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| {{DrugProjectFormSinglePage
| | #REDIRECT [[Radium-223 chloride]] |
| |authorTag={{AP}}
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| |genericName=Radium chloride (Ra-223)
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| |indicationType=treatment
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| |indication=patients with castration-resistant [[prostate cancer]], symptomatic [[bone metastases]] and no known visceral metastatic disease
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| |adverseReactions=[[nausea]], [[diarrhea]], [[vomiting]], and [[peripheral edema]]
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| |blackBoxWarningTitle=<b><span style="color:#FF0000;">TITLE</span></b>
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| |blackBoxWarningBody=<i><span style="color:#FF0000;">Condition Name:</span></i> (Content)
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| |offLabelAdultGuideSupport=There is limited information regarding <i>Off-Label Guideline-Supported Use</i> of Radium chloride in adult patients.
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| |offLabelAdultNoGuideSupport=There is limited information regarding <i>Off-Label Non–Guideline-Supported Use</i> of Radium chloride in adult patients.
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| |offLabelPedGuideSupport=There is limited information regarding <i>Off-Label Guideline-Supported Use</i> of Radium chloride in pediatric patients.
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| |offLabelPedNoGuideSupport=There is limited information regarding <i>Off-Label Non–Guideline-Supported Use</i> of Radium chloride in pediatric patients.
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| |contraindications=*Xofigo is contraindicated in pregnancy.
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| *Xofigo can cause fetal harm when administered to a pregnant woman based on its mechanism of action.
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| *Xofigo is not indicated for use in women.
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| *Xofigo is contraindicated in women who are or may become pregnant. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, apprise the patient of the potential hazard to the fetus
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| |warnings=====Bone Marrow Suppression====
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| *In the randomized trial, 2% of patients on the Xofigo arm experienced [[bone marrow failure]] or ongoing [[pancytopenia]] compared to no patients treated with [[placebo]]. There were two deaths due to [[bone marrow failure]] and for 7 of 13 patients treated with Xofigo, bone marrow failure was ongoing at the time of death. Among the 13 patients who experienced [[bone marrow failure]], 54% required blood transfusions. Four percent (4%) of patients on the Xofigo arm and 2% on the placebo arm permanently discontinued therapy due to [[bone marrow suppression]].
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| *In the randomized trial, deaths related to vascular hemorrhage in association with [[myelosuppression]] were observed in 1% of Xofigo-treated patients compared to 0.3% of patients treated with [[placebo]]. The incidence of infection-related deaths (2%), serious infections (10%), and [[febrile neutropenia]] (<1%) were similar for patients treated with Xofigo and [[placebo]]. [[Myelosuppression]]; notably [[thrombocytopenia]], [[neutropenia]], [[pancytopenia]], and [[leukopenia]]; has been reported in patients treated with Xofigo. In the randomized trial, [[complete blood counts]] (CBCs) were obtained every 4 weeks prior to each dose and the nadir CBCs and times of recovery were not well characterized. In a separate single-dose phase 1 study of Xofigo, [[neutrophil]] and [[platelet]] count nadirs occurred 2 to 3 weeks after Xofigo administration at doses that were up to 1 to 5 times the recommended dose, and most patients recovered approximately 6 to 8 weeks after administration.
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| *Hematologic evaluation of patients must be performed at baseline and prior to every dose of Xofigo. Before the first administration of Xofigo, the [[absolute neutrophil count]] ([[ANC]]) should be ≥ 1.5 x 109/L, the [[platelet]] count ≥ 100 x 109/L and [[hemoglobin]] ≥ 10 g/dL. Before subsequent administrations of Xofigo, the [[ANC]] should be ≥ 1 x 109/L and the [[platelet]] count ≥ 50 x 109/L. If there is no recovery to these values within 6 to 8 weeks after the last administration of Xofigo, despite receiving supportive care, further treatment with Xofigo should be discontinued. Patients with evidence of compromised [[bone marrow]] reserve should be monitored closely and provided with supportive care measures when clinically indicated. Discontinue Xofigo in patients who experience life-threatening complications despite supportive care for [[bone marrow failure]].
