21%). Median duration of response was 5.8 months (range 1.2-5.8 months).

Colorectal Cancer

Erbitux Clinical Trials in K-Ras Mutation-negative (Wild-type), EGFR- expressing, Metastatic Colorectal Cancer

Study 4 was a randomized, open-label, multicenter, study of 1217 patients with EGFR- expressing metastatic colorectal cancer. Patients were randomized (1:1) to receive either EU-approved cetuximab in combination with FOLFIRI or FOLFIRI alone as first-line treatment. Stratification factors were Eastern Cooperative Oncology Group (ECOG) performance status (0 and 1 versus 2) and region (sites in Western Europe versus Eastern Europe versus other).

FOLFIRI regimen included 14-day cycles of irinotecan (180 mg/m administered intravenously on Day 1), folinic acid (400 mg/m² [racemic] or 200 mg/m² [L-form] administered intravenously on Day 1), and 5-FU (400 mg/m bolus on Day 1 followed by 2400 mg/m as a 46-hour continuous infusion). Cetuximab was administered as a 400 mg/m² initial dose on day 1, week 1, followed by 250 mg/m² weekly administered 1 hour prior to chemotherapy. Study treatment continued until disease progression or unacceptable toxicity occurred.

Of the 1217 randomized patients, the median age was 61 years, 60% were male, 86% were Caucasian, and 96% had a baseline ECOG performance status 0-1, 60% had primary tumor localized in colon, 84% had 1-2 metastatic sites and 20% had received prior adjuvant and/or neoadjuvant chemotherapy. Demographics and baseline characteristics were similar between study arms.

K-Ras mutation status was available for 1079/1217 (89%) of the patients: 676 (63%) patients had K-Ras mutation-negative (wild-type) tumors and 403 (37%) patients had K-Ras mutation-positive tumors where testing assessed for the following somatic mutations in codons 12 and 13 (exon 2): G12A, G12D, G12R, G12C, G12S, G12V, G13D [see WARNINGS AND PRECAUTIONS].

Baseline characteristics and demographics in the K-Ras mutation-negative (wild-type) subset were similar to that seen in the overall population [see WARNINGS AND PRECAUTIONS].

The main outcome measure of this trial was progression-free survival assessed by an independent review committee (IRC). Overall survival and response rate were also assessed. A statistically significant improvement in PFS was observed for the cetuximab plus FOLFIRI arm compared with the FOLFIRI arm (median PFS 8.9 vs. 8.1 months, HR 0.85 [95% CI 0.74, 0.99], p-value=0.036). Overall survival was not significantly different at the planned, final analysis based on 838 events [HR=0.93, 95% CI (0.8, 1.1), p-value 0.327].

Results of the planned PFS and ORR analysis in all randomized patients and post-hoc PFS and ORR analysis in subgroups of patients defined by K-Ras mutation status, and post-hoc analysis of updated OS based on additional follow-up (1000 events) in all randomized patients and in subgroups of patients defined by K-Ras mutation status are presented in Table 8 and Figure 2. The treatment effect in the all-randomized population for PFS was driven by treatment effects limited to patients who have K-Ras mutation- negative (wild-type) tumors. There is no evidence of effectiveness in the subgroup of patients with K-Ras mutation-positive tumors.

Table 8: Clinical Efficacy in First-line EGFR-expressing Metastatic Colorectal Cancer (All Randomized and K-Ras Status)

