HERCEPTIN®
`Trastuzumab
`
`WARNING
`CARDIOMYOPATHY:
`HERCEPTIN administration can result in the development of ventricular dysfunction and congestive
`heart failure. Left ventricular function should be evaluated in all patients prior to and during treatment
`with HERCEPTIN. Discontinuation of HERCEPTIN treatment should be strongly considered in
`patients who develop a clinically significant decrease in left ventricular function. The incidence and sever-
`ity of cardiac dysfunction was particularly high in patients who received HERCEPTIN in combination
`with anthracyclines and cyclophosphamide. (See WARNINGS.)
`
`DESCRIPTION
`HERCEPTIN (Trastuzumab) is a recombinant DNA-derived humanized monoclonal antibody that selectively
`binds with high affinity in a cell-based assay (Kd = 5 nM) to the extracellular domain of the human epider-
`mal growth factor receptor2 protein, HER2.1,2 The antibody is an IgG1 kappa that contains human frame-
`work regions with the complementarity-determining regions of a murine antibody (4D5) that binds to HER2.
`The humanized antibody against HER2 is produced by a mammalian cell (Chinese Hamster Ovary) [CHO]
`suspension culture in a nutrient medium containing the antibiotic gentamicin. Gentamicin is not detectable
`in the final product.
`HERCEPTIN is a sterile, white to pale yellow, preservative-free lyophilized powder for intravenous (IV) admin-
`istration. Each vial of HERCEPTIN contains 440mg Trastuzumab, 9.9mg L-histidineHCl, 6.4mg L-histi-
`dine, 400 m g -trehalose dihydrate, and 1.8 mg polysorbate 20, USP. Reconstitution with 20 mL of the
`supplied Bacteriostatic Water for Injection, (BWFI) USP, containing 1.1%benzyl alcohol as a preservative,
`yields 21mL of a multi-dose solution containing 21mg/mL Trastuzumab, at a pH of approximately 6 .
`
`CLINICAL PHARMACOLOGY
`General
`The HER2 (or c-erbB2) proto-oncogene encodes a transmembrane receptor protein of 185kDa, which is struc-
`turally related to the epidermal growth factor receptor.1 HER2 protein overexpression is observed in 25%–30%
`of primary breast cancers. HER2 protein overexpression can be determined using an immunohistochemistry-
`based assessment of fixed tumor blocks.3
`Trastuzumab has been shown, in both in vitro assays and in animals, to inhibit the proliferation of human tumor
`cells that overexpress HER2.4-6
`Trastuzumab is a mediator of antibody-dependent cellular cytotoxicity (ADCC).7,8 In vitro, HERCEPTIN-
`mediated ADCC has been shown to be preferentially exerted on HER2 overexpressing cancer cells compared
`with cancer cells that do not overexpress HER2.
`
`Pharmacokinetics
`The pharmacokinetics of Trastuzumab were studied in breast cancer patients with metastatic disease. Short
`duration intravenous infusions of 10 to 500 mg once weekly demonstrated dose-dependent pharmacokinet-
`ics. Mean half-life increased and clearance decreased with increasing dose level. The half-life averaged 1.7
`and 12 days at the 10 and 500 mg dose levels, respectively. Trastuzumab’s volume of distribution was approx-
`imately that of serum volume (44 mL/kg). At the highest weekly dose studied (500 mg), mean peak serum
`concentrations were 377 microgram/mL.
`In studies using a loading dose of 4 mg/kg followed by a weekly maintenance dose of 2 mg/kg, a mean half-
`life of 5.8 days (range = 1 to 32 days) was observed. Between weeks 16 and 32, Trastuzumab serum con-
`centrations reached a steady-state with a mean trough and peak concentrations of approximately
`79microgram/mL and 123 microgram/mL, respectively.
`Detectable concentrations of the circulating extracellular domain of the HER2 receptor (shed antigen) are found
`in the serum of some patients with HER2 overexpressing tumors. Determination of shed antigen in baseline
`serum samples revealed that 64% (286/447) of patients had detectable shed antigen, which ranged as high
`as 1880 ng/mL (median = 11 ng/mL). Patients with higher baseline shed antigen levels were more likely to
`have lower serum trough concentrations. However, with weekly dosing, most patients with elevated shed
`antigen levels achieved target serum concentrations of Trastuzumab by week 6.
`Data suggest that the disposition of Trastuzumab is not altered based on age or serum creatinine (up to
`2.0 mg/dL). No formal interaction studies have been performed.
