英文药名：CAPRELSA(vandetanib  filmcoated tablets) 中文药名：凡德他尼片 生产厂家：阿斯利康公司 药品简介 阿斯利康甲状腺癌新药Caprelsa获欧洲批准上市 近日，欧洲当局批准阿斯利康公司新药Caprelsa（凡德他尼）用于治疗甲状腺癌，该药于去年4月份已在美国获得批准。 阿斯利康曾将凡德他尼视为一个重磅抗癌药，但在延长肺癌患者生存期上遇到了很大的障碍。 现在，该药物主要用于治疗不能切除的晚期或转移性甲状腺髓样癌患者，该疾病的发生率在甲状腺癌患者中占5-10%。 Caprelsa 100 mg & 300 mg film coated tablets 1. Name of the medicinal product Caprelsa 100 mg film-coated tablets. Caprelsa 300 mg film-coated tablets. 2. Qualitative and quantitative composition Each Caprelsa 100 mg film-coated tablet contains 100 mg of vandetanib. Each Caprelsa 300 mg film-coated tablet contains 300 mg of vandetanib. For a full list of excipients, see section 6.1. 3. Pharmaceutical form Film-coated (tablet) Caprelsa 100 mg: Round, biconvex, white film-coated tablets with 'Z100' impressed on one side. Caprelsa 300 mg: Oval-shaped, biconvex, white film-coated tablets with 'Z300' impressed on one side. 4. Clinical particulars 4.1 Therapeutic indications Caprelsa is indicated for the treatment of aggressive and symptomatic medullary thyroid cancer (MTC) in patients with unresectable locally advanced or metastatic disease. For patients in whom Rearranged during Transfection (RET) mutation is not known or is negative, a possible lower benefit should be taken into account before individual treatment decision (see important information in sections 4.4 and 5.1). 4.2 Posology and method of administration Treatment should be initiated and supervised by a physician experienced in treatment of MTC and in the use of anticancer medicinal products and experienced in the assessment of electrocardiogram (ECG). Only one supply per prescription is allowed. For a further supply, a new perscription is required. Posology The recommended dose is 300 mg once a day, taken with or without food at about the same time each day. If a dose is missed, it should be taken as soon as the patient remembers. If it is less than 12 hours to the next dose, the patient should not take the missed dose. Patients should not take a double dose (two doses at the same time) to make up for a forgotten dose. Patients treated with Caprelsa must be given the patient alert card and be informed about the risks of Caprelsa (see also package leaflet). Duration Vandetanib may be administered until patients with MTC are no longer benefiting from treatment. Dose adjustments QTc interval should be carefully assessed prior to initiation of treatment. In the event of common terminology criteria for adverse events (CTCAE) grade 3 or higher toxicity or prolongation of the ECG QTc interval, dosing with vandetanib should be at least temporarily stopped and resumed at a reduced dose when toxicity has resolved or improved to CTCAE grade 1 (see section 4.4). The 300 mg daily dose can be reduced to 200 mg (two 100 mg tablets), and then to 100 mg if necessary. The patient must be monitored appropriately. Due to the 19-day half-life, adverse reactions including a prolonged QTc interval may not resolve quickly (see section 4.4). Special patient populations Paediatric population The safety and efficacy in children have not been established. Therefore, vandetanib is not indicated for use in paediatric patients. Elderly No adjustment in starting dose is required for elderly patients. There is limited clinical data with vandetanib in patients with MTC aged over 75. Renal impairment A pharmacokinetic study in volunteers with mild, moderate and severe renal impairment shows that exposure to vandetanib after single dose is increased up to 1.5, 1.6 and 2-fold respectively in patients with mild, moderate (creatinine clearance ≥ 30 to < 50 ml/min) and severe (clearance below 30 ml/min) renal impairment at baseline (see section 5.2). Clinical data suggest that no change in starting dose is required in patients with mild renal impairment. There is limited data with 300 mg in patients with moderate renal impairment: the dose needed to be lowered to 200 mg in 5 out of 6 patients. The starting dose could be reduced to 200 mg in patients with moderate renal impairment; safety and efficacy have however not been established with 200 mg (see section 4.4). Vandetanib is not recommended for use in patients with severe renal impairment since there is limited data in patients with severe renal impairment, and safety and efficacy have not been established. Hepatic impairment Vandetanib is not recommended for use in patients with hepatic impairment (serum bilirubin greater than 1.5 times upper limit of normal), since there is limited data in patients with hepatic impairment, and safety and efficacy have not been established (see section 4.4). Pharmacokinetic data from volunteers, suggests that no change in starting dose is required in patients with mild, moderate or severe hepatic impairment (see section 5.2). Method of administration For patients who have difficulty swallowing, vandetanib tablets may be dispersed in half a glass of non-carbonated drinking water. No other liquids should be used. The tablet is to be dropped in water, without crushing, stirred until dispersed (approximately 10 minutes) and the resultant dispersion swallowed immediately. Any residues in the glass are to be mixed with half a glass of water and swallowed. The liquid can also be administered through nasogastric or gastrostomy tubes. 