  All Randomized K-Ras Mutation-negative (Wild-type) K-Ras Mutation-positive
EU- Approved Cetuximab plus FOLFIRI
(N=608)
FOLFIRI
(n=609)
EU- Approved Cetuximab plus FOLFIRI
(n=320)
FOLFIRI
(n=356)
EU- Approved Cetuximab plus FOLFIRI
(n=216)
FOLFIRI
(n=187)
Progression-Free Survival
Number of Events (%) 343 (56) 371 (61) 165(52) 214 (60) 138 (64) 112 (60)
Median (months) (95% CI) 8.9 (8.0, 9.4) 8.1 (7.6, 8.8) 9.5 (8.9, 11.1) 8.1 (7.4, 9.2) 7.5 (6.7, 8.7) 8.2 (7.4, 9.2)
HR (95% CI) 0.85 (0.74, 0.99) 0.70 (0.57, 0.86) 1.13 (0.88, 1.46)
p-valuea 0.0358
Overall Survivalb
Number of Events (%) 491 (81) 509 (84) 244 (76) 292 (82) 189 (88) 159 (85)
Median (months) (95% CI) 19.6 (18, 21) 18.5 (17, 20) 23.5 (21, 26) 19.5 (17, 21) 16.0 (15, 18) 16.7 (15, 19)
HR (95% CI) 0.88 (0.78, 1.0) 0.80 (0.67, 0.94) 1.04 (0.84, 1.29)
Objective Response Rate
ORR (95% CI) 46% (42, 50) 38% (34, 42) 57% (51, 62) 39% (34, 44) 31% (25, 38) 35% (28, 43)
a Based on the Stratified Log-rank test.
b Post-hoc updated OS analysis, results based on an additional 162 events.

Figure 2: Kaplan-Meier Curve for Overall Survival in the K-Ras Mutation-negative (Wild-type) Population in Study 4

Kaplan-Meier Curve for Overall Survival in the K-Ras Mutation-negative (Wild-type) Population - Illustration

Study 5 was a multicenter, open-label, randomized, clinical trial conducted in 572 patients with EGFR-expressing, previously treated, recurrent mCRC. Patients were randomized (1:1) to receive either Erbitux plus best supportive care (BSC) or BSC alone. Erbitux was administered as a 400 mg/m² initial dose, followed by 250 mg/m² weekly until disease progression or unacceptable toxicity.

Of the 572 randomized patients, the median age was 63 years, 64% were male, 89% were Caucasian, and 77% had baseline ECOG performance status of 0-1. Demographics and baseline characteristics were similar between study arms. All patients were to have received and progressed on prior therapy including an irinotecan-containing regimen and an oxaliplatin-containing regimen.

K-Ras status was available for 453/572 (79%) of the patients: 245 (54%) patients had K-Ras mutation-negative (wild-type) tumors and 208 (46%) patients had K-Ras mutation- positive tumors where testing assessed for the following somatic mutations in codons 12 and 13 (exon 2): G12A, G12D, G12R, G12C, G12S, G12V, G13D [see WARNINGS AND PRECAUTIONS].

The main outcome measure of the study was overall survival. Results are presented in Table 9 and Figure 3.

Table 9: Overall Survival in Previously Treated EGFR-expressing Metastatic Colorectal Cancer (All Randomized and K-Ras Status)

  All Randomized K-Ras Mutation-negative (Wild-type) K-Ras Mutation-positive
Erbitux plus BSC
(N=287)
BSC
(N=285)
Erbitux plus BSC
(N=117)
BSC
(N=128)
Erbitux plus BSC
(N=108)
BSC (N=100)
Median (months) 6.1 4.6 8.6 5.0 4.8 4.6
(95% CI) (5.4, 6.7) (4.2, 4.9) (7.0, 10.3) (4.3, 5.7) (3.9, 5.6) (3.6, 4.9)
HR 0.77 (0.64, 0.92) 0.63 (0.47, 0.84) 0.91 (0.67, 1.24)
(95% CI)
p-valuea 0.0046    
a Based on the Stratified Log-rank test.