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| *The safety and efficacy of concomitant chemotherapy with Xofigo have not been established. Outside of a clinical trial, concomitant use with chemotherapy is not recommended due to the potential for additive [[myelosuppression]]. If chemotherapy, other systemic radioisotopes or hemibody external radiotherapy are administered during the treatment period, Xofigo should be discontinued.
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| |clinicalTrials=<i>Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.</i>
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| *In the randomized clinical trial in patients with metastatic castration-resistant [[prostate cancer]] with [[bone metastases]], 600 patients received intravenous injections of 50 kBq/kg (1.35 microcurie/kg) of Xofigo and best standard of care and 301 patients received placebo and best standard of care once every 4 weeks for up to 6 injections. Prior to randomization, 58% and 57% of patients had received [[docetaxel]] in the Xofigo and placebo arms, respectively. The median duration of treatment was 20 weeks (6 cycles) for Xofigo and 18 weeks (5 cycles) for [[placebo]].
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| *The most common adverse reactions (≥ 10%) in patients receiving Xofigo were [[nausea]], [[diarrhea]], [[vomiting]], and [[peripheral edema]] (Table 3). Grade 3 and 4 adverse events were reported among 57% of Xofigo-treated patients and 63% of placebo-treated patients. The most common hematologic laboratory abnormalities in Xofigo-treated patients (≥ 10%) were [[anemia]], [[lymphocytopenia]], [[leukopenia]], [[thrombocytopenia]], and [[neutropenia]].
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| *Treatment discontinuations due to adverse events occurred in 17% of patients who received Xofigo and 21% of patients who received placebo. The most common hematologic laboratory abnormalities leading to discontinuation for Xofigo were [[anemia]] (2%) and [[thrombocytopenia]] (2%).
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| Table 3 shows adverse reactions occurring in ≥ 2% of patients and for which the incidence for Xofigo exceeds the incidence for placebo.
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| [[file:Radium AR1.png|none|400px]]
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| ====Laboratory Abnormalities====
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| Table 4 shows hematologic laboratory abnormalities occurring in > 10% of patients and for which the incidence for Xofigo exceeds the incidence for placebo.
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| [[file:Radium AR2.png|none|400px]]
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| *As an adverse reaction, grade 3-4 [[thrombocytopenia]] was reported in 6% of patients on Xofigo and in 2% of patients on placebo. Among patients who received Xofigo, the laboratory abnormality grade 3-4 [[thrombocytopenia]] occurred in 1% of [[docetaxel]] naïve patients and in 4% of patients who had received prior [[docetaxel]]. Grade 3-4 [[neutropenia]] occurred in 1% of [[docetaxel]] naïve patients and in 3% of patients who have received prior [[docetaxel]].
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| ====Fluid Status====
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| *Dehydration occurred in 3% of patients on Xofigo and 1% of patients on placebo. Xofigo increases adverse reactions such as [[diarrhea]], [[nausea]], and [[vomiting]] which may result in [[dehydration]]. Monitor patients’ oral intake and fluid status carefully and promptly treat patients who display signs or symptoms of dehydration or [[hypovolemia]].
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| ====Injection Site Reactions====
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| *[[Erythema]], [[pain]], and [[edema]] at the injection site were reported in 1% of patients on Xofigo.
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| ====Secondary Malignant Neoplasms====
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| *Xofigo contributes to a patient’s overall long-term cumulative radiation exposure. Long-term cumulative radiation exposure may be associated with an increased risk of cancer and hereditary defects. Due to its mechanism of action and neoplastic changes, including [[osteosarcomas]], in rats following administration of radium-223 dichloride, Xofigo may increase the risk of [[osteosarcoma]] or other secondary malignant neoplasms.
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| *However, the overall incidence of new malignancies in the randomized trial was lower on the Xofigo arm compared to placebo (<1% vs. 2%; respectively), but the expected latency period for the development of secondary malignancies exceeds the duration of follow up for patients on the trial.