4.3 Contraindications • Hypersensitivity to the active substance or to any of the excipients listed in section 6.1. • Congenital long QTc syndrome. • Patients with a QTc interval over 480 msec. • Concomitant use of vandetanib with the following medicinal products known to also prolong the QTc interval and / or induce Torsades de pointes: Arsenic, cisapride, erythromycine intravenous (IV), toremifene, mizolastine, moxifloxacine, Class IA and III antiarrhythmics (see section 4.5). • Breast-feeding (see section 4.6). 4.4 Special warnings and precautions for use In view of the associated risks, it is important to limit treatment with vandetanib to patients who are in real need for treatment, i.e., with a symptomatic-aggressive course of the disease. Either symptomatic disease or progressive disease alone is not enough to prompt the need of treatment with vandetanib. Rate of change in biomarker levels such as of calcitonin (CTN) and/or carcinoembryonic antigen (CEA) as well as the rate of change of tumor volume during watchful waiting might help to identify not only patients in need for treatment but also the optimal moment to commence treatment with vandetanib. QTc prolongation and Torsades de Pointes Vandetanib at a dose of 300 mg is associated with a substantial and concentration dependent prolongation in QTc (mean 28 msec, median 35 msec). First QT prolongations occurred most often in the first 3 months of treatment, but continued to first occur after this time. The half-life of vandetanib (19 days) renders this prolongation in QTc interval particularly problematic (see section 4.8). At a dose of 300 mg per day in MTC, ECG QTc prolongation to above 500 msec was observed in a phase III study in 11% of patients. ECG QTc prolongation appears to be dose-dependent. Torsades de pointes and ventricular tachycardia have been uncommonly reported in patients administered vandetanib 300 mg daily. The risk of torsades may be increased in patients with electrolyte imbalance (see section 4.8). Vandetanib treatment must not be started in patients whose ECG QTc interval is greater than 480 msec. Vandetanib should not be given to patients who have a history of Torsades de pointes unless all risk factors that contributed to Torsades have been corrected. Vandetanib has not been studied in patients with ventricular arrhythmias or recent myocardial infarction. An ECG, and levels of serum potassium, calcium and magnesium and thyroid stimulating hormone (TSH) should be obtained at baseline, at 1, 3, 6 and 12 weeks after starting treatment and every 3 months for at least a year thereafter. This schedule should apply to the period after dose reduction due to QTc prolongation and after dose interruption for more than two weeks. ECGs and blood tests should also be obtained as clinically indicated during this period and afterwards. Frequent ECG monitoring of the QTc interval should be continued. Serum potassium, serum magnesium and serum calcium should be kept within normal range to reduce the risk of ECG QTc prolongation. Additional monitoring of QTc, electrolytes and renal function are required especially in case of diarrhoea, increase in diarrhoea/dehydration, electrolyte imbalance and/or impaired renal function. If QTc increases markedly but stays below 500 msec, cardiologist advice should be sought. The administration of vandetanib with substances known to prolong the ECG QTc interval is contraindicated or not recommended (see section 4.3 and 4.5). The concomitant use of vandetanib with ondansetron is not recommended (see section 4.5) Patients who develop a single value of a QTc interval of ≥500 msec should stop taking vandetanib. Dosing can be resumed at a reduced dose after return of the QTc interval to pretreatment status has been confirmed and correction of possible electrolyte imbalance has been made. Posterior reversible encephalopathy syndrome, PRES (Reversible posterior leukoencephalopathy syndrome-RPLS) PRES is a syndrome of subcortical vasogenic oedema diagnosed by a MRI of the brain, has been observed infrequently with vandetanib treatment in combination with chemotherapy. PRES has also been observed in patients receiving vandetanib as monotherapy. This syndrome should be considered in any patient presenting with seizures, headache, visual disturbances, confusion or altered mental function. Brain MRI should be performed in any patient presenting with seizures, confusion or altered mental status. Rearranged during transfection (RET) status Patients without RET mutation may have a decreased benefit from vandetanib treatment and the benefit/risk balance for this group of patients may therefore differ from that of the group with RET mutations. For patients whose RET mutation status could be negative, a possible lower benefit should be taken into account before individual treatment decisions and the use of vandetanib should be carefully considered because of the treatment related risks. Therefore RET mutation testing is recommended. When establishing RET mutation status, tissue samples should be obtained if possible at the time of initiation of treatment rather than at the time of diagnosis (see sections 4.1 and 5.1). Skin reactions Rash and other skin reactions (including photosensitivity reactions and palmar-plantar erythrodysaesthesia syndrome) have been observed in patients who have received vandetanib. Mild to moderate skin reactions can be managed by symptomatic treatment, or by dose reduction or interruption. More severe skin reactions (such as Stevens-Johnson