`Mean serum trough concentrations of Trastuzumab, when administered in combination with paclitaxel,
`were consistently elevated approximately 1.5-fold as compared with serum concentrations of Trastuzumab
`used in combination with anthracycline plus cyclophosphamide. In primate studies, administration of
`Trastuzumab with paclitaxel resulted in a reduction in Trastuzumab clearance. Serum levels of Trastuzumab
`in combination with cisplatin, doxorubicin or epirubicin plus cyclophosphamide did not suggest any inter-
`actions; no formal drug interaction studies were performed.
`
`CLINICAL STUDIES
`The safety and efficacy of HERCEPTIN were studied in a randomized, controlled clinical trial in combina-
`tion with chemotherapy (469patients) and an open-label single agent clinical trial (222 patients). Both tri-
`als studied patients with metastatic breast cancer whose tumors overexpressthe HER2 protein. Patients were
`eligible if they had 2+ or 3+ levels of overexpression (based on a 0–3+ scale) by immunohistochemical assess-
`ment of tumor tissue performed by a central testing lab.
`A multicenter, randomized, controlled clinical trial was conducted in 469patients with metastatic breast can-
`cer who had not been previously treated with chemotherapy for metastatic disease. Patients were random-
`ized to receive chemotherapy alone or in combination with HERCEPTIN given intravenously as a 4 mg/kg
`loading dose followed by weekly doses of HERCEPTIN at 2mg/kg. For those who had received prior anthra-
`cycline therapy in the adjuvant setting, chemotherapy consisted of paclitaxel (175 m g / m2 over 3hours every
`21 days for at least six cycles); for all other patients, chemotherapy consisted of anthracycline plus cyclophos-
`phamide (AC: doxorubicin 60 m g / m2 or epirubicin 75 m g / m2 plus 600 m g / m2 cyclophosphamide every
`21 days for six cycles). Compared with patients in the AC subgroups (n = 281), patients in the paclitaxel sub-
`groups (n = 188) were more likely to have had the following: poor prognostic factors (premenopausal sta-
`tus, estrogen or progesterone receptor negative tumors, positive lymph nodes), prior therapy (adjuvant
`chemotherapy, myeloablative chemotherapy, radiotherapy), and a shorter disease-free interval.
`Compared with patients randomized to chemotherapy alone, the patients randomized to HERCEPTIN and
`chemotherapy experienced a significantly longer time to disease progression, a higher overall response rate
`(ORR), a longer median duration of response, and a higher one-year survival rate. (See Table1.) These treat-
`ment effects were observed both in patients who received HERCEPTIN plus paclitaxel and in those who received
`HERCEPTIN plus AC, however the magnitude of the effects was greater in the paclitaxel subgroup. The
`degree of HER2 overexpression was a predictor of treatment effect. (See CLINICAL STUDIES: HER2 pro -
`tein overexpression.)
`
`Table 1
`Phase III Clinical Efficacy in First-Line Treatment
`
`Combined Results
`HERCEPTIN
`+
`All
`All
`Chemotherapy Chemotherapy
`(n = 235)
`(n = 234)
`
`Paclitaxel subgroup
`HERCEPTIN
`+
`Paclitaxel
`
`Paclitaxel
`
`AC subgroup
`HERCEPTIN
`+
`ACa
`
`AC
`
`(n = 92)
`
`(n = 96)
`
`(n = 143)
`
`(n = 138)
`
`7.2
`6.9, 8.2
`<0.0001
`
`4.5
`4.3, 4.9
`
`6.7
`5.2, 9.9
`
`2.5
`2.0, 4.3
`
`7.6
`7.2, 9.1
`
`5.7
`4.6, 7.1
`
`0.002
`
`<0.0001
`
`45
`39, 51
`
`<0.001
`
`8.3
`5.5, 14.8
`
`79
`74, 84
`
`<0.01
`
`29
`23, 35
`
`5.8
`3.9, 8.5
`
`68
`62, 74
`
`38
`28, 48
`
`8.3
`5.1, 11.0
`
`73
`66, 80
`
`15
`8, 22
`
`50
`42, 58
`
`<0.001
`
`4.3
`3.7, 7.4
`
`61
`51, 71
`
`8.4
`5.8, 14.8
`
`83
`77, 89
`
`0.08
`
`38
`30, 46
`
`6.4
`4.5, 8.5
`
`73
`66, 82
`
`0.10
`
`0.04
`
`Primary Endpoint
`Time to Progressionb,c
`Median (months)
`95% confidence interval
`p-value (log rank)
`
`Secondary Endpoints
`Overall Response Rateb
`Rate (percent)
`95% confidence interval
`p-value (2-test)
`Duration of Responseb,c
`Median (months)
`25%, 75% quantile
`1-Year Survivalc
`Percent alive
`95% confidence interval
`p-value (Z-test)
`
`a AC  anthracycline (doxorubicin or epirubicin) and cyclophosphamide.
