Gemcitabine Other names: dFdC 2', 2'-difluoro-2'deoxycytidine

Yellow fever and other live attenuated vaccines are not recommended due to the risk of systemic, possibly fatal, disease, particularly in immunosuppressed patients.

Gemcitabine should be used with caution in patients with hepatic impairment or with impaired renal function as there is insufficient information from clinical studies to allow clear dose recommendation for this patient population.

Administration of gemcitabine in patients with concurrent liver metastases or a pre-existing medical history of hepatitis, alcoholism or liver cirrhosis may lead to exacerbation of the underlying hepatic impairment.

Laboratory evaluation of renal and hepatic function (including virological tests) should be performed periodically.

In fertility studies gemcitabine caused hypospermatogenesis in male mice. Therefore, men being treated with gemcitabine are advised not to father a child during and up to 6 months after treatment and to seek further advice regarding cryoconservation of sperm prior to treatment because of the possibility of infertility due to therapy with gemcitabine.

Concurrent (given together or ≤7 days apart): Toxicity associated with this multimodality therapy is dependent on many different factors, including dose of gemcitabine, frequency of gemcitabine administration, dose of radiation, radiotherapy planning technique, the target tissue, and target volume. Pre-clinical and clinical studies have shown that gemcitabine has radiosensitising activity. In a single trial, where gemcitabine at a dose of 1,000 mg/m² was administered concurrently for up to 6 consecutive weeks with therapeutic thoracic radiation to patients with non-small cell lung cancer, significant toxicity in the form of severe, and potentially life threatening mucositis, especially oesophagitis, and pneumonitis was observed, particularly in patients receiving large volumes of radiotherapy [median treatment volumes 4,795 cm³]. Studies done subsequently have suggested that it is feasible to administer gemcitabine at lower doses with concurrent radiotherapy with predictable toxicity, such as a phase II study in non-small cell lung cancer, where thoracic radiation doses of 66 Gy were applied concomitantly with an administration with gemcitabine (600 mg/m², four times) and cisplatin (80 mg/m² twice) during 6 weeks. The optimum regimen for safe administration of gemcitabine with therapeutic doses of radiation has not yet been determined in all tumour types.

Non-concurrent (given >7 days apart): Analysis of the data does not indicate any enhanced toxicity when gemcitabine is administered more than 7 days before or after radiation, other than radiation recall. Data suggest that gemcitabine can be started after the acute effects of radiation have resolved or at least one week after radiation.

Radiation injury has been reported on targeted tissues (e.g. oesophagitis, colitis, and pneumonitis) in association with both concurrent and non-concurrent use of gemcitabine.

Clinical findings consistent with the haemolytic uraemic syndrome (HUS) were rarely reported (post-marketing data) in patients receiving gemcitabine. HUS is a potentially life-threatening disorder. Gemcitabine should be discontinued at the first signs of any evidence of microangiopathic haemolytic anaemia, such as rapidly falling haemoglobin with concomitant thrombocytopaenia, elevation of serum bilirubin, serum creatinine, blood urea nitrogen, or LDH. Renal failure may not be reversible with discontinuation of therapy and dialysis may be required.

Pulmonary effects, sometimes severe (such as pulmonary oedema, interstitial pneumonitis or adult respiratory distress syndrome (ARDS)) have been reported in association with gemcitabine therapy. The aetiology of these effects is unknown. If such effects develop, consideration should be made to discontinuing gemcitabine therapy. Early use of supportive care measure may help ameliorate the condition.

Reports of posterior reversible encephalopathy syndrome (PRES) with potentially severe consequences have been reported in patients receiving gemcitabine as single agent or in combination with other chemotherapeutic agents. Acute hypertension and seizure activity were reported in most gemcitabine patients experiencing PRES, but other symptoms such as headache, lethargy, confusion and blindness could also be present. Diagnosis is optimally confirmed by magnetic resonance imaging (MRI). PRES was typically reversible with appropriate supportive measures. Gemcitabine should be permanently discontinued and supportive measures implemented, including blood pressure control and anti-seizure therapy, if PRES develops during therapy.