syndrome) may require systemic glucocorticosteroids and permanent discontinuation of vandetanib. Care should be taken with sun exposure by wearing protective clothing and /or sunscreen due to the potential risk of phototoxicity reactions associated with vandetanib treatment. Diarrhoea Diarrhoea is a disease related symptom as well as a known undesirable effect of vandetanib. Routine anti-diarrhoeal agents are recommended for the treatment of diarrhoea. QTc and serum electrolytes should be monitored more frequently. If severe diarrhoea (CTCAE grade 3-4) develops, vandetanib should be stopped until diarrhoea improves. Upon improvement, treatment should be resumed at a reduced dose (see sections 4.2 and 4.8). Haemorrhage Caution should be used when administering vandetanib to patients with brain metastases, as intracranial haemorrhage has been reported. Heart failure Heart failure has been observed in patients who received vandetanib. Temporary or permanent discontinuation of therapy may be necessary in patients with heart failure. It may not be reversible on stopping vandetanib. Some cases have been fatal. Hypertension Hypertension, including hypertensive crisis, has been observed in patients treated with vandetanib. Patients should be monitored for hypertension and controlled as appropriate. If high blood pressure cannot be controlled with medical management, vandetanib should not be restarted until the blood pressure is controlled medically. Reduction in dose may be necessary (see section 4.8). Patients with renal impairment Vandetanib is not recommended for use in patients with moderate or severe renal impairment since there is limited data, and safety and efficacy have not been established (see sections 4.2, 5.1, and 5.2). Patients with hepatic impairment Vandetanib is not recommended for use in patients with hepatic impairment (serum bilirubin greater than 1.5 times upper limit of normal), since there is limited data in patients with hepatic impairment, and safety and efficacy have not been established. Pharmacokinetic data from volunteers, suggests that no change in starting dose is required in patients with mild, moderate or severe hepatic impairment (see sections 4.2 and 5.2). Alanine aminotransferase elevations Alanine aminotransferase elevations occur commonly in patients treated with vandetanib. The majority of elevations resolve while continuing treatment, others usually resolve after a 1-2 week interruption in therapy. Periodic monitoring of alanine aminotransferase is recommended. Interstitial lung disease Interstitial Lung Disease (ILD) has been observed in patients receiving vandetanib and some cases have been fatal. If a patient presents with respiratory symptoms such as dyspnoea, cough and fever, vandetanib treatment should be interrupted and prompt investigation initiated. If ILD is confirmed, vandetanib should be permanently discontinued and the patient treated appropriately. CYP3A4 inducers The concomitant use of vandetanib with strong CYP3A4 inducers (such as rifampicin, St Johns'Wort, carbamazepine, phenobarbital) should be avoided (see section 4.5). CTN less than 500 pg/ml The benefit of vandetanib in patients with CTN less than 500 pg/ml has not been determined, therefore use in patients with CTN < 500 pg/ml should be carefully considered because of the treatment related risks of vandetanib. Patient Alert Card All prescribers of Caprelsa must be familiar with the Physician Information and Management Guidelines. The prescriber must discuss the risks of Caprelsa therapy with the patient. The patient will be provided with the Patient Alert Card with each prescription. 4.5 Interaction with other medicinal products and other forms of interaction Pharmacokinetic interactions Effect of vandetanib on other medicinal products In healthy subjects, the exposure for midazolam (CYP3A4 substrate) was not affected when given together with a single dose of vandetanib at 800 mg. Vandetanib is an inhibitor of the organic cation 2 (OCT2) transporter. In healthy subjects with wild type for OCT2, the AUC(0-t) and Cmax for metformin (OCT2 substrate) were increased by 74 % and 50 %, respectively and CLR of metformin was decreased by 52 % when given together with vandetanib. Appropriate clinical and/or laboratory monitoring is recommended for patients receiving concomitant metformin and vandetanib, and such patients may require a lower dose of metformin. In healthy subjects, the AUC(0-t) and Cmax for digoxin (P-gp substrate) were increased by 23 % and 29 % respectively, when given together due to P-gp inhibition by vandetanib. Furthermore, the bradycardiac effect of digoxin may increase the risk of vandetanib QTc interval prolongation and Torsade de Pointes. Therefore, an appropriate clinical (e.g. ECG) and/or laboratory monitoring is recommended for patients receiving concomitant digoxin and vandetanib, and such patients may require a lower dose of digoxin. (For vandetanib monitoring, see section 4.2 Posology and method of administration and section 4.4 Special warnings and special precautions). As regards other P-gp substrates such as dabigatran, a clinical monitoring is recommended in case of combination with vandetanib. Effect of other medicinal products on vandetanib In healthy subjects, no clinically significant interaction was shown between vandetanib (a single dose of 300 mg) and the potent CYP3A4 inhibitor, itraconazole (repeated doses of 200 mg once daily). In healthy male subjects, the exposure to vandetanib was reduced by 40 % when given together with the potent CYP3A4 inducer, rifampicin. Administration of vandetanib with potent CYP3A4 inducers should be avoided. In healthy subjects, the Cmax for vandetanib was decreased by 15 % while the AUC (0-t) for vandetanib was not affected when given together with omeprazole. Neither the Cmax nor the AUC (0-t) for vandetanib was affected when given together with ranitidine. Therefore no change in dose of vandetanib is required when vandetanib is given with either omeprazole or ranitidine. Pharmacodynamic interactions Biliary excretion of unchanged vandetanib is one of the excretion pathways for vandetanib. Vandetanib is not a substrate of multidrug resistance protein 2 (MRP2), p-glycoprotein (Pgp) or breast cancer resistance protein (BCRP). Medicinal products known to prolong QTc interval Vandetanib has been shown to prolong the ECG QTc interval; Torsades de pointes have been uncommonly reported. Therefore the concomitant use of vandetanib with medicinal products known to also prolong the QTc interval and/or induce Torsades de pointes is either contraindicated or not recommended depending on existing alternative therapies. • Combinations contraindicated (see section 4.3): Cisapride, erythromycine intravenous (IV), toremifen, mizolastine, moxifloxacine, arsenic, Class I A and III antiarrhythmics • Combinations not recommended: Methadone, haloperidol, amisulpride, chlorpromazine, sulpiride, zuclopenthixol, halofantrine, pentamidine and lumefantrine. If there is no appropriate alternative therapy, not recommended combinations with vandetanib may be made with additional ECG monitoring of the QTc interval, evaluation of electrolytes and further control at onset or worsening of diarrhoea. Results of a pharmacodynamic and pharmacokinetic interaction study indicated that co-administration with ondansetron in healthy patients appeared to have little effect on the pharmacokinetics of vandetanib, but had a small additive effect on the prolongation of the QTc interval of approximately 10 ms. Therefore, the concomitant use of ondansetron with vandetanib is not-recommended. If ondansetron is administered with vandetanib, closer monitoring of serum electrolytes and ECGs and aggressive management of any abnormalities is required. Vitamin K antagonists Due to the increased thrombotic risk in patients with cancer, the use of anticoagulation is frequent. In consideration of the high intra-individual variability of the response to anticoagulation, and the possibility of interaction between vitamin K antagonists and chemotherapy, an increased frequency of the INR (International Normalised Ratio) monitoring is recommended, if it is decided to treat the patient with vitamin K antagonists. 4.6 Fertility, pregnancy and lactation Women of childbearing potential Women of childbearing potential must use effective contraception during therapy and for at least four months following the last dose. Pregnancy There is a limited amount of data on the use of vandetanib during pregnancy. As expected from its pharmacological actions, vandetanib has shown significant effects on all stages of female reproduction in rats (see section 5.3). If vandetanib is used during pregnancy or if the patient becomes pregnant while receiving vandetanib, she should be apprised of the potential for foetal abnormalities or loss of the pregnancy. Treatment should only be continued in pregnant women if the potential benefit to the mother outweighs the risk to the foetus. Breast-feeding There are no data on the use of vandetanib in breast-feeding women. Vandetanib and/or its metabolites is excreted into milk in rats and found in plasma of pups following dosing to lactating rats (see section 5.3). Breast-feeding is contraindicated while receiving vandetanib therapy. Fertility In rats, vandetanib had no effect on male fertility but impaired female fertility (see section 5.3). 4.7 Effects on ability to drive and use machines No studies to establish the effects of vandetanib on ability to drive and use machines have been conducted. However, fatigue and blurred vision have been reported and those patients who experience these symptoms should observe caution when driving or using machines. 4.8 Undesirable effects Overall summary of adverse drug reactions The most commonly reported adverse drug reactions have been diarrhoea, rash, nausea, hypertension, and headache. Adverse drug reactions during clinical trials The following adverse reactions have been identified in clinical studies with patients receiving vandetanib as treatment for MTC. Their frequency is presented in Table 1, adverse drug reactions using Council for International Organizations of Medical Sciences (CIOMS III), listed by MedDRA System Organ Class (SOC) and at the preferred term level and then by frequency classification. Frequencies of occurrence of undesirable effects are defined as: very common (≥ 1/10); common (≥ 1/100 to < 1/10); uncommon (≥ 1/1,000 to < 1/100); rare (≥ 1/10,000 to < 1/1000); very rare (< 1/10,000) and not known (cannot be estimated from the available data). This section includes only data derived from completed studies where patient exposure is known. Table 1 Adverse drug reactions and system organ class System Organ Class Very commom Common Uncommon Infection and