`b Assessed by an independent Response Evaluation Committee.
`c Kaplan-Meier Estimate
`
`HERCEPTIN was studied as a single agent in a multicenter, open-label, single-arm clinical trial inpatients
`with HER2 overexpressing metastatic breast cancer who had relapsed following one or two prior chemother-
`apy regimens for metastatic disease. Of 222 patients enrolled, 66% had received prior adjuvant chemother-
`apy, 68% had received two prior chemotherapy regimens for metastatic disease, and 25% had received prior
`
`myeloablative treatment with hematopoietic rescue. Patients were treated with a loading dose of 4 mg/kg IV
`followed by weekly doses of HERCEPTIN® (Trastuzumab) at 2mg/kg IV. The ORR (complete response+ p a r-
`tial response), as determined by an independent Response Evaluation Committee, was 14%, with a 2% com-
`plete response rate and a 12% partial response rate. Complete responses were observed only in patients with
`disease limited to skin and lymph nodes. The degree of HER2 overexpression was a predictor of treatment
`effect. (See CLINICAL STUDIES: HER2 protein overexpression.)
`HER2 protein overexpression
`Relationship to Response: In the clinical studies described, patient eligibility was determined by testing
`tumor specimens for overexpression of HER2 protein. Specimens were tested with a research-use-only immuno-
`histochemical assay (referred to as the Clinical Trial Assay, CTA) and scored as 0, 1+, 2+, or 3+ with 3+ indi-
`cating the strongest positivity. Only patients with 2+ or 3+ positive tumors were eligible (about 33% of those
`screened).
`Data from both efficacy trials suggest that the beneficial treatment effects were largely limited to patients with
`the highest level of HER2 protein overexpression (3+). (See Table 2.)
`
`Table 2
`Treatment Effect versus Level of HER2 Expression
`
`Single-Arm
`Trial
`
`HERCEPTIN
`
`Treatment Subgroups in
`Randomized Trial
`
`HERCEPTIN
`+ Paclitaxel
`
`Paclitaxel
`
`HERCEPTIN
`+ AC
`
`AC
`
`4%
`(2/50)
`17%
`(29/172)
`
`21%
`(5/24)
`44%
`(30/68)
`
`16%
`(3/19)
`14%
`(11/77)
`
`40%
`(14/35)
`53%
`(57/108)
`
`43%
`(18/42)
`36%
`(35/96)
`
`N/Aa
`
`N/Aa
`
`4.4
`(2.2, 6.6)
`7.1
`(6.2, 12.0)
`
`3.2
`(2.0, 5.6)
`2.2
`(1.8, 4.3)
`
`7.8
`(6.4, 10.1)
`7.3
`(7.1, 9.2)
`
`7.1
`(4.8, 9.8)
`4.9
`(4.5, 6.9)
`
`Overall
`Response Rate
`2+
`overexpression
`3+
`overexpression
`
`Median time to
`progression
`(months)
`(95% Cl)
`2+
`overexpression
`3+
`overexpression
`
`a N/A = Not Assessed
`
`Immunohistochemical Detection: In clinical trials, the Clinical Trial Assay (CTA) was used for immuno-
`histochemical detection of HER2 protein overexpression. The DAKO HercepTestTM, another immunohis-
`tochemical test for HER2 protein overexpression, has not been directly studied for its ability to predict
`HERCEPTIN treatment effect, but has been compared to the CTA on over 500 breast cancer histology spec-
`imens obtained from the National Cancer Institute Cooperative Breast Cancer Tissue Resource. Based
`upon these results and an expected incidence of 33% of 2+ or 3+ HER2 overexpression in tumors from women
`with metastatic breast cancer, one can estimate the correlation of the HercepTestT M results with CTA results.
