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Alimta (Pemetrexed Disodium) - Indications and Dosage

 
 



INDICATIONS AND USAGE

Mesothelioma: ALIMTA in combination with cisplatin is indicated for the treatment of patients with malignant pleural mesothelioma whose disease is unresectable or who are otherwise not candidates for curative surgery.

Non-Small Cell Lung Cancer: ALIMTA as a single-agent is indicated for the treatment of patients with locally advanced or metastatic non-small cell lung cancer after prior chemotherapy.

The effectiveness of ALIMTA in second-line NSCLC was based on the surrogate endpoint, response rate. There are no controlled trials demonstrating a clinical benefit, such as a favorable survival effect or improvement of disease-related symptoms.

DOSAGE AND ADMINISTRATION

ALIMTA is for Intravenous Infusion Only

COMBINATION USE WITH CISPLATIN

Malignant Pleural Mesothelioma --The recommended dose of ALIMTA is 500 mg/m2 administered as an intravenous infusion over 10 minutes on Day 1 of each 21-day cycle. The recommended dose of cisplatin is 75 mg/m2 infused over 2 hours beginning approximately 30 minutes after the end of ALIMTA administration. Patients should receive hydration consistent with local practice prior to and/or after receiving cisplatin. See cisplatin package insert for more information.

SINGLE-AGENT USE

Non-Small Cell Lung Cancer --The recommended dose of ALIMTA is 500 mg/m2 administered as an intravenous infusion over 10 minutes on Day 1 of each 21-day cycle.

PREMEDICATION REGIMEN

Corticosteroid --Skin rash has been reported more frequently in patients not pretreated with a corticosteroid. Pretreatment with dexamethasone (or equivalent) reduces the incidence and severity of cutaneous reaction. In clinical trials, dexamethasone 4 mg was given by mouth twice daily the day before, the day of, and the day after ALIMTA administration.

Vitamin Supplementation --To reduce toxicity, patients treated with ALIMTA must be instructed to take a low-dose oral folic acid preparation or multivitamin with folic acid on a daily basis. At least 5 daily doses of folic acid must be taken during the 7-day period preceding the first dose of ALIMTA; and dosing should continue during the full course of therapy and for 21 days after the last dose of ALIMTA. Patients must also receive one (1) intramuscular injection of vitamin B12 during the week preceding the first dose of ALIMTA and every 3 cycles thereafter. Subsequent vitamin B12 injections may be given the same day as ALIMTA. In clinical trials, the dose of folic acid studied ranged from 350 to 1000 g, and the dose of vitamin B12 was 1000 g. The most commonly used dose of oral folic acid in clinical trials was 400 g (see WARNINGS).

LABORATORY MONITORING AND DOSE REDUCTION RECOMMENDATIONS

Monitoring --Complete blood cell counts, including platelet counts, should be performed on all patients receiving ALIMTA. Patients should be monitored for nadir and recovery, which were tested in the clinical study before each dose and on days 8 and 15 of each cycle. Patients should not begin a new cycle of treatment unless the ANC is >/=1500 cells/mm3, the platelet count is >/=100,000 cells/mm3, and creatinine clearance is >/=45 mL/min. Periodic chemistry tests should be performed to evaluate renal and hepatic function.

Dose Reduction Recommendations --Dose adjustments at the start of a subsequent cycle should be based on nadir hematologic counts or maximum nonhematologic toxicity from the preceding cycle of therapy. Treatment may be delayed to allow sufficient time for recovery. Upon recovery, patients should be retreated using the guidelines in Tables 8-10, which are suitable for using ALIMTA as a single agent or in combination with cisplatin.

Table 8: Dose Reduction for ALIMTA (single-agent or
in combination) and Cisplatin - Hematologic Toxicities
Nadir ANC <500/mm3 and
nadir platelets >/=50,000/mm3.
75% of previous dose
(both drugs).
Nadir platelets <50,000/mm3
regardless of nadir ANC.
50% of previous dose (both drugs).

