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SUMMARY OF THE RISK MANAGEMENT PLAN

Summary of risk management plan for Inlyta

This is a summary of the risk management plan (RMP) for Inlyta. The RMP details important risks of Inlyta, how these risks can be minimised, and how more information will be obtained about Inlyta's risks and uncertainties (missing information).

Inlyta's summary of product characteristics (SmPC) and its package leaflet give essential information to healthcare professionals and patients on how Inlyta should be used.

This summary of the RMP for Inlyta should be read in the context of all this information including the assessment report of the evaluation and its plain-language summary, all which is part of the European Public Assessment Report (EPAR).

There are no new important safety concerns identified with axitinib, however changes to the current ones are included in updates of Inlyta's RMP.

The Medicine and What It Is Used For

Inlyta is authorised for the treatment of adult patients with advanced renal cell carcinoma after failure of prior treatment with sunitinib or a cytokine. It contains axitinib as the active substance and it is given by oral route of administration.

Further information about the evaluation of Inlyta’s benefits can be found in Inlyta’s EPAR, including in its plain-language summary, available on the EMA website, under themedicine’s webpage

https://www.ema.europa.eu/en/medicines/human/EPAR/inlyta

Risks Associated With the Medicine and Activities to Minimise or Further Characterise the Risks

Important risks of Inlyta, together with measures to minimise such risks and the proposed studies for learning more about Inlyta’s risks, are outlined below.

Measures to minimise the risks identified for medicinal products can be:

Specific Information, such as warnings, precautions, and advice on correct use, in the package leaflet and SmPC addressed to patients and healthcare professionals

Important advice on the medicine’s packaging;

The authorised pack size — the amount of medicine in a pack is chosen so to ensure that the medicine is used correctly;

The medicine’s legal status — the way a medicine is supplied to the public (e.g. with or without prescription) can help to minimise its risks.

Together, these measures constitute routine risk minimisation measures.

In addition to these measures, information about adverse reactions is collected continuously and regularly analysed, including Periodic Safety Update Report assessment, so that immediate action can be taken as necessary. These measures constitute routine pharmacovigilance activities.

If important information that may affect the safe use of Inlyta is not yet available, it is listed under ‘missing information’ below.

List of Important Risks and Missing Information

Important risks of Inlyta are risks that need special risk management activities to further investigate or minimise the risk, so that the medicinal product can be safely administered. Important risks can be regarded as identified or potential. Identified risks are concerns for which there is sufficient proof of a link with the use of Inlyta. Potential risks are concerns for which an association with the use of this medicine is possible based on available data, but this association has not been established yet and needs further evaluation. Missing information refers to information on the safety of the medicinal product that is currently missing and needs to be collected.

Table 1. List of Important Risks and Missing Information

Important identified risks Arterial embolic and thrombotic events Gastrointestinal perforation and fistula Haemorrhage Posterior Reversible Encephalopathy Syndrome Venous Embolic and Thrombotic Event Effects on the exocrine pancreas Renal failure Congestive heart failure/cardiomyopathy

Important potential risks Torsade de pointes due to QT prolongation Reproductive and developmental toxicity Carcinogenicity Osteonecrosis of the jaw

Missing information Risks in pregnant and lactating women Risks in paediatric subjects Risks in subjects with moderate and severe renal impairment (serum

creatinine >1.5 times the ULN or calculated creatinine clearance <60 mL/min)

Risks in subjects with severe hepatic impairment (Child-Pugh Class C) Risks in subjects with brain metastasis, spinal cord compression, or

carcinomatous meningitis Risks in subjects with active peptic ulcer disease Risks in subjects with a recent major surgery (within 4 weeks) or

radiation therapy (within 2 weeks)

ULN = Upper Limit of Normal

Summary of Important Risks

Table 2. Important Identified Risk: Arterial Embolic and Thrombotic Events

Evidence for linking the risk to the medicine

Evidence Source:

Inlyta clinical trials and post-marketing reports.

Strength of evidence:Arterial embolic and thrombotic events have been reported for other vascular endothelial growth factor inhibitors, and have been reported in Inlyta clinical trials and in the post-marketing setting.

Risk factors and risk groups Cancer patients have an increased risk of arterial embolic and thrombotic events. Increasing age, smoking, hypertension, hypercholesterolemia, polycythaemia, and a history of arterial embolic and thrombotic events are other recognised predisposing risk factors for arterial embolic and thrombotic events.