Due to the risk of cardiac and/or vascular disorders with gemcitabine, particular caution must be exercised with patients presenting a history of cardiovascular events.

Gemcitabine can suppress bone marrow function as manifested by leucopaenia, thrombocytopaenia and anaemia.

Patients receiving gemcitabine should be monitored prior to each dose for platelet, leucocyte and granulocyte counts. Suspension or modification of therapy should be considered when drug-induced bone marrow depression is detected. However, myelosuppression is short lived and usually does not result in dose reduction and rarely in discontinuation.

Peripheral blood counts may continue to deteriorate after gemcitabine administration has been stopped. In patients with impaired bone marrow function, the treatment should be started with caution. As with other cytotoxic treatments, the risk of cumulative bone-marrow suppression must be considered when gemcitabine treatment is given together with other chemotherapy.

Capillary leak syndrome has been reported in patients receiving gemcitabine as single agent or in combination with other chemotherapeutic agents. The condition is usually treatable if recognised early and managed appropriately, but fatal cases have been reported. The condition involves systemic capillary hyperpermeability during which fluid and proteins from the intravascular space leak into the interstitium. The clinical features include generalised oedema, weight gain, hypoalbuminaemia, severe hypotension, acute renal impairment and pulmonary oedema. Gemcitabine should be discontinued and supportive measures implemented if capillary leak syndrome develops during therapy. Capillary leak syndrome can occur in later cycles and has been associated in the literature with adult respiratory distress syndrome.

There are no adequate data from the use of gemcitabine in pregnant women. Studies in animals have shown reproductive toxicity. Based on results from animal studies and the mechanism of action of gemcitabine, this substance should not be used during pregnancy unless clearly necessary. Women should be advised not to become pregnant during treatment with gemcitabine and to warn their attending physician immediately, should this occur after all.

It is not known whether gemcitabine is excreted in human milk and adverse effects on the suckling child cannot be excluded. Breast-feeding must be discontinued during gemcitabine therapy.

Fertility

In fertility studies gemcitabine caused hypospermatogenesis in male mice. Therefore, men being treated with gemcitabine are advised not to father a child during and up to 6 months after treatment and to seek further advice regarding cryoconservation of sperm prior to treatment because of the possibility of infertility due to therapy with gemcitabine.

No studies on the effects on the ability to drive and use machines have been performed. However, gemcitabine has been reported to cause mild to moderate somnolence, especially in combination with alcohol consumption. Patients should be cautioned against driving or operating machinery until it is established that they do not become somnolent.

The most commonly reported adverse drug reactions associated with Gemcitabine treatment include: nausea with or without vomiting, raised liver transaminases (AST/ALT) and alkaline phosphatase, reported in approximately 60% of patients; proteinuria and haematuria reported in approximately 50% patients; dyspnoea reported in 10-40% of patients (highest incidence in lung cancer patients); allergic skin rashes occur in approximately 25% of patients and are associated with itching in 10% of patients.

The frequency and severity of the adverse reactions are affected by the dose, infusion rate and intervals between doses. Dose-limiting adverse reactions are reductions in thrombocyte, leucocyte and granulocyte counts.

Clinical trial data

Frequencies are defined as: Very common (≥1/10), Common (≥1/100 to <1/10), Uncommon (≥1/1000 to <1/100), Rare (≥1/10,000 to <1/1000), Very Rare (<1/10,000), Not known (cannot be estimated from the available data).

The following table of undesirable effects and frequencies is based on data from clinical trials. Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness.