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| ====Subsequent Treatment with Cytotoxic Chemotherapy====
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| *In the randomized clinical trial, 16% patients in the Xofigo group and 18% patients in the placebo group received cytotoxic chemotherapy after completion of study treatments. Adequate safety monitoring and laboratory testing was not performed to assess how patients treated with Xofigo will tolerate subsequent cytotoxic chemotherapy.
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| |drugInteractions=*No formal clinical drug interaction studies have been performed.
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| *Subgroup analyses indicated that the concurrent use of [[bisphosphonates]] or [[calcium channel blockers]] did not affect the safety and efficacy of Xofigo in the randomized clinical trial.
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| |FDAPregCat=X
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| |useInPregnancyFDA=*Xofigo can cause fetal harm when administered to a pregnant woman based on its mechanism of action. While there are no human or animal data on the use of Xofigo in pregnancy and Xofigo is not indicated for use in women, maternal use of a radioactive therapeutic agent could affect development of a fetus. Xofigo is contraindicated in women who are or may become pregnant while receiving the drug. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, apprise the patient of the potential hazard to the fetus and the potential risk for pregnancy loss. Advise females of reproductive potential to avoid becoming pregnant during treatment with Xofigo.
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| |useInNursing=*Xofigo is not indicated for use in women. It is not known whether radium-223 dichloride is excreted in human milk. Because many drugs are excreted in human milk, and because of potential for serious adverse reactions in nursing infants from Xofigo, a decision should be made whether to discontinue nursing, or discontinue the drug taking into account the importance of the drug to the mother.
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| |useInPed=<i>The safety and efficacy of Xofigo in pediatric patients have not been established.</i>
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| *In single- and repeat-dose toxicity studies in rats, findings in the bones (depletion of osteocytes, osteoblasts, osteoclasts, fibro-osseous lesions, disruption/disorganization of the physis/growth line) and teeth (missing, irregular growth, fibro-osseous lesions in bone socket) correlated with a reduction of osteogenesis that occurred at clinically relevant doses beginning in the range of 20 – 80 kBq (0.541 - 2.16 microcurie) per kg body weight.
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| |useInGeri=*Of the 600 patients treated with Xofigo in the randomized trial, 75% were 65 years of age and over and while 33% were 75 years of age and over. No dosage adjustment is considered necessary in elderly patients. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.
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| |useInRenalImpair=*No dedicated [[renal impairment]] trial for Xofigo has been conducted. Based on subgroup analyses in the randomized clinical trial, dose adjustment is not needed in patients with existing mild ([[creatinine clearance]] ([[CrCl]]) 60 to 89 mL/min) or moderate ([[CrCl]] 30 to 59 mL/min) [[renal impairment]]. No dose adjustment can be recommended for patients with severe [[renal impairment]] ([[CrCl]] less than 30 mL/min) due to limited data available (n = 2).
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| |useInHepaticImpair=*No dedicated [[hepatic impairment]] trial for Xofigo has been conducted. Since radium-223 is neither metabolized by the liver nor eliminated via the bile, hepatic impairment is unlikely to affect the pharmacokinetics of radium-223 dichloride. Based on subgroup analyses in the randomized clinical trial, dose adjustment is not needed in patients with mild [[hepatic impairment]]. No dose adjustments can be recommended for patients with moderate or severe [[hepatic impairment]] due to lack of clinical data.
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| |othersTitle=Males of Reproductive Potential
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| |useInOthers=*'''Contraception''': Because of potential effects on spermatogenesis associated with radiation, advise men who are sexually active to use condoms and their female partners of reproductive potential to use a highly effective contraceptive method during and for 6 months after completing treatment with Xofigo.
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| *'''Infertility''': There are no data on the effects of Xofigo on human fertility. There is a potential risk that radiation by Xofigo could impair human fertility
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| |overdose=<i>There have been no reports of inadvertent overdosing of Xofigo during clinical studies.</i>
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| *There is no specific antidote. In the event of an inadvertent overdose of Xofigo, utilize general supportive measures, including monitoring for potential hematological and gastrointestinal toxicity, and consider using medical countermeasures such as [[aluminum hydroxide]], [[barium sulfate]], [[calcium carbonate]], [[calcium gluconate]], [[calcium phosphate]], or [[sodium alginate]].