Figure 3: Kaplan-Meier Curve for Overall Survival in Patients with K-Ras Mutation-negative (Wild-type) Metastatic Colorectal Cancer in Study 5

Kaplan-Meier Curve for Overall Survival - Illustration

Study 6 was a multicenter, clinical trial conducted in 329 patients with EGFR-expressing recurrent mCRC. Tumor specimens were not available for testing for K-Ras mutation status. Patients were randomized (2:1) to receive either Erbitux plus irinotecan (218 patients) or Erbitux monotherapy (111 patients). Erbitux was administered as a 400 mg/m² initial dose, followed by 250 mg/m² weekly until disease progression or unacceptable toxicity. In the Erbitux plus irinotecan arm, irinotecan was added to Erbitux using the same dose and schedule for irinotecan as the patient had previously failed. Acceptable irinotecan schedules were 350 mg/m² every 3 weeks, 180 mg/m² every 2 weeks, or 125 mg/mweekly times four doses every 6 weeks. Of the 329 patients, the median age was 59 years, 63% were male, 98% were Caucasian, and 88% had baseline Karnofsky performance status ≥80. Approximately two-thirds had previously failed 632 oxaliplatin treatment.

The efficacy of Erbitux plus irinotecan or Erbitux monotherapy, based on durable objective responses, was evaluated in all randomized patients and in two pre-specified subpopulations: irinotecan refractory patients, and irinotecan and oxaliplatin failures. In patients receiving Erbitux plus irinotecan, the objective response rate was 23% (95% confidence interval 18%-29%), median duration of response was 5.7 months, and median time to progression was 4.1 months. In patients receiving Erbitux monotherapy, the objective response rate was 11% (95% confidence interval 6%-18%), median duration of response was 4.2 months, and median time to progression was 1.5 months. Similar response rates were observed in the pre-defined subsets in both the combination arm and monotherapy arm of the study.

Last reviewed on RxList: 7/12/2012
This monograph has been modified to include the generic and brand name in many instances.

PATIENT INFORMATION

Advise patients:

  • To report signs and symptoms of infusion reactions such as fever, chills, or breathing problems.
  • Of the potential risks of using Erbitux during pregnancy or nursing and of the need to use adequate contraception in both males and females during and for 6 months following the last dose of Erbitux therapy.
  • That nursing is not recommended during, and for 2 months following the last dose of Erbitux therapy.
  • To limit sun exposure (use sunscreen, wear hats) while receiving and for 2 months following the last dose of Erbitux.

Last reviewed on RxList: 7/12/2012
This monograph has been modified to include the generic and brand name in many instances.

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PATIENT INFORMATION

Advise patients:

  • To report signs and symptoms of infusion reactions such as fever, chills, or breathing problems.
  • Of the potential risks of using Erbitux during pregnancy or nursing and of the need to use adequate contraception in both males and females during and for 6 months following the last dose of Erbitux therapy.
  • That nursing is not recommended during, and for 2 months following the last dose of Erbitux therapy.
  • To limit sun exposure (use sunscreen, wear hats) while receiving and for 2 months following the last dose of Erbitux.

Last reviewed on RxList: 7/12/2012
This monograph has been modified to include the generic and brand name in many instances.

Disclaimer

Erbitux Consumer

IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.

CETUXIMAB - INJECTION

(se-TUX-i-mab)

COMMON BRAND NAME(S): Erbitux

WARNING: Severe (sometimes fatal) infusion reactions have occurred with cetuximab. Seek immediate medical attention if you have difficulty breathing, hoarseness, itching, or dizziness, as your treatment should be stopped.

Rare deaths (due to heart attack, sudden death) have occurred in patients with head and neck cancer treated with radiation therapy and cetuximab. This may rarely occur days to a few months after the last dose of this medication. Tell your doctor if you have heart disease (e.g., coronary artery disease, congestive heart failure, arrhythmias). Blood levels of certain minerals should be checked often (see Notes section). Seek immediate medical attention if you develop: chest pain, unexplained jaw/left arm pain.