infestation disorders Nasopharyngitis bronchitis, upper respiratory tract infections, urinary tract infections Pneumonia, sepsis, influenza, cystitis, sinusitis, laryngitis, folliculitis, furuncle, fungal infection, pyelonephritis Appendicitis, staphloccocal infection, diverticulitis, cellulitis, abdominal wall abscess Endocrine disorders   Hypothyroidism   Metabolism and nutrition disorders Appetite decreased, Hypocalcaemia Hypokalaemia, hypercalcaemia, hyperglycemia, dehydration, hyponatremia Malnutrition Psychiatric disorders Insomnia, Depression Anxiety   Nervous sytem disorders Headache, paresthesia, dysaesthesia, dizziness Tremor, lethargy, loss of consciousness, balance disorders, dysgeusia Convulsion, clonus, brain oedema Eye disorders Vision blurred, corneal structural change (including corneal deposits and corneal opacity) Visual impairment, halo vision, photopsia, glaucoma, conjunctivitis, dry eye, keratopathy Cataract, accomodation disorders Cardiac disorders Prolongation of ECG QTc interval(*) (**)   Heart failure, acute heart failure, rate and rhythm disorders, cardiac conduction disorders, ventricular arrhythmia and cardiac arrest Vascular disorders Hypertension Hypertensive crisis, ischemic cerebrovascular conditions   Respiratory, thoracic and mediastinal disorders   Epistaxis, hemoptysis, pneumonitis Respiratory failure, pneumonia aspiration Gastrointestinal disorders Abdominal pain, diarrhoea, nausea, vomiting, dyspepsia Colitis, dry mouth, stomatitis, dysphagia, constipation, gastritis, gastrointestinal haemorrhage Pancreatitis, peritonitis, ileus, intestinal perforation, faecal incontinence Hepatobiliary disorders   Cholelithiasis   Skin and subcutaneous tissue disorders Photosensitivity reaction, rash and other skin rections (including acne, dry skin, dermatitis, pruritis), nail disorders Palmar-plantar erythrodysaesthiesia syndrome, alopecia Bullous dermatitis Renal and urinary disorders Proteinuria, nephrolithiasis Dysuria, hematuria, renal failure, pollakiuria, micturition urgency Chromaturia, anuria General disorders and administration site conditions Asthenia, fatigue, pain, oedema Pyrexia Impaired healing Investigations ECG QTc interval prolonged Increase of serum ALT and AST, weight decreased blood creatinine increased Increased haemoglobin,serum amylase increased 13.4% vandetanib patients had QTc (Bazett's) ≥ 500 ms compared with 1.0% placebo patients. QTcF prolongation was > 20 ms in over 91% of patients, > 60 ms in 35%, > 100 ms in 1.7%. Eight percent of patients had a dose reduction due to QTc prolongation. including two deaths in patients with QTc > 550 ms (one due to sepsis and one due to heart failure) Events such as Torsades de pointes, Stevens-Johnson syndrome, erythema multiforme, interstitial lung disease (sometimes fatal) and PRES (RPLS) have occurred in patients treated with vandetanib monotherapy. It is expected that these would be uncommon adverse reactions in patients receiving vandetanib for MTC. Ocular events such as blurred vision are common in patients who received vandetanib for MTC. Scheduled slit lamp examinations have revealed corneal opacities (vortex keratopathies) in treated patients; however routine slit lamp examinations are not required for patients receiving vandetanib. At various exposure durations, median haemoglobin levels in patients treated with vandetanib were increased by 0.5-1.5 g/dl compared to baseline. Reporting of suspected adverse reactions Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via: Yellow Card Scheme Website: www.mhra.gov.uk/yellowcard 4.9 Overdose There is no specific treatment in the event of overdose with vandetanib and possible symptoms of overdose have not been established. An increase in the frequency and severity of some adverse reactions, like rash, diarrhoea and hypertension was observed at multiple doses at and above 300 mg in healthy volunteer studies and in patients. In addition, the possibility of QTc prolongation and Torsades de pointes should be considered. Adverse reactions associated with overdose are to be treated symptomatically; in particular, severe diarrhoea must be managed appropriately. In the event of an overdose, further doses must be interrupted, and appropriate measures taken to assure that an adverse event has not occurred, i.e. ECG within 24 hours to determine QTc prolongation. Adverse reactions associated with overdose may be prolonged due to the long half-life of vandetanib (see section 5.2). 5. Pharmacological properties 5.1 Pharmacodynamic properties Pharmacotherapeutic Group: antineoplastic agent, protein kinase inhibitor, ATC Code: L01XE12 Mechanism of action and pharmacodynamic effects Vandetanib is a potent inhibitor of vascular endothelial growth factor receptor-2 (VEGFR-2 also known as kinase insert domain containing receptor [KDR]), epidermal growth factor receptor (EGFR) and RET tyrosine kinases. Vandetanib is also a sub-micromolar inhibitor of vascular endothelial receptor-3 tyrosine kinase. Vandetanib inhibits VEGF-stimulated endothelial cell migration, proliferation, survival and new blood vessel formation in in vitro models of angiogenesis. In addition, vandetanib inhibits epidermal growth factor (EGF)-stimulated EGF receptor tyrosine kinase in tumour cells and endothelial cells. Vandetanib inhibits EGFR-dependent cell proliferation and cell survival in vitro. Vandetanib also inhibits both