`Of specimens testing 3+ (strongly positive) on the HercepTestTM, 94% would be expected to test at least 2+
`on the CTA (i.e., meeting the study entry criterion) including 82% which would be expected to test 3+ on
`the CTA (i.e., the reading most associated with clinical benefit). Of specimens testing 2+ (weakly positive)
`on the HercepTestT M, only 34% would be expected to test at least 2+ on the CTA, including 14% which would
`be expected to test 3+ on the CTA.
`
`INDICATIONS AND USAGE
`HERCEPTIN as a single agent is indicated for the treatment of patients with metastatic breast cancer whose
`tumors overexpress the HER2 protein and who have received one or more chemotherapy regimens for their
`metastatic disease. HERCEPTIN in combination with paclitaxel is indicated for treatment of patients with
`metastatic breast cancer whose tumors overexpress the HER2 protein and who have not received
`c h e m o t h e rapy for their metastatic disease. HERCEPTIN should only be used in patients whose tumors have
`HER2 protein overexpression. (See CLINICAL STUDIES: HER2 protein overexpression for informa-
`tion regarding HER2 protein testing and the relationship between the degree of overexpression and the
`treatment effect.)
`
`CONTRAINDICATIONS
`None known.
`
`WARNINGS
`Cardiotoxicity:
`Signs and symptoms of cardiac dysfunction, such as dyspnea, increased cough, paroxysmal nocturnal dys-
`pnea, peripheral edema, S3 gallop, or reduced ejection fraction, have been observed in patients treated with
`HERCEPTIN. Congestive heart failure associated with HERCEPTIN therapy may be severe and has been
`associated with disabling cardiac failure, death, and mural thrombosis leading to stroke. The clinical status
`of patients in the trials who developed congestive heart failure were classified for severity using the New York
`Heart Association classification system (IIV, where IV is the most severe level of cardiac failure).
`(SeeTable 3.)
`
`Table 3
`Incidence and Severity of Cardiac Dysfunction
`
`HERCEPTINa
`alone
`n = 213
`
`HERCEPTIN+
`Paclitaxelb
`n = 91
`
`Paclitaxelb
`n = 95
`
`HERCEPTIN+
`Anthracycline+
`cyclophosphamideb
`n = 143
`
`Anthracycline+
`cyclophosphamideb
`n = 135
`
`Any Cardiac
`Dysfunction
`
`Class III-IV
`
`7%
`
`5%
`
`11%
`
`4%
`
`1%
`
`1%
`
`28%
`
`19%
`
`7%
`
`3%
`
`a Open-label, single-agent Phase 2 study (94% received prior anthracyclines).
`b Randomized Phase III study comparing chemotherapy plus HERCEPTIN to chemotherapy alone, where
`chemotherapy is either anthracycline/cyclophosphamide or paclitaxel.
`Candidates for treatment with HERCEPTIN should undergo thorough baseline cardiac assessment includ-
`ing history and physical exam and one or more of the following: EKG, echocardiogram, and MUGA scan.
`There are no data regarding the most appropriate method of evaluation for the identification of patients
`at risk for developing cardiotoxicity. Monitoring may not identify all patients who will develop cardiac
`d y s f u n c t i o n .
`Extreme cautionshould be exercised in treating patients with pre-existing cardiac dysfunction.
`Patients receiving HERCEPTIN should undergo frequent monitoring for deteriorating cardiac function.
`The probability of cardiac dysfunction was highest in patients who received HERCEPTIN concurrently with
`anthracyclines. The data suggest that advanced age may increase the probability of cardiac dysfunction.
`Pre-existing cardiac disease or prior cardiotoxic therapy (e.g., anthracycline or radiation therapy to the
`chest) may decrease the ability to tolerate HERCEPTIN therapy; however, the data are not adequate to eval-
`uate the correlation between HERCEPTIN-induced cardiotoxicity and these factors.
`Discontinuation of HERCEPTIN therapy should be strongly considered in patients who develop clinically
`significant congestive heart failure. In the clinical trials, most patients with cardiac dysfunction responded
`to appropriate medical therapy often including discontinuation of HERCEPTIN. The safety of continuation
`or resumption of HERCEPTIN in patients who have previously experienced cardiac toxicity has not been
`studied. There are insufficient data regarding discontinuation of HERCEPTIN therapy in patients with
`asymptomatic decreases in ejection fraction; such patients should be closely monitored for evidence of
`clinical deterioration.
`
`PRECAUTIONS
`General: HERCEPTIN therapy should be used with caution in patients with known hypersensitivity to
`Trastuzumab, Chinese Hamster Ovary cell proteins, or any component of this product.