USES: Cetuximab is used alone or with other anti-cancer drugs to treat colorectal cancer that has spread to other parts of the body. These patients generally cannot tolerate or have not responded to another drug called irinotecan. This medication is also used to treat head and neck cancer. Cetuximab works by slowing cancer cell growth. This action occurs when this drug binds to a specific protein (epidermal growth factor receptor-EGFR) on the cancer cells. Cetuximab is a man-made protein (monoclonal antibody).

OTHER USES: This section contains uses of this drug that are not listed in the approved professional labeling for the drug but that may be prescribed by your health care professional. Use this drug for a condition that is listed in this section only if it has been so prescribed by your health care professional.

Cetuximab may also be used for kidney cancer.

HOW TO USE: Cetuximab is given by injection into a vein usually once a week by a healthcare professional. Another drug (e.g., diphenhydramine) may be given before you receive cetuximab to lessen the chance of certain side effects. The first dose (loading dose) is larger and is given over 2 hours. All other doses (maintenance doses) are smaller and are given over 1 hour if tolerated. The dosage is based on your medical condition and response to treatment.

A healthcare professional should watch you for at least 1 hour after your infusion is finished to make sure you do not have an infusion reaction. (See Warning section). If you experience a severe infusion reaction, your infusion will be stopped and your doctor may decide to stop further treatments.

Disclaimer

Erbitux Consumer (continued)

SIDE EFFECTS: (see also Warning section)

Nausea, vomiting, constipation, diarrhea, headache, stomachache, backache, fever/chills, trouble sleeping, weight loss, fatigue, drowsiness, eye redness/itching, nail changes, and dry skin may occur. Nausea and vomiting can be quite severe. In some cases, drug therapy may be necessary to prevent or relieve nausea and vomiting. Not eating before your treatment may help relieve vomiting. Changes in diet such as eating several small meals or limiting activity may help lessen some of these effects. If these effects persist or worsen, notify your doctor or pharmacist promptly.

Many people using this medication have serious side effects. However, your doctor has prescribed this drug because he or she has judged that the benefit to you is greater than the risk of side effects. Careful monitoring by your doctor may decrease your risk.

An acne-like rash may occur. Depending on how severe this rash is, your doctor may delay your cetuximab treatment, lower your dose, treat the rash with antibiotics, or stop treatment with cetuximab to decrease this potentially serious side effect.

Tell your doctor immediately if any of these unlikely but serious side effects occur: confusion, depression, swelling of hands/feet/lower legs, dehydration, serious infection (e.g., high fever, chills, persistent sore throat), change in amount of urine, decreased vision, severe dizziness, fast/slow/irregular heartbeat.

Rarely, very serious lung problems may occur. Seek immediate medical attention if you develop: trouble breathing.

A very serious allergic reaction to this drug is unlikely, but seek immediate medical attention if it occurs. Symptoms of a serious allergic reaction may include: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.

This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.

In the US -

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.

Read the Erbitux (cetuximab) Side Effects Center for a complete guide to possible side effects »

PRECAUTIONS: Before receiving cetuximab, tell your doctor or pharmacist if you are allergic to it or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.

Before using this medication, tell your doctor or pharmacist your medical history, especially of: lung disease, radiation therapy, heart disease (e.g., coronary artery disease, congestive heart failure, arrhythmias).

This medication may make you drowsy. Do not drive, use machinery, or do any activity that requires alertness until you are sure you can perform such activities safely. Limit alcoholic beverages.

Sunlight may worsen any skin reactions that may occur while you are using this drug. Avoid prolonged sun exposure, tanning booths, and sunlamps during treatment and for 2 months after your last treatment with cetuximab. Use a sunscreen and wear protective clothing when outdoors.

This medication may harm an unborn baby. This medication is not recommended for use during pregnancy. Both males and females using this drug must avoid becoming pregnant or causing pregnancy. Therefore, both males and females using this drug must use at least 2 reliable forms of birth control (e.g., condoms, birth control pills) while using this medication and for 6 months after treatment is ended. Consult your doctor for information on reliable birth control. If you or your partner becomes pregnant while using this drug or during the 6 months after the last treatment, tell both of your doctors immediately.

