英文药名：Besponsa（inotuzumab ozogamicin powder solution for infusion） 中文药名：奥英妥珠单抗冻干粉注射剂 生产厂家：辉瑞有限公司 药品介绍 近日，欧洲药品管理局（EMA）人用医药产品委员会（CHMP）已发布积极意见，支持批准Besponsa作为一种单药疗法，用于既往接受至少一种酪氨酸激酶抑制剂（TKI）治疗失败的复发性或难治性CD22阳性B细胞前体费城染色体阴性（Ph-）急性淋巴细胞白血病（ALL）和费城染色体阳性（Ph+）急性淋巴细胞白血病（ALL）成人患者的治疗。 Besponsa是一种抗体药物偶联物（ADC），由靶向CD22的单克隆抗体inotuzumab与细胞毒制剂卡奇霉素（calicheamicin）偶联而成。CD22是在癌细胞上发现的一种细胞表面抗原，存在于几乎所有的B-ALL患者中。Besponsa靶向结合恶性B细胞表面的CD22抗原后内化进入细胞内，释放出细胞毒制剂卡奇霉素，摧毁癌细胞。 作用机制 Inotuzumab ozogamicin是一个指向CD22抗体-药物结合物(ADC)。Inotuzumab识别人CD22。小分子，N-乙酰l-ɣ-calicheamicin，是一种细胞毒药物被共价地附着至抗体通过一个连接物。非临床数据提示inotuzumab ozogamicin的抗癌活性是由于ADC结合至CD22-表达肿瘤细胞，接着通过ADC-CD22复合物的内化作用，和通过连接物的水解裂解在细胞内释放N-乙酰基-γ-卡奇霉素丁酰肼[dimethylhydrazide]。N-乙酰基-γ-卡奇霉素丁酰肼的活化丁酰肼诱导双链DNA断裂，随后诱导细胞周期停止和凋亡细胞死亡。 适应证和用途 BESPONSA是一种指向CD22抗体-药物结合物(ADC)适用为有复发或难治性B-细胞前体急性淋巴原始细胞性白血病(ALL)成年的治疗。 剂量和给药方法 ●在所有输注前用一种皮质激素，解热药，和抗组织胺预先给药。 ● 对疗程1和随后疗程给药方案，依赖于对治疗反应被显示如下。对给药细节见完整处方资料。 ●对冻干粉的重建和制备和重建药物的给药指导见完整处方资料。 剂型和规格 注射用：0.9mg冻干粉在单次-剂量小瓶为重建和进一步稀释。 注射用：1mg冻干粉-剂量小瓶 禁忌证 无。 警告和注意事项 ●骨髓抑制：监视完全血细胞计数；对感染的体征和症状；出血；或治疗期间骨髓抑制其他效应；适当地处理。 ●输注相关反应：输注结束期间和后至少监视输注相关反应。 ●QT间期延长：在基线和监视治疗期间得到心电图(ECGs)和电解质。当用同时药物已知延长QT间期监视更频。 ●胚胎-胎儿毒性：可能致胎儿危害。忠告有生殖潜能女性对胎儿潜在风险和使用有效避孕。 不良反应 最常见(≥ 20%)不良反应是血小板减少，中性细胞减少，感染，贫血，白细胞减少，疲乏，出血，发热，恶心，头痛，发热性中性细胞减少，转氨酶增加，腹痛，ɣ-谷氨酸转氨酶增加，和高胆固醇血症。 在特殊人群中使用 哺乳：建议不哺乳喂养. BESPONSA 1mg powder for concentrate for solution for infusion Pfizer Limited contact details Active ingredient inotuzumab ozogamicin Legal Category POM: Prescription only medicine 1. Name of the medicinal product BESPONSA 1 mg powder for concentrate for solution for infusion 2. Qualitative and quantitative composition Each vial contains 1 mg inotuzumab ozogamicin. After reconstitution (see section 6.6), 1 mL of solution contains 0.25 mg inotuzumab ozogamicin. Inotuzumab ozogamicin is an antibody-drug conjugate (ADC) composed of a recombinant humanised IgG4 kappa CD22-directed monoclonal antibody (produced in Chinese hamster ovary cells by recombinant DNA technology) that is covalently linked to N-acetyl-gamma-calicheamicin dimethylhydrazide. For the full list of excipients, see section 6.1. 3. Pharmaceutical form Powder for concentrate for solution for infusion. White to off-white, lyophilised cake or powder. 4. Clinical particulars 4.1 Therapeutic indications BESPONSA is indicated as monotherapy for the treatment of adults with relapsed or refractory CD22-positive B cell precursor acute lymphoblastic leukaemia (ALL). Adult patients with Philadelphia chromosome positive (Ph+) relapsed or refractory B cell precursor ALL should have failed treatment with at least 1 tyrosine kinase inhibitor (TKI). 