`Drug Interactions: There have been no formal drug interaction studies performed with HERCEPTIN in
`humans. Administration of paclitaxel in combination with HERCEPTIN resulted in a two-fold decrease in
`HERCEPTIN clearance in a non-human primate study and in a 1.5-fold increase in HERCEPTIN serum lev-
`els in clinical studies (see Pharmacokinetics).
`
`

`

`Benzyl Alcohol: For patients with a known hypersensitivity to benzyl alcohol (the preservative in Bacteriostatic
`Water for Injection) reconstitute HERCEPTIN® (Trastuzumab) with Sterile Water for Injection (SWFI), USP.
`DISCARD THE SWFI-RECONSTITUTED HERCEPTIN VIAL FOLLOWING A SINGLE USE.
`Immunogenicity: Of 903 patients who have been evaluated, human anti-human antibody (HAHA) to
`Trastuzumab was detected in onepatient, who had no allergic manifestations.
`Carcinogenesis, Mutagenesis, Impairment of Fertility:
`Carcinogenesis HERCEPTIN has not been tested for its carcinogenic potential.
`M u t a g e n e s i s No evidence of mutagenic activity was observed in Ames tests using six different test strains
`of bacteria, with and without metabolic activation, at concentrations of up to 5000 g/mL Trastuzumab. Human
`peripheral blood lymphocytes treated i nv i t r o at concentrations of up to 5000 g/plate Trastuzumab, with and
`without metabolic activation, revealed no evidence of mutagenic potential. In an i nv i v o mutagenic assay (the
`micronucleus assay), no evidence of chromosomal damage to mouse bone marrow cells was observed fol-
`lowing bolus intravenous doses of up to 118 mg/kg Trastuzumab.
`Impairment of Fertility A fertility study has been conducted in female cynomolgus monkeys at doses up
`to 25times the weekly human maintenance dose of 2mg/kg HERCEPTIN and has revealed no evidence of
`impaired fertility.
`Pregnancy Category B: Reproduction studies have been conducted in cynomolgus monkeys at doses up
`to 25 times the weekly human maintenance dose of 2 mg/kg HERCEPTIN and have revealed no evidence
`of impaired fertility or harm to the fetus. However, HER2 protein expression is high in many embryonic tis-
`sues including cardiac and neural tissues; in mutant mice lacking HER2, embryos died in early gestation.9
`Placental transfer of HERCEPTIN during the early (Days20–50 of gestation) and late (Days120–150 of ges-
`tation) fetal development period was observed in monkeys. There are, however, no adequate and well-
`controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human
`response, this drug should be used during pregnancy only if clearly needed.
`Nursing Mothers: A study conducted in lactating cynomolgus monkeys at doses 25times the weekly human
`maintenance dose of 2mg/kg HERCEPTIN demonstrated that Trastuzumab is secreted in the milk. The pres-
`ence of Trastuzumab in the serum of infant monkeys was not associated with any adverse effects on their growth
`or development from birth to 3 months of age. It is not known whether HERCEPTIN is excreted in human
`milk. Because human IgG is excreted in human milk, and the potential for absorption and harm to the infant
`is unknown, women should be advised to discontinue nursing during HERCEPTIN therapy and for 6 months
`after the last dose of HERCEPTIN.
`Pediatric Use: The safety and effectiveness of HERCEPTIN in pediatric patients have not been established.
`Geriatric Use: HERCEPTIN has been administered to 133 patients who were 65 years of age or over. The
`risk of cardiac dysfunction may be increased in geriatric patients. The reported clinical experience is not ade-
`quate to determine whether older patients respond differently from younger patients.
`
`ADVERSE REACTIONS
`A total of 958 patients have received HERCEPTIN alone or in combination with chemotherapy. Data in the
`table below are based on the experience with the recommended dosing regimen for HERCEPTIN in the ran-
`domized controlled clinical trial in 234 patients who received HERCEPTIN in combination with chemother-
`apy and four open-label studies of HERCEPTIN as a single agent in 352 patients at doses of 10–500 mg
`administered weekly.
`Cardiac Failure/Dysfunction: For a description of cardiac toxicities, see WARNINGS.
`Anemia and Leukopenia: An increased incidence of anemia and leukopenia was observed in the treatment
`group receiving HERCEPTIN and chemotherapy, especially in the HERCEPTIN and ACsubgroup, compared
`with the treatment group receiving chemotherapy alone. The majority of these cytopenic events were mild
`or moderate in intensity, reversible, and none resulted in discontinuation of therapy with HERCEPTIN.