wild type and the majority of mutated, activated forms of RET, and significantly inhibits the proliferation of MTC cell lines in vitro. In vivo vandetanib administration reduced tumour cell-induced angiogenesis, tumour vessel permeability, tumour microvessel density, and inhibited tumour growth of a range of human xenograft tumour models in athymic mice. Vandetanib also inhibited the growth of MTC xenograft tumours in vivo. The precise mechanism of action of vandetanib in locally advanced or metastatic MTC is unknown. Clinical efficacy and safety Clinical data from MTC A randomized, double-blind, placebo--controlled study (Study 58) was conducted to demonstrate safety and efficacy of vandetanib 300 mg versus placebo. This study included 331 patients with unresectable locally advanced or metastatic MTC. Only patients with CTN ≥ 500 pg/mL (conventional units) or ≥ 146.3 pmol/L (international standard units) were enrolled. Of the patients enrolled in the study 10 patients on vandetanib and 4 on placebo (4% of all patients) had a world health organization performance status (WHO PS) score of ≥ 2 and 28 (12.1%) patients on vandetanib and 10 (10.1%) on placebo had cardiac impairment. Cardiac impairment was defined as patients with previous cardiovascular abnormality. The primary objective of this study was to demonstrate an improvement in progression-free survival (PFS) with vandetanib compared to placebo. The secondary endpoints were evaluation of overall objective response rate (ORR), disease control rate (DCR) defined as, partial response (PR) or complete response (CR) or stable disease (SD) lasting at least 24 weeks, duration of response (DOR), time to worsening of pain based on Brief Pain Inventory (BPI) worst pain scale, and overall survival (OS). The PFS primary endpoint, ORR and DCR were based on centralized, independent blinded review of the imaging data. Biochemical response with vandetanib as compared to placebo as measured by CTN and CEA was also assessed as secondary endpoints. Patients were treated with vandetanib or placebo until they reached objective disease progression. Upon objective disease progression based on the investigator's assessment, patients were discontinued from blinded study treatment and given the option to receive open-label vandetanib. Twenty-eight of the 231 patients (12.1%) on vandetanib and 3 of the 99 (3.0%) on placebo discontinued treatment because of an adverse event. Fourteen of the 28 patients (50%) who stopped vandetanib for an adverse event discontinued without a dose reduction. Five out of 6 patients (83%) with moderate renal failure who were treated with vandetanib had a dose reduction to 200 mg for adverse reaction; 1 patient required a further reduction to 100 mg. The result of the primary analysis of PFS showed a statistically significant improvement in PFS for patients randomized to vandetanib compared to placebo (Hazard Ratio (HR) = 0.46; 95% Confidence Interval (CI) = 0.31-0.69; p=0.0001). The median PFS for patients randomized to vandetanib has not been reached; however, based on statistical modeling of data observed up to the 43rd percentile, the median PFS is predicted to be 30.5 months with 95% confidence interval 25.5 to 36.5 months. The median PFS for patients randomized to placebo was 19.3 months. At 12 months, the proportion of patients alive and progression-free was 192 (83%) for patients randomized to vandetanib and 63 (63%) for patients randomized to placebo. In the vandetanib arm, a total of 73 (32%) patients progressed: 64 (28%) by response evaluation criteria in solid tumours (RECIST) progression and 9 (4%) by death in the absence of progression. The remaining 158 patients (68%) were censored in the analysis of PFS. In the placebo arm, a total of 51 (51%) of patients had progressed: 46 (46%) by RECIST progression and 5 (5%) by death in the absence of progression. The remaining 49 patients (49%) were censored in the analysis of PFS. Fig 1. Kaplan Meier plot of PFS months 0 6 12 18 24 30 36 n-vandetanib 231 196 169 140 40 1 0 n-placebo 100 71 57 45 13 0 0 vandetanib 300 mg, -placebo, y-axis=PFS, x-axis=time in months, n-vandetanib=number of patients at risk-vandetanib, n-placebo=number of patients at risk-placebo HR = 0.46, 95%CI (0.31-0.69), p = 0.0001 PFS N Median PFS HR 95% CI p-value Vandetanib 300 mg 73/231 (32%) Not reached (predicted 30.5 months) 0.46 0.31, 0.69 0.0001 Placebo 51/100 (51%) 19.3 months At the time of the primary analysis of PFS, 48 (15%) of the patients had died, and there was no significant difference in overall survival between treatment groups (HR = 0.89; = 99.98%CI = 0.28-2.85; p=0.712). At the time of this analysis, 32 patients (14%) on the vandetanib arm and 16 patients (16%) on the placebo arm had died. Most (95% of the patients) had metastatic disease. Fourteen patients treated with vandetanib, and 3 with placebo had unresectable locally advanced disease only. There is limited clinical experience with vandetanib in patients with unresectable locally advanced disease and without metastasis. Statistically significant advantages were seen for vandetanib for the secondary endpoints of response rate, disease control rate, and biochemical response. Table 2 Summary of other efficacy findings in study 58 ORRa N Response rate ORb 95% CI p-value Vandetanib 300 mg 104/231 45% 5.48 2.99, 10.79 < 0.0001 Placebo 13/100 13% DCRa N Response rate