Risk minimisation measures Routine risk minimisation measures:

SmPC Section 4.4 Special warnings and precautions for useSmPC Section 4.8 Undesirable effectsPackage Leaflet Section 2 What you need to know before you take Inlyta: Warnings and precautionsPackage Leaflet Section 4 Possible side effects

Additional risk minimisation measures:None.

Table 3. Important Identified Risk: Gastrointestinal perforation and fistula


Evidence Source:


Strength of evidence:In non-clinical studies, gastrointestinal toxicity to the alimentary tract was observed following repeat dosing, including haemorrhage and/or necrosis of the oral, stomach or intestinal mucosa. Gastrointestinal perforation and fistula have been reported in Inlyta clinical trials and in the post-marketing setting.

Risk factors and risk groups Acute conditions involving the bowel, including tumour at the site of perforation, acute diverticulitis, bowel obstruction and carcinomatosis, as well as radiation, may be associated with an increased risk of developing gastrointestinal perforation. Risk factors for fistula formation in subjects with renal cell carcinoma who are treated with anti-angiogenic agents are unknown.



Additional risk minimisation measures:None.

Table 4. Important Identified Risk: Haemorrhage


Evidence Source:


Strength of evidence:Haemorrhage has been reported with other tyrosine kinase inhibitors and has been reported in Inlyta clinical trials and in the post-marketing setting.

Risk factors and risk groups From clinical trials data in subjects with advanced renal cell carcinoma, tissues with tumour involvement appear to be more likely to haemorrhage than uninvolved tissues.



Additional risk minimisation measures: None.

Table 5. Important Identified Risk: Posterior Reversible Encephalopathy Syndrome


Evidence Source:


Strength of evidence:Posterior reversible encephalopathy syndrome has been reported in clinical trials and in the post-marketing setting and may be related to the known adverse reaction of hypertension with Inlyta.

Risk factors and risk groups Posterior reversible encephalopathy syndrome has been most frequently observed with acute increases in blood pressure, which may account for its occurrence in patients with uncontrolled hypertension, renal failure or eclampsia.




Table 6. Important Identified Risk: Venous Embolic and Thrombotic Events


Evidence Source:


Strength of evidence:Venous embolic and thrombotic events have been reported for other vascular endothelial growth factor inhibitors, and have been reported in Inlyta clinical trials and in the post-marketing setting.

Risk factors and risk groups Cancer patients have an increased risk of venous embolic and thrombotic events. No other risk factor for venous embolic and thrombotic events has been identified in Inlyta studies.




Table 7. Important Identified Risk: Effects on the Exocrine Pancreas


Evidence Source:


Strength of evidence:In non-clinical studies, a decrease in zymogen granules and concomitant increase in acinar cells in the pancreas were observed after 28 days of Inlyta administration.

Risk factors and risk groups No risk group has been identified.


SmPC Section 4.8 Undesirable effects


Table 8. Important Identified Risk: Renal Failure


Evidence Source:


Strength of evidence:Most cases of renal failure in the clinical trial and in the post-marketing setting involved known risk factors which may have contributed to the development of renal failure.

Risk factors and risk groups In a retrospective review of 108 Korean patients with renal cell carcinoma, 39.8% developed chronic kidney disease post-surgery. Risk factors identified for renal failure include advanced age; chronic infection; diabetes; hypertension; heart failure; immune disorders, such as lupus, immunoglobulin A nephropathy and scleroderma; hepatic disease; prostate gland enlargement; and bladder outlet obstruction. Risk factors for prerenal acute renal failure include dehydration, heart failure, sepsis, and severe blood loss.


SmPC Section 4.2 Posology and method of administrationSmPC Section 4.8 Undesirable effectsSmPC Section 5.2 Pharmacokinetic propertiesPackage Leaflet Section 4 Possible side effects


Table 9. Important Identified Risk: Congestive Heart Failure/Cardiomyopathy


Evidence Source:


Strength of evidence:Congestive heart failure/cardiomyopathy has been reported with other tyrosine kinase inhibitors and has been reported in Inlyta clinical trials and in the post-marketing setting.