`Hematologic toxicity is infrequent following the administration of HERCEPTIN as a single agent, with an
`incidence of GradeIII toxicities for WBC, platelets, hemoglobin all<1%. No GradeIV toxicities were observed.
`D i a r r h e a : Of patients treated with HERCEPTIN as a single agent, 25% experienced diarrhea. An increased
`incidence of diarrhea, primarily mild to moderate in severity, was observed in patients receiving HERCEPTIN
`in combination with chemotherapy.
`Infection: An increased incidence of infections, primarily mild upper respiratory infections of minor clin-
`ical significance or catheter infections, was observed in patients receiving HERCEPTIN in combination with
`chemotherapy.
`Infusion-Associated Symptoms: During the first infusion with HERCEPTIN, a symptom complex most com-
`monly consisting of chills and/or fever was observed in about 40% of patients. The symptoms were usual-
`ly mild to moderate in severity and were treated with acetaminophen, diphenhydramine, and meperidine (with
`or without reduction in the rate of HERCEPTIN infusion). HERCEPTIN discontinuation was infrequent. Other
`signs and/or symptoms may include nausea, vomiting, pain (in some cases at tumor sites), rigors, headache,
`dizziness, dyspnea, hypotension, rash, and asthenia. The symptoms occurred infrequently with subsequent
`HERCEPTIN infusions.
`
`Table 4
`Adverse Events Occurring in  5% of Patients or at
`Increased Incidence in the HERCEPTIN Arm of the Randomized Study
`(Percent of Patients)
`
`Single
`Agent
`n = 352
`
`HERCEPTIN
`+ Paclitaxel
`n = 91
`
`Paclitaxel
`Alone
`n = 95
`
`HERCEPTIN
`+ AC
`n = 143
`
`AC Alone
`n = 135
`
`Body as a Whole
`Pain
`Asthenia
`Fever
`Chills
`Headache
`Abdominal pain
`Back pain
`Infection
`Flu syndrome
`Accidental injury
`Allergic reaction
`Cardiovascular
`Tachycardia
`Congestive heart failure
`Digestive
`Nausea
`Diarrhea
`Vomiting
`Nausea and vomiting
`Anorexia
`Heme & Lymphatic
`Anemia
`Leukopenia
`Metabolic
`Peripheral edema
`Edema
`Musculoskeletal
`Bone pain
`Arthralgia
`Nervous
`Insomnia
`Dizziness
`Paresthesia
`Depression
`Peripheral neuritis
`Neuropathy
`Respiratory
`Cough increased
`Dyspnea
`Rhinitis
`Pharyngitis
`Sinusitis
`Skin
`Rash
`Herpes simplex
`Acne
`Urogenital
`Urinary tract infection
`
`47
`42
`36
`32
`26
`22
`22
`20
`10
`6
`3
`
`5
`7
`
`33
`25
`23
`8
`14
`
`4
`3
`
`10
`8
`
`7
`6
`
`14
`13
`9
`6
`2
`1
`
`26
`22
`14
`12
`9
`
`18
`2
`2
`
`5
`
`61
`62
`49
`41
`36
`34
`34
`47
`12
`13
`8
`
`12
`11
`
`51
`45
`37
`14
`24
`
`14
`24
`
`22
`10
`
`24
`37
`
`25
`22
`48
`12
`23
`13
`
`41
`27
`22
`22
`21
`
`38
`12
`11
`
`18
`
`62
`57
`23
`4
`28
`22
`30
`27
`5
`3
`2
`
`4
`1
`
`9
`29
`28
`11
`16
`
`9
`17
`
`20
`8
`
`18
`21
`
`13
`24
`39
`13
`16
`5
`
`22
`26
`5
`14
`7
`
`18
`3
`3
`
`14
`
`57
`54
`56
`35
`44
`23
`27
`47
`12
`9
`4
`
`10
`28
`
`76
`45
`53
`18
`31
`
`36
`52
`
`20
`11
`
`7
`8
`
`29
`24
`17
`20
`2
`4
`
`43
`42
`22
`30
`13
`
`27
`7
`3
`
`13
`
`42
`55
`34
`11
`31
`18
`15
`31
`6
`4
`2
`
`5
`7
`
`77
`26
`49
`9
`26
`
`26
`34
`
`17
`5
`
`7
`9
`
`15
`18
`11
`12
`2
`4
`
`29
`25
`16
`18
`6
`
`17
`9
`<1
`
`7
`
`Other serious adverse events
`The following other serious adverse events occurred in at least one of the 958 patients treated with
`HERCEPTIN® (Trastuzumab):
`Body as a Whole: cellulitis, anaphylactoid reaction, ascites, hydrocephalus, radiation injury, deafness,
`amblyopia
`Cardiovascular: vascular thrombosis, pericardial effusion, heart arrest, hypotension, syncope, hemorrhage,