ORb 95% CI p-value Vandetanib 300 mg 200/231 87% 2.64 1.48, 4.69 0.001 Placebo 71/100 71% CTN Response N Response rate ORb 95% CI p-value Vandetanib 300 mg 160/231 69% 72.9 26.2, 303.2 < 0.0001 Placebo 3/100 3% CEA Response N Response rate ORb 95% CI p-value Vandetanib 300 mg 119/231 52% 52.0 16.0, 320.3 < 0.0001 Placebo 2/100 2% a Overall response rate = complete + partial responses. Disease control rate = response rate + stable disease at 24 weeks. Intent-to-treat (ITT) analysis includes patients who received open-label vandetanib before progression according to the central read. b OR=Odds Ratio. A value > 1 favors vandetanib. The analysis was performed using a logistic regression model with treatment as the only factor. N=Number of events/number of randomised patients; A statistically significant advantage was seen for vandetanib for the secondary endpoint of time to worsening of pain (derived as a composite endpoint using the worst pain score from BPI and patient reported opioid analgesic use) (vandetanib 49%, placebo 57%, HR 0.61, 97.5%CI 0.43-0.87, p< 0.006: 8 vs. 3 months). There were no statistically significant differences observed for the exploratory endpoint of diarrhoea (reported as stool frequency). RET mutation status in Study 58 In Study 58, RET mutation testing was performed by using the polymerase chain reaction (PCR) based Amplification Refractory Mutation System (ARMS) assay for the M918T mutation, and direct sequencing of DNA for mutations in exons 10, 11, 13, 14, 15 and 16 (site of M918T mutation) on all sporadic patients where DNA was available (297/298). However, RET status could not be tested in a large proportion of patients (mainly because of unavailable results for direct sequencing of DNA) and response rate was somewhat lower in the patients with unknown RET status compared with RET mutation positive status: 51.8% vs. 35.9 % respectively. In the blinded comparison of vandetanib vs. placebo, only 2 patients known to be RET negative at all 6 exons received vandetanib and none demonstrated responses. A post-hoc subgroup analysis of RET negative status based on absence of M918T mutation of the pivotal study 58 was performed. A patient was considered to have a RET mutation if either an M918T mutation by the ARMS assay, or a RET mutation in any exons sequenced was present in the tumour. Actually 79 patients were identified by absence of an M918T mutation and no RET mutation identified at any of the other 6 exons tested but in 71 of such patients sequencing of the 6 exons was incomplete. M918T mutation is the most frequent mutation observed in patients with sporadic MTC; however it cannot be ruled out that some patients tested RET negative for M918T mutation might be positive for mutation on other exons. Results according to RET status (positive, unknown and RET M918T mutation negative definition) are presented in Table 3. Table 3: Summary of efficacy findings in a segment of patients according to RET mutation status Patients with documented RET mutation (n=187) Patients with no M918T mutation and other mutations not tested or negative (n=79)* Objective response rate (vandetanib arm) 52% 35% Efficacy endpoint PFS HR (95%) confidence interval 0.45 (0.26, 0.78) 0.57 (0.29, 1.13) RET mutation status was obtained at the time of diagnosis in a majority of atients and could have changed since. Paediatric population The European Medicines Agency has deferred the obligation to submit the results of studies with vandetanib in one or more subsets of the paediatric population in hereditary medullary thyroid carcinoma (see 4.2 for information on paediatric use). This medicinal product has been authorized under a so called “conditional approval” scheme. This means that further evidence on this medicinal product is awaited. The European Medicines Agency (EMA) will review new information on the product every year and this SmPC will be updated as necessary. 5.2 Pharmacokinetic properties Absorption Following oral administration of vandetanib absorption is slow with peak plasma concentrations typically achieved at a median of 6 hours, range 4-10 hours, after dosing. Vandetanib accumulates approximately 8-fold on multiple dosing with steady state achieved from approximately 2 months. Distribution Vandetanib binds to human serum albumin and alpha-1-acid-glycoprotein with in vitro protein binding being approximately 90%. In ex vivo plasma samples from colorectal cancer patients at steady state exposure after 300 mg once daily, the mean percentage protein binding was 93.7% (range 92.2 to 95.7%). The pharmacokinetics of vandetanib at the 300 mg dose in MTC patients are characterised by a volume of distribution of approximately 7450 l. Biotransformation Following oral dosing of 14C- vandetanib, unchanged vandetanib and metabolites vandetanib N-oxide and N-desmethyl vandetanib were detected in plasma, urine and feces. A glucuronide conjugate was seen as a minor metabolite in excreta only. N-desmethyl-vandetanib is primarily produced by CYP3A4, and vandetanib-N-oxide by flavin-containing monooxygenase enzymes (FM01 and FMO3). N-desmethyl-vandetanib and vandetanib-N-oxide circulate at concentrations of approximately 11% and 1.4% of those of vandetanib. Elimination The pharmacokinetics of vandetanib at the 300 mg dose in MTC patients are characterised by a clearance of approximately 13.2 l/h. and plasma half-life of approximately 