ADVERSE REACTIONS
Adverse reactions to tamoxifen are relatively mild and rarely severe enough to require discontinuation of treatment in breast cancer patients.
Continued clinical studies have resulted in further information which better indicates the incidence of adverse reactions with tamoxifen as compared to placebo.
In one single-dose pharmacokinetic study in healthy perimenopausal and postmenopausal female volunteers, throat irritation was reported by 3 of 60 evaluable subjects (5.0%) in the SOLTAMOX™ treatment groups while none of the subjects in the tamoxifen reference group reported this event. All events were mild and occurred within an hour after dosing. All events were resolved within 24 hours.
Metastatic Breast Cancer
Increased bone and tumor pain and, also, local disease flare have occurred, which are sometimes associated with a good tumor response. Patients with increased bone pain may require additional analgesics. Patients with soft tissue disease may have sudden increases in the size of preexisting lesions, sometimes associated with marked erythema within and surrounding the lesions and/or the development of new lesions. When they occur, the bone pain or disease flare are seen shortly after starting tamoxifen and generally subside rapidly.
In patients treated with tamoxifen for metastatic breast cancer, the most frequent adverse reaction to tamoxifen is hot flashes.
Other adverse reactions which are seen infrequently are hypercalcemia, peripheral edema, distaste for food, pruritus vulvae, depression, dizziness, light-headedness, headache, hair thinning and/or partial hair loss, and vaginal dryness.
Premenopausal Women
The following table summarizes the incidence of adverse reactions reported at a frequency of 2% or greater from clinical trials (Ingle, Pritchard, Buchanan) which compared tamoxifen therapy to ovarian ablation in premenopausal patients with metastatic breast cancer.
| TAMOXIFEN
All Effects | OVARIAN
ABLATION
All Effects |
|---|
| Adverse ReactionsSome women had more than one adverse reaction. | % of Women
n=104 | % of Women
n=100 |
|---|
| Flush | 33 | 46 |
| Amenorrhea | 16 | 69 |
| Altered Menses | 13 | 5 |
| Oligomenorrhea | 9 | 1 |
| Bone Pain | 6 | 6 |
| Menstrual Disorder | 6 | 4 |
| Nausea | 5 | 4 |
| Cough/Coughing | 4 | 1 |
| Edema | 4 | 1 |
| Fatigue | 4 | 1 |
| Musculoskeletal Pain | 3 | 0 |
| Pain | 3 | 4 |
| Ovarian Cyst(s) | 3 | 2 |
| Depression | 2 | 2 |
| Abdominal Cramps | 1 | 2 |
| Anorexia | 1 | 2 |
Male Breast Cancer
Tamoxifen is well tolerated in males with breast cancer. Reports from the literature and case reports suggest that the safety profile of tamoxifen in males is similar to that seen in women. Loss of libido and impotence have resulted in discontinuation of tamoxifen therapy in male patients. Also, in oligospermic males treated with tamoxifen, LH, FSH, testosterone and estrogen levels were elevated. No significant clinical changes were reported.
Adjuvant Breast Cancer
In the NSABP B-14 study, women with axillary node-negative breast cancer were randomized to 5 years of tamoxifen 20 mg/day or placebo following primary surgery. The reported adverse effects are tabulated below (mean follow-up of approximately 6.8 years) showing adverse events more common on tamoxifen than on placebo. The incidence of hot flashes (64% vs. 48%), vaginal discharge (30% vs. 15%), and irregular menses (25% vs. 19%) were higher with tamoxifen compared with placebo. All other adverse effects occurred with similar frequency in the 2 treatment groups, with the exception of thrombotic events; a higher incidence was seen in tamoxifen-treated patients (through 5 years, 1.7% vs. 0.4%). Two of the patients treated with tamoxifen who had thrombotic events died.
In the Eastern Cooperative Oncology Group (ECOG) adjuvant breast cancer trial, tamoxifen or placebo was administered for 2 years to women following mastectomy. When compared to placebo, tamoxifen showed a significantly higher incidence of hot flashes (19% vs. 8% for placebo). The incidence of all other adverse reactions was similar in the 2 treatment groups with the exception of thrombocytopenia where the incidence for tamoxifen was 10% vs. 3% for placebo, an observation of borderline statistical significance.