`shock arrhythmia
`D i g e s t i v e : hepatic failure, gastroenteritis, hematemesis, ileus, intestinal obstruction, colitis, esophageal
`ulcer, stomatitis, pancreatitis, hepatitis
`Endocrine: hypothyroidism
`Hematological: pancytopenia, acute leukemia, coagulation disorder, lymphangitis
`M e t a b o l i c : hypercalcemia, hypomagnesemia, hyponatremia, hypoglycemia, growth retardation, weight loss
`Musculoskeletal: pathological fractures, bone necrosis, myopathy
`Nervous: convulsion, ataxia, confusion, manic reaction
`Respiratory: apnea, pneumothorax, asthma, hypoxia, laryngitis
`Skin: herpes zoster, skin ulceration
`U r o g e n i t a l : hydronephrosis, kidney failure, cervical cancer, hematuria, hemorrhagic cystitis, pyelonephritis
`
`OVERDOSAGE
`There is no experience with overdosage in human clinical trials. Single doses higher than 500 mg have not
`been tested.
`
`DOSAGE AND ADMINISTRATION
`Usual Dose
`The recommended initial loading dose is 4 mg/kg Trastuzumab administered as a 90-minute infusion. The
`recommended weekly maintenance dose is 2 m g / k g Trastuzumab and can be administered as a 30-minute infu-
`sion if the initial loading dose was well tolerated. HERCEPTIN may be administered in an outpatient set-
`ting. DO NOT ADMINISTER AS AN IV PUSH OR BOLUS (see ADMINISTRATION).
`Preparation for Administration
`Use appropriate aseptic technique. Each vial of HERCEPTIN should be reconstituted with 20mL of BWFI,
`USP, 1.1% benzyl alcohol preserved, as supplied, to yield a multi-dose solution containing 21 m g / m L
`Trastuzumab. Immediately upon reconstitution with BWFI, the vial of HERCEPTIN must be labeled in the
`area marked “Do not use after:” with the future date that is 28 days from the date of reconstitution.
`If the patient has known hypersensitivity to benzyl alcohol, HERCEPTIN must be reconstituted with Sterile
`Water for Injection (see PRECAUTIONS). HERCEPTIN WHICH HAS BEEN RECONSTITUTED WITH
`SWFI MUST BE USED IMMEDIATELY AND ANY UNUSED PORTION DISCARDED. USE OF
`OTHER RECONSTITUTION DILUENTS SHOULD BE AVOIDED.
`Determine the number of mg of Trastuzumab needed, based on a loading dose of 4 m g Trastuzumab/kg body
`weight or a maintenance dose of 2 mg Trastuzumab/kg body weight. Calculate the volume of 21 mg/mL
`Trastuzumab solution and withdraw this amount from the vial and add it to an infusion bag containing 250 m L
`of 0.9%sodium chloride, USP. DEXTROSE (5%) SOLUTION SHOULD NOT BE USED. Gently invert
`the bag to mix the solution. The reconstituted preparation results in a colorless to pale yellow transparent
`solution. Parenteral drug products should be inspected visually for particulates and discoloration prior to admin-
`istration.
`No incompatibilities between HERCEPTIN and polyvinylchloride or polyethylene bags have been observed.
`Administration
`Treatment may be administered in an outpatient setting by administration of a 4 mg/kg Trastuzumab load-
`ing dose by intravenous (IV) infusion over 90 minutes. DO NOT ADMINISTER AS AN IV PUSH OR
`B O L U S . Patients should be observed for fever and chills or other infusion-associated symptoms (see
`ADVERSE REACTIONS). If prior infusions are well tolerated, subsequent weekly doses of 2 m g / k g
`Trastuzumab may be administered over 30minutes.
`HERCEPTIN should not be mixed or diluted with other drugs. HERCEPTIN infusions should not be
`administered or mixed with Dextrose solutions.