Based on information from related drugs, cetuximab may pass into breast milk. Because of potential harm to the infant, breast-feeding is not recommended while using cetuximab and for 2 months after the end of treatment. Consult your doctor before breast-feeding.

Disclaimer

Erbitux Consumer (continued)

DRUG INTERACTIONS: Your healthcare professionals (e.g., doctor or pharmacist) may already be aware of any possible drug interactions and may be monitoring you for it. Do not start, stop or change the dosage of any medicine before checking with them first.

Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use.

Keep a list of all your medications with you, and share the list with your doctor and pharmacist.

OVERDOSE: If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US national poison hotline at 1-800-222-1222. Canadian residents should call their local poison control center directly.

NOTES: Medical tests and regular physical exams should be performed to check for side effects. Laboratory tests should be performed before giving cetuximab to check for the EGFR protein on your tumor. Certain laboratory tests (e.g., calcium, magnesium, potassium levels) will be performed from time to time while you are being treated with cetuximab and up to 8 weeks after your last infusion. Consult your doctor for more details. Keep all scheduled medical appointments.

MISSED DOSE: It is important that you receive cetuximab as scheduled by your doctor. If you miss a dose, contact your doctor immediately to obtain a new dosing schedule.

STORAGE: Not applicable. This medication is given in a hospital or clinic and will not be stored at home.

MEDICAL ALERT: Your condition can cause complications in a medical emergency. For enrollment information call MedicAlert at 1-800-854-1166 (USA), or 1-800-668-1507 (Canada).

Information last revised March 2012. Copyright(c) 2012 First Databank, Inc.

Erbitux Patient Information Including Side Effects

Brand Names: Erbitux

Generic Name: cetuximab (Pronunciation: se TUX i mab)

What is cetuximab (Erbitux)?

Cetuximab is a cancer medication that interferes with the growth of cancer cells and slows their growth and spread in the body.

Cetuximab is used to treat cancers of the colon and rectum. It is also used to treat head and neck cancer.

Cetuximab may also be used for other purposes not listed in this medication guide.

What are the possible side effects of cetuximab (Erbitux)?

Some people receiving a cetuximab injection have had a reaction to the infusion (when the medicine is injected into the vein). Tell your caregiver right away if you feel short of breath, weak or dizzy, nauseated, itchy, or have wheezing, noisy breathing, or a hoarse voice during the injection.

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Call your doctor at once if you have any of these serious side effects:

  • an acne-like skin rash or any severe skin rash;
  • slow heart rate, weak pulse, fainting, slow breathing (breathing may stop);
  • chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, general ill feeling;
  • fever, chills, body aches, flu symptoms;
  • easy bruising or bleeding;
  • urinating more or less than usual;
  • hot dry skin with weakness or dizziness;
  • confusion; or
  • white patches or sores inside your mouth or on your lips.

Less serious side effects may include:

  • dry, cracked, or swollen skin;
  • changes in your fingernails or toenails;
  • headache;
  • nausea, vomiting, stomach pain, loss of appetite;
  • diarrhea, constipation;
  • dry mouth, trouble swallowing;
  • cough or sore throat;
  • weight loss; or
  • weakness.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

Read the Erbitux (cetuximab) Side Effects Center for a complete guide to possible side effects »

What is the most important information I should know about cetuximab (Erbitux)?

You should not use this medication if you are allergic to cetuximab or to mouse protein.

Before receiving cetuximab, tell your doctor if you have heart rhythm problems, congestive heart failure, breathing problems, or coronary artery disease. Tell your doctor if you are also being treated with cisplatin (Platinol).

After you receive this medicine, your doctor will need to watch you for about an hour. This is to make sure you do not have any serious side effects from the medicine.

Some people receiving a cetuximab injection have had a reaction to the infusion (when the medicine is injected into the vein). Tell your caregiver right away if you feel short of breath, weak or dizzy, nauseated, itchy, or have wheezing, noisy breathing, or a hoarse voice during the injection.