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| Single Xofigo doses up to 250 kBq (6.76 microcurie) per kg body weight were evaluated in a phase 1 clinical trial and no dose-limiting toxicities were observed.
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| |drugBox=[[file:Radium Chembox.png|none|200px]]
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| |mechAction=*The active moiety of Xofigo is the alpha particle-emitting isotope radium-223 (as radium Ra 223 dichloride), which mimics [[calcium]] and forms complexes with the bone mineral [[hydroxyapatite]] at areas of increased bone turnover, such as bone metastases (see Table 2). The high linear energy transfer of alpha emitters (80 keV/micrometer) leads to a high frequency of [[double-strand DNA]] breaks in adjacent cells, resulting in an anti-tumor effect on bone metastases. The alpha particle range from radium-223 dichloride is less than 100 micrometers (less than 10 cell diameters) which limits damage to the surrounding normal tissue.
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| |PD=*Compared with [[placebo]], there was a significant difference in favor of Xofigo for all five serum biomarkers for bone turnover studied in a phase 2 randomized study (bone formation markers: bone [[alkaline phosphatase]] ([[ALP]]), total [[ALP]] and [[procollagen I N propeptide]] ([[PINP]]), bone resorption markers: [[C-terminal cross linking telopeptide of type I collagen]] ([[S-CTX-I]]) and [[type I collagen crosslinked C-telopeptide]] ([[ICTP]])).
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| |PK=<i>The pharmacokinetics of radium-223 dichloride in blood was linear in terms of dose proportionality and time independence in the dose range investigated (46 to 250 kBq [1.24 to 6.76 microcurie] per kg body weight).</i>
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| ====Distribution====
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| *After intravenous injection, radium-223 is rapidly cleared from the blood and is distributed primarily into bone or is excreted into intestine. Fifteen minutes post-injection, about 20% of the injected radioactivity remained in blood. At 4 hours, about 4% of the injected radioactivity remained in blood, decreasing to less than 1% at 24 hours after the injection. At 10 minutes post-injection, radioactivity was observed in bone and in intestine. At 4 hours post-injection, the percentage of the radioactive dose present in bone and intestine was approximately 61% and 49%, respectively. No significant uptake was seen in other organs such as heart, liver, kidneys, urinary bladder, and spleen at 4 hours post-injection.
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| ====Metabolism====
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| *Radium-223 is an isotope that decays and is not metabolized.
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| ====Special Population====
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| *'''Pediatric patients''': Safety and effectiveness of Xofigo have not been established in children and adolescents below 18 years of age.
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| *'''Patients with hepatic impairment''': No dedicated pharmacokinetic study in patients with hepatic impairment has been conducted. However, since radium-223 is not metabolized and there is no evidence of hepato-biliary excretion based on imaging data, hepatic impairment is not expected to affect the pharmacokinetics of radium-223 dichloride.
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| *'''Patients with renal impairment''': No dedicated pharmacokinetic study in patients with renal impairment has been conducted. However, since excretion in urine is minimal and the major route of elimination is via the feces, renal impairment is not expected to affect the pharmacokinetics of radium-223 dichloride.
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| |nonClinToxic=====Carcinogenesis, Mutagenesis, Impairment of Fertility====
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| *Animal studies have not been conducted to evaluate the carcinogenic potential of radium-223 dichloride. However, in repeat-dose toxicity studies in rats, osteosarcomas, a known effect of bone-seeking radionuclides, were observed at clinically relevant doses 7 to 12 months after the start of treatment. The presence of other neoplastic changes, including lymphoma and mammary gland carcinoma, was also reported in 12- to 15-month repeat-dose toxicity studies in rats.
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| *Genetic toxicology studies have not been conducted with radium-223 dichloride. However, the mechanism of action of radium-223 dichloride involves induction of double-strand DNA breaks, which is a known effect of radiation.