NSABP B-14 Study | % of Women |
|---|
| TAMOXIFEN
(n=1422) | Placebo
(n=1437) |
|---|
| Hot Flashes | 64 | 48 |
| Fluid Retention | 32 | 30 |
| Vaginal Discharge | 30 | 15 |
| Nausea | 26 | 24 |
| Irregular Menses | 25 | 19 |
| Weight Loss (>5%) | 23 | 18 |
| Skin Changes | 19 | 15 |
| Increased SGOT | 5 | 3 |
| Increased Bilirubin | 2 | 1 |
| Increased Creatinine | 2 | 1 |
| ThrombocytopeniaDefined as a platelet count of <100,000/mm3 | 2 | 1 |
| Thrombotic Events | | |
| Deep Vein Thrombosis | 0.8 | 0.2 |
| Pulmonary Embolism | 0.5 | 0.2 |
| Superficial Phlebitis | 0.4 | 0.0 |
In other adjuvant studies, Toronto and tamoxifen Adjuvant Trial Organization (NATO), women received either tamoxifen or no therapy. In the Toronto study, hot flashes were observed in 29% of patients for tamoxifen vs. 1% in the untreated group. In the NATO trial, hot flashes and vaginal bleeding were reported in 2.8% and 2.0% of women, respectively, for tamoxifen vs. 0.2% for each in the untreated group.
Ductal Carcinoma in Situ (DCIS)
The type and frequency of adverse events in the NSABP B-24 trial were consistent with those observed in the other adjuvant trials conducted with tamoxifen.
Reduction in Breast Cancer Incidence in High Risk Women
In the NSABP P-1 Trial, there was an increase in five serious adverse effects in the tamoxifen group: endometrial cancer (33 cases in the tamoxifen group vs. 14 in the placebo group); pulmonary embolism (18 cases in the tamoxifen group vs. 6 in the placebo group); deep vein thrombosis (30 cases in the tamoxifen group vs. 19 in the placebo group); stroke (34 cases in the tamoxifen group vs. 24 in the placebo group); cataract formation (540 cases in the tamoxifen group vs. 483 in the placebo group) and cataract surgery (101 cases in the tamoxifen group vs. 63 in the placebo group) (See WARNINGS and Table 3 in CLINICAL PHARMACOLOGY).
The following table presents the adverse events observed in NSABP P-1 by treatment arm. Only adverse events more common on tamoxifen than placebo are shown.
NSABP P-1 Trial: All Adverse Events | % of Women |
|---|
| TAMOXIFEN
(n=1422) | Placebo
(n=1437) |
|---|
| Self Reported Symptoms | N=6441Number with Quality of Life Questionnaires | N=6469 |
| Hot Flashes | 80 | 68 |
| Vaginal Discharges | 55 | 35 |
| Vaginal Bleeding | 23 | 22 |
| Laboratory Abnormalities | N=6520Number with Treatment Follow-up Forms | N=6535 |
| Platelets decreased | 0.7 | 0.3 |
| Adverse Effects | N=6492Number with Adverse Drug Reaction Forms | N=6484 |
| Other Toxicities | | |
| Mood | 11.6 | 10.8 |
| Infection/Sepsis | 6.0 | 5.1 |
| Constipation | 4.4 | 3.2 |
| Alopecia | 5.2 | 4.4 |
| Skin | 5.6 | 4.7 |
| Allergy | 2.5 | 2.1 |
In the NSABP P-1 trial, 15.0% and 9.7% of participants receiving tamoxifen and placebo therapy, respectively, withdrew from the trial for medical reasons. The following are the medical reasons for withdrawing from tamoxifen and placebo therapy, respectively: Hot flashes (3.1% vs. 1.5%) and Vaginal Discharge (0.5% vs. 0.1%).
In the NSABP P-1 trial, 8.7% and 9.6% of participants receiving tamoxifen and placebo therapy, respectively, withdrew for non-medical reasons.
On the NSABP P-1 trial, hot flashes of any severity occurred in 68% of women on placebo and in 80% of women on tamoxifen. Severe hot flashes occurred in 28% of women on placebo and 45% of women on tamoxifen. Vaginal discharge occurred in 35% and 55% of women on placebo and tamoxifen respectively; and was severe in 4.5% and 12.3% respectively. There was no difference in the incidence of vaginal bleeding between treatment arms.
Postmarketing Experience
Less frequently reported adverse reactions are vaginal bleeding, vaginal discharge, menstrual irregularities, skin rash and headaches. Usually these have not been of sufficient severity to require dosage reduction or discontinuation of treatment. Very rare reports of erythema multiforme, Stevens-Johnson syndrome, bullous pemphigoid, interstitial pneumonitis, and rare reports of hypersensitivity reactions including angioedema have been reported with tamoxifen therapy. In some of these cases, the time to onset was more than one year. Rarely, elevation of serum triglyceride levels, in some cases with pancreatitis, may be associated with the use of tamoxifen (see PRECAUTIONS, Drug/Laboratory Testing Interactions section).
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