To be sure this medication is helping your condition and not causing harmful effects, your blood will need to be tested on a regular basis. It is important that you not miss any scheduled visits to your doctor. You may need to have blood tests for several weeks after your cetuximab treatment has ended.

Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds) while you are receiving cetuximab and for at least 2 months after your treatment ends. Cetuximab can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun.

Side Effects Centers

Erbitux Patient Information including How Should I Take

What should I discuss with my healthcare provider before I receive cetuximab (Erbitux)?

You should not use this medication if you are allergic to cetuximab or to mouse protein.

If you have any of these other conditions, you may need a dose adjustment or special tests to safely use cetuximab:

  • heart rhythm problems;
  • lung disease or a breathing disorder;
  • congestive heart failure; or
  • coronary artery disease (clogged arteries).

FDA pregnancy category C. It is not known whether cetuximab is harmful to an unborn baby. Before you receive this medication, tell your doctor if you are pregnant or plan to become pregnant during treatment.

You should not breast-feed a baby while you are receiving cetuximab and for at least 60 days after your treatment ends.

How is cetuximab given (Erbitux)?

Cetuximab is given as an injection through a needle placed into a vein. You will receive this injection in a clinic or hospital setting. The medicine must be given slowly through an IV infusion pump, and can take up to 2 hours to complete.

After your cetuximab infusion, your doctor will need to watch you for about an hour. This is to make sure you do not have any serious side effects from the medicine.

If you are also being treated with radiation, you will receive cetuximab one week before your radiation treatment.

To be sure this medication is helping your condition and not causing harmful effects, your blood will need to be tested on a regular basis. Your kidney or liver function may also need to be tested. It is important that you not miss any scheduled visits to your doctor.

You may need to have blood tests for several weeks after your cetuximab treatment has ended.

Side Effects Centers

Erbitux Patient Information including If I Miss a Dose

What happens if I miss a dose (Erbitux)?

Call your doctor for instructions if you miss an appointment for your cetuximab infusion.

What happens if I overdose (Erbitux)?

Seek emergency medical attention if you think you have received too much of this medicine. Symptoms of a cetuximab overdose are not known.

What should I avoid while receiving cetuximab (Erbitux)?

Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds) while you are receiving cetuximab and for at least 2 months after your treatment ends. Cetuximab can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun.

What other drugs will affect cetuximab (Erbitux)?

Tell your doctor if you are also being treated with cisplatin (Platinol).

There may be other drugs that can interact with cetuximab. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor.

Where can I get more information?

Your doctor or pharmacist can provide more information about cetuximab.


Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed.

Every effort has been made to ensure that the information provided by Cerner Multum, Inc. ('Multum') is accurate, up-to-date, and complete, but no guarantee is made to that effect. Drug information contained herein may be time sensitive. Multum information has been compiled for use by healthcare practitioners and consumers in the United States and therefore Multum does not warrant that uses outside of the United States are appropriate, unless specifically indicated otherwise. Multum's drug information does not endorse drugs, diagnose patients or recommend therapy. Multum's drug information is an informational resource designed to assist licensed healthcare practitioners in caring for their patients and/or to serve consumers viewing this service as a supplement to, and not a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners. The absence of a warning for a given drug or drug combination in no way should be construed to indicate that the drug or drug combination is safe, effective or appropriate for any given patient. Multum does not assume any responsibility for any aspect of healthcare administered with the aid of information Multum provides. The information contained herein is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. If you have questions about the drugs you are taking, check with your doctor, nurse or pharmacist.

Copyright 1996-2012 Cerner Multum, Inc. Version: 4.02. Revision date: 12/15/2010.

Your use of the content provided in this service indicates that you have read,understood and agree to the End-User License Agreement,which can be accessed by clicking on this link.

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Side Effects Centers

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