Posology : מינונים

4.2 Posology and method of administration
Pemetrexed Sandoz must only be administered under the supervision of a physician qualified in the use of anti-cancer chemotherapy.
Posology
Pemetrexed Sandoz in combination with cisplatin
The recommended dose of pemetrexed is 500 mg/m2 of body surface area (BSA) administered as an intravenous infusion over 10 minutes on the first day of each 21-day cycle. The recommended dose of cisplatin is 75 mg/m2 BSA infused over two hours approximately 30 minutes after completion of the pemetrexed infusion on the first day of each 21-day cycle. Patients must receive adequate anti-emetic treatment and appropriate hydration prior to and/or after receiving cisplatin (see also cisplatin Summary of Product Characteristics for specific dosing advice).
Pemetrexed Sandoz as single agent
In patients treated for non-small cell lung cancer after prior chemotherapy, the recommended dose of pemetrexed is 500 mg/m2 BSA administered as an intravenous infusion over 10 minutes on the first day of each 21-day cycle.
Pre-medication regimen
To reduce the incidence and severity of skin reactions, a corticosteroid should be given the day prior to, on the day of, and the day after pemetrexed administration. The corticosteroid should be equivalent to 4 mg of dexamethasone administered orally twice a day (see section 4.4).
To reduce toxicity, patients treated with pemetrexed must also receive vitamin supplementation (see section 4.4). Patients must take oral folic acid or a multivitamin containing folic acid (350 to 1,000 micrograms) on a daily basis. At least five doses of folic acid must be taken during the seven days preceding the first dose of pemetrexed, and dosing must continue during the full course of therapy and for 21 days after the last dose of pemetrexed. Patients must also receive an intramuscular injection of vitamin B12 (1,000 micrograms) in the week preceding the first dose of pemetrexed and once every three cycles thereafter. Subsequent vitamin B12 injections may be given on the same day as pemetrexed.
Monitoring
Patients receiving pemetrexed should be monitored before each dose with a complete blood count, including a differential white cell count (WCC) and platelet count. Prior to each chemotherapy administration, blood chemistry tests should be collected to evaluate renal and hepatic function.
Before the start of any cycle of chemotherapy, patients are required to have the following: absolute neutrophil count (ANC) should be ≥ 1,500 cells/mm3 and platelets should be ≥ 100,000 cells/mm3.
Creatinine clearance should be ≥ 45 ml/min.
The total bilirubin should be ≤ 1.5 times upper limit of normal. Alkaline phosphatase (AP), aspartate aminotransferase (AST or SGOT), and alanine aminotransferase (ALT or SGPT) should be ≤ 3 times upper limit of normal. Alkaline phosphatase, AST, and ALT ≤ 5 times upper limit of normal is acceptable if liver has tumour involvement.
Dose adjustments
Dose adjustments at the start of a subsequent cycle should be based on nadir haematologic counts or maximum non-haematologic toxicity from the preceding cycle of therapy. Treatment may be delayed to allow sufficient time for recovery. Upon recovery, patients should be re-treated using the guidelines in Tables 1, 2, and 3, which are applicable for Pemetrexed Sandoz used as a single agent or in combination with cisplatin.
Table 1. Dose modification table for Pemetrexed Sandoz (as single agent or in combination) and cisplatin - Haematologic toxicities Nadir ANC < 500/mm3 and nadir platelets ≥ 50,000/mm3                     75% of previous dose (both pemetrexed and cisplatin) Nadir platelets < 50,000/mm3 regardless of nadir ANC                     75% of previous dose (both pemetrexed and cisplatin) Nadir platelets < 50,000/mm with bleeding , regardless of nadir ANC 50% of previous dose (both pemetrexed and cisplatin) 3             a a
These criteria meet the National Cancer Institute Common Toxicity Criteria (CTC v2.0; NCI 1998) definition of ≥ CTC Grade 2 bleeding.
If patients develop non-haematologic toxicities ≥ Grade 3 (excluding neurotoxicity), Pemetrexed Sandoz should be withheld until resolution to less than or equal to the patient’s pre-therapy value. Treatment should be resumed according to the guidelines in Table 2.
Table 2. Dose modification table for Pemetrexed Sandoz (as single agent or in combination) and cisplatin - Non-haematologic toxicitiesa, b Dose of pemetrexed (mg/m2) Dose for cisplatin (mg/m2)
Any Grade 3 or 4 toxicities except mucositis                                            75% of previous dose         75% of previous dose Any diarrhoea requiring hospitalisation (irrespective of grade) or Grade 3 or 4         75% of previous dose         75% of previous dose diarrhoea
Grade 3 or 4 mucositis                                                                  50% of previous dose        100% of previous dose a
National Cancer Institute Common Toxicity Criteria (CTC v2.0; NCI 1998) b
Excluding neurotoxicity
In the event of neurotoxicity, the recommended dose adjustment for Pemetrexed Sandoz and cisplatin is documented in Table 3. Patients should discontinue therapy if Grade 3 or 4 neurotoxicity is observed.
Table 3. Dose modification table for Pemetrexed Sandoz (as single agent or in combination) and cisplatin - Neurotoxicity CTCa Grade                                               Dose of pemetrexed (mg/m2)                          Dose for cisplatin (mg/m2) 0-1                                                          100% of previous dose                              100% of previous dose   2                                                            100% of previous dose                               50% of previous dose a
National Cancer Institute Common Toxicity Criteria (CTC v2.0; NCI 1998) Treatment with Pemetrexed Sandoz should be discontinued if a patient experiences any haematologic or non-haematologic Grade 3 or 4 toxicity after 2 dose reductions or immediately if Grade 3 or 4 neurotoxicity is observed.
Special populations
Elderly
In clinical studies, there has been no indication that patients 65 years of age or older are at increased risk of adverse events compared to patients younger than 65 years old. No dose reductions other than those recommended for all patients are necessary.
Paediatric population
There is no relevant use of pemetrexed in the paediatric population in malignant pleural mesothelioma and non-small cell lung cancer.
Renal impairment (standard Cockcroft and Gault formula or glomerular filtration rate measured Tc99m DPTA serum clearance method) Pemetrexed is primarily eliminated unchanged by renal excretion. In clinical studies, patients with creatinine clearance of ≥ 45 ml/min required no dose adjustments other than those recommended for all patients. There are insufficient data on the use of pemetrexed in patients with creatinine clearance below 45 ml/min; therefore, the use of pemetrexed is not recommended (see section 4.4).
Patients with hepatic impairment
No relationships between AST (SGOT), ALT (SGPT), or total bilirubin and pemetrexed pharmacokinetics were identified. However, patients with hepatic impairment, such as bilirubin > 1.5 times the upper limit of normal and/or aminotransferase > 3.0 times the upper limit of normal (hepatic metastases absent) or > 5.0 times the upper limit of normal (hepatic metastases present), have not been specifically studied.
Method of administration
Pemetrexed Sandoz is for intravenous use. Pemetrexed Sandoz should be administered as an intravenous infusion over 10 minutes on the first day of each 21-day cycle.
For precautions to be taken before handling or administering Pemetrexed Sandoz and for instructions on reconstitution and dilution of the medicinal product before administration, see section 6.6.