Infections and infestations

Common: Infections

Not known: Sepsis

Blood and lymphatic system disorders

Very common: Leucopaenia (Neutropaenia Grade 3 = 19.3 %; Grade 4 = 6 %). Bone-marrow suppression is usually mild to moderate and mostly affects the granulocyte count, Thrombocytopaenia, Anaemia

Common: Febrile neutropaenia

Very rare: Thrombocytosis, Thrombotic microangiopathy

Immune system disorders

Very Rare: Anaphylactoid reaction

Metabolism and nutrition disorders

Common: Anorexia

Nervous system disorders

Common: Headache, Insomnia, Somnolence

Uncommon: Cerebrovascular accident

Very rare: Posterior reversible encephalopathy syndrome

Cardiac disorders

Uncommon: Arrhythmias, predominantly supraventricular in nature, Heart failure

Rare: Myocardial infarct

Vascular disorders

Rare: Clinical signs of peripheral vasculitis and gangrene, Hypotension

Very rare: Capillary leak syndrome

Respiratory, thoracic and mediastinal disorders

Very common: Dyspnoea –usually mild and passes rapidly without treatment

Common: Cough, Rhinitis

Uncommon: Interstitial pneumonitis, Bronchospasm – usually mild and transient but may require parenteral treatment

Rare: Pulmonary oedema, Adult respiratory distress syndrome

Not known: Pulmonary eosinophilia

Gastrointestinal disorders

Very common: Vomiting, Nausea

Common: Diarrhoea, Stomatitis and ulceration of the mouth, Constipation

Very rare: Ischaemic colitis

Hepatobiliary disorders

Very common: Elevation of liver transaminases (AST and ALT) and alkaline phosphatase

Common: Increased bilirubin

Uncommon: Serious hepatotoxicity, including liver failure and death

Rare: Increased gamma-glutamyl transferase (GGT)

Skin and subcutaneous tissue disorders

Very common: Allergic skin rash frequently associated with pruritus, Alopecia

Common: Itching, Sweating

Rare: Severe skin reactions, including desquamation and bullous skin eruptions, Ulceration, Vesicle and sore formation, Scaling

Very rare: Toxic epidermal necrolysis, Stevens-Johnson Syndrome

Not known: Pseudocellulitis

Musculoskeletal and connective tissue disorders

Common: Back pain, Myalgia

Renal and urinary disorders

Very Common: Haematuria, Mild proteinuria

Uncommon: Renal failure, Haemolytic uraemic syndrome

General disorders and administration site conditions

Very common: Influenza-like symptoms – the most common symptoms are fever, headache, chills, myalgia, asthenia and anorexia. Cough, rhinitis, malaise, perspiration and sleeping difficulties have also been reported. Oedema/peripheral oedema, including facial oedema. Oedema is usually reversible after stopping treatment

Common: Fever, Asthenia, Chills

Rare: Injection site reactions – mainly mild in nature

Injury, poisoning, and procedural complications

Rare: Radiation toxicity, Radiation recall

Combination use in breast cancer

The frequency of grade 3 and 4 haematological toxicities, particularly neutropaenia, increases when gemcitabine is used in combination with paclitaxel. However, the increase in these adverse reactions is not associated with an increased incidence of infections or haemorrhagic events. Fatigue and febrile neutropaenia occur more frequently when gemcitabine is used in combination with paclitaxel. Fatigue, which is not associated with anaemia, usually resolves after the first cycle.

Grade 3 and 4 Adverse Events. Paclitaxel versus gemcitabine plus paclitaxel:

* Grade 4 neutropaenia lasting for more than 7 days occurred in 12.6% of patients in the combination arm and 5.0% of patients in the paclitaxel arm.

Combination use in bladder cancer

Grade 3 and 4 Adverse Events. MVAC versus Gemcitabine plus cisplatin:

* Methotrexate, vinblastine, doxorubicin and cisplatin

Combination use in ovarian cancer

Grade 3 and 4 Adverse Events. Carboplatin versus gemcitabine plus carboplatin:

Sensory neuropathy was also more frequent in the combination arm than with single agent carboplatin.