Risk factors and risk groups In cases of congestive heart failure/cardiomyopathy, for which medical history was reported, most patients had a personal or family history of coronary artery disease and/or one or more risk factors, including cigarette smoking, hypertension, hyperlipidaemia, diabetes, advanced age, and obesity.




Table 10. Important Potential Risk: Torsade de pointes due to QT Prolongation


Evidence Source:


Strength of evidence:QT prolongation has been reported with other vascular endothelial growth factor inhibitors. However, the relationship between Inlyta administration and QT prolongation leading to Torsade de pointes is not yet established.

Risk factors and risk groups No risk factors have been identified. Theoretically patients who have baseline QT interval prolongation, cardiac disease, or receive other medications that cause QT interval prolongation may be at increased risk.

Risk minimisation measures Routine risk minimisation measures

No risk minimisation measures identified.


Table 11. Important Potential Risk: Reproductive and Developmental Toxicity


Evidence Source:


Strength of evidence:Non-clinical studies identified effects on male and female reproductive organs with Inlyta administration for ≥28 days. However, the relationship between Inlyta administration and reproductive and developmental toxicity in humans is not yet established.



SmPC Section 4.6 Fertility, pregnancy and lactationSmPC Section 5.3 Pre-clinical safety dataPackage Leaflet Section 2 What you need to know before you take Inlyta: Warnings and precautions


Table 12. Important Potential Risk: Carcinogenicity


Evidence Source:


Strength of evidence:Pre-clinical carcinogenicity study and spontaneous reports of second primary malignancy. However, the relationship between Inlyta administration and carcinogenicity in humans is not yet established.



No risk minimisation measures identified.


Table 13. Important Potential Risk: Osteonecrosis of the Jaw


Evidence Source:


Strength of evidence:Osteonecrosis of the jaw has been reported with other vascular endothelial growth factor inhibitors. However, the relationship between Inlyta administration and osteonecrosis of the jaw is not yet established.

Risk factors and risk groups Risk factors for osteonecrosis of the jaw include bisphosphonates, diabetes, alcoholism, cigarette smoking, obesity, hyperlipidaemia, pancreatitis, chemotherapy with L-asparaginase, radiotherapy, receipt of parenteral steroids, jaw trauma, and dental procedures.


None.


Table 14. Missing Information: Risks in Pregnant and Lactating Women

Risk minimisation measures Information regarding use during pregnancy and lactation is provided in the SmPC Section 4.6 and 5.3 and Package Leaflet Section 2.

Table 15. Missing Information: Risks in Paediatric Subjects

Risk minimisation measures Information regarding use in paediatric patients is provided in the SmPC Section 4.2 and Package Leaflet Section 2.

Table 16. Missing Information: Risks in Subjects with Moderate and Severe Renal Impairment (Serum Creatinine >1.5 times the ULN or Calculated Creatinine Clearance <60 mL/min)

Risk minimisation measures Information regarding use in patients with renal impairment is provided in the SmPC Section 4.2 and 5.2.

Table 17. Missing Information: Risks in Subjects with Severe Hepatic Impairment (Child-Pugh Class C)

Risk minimisation measures Information regarding use in patients with hepatic impairment is provided in the SmPC Section 4.2, 4.4 and 5.2 and Package Leaflet Section 2.

Table 18. Missing Information: Risks in Subjects with Brain Metastasis, Spinal Cord Compression, or Carcinomatous Meningitis

Risk minimisation measures Information regarding use in patients with brain metastasis is provided in the SmPC Section 4.4.

Table 19. Missing Information: Risks in Subjects with Active Peptic Ulcer Disease

Risk minimisation measures Although the SmPC does not contain any specific wording related to peptic ulcer disease, SmPC, Section 4.4 includes the warnings about gastrointestinalperforation and haemorrhage; Package Leaflet Section 2 and Section 4.

Table 20. Missing Information: Risks in Subjects with a Recent Major Surgery (within 4 weeks) or Radiation Therapy (within 2 weeks)

Risk minimisation measures Information regarding use in patients with wound healing complications is provided in the SmPC Section 4.4; Package Leaflet Section 2.

Post-Authorisation Development Plan

Studies which are Conditions of the Marketing Authorisation

There are no studies which are conditions of the marketing authorisation or specific obligation of Inlyta.

Other Studies in Post-Authorisation Development Plan

There are no studies required for Inlyta.

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