`Stability and Storage
`Vials of HERCEPTIN are stable at 2–8°C (36–46°F) prior to reconstitution. Do not use beyond the expi-
`ration date stamped on the vial. A vial of HERCEPTIN reconstituted with BWFI, as supplied, is stable for
`28days after reconstitution when stored refrigerated at 2–8°C (36–46°F), and the solution is preserved for
`multiple use. Discard any remaining multi-dose reconstituted solution after 28days. If unpreserved SWFI
`(not supplied) is used, the reconstituted HERCEPTIN solution should be used immediately and any unused
`portion must be discarded. DO NOT FREEZE HERCEPTIN THAT HAS BEEN RECONSTITUTED.
`The solution of HERCEPTIN for infusion diluted in polyvinylchloride or polyethylene bags containing
`0.9% Sodium Chloride for Injection, USP, may be stored at 2–8°C (36–46°F) for up to 24 hours prior to
`use. Diluted HERCEPTIN has been shown to be stable for up to 24 hours at room temperature (2–25°C).
`However, since diluted HERCEPTIN contains no effective preservative, the reconstituted and diluted
`solution should be stored refrigerated (2–8°C).
`HOW SUPPLIED
`HERCEPTIN is supplied as a lyophilized, sterile powder containing 440mg Trastuzumab per vial under vacuum.
`Each carton contains one vial of 440mg HERCEPTIN®(Trastuzumab) and one 30mL vial of Bacteriostatic
`Water for Injection, USP, 1.1% benzyl alcohol. NDC 50242-134-60.
`
`REFERENCES
`1. Coussens L, Yang-Feng TL, Liao Y-C, Chen E, Gray A, McGrath J, et al. Tyrosine kinase receptor with
`extensive homology to EGF receptor shares chromosomal location with neu oncogene. Science 1985;
`230:1132-9.
`2. Slamon DJ, Godolphin W, Jones LA, Holt JA, Wong SG, Keith DE, etal. Studies of the HER2/n e u p r o t o -
`oncogene in human breast and ovarian cancer. Science 1989; 244:707-12.
`3. Press MF, Pike MC, Chazin VR, Hung G, Udove JA, Markowicz M, etal. Her-2/neu expression in node-
`negative breast cancer: direct tissue quantitation by computerized image analysis and association of over-
`expression with increased risk of recurrent disease. Cancer Res 1993; 53:4960-70.
`4. Hudziak RM, Lewis GD, Winget M, Fendly BM, Shepard HM, Ullrich A. p185H E R 2 monoclonal antibody
`has antiproliferative effects in vitro and sensitizes human breast tumor cells to tumor necrosis factor. Mol
`Cell Biol 1989; 9:1165-72.
`5. Lewis GD, Figari I, Fendly B, Wong WL, Carter P, Gorman C, etal. Differential responses of human tumor
`cell lines to anti-p185HER2 monoclonal antibodies. Cancer Immunol Immunother 1993; 37:255-63.
`6. Baselga J, Norton L, Albanell J, Kim Y-M, Mendelsohn J. Recombinant humanized anti-HER2 antibody
`( H e r c e p t i nT M) enhances the antitumor activity of paclitaxel and doxorubicin against HER2/n e u o v e r e x p r e s s i n g
`human breast cancer xenografts. Cancer Res. 1998; 58: 2825-2831.
`7. Hotaling TE, Reitz B, Wolfgang-Kimball D, Bauer K, Fox JA. The humanized anti-HER2 antibody
`r h u M A b HER2 mediates antibody dependent cell-mediated cytotoxicity via FcR III [abstract]. Proc
`Annu Meet Am Assoc Cancer Res 1996; 37:471.
`8. Pegram MD, Baly D, Wirth C, Gilkerson E, Slamon DJ, Sliwkowski MX, etal. Antibody dependent cell-
`mediated cytotoxicity in breast cancer patients in PhaseIII clinical trials of a humanized anti-HER2 anti-
`body [abstract]. Proc Am Assoc Cancer Res 1997; 38:602.
`9. Lee, KS. Requirement for neuroregulin receptor, erbB2, in neural and cardiac development. Nature 1995;
`379: 394-96.
`
`HERCEPTIN® (Trastuzumab)
`Manufactured by:
`Genentech, Inc.
`1 DNA Way
`South San Francisco, CA 94080-4990
`
`4817400
`September 1998
`©1998 Genentech, Inc.
`
`