19 days. Within a 21 day collection period after a single dose of 14C-vandetanib, approximatley 69% was recovered with 44% in faeces and 25% in urine. Excretion of the dose was slow and further excretion beyond 21 days would be expected based on the plasma half-life. Special populations Renal impairment A single dose pharmacokinetic study in volunteers indicated that exposure to vandetanib is enhanced (up to 1.5, 1.6 and 2-fold) in mild, moderate and severe renal impaired subjects respectively compared to subjects with normal renal function (see sections 4.2, 4.4 and 4.5). Hepatic impairment A single dose pharmacokinetic study in volunteers indicated that hepatic impairment did not affect exposure to vandetanib. There is limited data in patients with hepatic impairment (serum bilirubin greater than 1.5 times upper limit of normal (see sections 4.2 and 4.4). Food Effect Exposure to vandetanib is not affected by food. 5.3 Preclinical safety data Vandetanib has shown no mutagenic or clastogenic potential. In repeat-dose toxicity studies of up to 9 months duration, effects included emesis, body weight loss and diarrhoea in dogs and physeal dysplasia in young dogs and rats with open growth plates. In rats, effects on teeth, kidney and skin were noted. These findings occurred at clinically-relevant plasma concentrations, were largely reversible within 4 weeks of cessation of dosing and were attributable to inhibition of vascular endothelial growth factor receptor (VEGFR) or EGFR. Effects noted in other studies included inhibition of human ether-a-go-go related gene (hERG) current and prolongation of QTc interval in dogs. Elevation of systolic and diastolic blood pressure was observed in rats and dogs. In mice, vandetanib was shown to delay but not prevent wound healing. Vandetanib also showed evidence of phototoxic potential in an in vitro cytotoxicity assay. In an animal model of wound-healing, mice dosed with vandetanib had reduced skin-breaking strength compared with controls. This suggests that vandetanib slows but does not prevent wound healing. The appropriate interval between discontinuation of vandetanib and subsequent elective surgery required to avoid the risks of impaired wound healing has not been determined. In clinical studies, a small number of patients had surgery while receiving vandetanib and there were no reported wound healing complications. Reproductive toxicology Vandetanib had no effect on fertility in male rats. In a female fertility study, there was a trend towards increased oestrus cycle irregularity, a slight reduction in pregnancy incidence and increase in implantation loss. In a repeat-dose toxicity study in rats, there was a decrease in the number of corpora lutea in the ovaries of rats given vandetanib for 1 month. In rats, embryofoetal toxicity was evident as foetal loss, delayed foetal development, heart vessel abnormalities and precocious ossification of some skull bones. In a rat pre- and post-natal development study, at doses producing maternal toxicity during gestation and/or lactation, vandetanib increased pre-birth loss and reduced post-natal pup growth. Vandetanib was excreted into milk in rat and found in plasma of pups following dosing to lactating rats. Carcinogenicity Carcinogenicity studies have not been conducted with vandetanib. 6. Pharmaceutical particulars 6.1 List of excipients Tablet core Calcium hydrogen phosphate dihydrate Microcrystalline cellulose Crospovidone (type A) Povidone (K 29-32) Magnesium stearate Film-coating Hypromellose Macrogol (300) Titanium dioxide (E171) 6.2 Incompatibilities Not applicable. 6.3 Shelf life 4 years. 6.4 Special precautions for storage Do not store above 30°C. 6.5 Nature and contents of container PVC/ PVDC/Alu blisters, sealed with aluminium foil, each containing 30 film-coated tablets. 6.6 Special precautions for disposal and other handling No special requirements. 7. Marketing authorisation holder AstraZeneca AB SE-151 85 Södertälje Sweden 8. Marketing authorisation number(s) EU/1/11/749/001 - Caprelsa 100 mg film-coated tablets. EU/1/11/749/002 - Caprelsa 300 mg film-coated tablets 9. Date of first authorisation/renewal of the authorisation 17th February 2012 10. Date of revision of the text 20th December 2013 Detailed information on this medicinal product is available on the website of the European Medicines Agency http://www.ema.europa.eu FDA批准罕见甲状腺癌新治疗药物 ——凡德他尼是首个获批的甲状腺髓样癌治疗药物 美国食品药典监督管理局（FDA）今天批准凡德他尼用于无法手术、肿瘤持续增长或已出现症状的成年晚期（出现转移）甲状腺髓样癌患者治疗。 甲状腺癌是位于颈部的甲状腺呈现癌性生长。甲状腺髓样癌是甲状腺中一种特定细胞的癌性增长，可自发或由遗传产生。 根据美国国立癌症研究院（NCI）的统计，2010年，美国共新诊断44600例甲状腺癌病例，死亡1690例。甲状腺髓样癌约占所有甲状腺癌的3-5%，2010年约新诊断1300-2200例，使其成为甲状腺癌罕见种类之一。 甲状腺髓样癌的常见症状包括：咳嗽、吞咽困难、甲状腺增大、颈部肿胀、甲状腺肿块、声音改变或嘶哑。 凡德他尼片用于控制甲状腺髓样癌的生长和扩散能力，在此之前FDA还没有批准过用于这类治疗的药物。凡德他尼片为每日口服给药。 凡德他尼的安全性和有效性由一项纳入331例晚期甲状腺髓样癌患者的单一、随机国际性临床试验所证实。纳入的患者被分配接受凡德他尼或安慰剂（糖丸）治疗。 这项临床试验设计了对患者个体癌症病情无进展生存期进行考察。与安慰剂组相比，凡德他尼组病情无进展生存期明显延长，两组的病情无进展生存期中位数分别为16.4个月和超过22.6个月。还需要很长的时间才能确定凡德他尼组病情无进展生存期中位数确切数值和断定该组整体生存期（Overall Survival）是否会长于安慰剂组。 FDA药品评价研究中心肿瘤学药品办公室主任Richard Pazdur博士评价说：“凡德他尼获批，实现了FDA对批准罕见和难以治愈疾病治疗药物的承诺。” 凡德他尼的常见副作用包括：腹泻、皮疹、恶心、高血压、头痛、疲劳、食欲下降、胃癌(腹部)疼痛。临床研究期间凡德他尼严重不良反应共导致5例患者死亡，其死亡原因包括呼吸并发症、心衰以及血液细菌感染(败血症)。 凡德他尼可以影响心脏的生物电活动，在某些情况下引起心律失常，可能导致死亡。凡德他尼获批前提交的“风险评估和减缓战略”（REMS），提醒医疗保健专业人员注意凡德他尼的严重心脏病相关风险。按照这份风险评估和减缓战略，为限制药物流通过程，只有经过认证的医疗保健人员和药房才可以开具和发放凡德他尼。患者也会收到FDA批准的含药物潜在风险内容的治疗指南文件。 凡德他尼由位于威尔明顿的AstraZeneca Pharmaceuticals LP公司销售