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| Animal studies have not been conducted to evaluate the effects of radium-223 dichloride on male or female fertility or reproductive function. Xofigo may impair fertility and reproductive function in humans based on its mechanism of action.
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| |clinicalStudies=*The efficacy and safety of Xofigo were evaluated in a double-blind, randomized, placebo-controlled phase 3 clinical trial of patients with castration-resistant [[prostate cancer]] with symptomatic [[bone metastases]]. Patients with visceral metastases and malignant [[lymphadenopathy]] exceeding 3 cm were excluded. The primary efficacy endpoint was overall survival. A key secondary efficacy endpoint was time to first symptomatic skeletal event (SSE) defined as external beam radiation therapy (EBRT) to relieve skeletal symptoms, new symptomatic [[pathologic bone fracture]], occurrence of [[spinal cord compression]], or tumor-related orthopedic surgical intervention. There were no scheduled radiographic assessments performed on study. All patients were to continue androgen deprivation therapy. At the cut-off date of the pre-planned interim analysis, a total of 809 patients had been randomized 2:1 to receive Xofigo 50 kBq (1.35 microcurie)/kg intravenously every 4 weeks for 6 cycles (n = 541) plus best standard of care or matching placebo plus best standard of care (n = 268). Best standard of care included local EBRT, [[corticosteroids]], [[antiandrogens]], [[estrogens]], [[estramustine]] or [[ketoconazole]]. Therapy was continued until unacceptable toxicity or initiation of cytotoxic chemotherapy, other systemic radioisotope, hemi-body EBRT or other investigational drug. Patients with [[Crohn’s disease]], [[ulcerative colitis]], prior hemibody radiation or untreated imminent [[spinal cord compression]] were excluded from the study. In patients with bone fractures, orthopedic stabilization was performed before starting or resuming treatment with Xofigo.
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| *The following patient demographics and baseline disease characteristics were balanced between the arms. The median age was 71 (range 44-94) with a racial distribution of 94% Caucasian, 4% Asian, 2% Black and <1% Other. Patients were enrolled predominantly from Europe (85%) with 4% of patients enrolled from North America. ECOG performance status was 0-1 in 86% of patients. Eighty-five percent of patients had 6 or more bone scan lesions and of those 40% had > 20 lesions or a superscan. Opiate pain medications were used for cancer-related pain in 54% of patients, non-opiate pain medications in 44% of patients and no pain medications in 2% of patients. Patients were stratified by baseline [[ALP]], [[bisphosphonate]] use, and prior [[docetaxel]] exposure. Prior [[bisphosphonates]] were used by 41% of patients and 58% had received prior [[docetaxel]]. During the treatment period, 83% of Xofigo patients and 82% of placebo patients received [[gonadotropin-releasing hormone]] agonists and 21% of Xofigo patients and 34% of placebo patients received concomitant [[antiandrogens]]. Use of systemic [[steroids]] (41%) and [[bisphosphonates]] (40%) was balanced between the arms.
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| *The pre-specified interim analysis of overall survival revealed a statistically significant improvement in patients receiving XOFIGO plus best standard of care compared with patients receiving placebo plus best standard of care. An exploratory updated overall survival analysis performed before patient crossover with an additional 214 events resulted in findings consistent with the interim analysis (Table 5).
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| [[file:Radium Cs1.png|none|400px]]
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| The Kaplan-Meier curves for overall survival based on the updated survival results are shown in Figure 1.
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| [[file:Radium CS2.png|none|400px]]
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| |alcohol=Alcohol-Radium chloride interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.
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| }}
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| {{Chembox new
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| | Name = Radium chloride
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| | Section1 = {{Chembox Identifiers
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| | CASNo = 10025-66-8
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| }}
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| | Section2 = {{Chembox Properties
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| | Formula = RaCl<sub>2</sub>
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| | MolarMass = 296.94 g/mol
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| | MeltingPt = }}
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| }}
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| ==References==
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| {{reflist|2}}
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| [[Category:Radium compounds]]
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| [[Category:Chlorides]]
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| [[Category:Metal halides]]
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