If patients develop nonhematologic toxicities (excluding neurotoxicity) >/=Grade 3 (except Grade 3 transaminase elevations), ALIMTA should be withheld until resolution to less than or equal to the patient's pre-therapy value. Treatment should be resumed according to guidelines in Table 9.

Table 9: Dose Reduction for ALIMTA (single-agent or in
combination) and Cisplatin - Nonhematologic Toxicities a, b
Dose of
ALIMTA
(mg/m2)
Dose of
Cisplatin
(mg/m2)
Any Grade 3 c or 4
toxicities except mucositis
75% of
previous dose
75% of
previous dose
Any diarrhea requiring
hospitalization
(irrespective of Grade)
or Grade 3 of 4 diarrhea
75% of
previous dose
75% of
previous dose
Grade 3 or 4 mucositis 50% of
previous dose
100% of
previous dose
a NCI Common Toxicity Criteria (CTC).
b Excluding neurotoxicity.
c Except Grade 3 transaminase elevation.

In the event of neurotoxicity, the recommended dose adjustments for ALIMTA and cisplatin are described in Table 10. Patients should discontinue therapy if Grade 3 or 4 neurotoxicity is experienced.

Table 10: Dose Reduction for ALIMTA (single-agent
or in combination) and Cisplatin - Neurotoxicity
CTC Grade Dose of ALIMTA
(mg/m2)
Dose of Cisplatin
(mg/m2)
0-1 100% of previous dose 100% of previous dose
2 100% of previous dose 50% of previous dose

ALIMTA therapy should be discontinued if a patient experiences any hematologic or nonhematologic Grade 3 or 4 toxicity after 2 dose reductions (except Grade 3 transaminase elevations) or immediately if Grade 3 or 4 neurotoxicity is observed.

Elderly Patients --No dose reductions other than those recommended for all patients are necessary for patients >/=65 years of age.

Children --ALIMTA is not recommended for use in children, as safety and efficacy have not been established in children.

Renally Impaired Patients --In clinical studies, patients with creatinine clearance >/=45 mL/min required no dose adjustments other than those recommended for all patients. Insufficient numbers of patients with creatinine clearance below 45 mL/min have been treated to make dosage recommendations for this group of patients. Therefore, ALIMTA should not be administered to patients whose creatinine clearance is <45 mL/min using the standard Cockcroft and Gault formula (below) or GFR measured by Tc99m-DPTA serum clearance method:

Males: [140 - Age in years] × Actual Body Weight (kg
72 × Serum Creatinine (mg/dL)
= mL/min
Females: Estimated creatinine clearance for males × 0.85

Caution should be exercised when administering ALIMTA concurrently with NSAIDs to patients whose creatinine clearance is <80 mL/min (see Drug Interactions under PRECAUTIONS).

Hepatically Impaired Patients --ALIMTA is not extensively metabolized by the liver. Dose adjustments based on hepatic impairment experienced during treatment with ALIMTA are provided in Table 9 (see Patients with Hepatic Impairment under PRECAUTIONS).

HOW SUPPLIED

ALIMTA® , pemetrexed for injection is available in sterile single-use vials containing 500 mg pemetrexed.

NDC 0002-7623-01 (VL7623): single-use vial with flip-off cap individually packaged in a carton.

Storage

ALIMTA, pemetrexed for injection, should be stored at 25°C (77°F); excursions permitted to 15-30°C (59-86°F) [see USP Controlled Room Temperature].

Chemical and physical stability of reconstituted and infusion solutions of ALIMTA were demonstrated for up to 24 hours following initial reconstitution, when stored refrigerated, 2-8°C (36-46°F), or at 25°C (77°F), excursions permitted to 15-30°C (59-86°F) [see USP Controlled Room Temperature]. When prepared as directed, reconstituted and infusion solutions of ALIMTA contain no antimicrobial preservatives. Discard unused portion.

ALIMTA is not light sensitive.

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