4.2 Posology and method of administration BESPONSA should be administered under the supervision of a physician experienced in the use of cancer therapy and in an environment where full resuscitation facilities are immediately available. When considering the use of BESPONSA as a treatment for relapsed or refractory B cell ALL, baseline CD22 positivity of > 0% using a validated and sensitive assay is required prior to initiating treatment (see section 5.1). For patients with circulating lymphoblasts, cytoreduction with a combination of hydroxyurea, steroids, and/or vincristine to a peripheral blast count ≤ 10,000/mm3 is recommended prior to the first dose. Pre-medication with a corticosteroid, antipyretic, and antihistamine is recommended prior to dosing (see section 4.4). For patients with a high tumour burden, pre-medication to reduce uric acid levels and hydration is recommended prior to dosing (see section 4.4). Patients should be observed during, and for at least 1 hour after the end of infusion for symptoms of infusion related reactions (see section 4.4). Posology BESPONSA should be administered in 3- to 4-week cycles. For patients proceeding to haematopoietic stem cell transplant (HSCT), the recommended duration of treatment is 2 cycles. A third cycle may be considered for those patients who do not achieve a complete remission (CR) or complete remission with incomplete haematological recovery (CRi) and minimal residual disease (MRD) negativity after 2 cycles (see section 4.4). For patients not proceeding to HSCT, additional cycles of treatment, up to a maximum of 6 cycles, may be administered. Patients who do not achieve a CR/CRi within 3 cycles should discontinue treatment. Table 1 shows the recommended dosing regimens. For the first cycle, the recommended total dose of BESPONSA for all patients is 1.8 mg/m2 per cycle, given as 3 divided doses on Days 1 (0.8 mg/m2), 8 (0.5 mg/m2), and 15 (0.5 mg/m2). Cycle 1 is 3 weeks in duration, but may be extended to 4 weeks if the patient achieves a CR or CRi, and/or to allow recovery from toxicity. For subsequent cycles, the recommended total dose of BESPONSA is 1.5 mg/m2 per cycle given as 3 divided doses on Days 1 (0.5 mg/m2), 8 (0.5 mg/m2), and 15 (0.5 mg/m2) for patients who achieve a CR/CRi or 1.8 mg/m2 per cycle given as 3 divided doses on Days 1 (0.8 mg/m2), 8 (0.5 mg/m2), and 15 (0.5 mg/m2) for patients who do not achieve a CR/CRi. Subsequent cycles are 4 weeks in duration. Table 1. Dosing regimen for Cycle 1 and subsequent cycles depending on response to treatment Abbreviations: ANC=absolute neutrophil counts; CR=complete remission; CRi=complete remission with incomplete haematological recovery. a+/- 2 days (maintain minimum of 6 days between doses). b For patients who achieve a CR/CRi, and/or to allow for recovery from toxicity, the cycle length may be extended up to 28 days (i.e. 7-day treatment-free interval starting on Day 21). c CR is defined as < 5% blasts in the bone marrow and the absence of peripheral blood leukaemic blasts, full recovery of peripheral blood counts (platelets ≥ 100 × 109/L and ANC≥1 ×109/L) and resolution of any extramedullary disease. d CRi is defined as < 5% blasts in the bone marrow and the absence of peripheral blood leukaemic blasts, incomplete recovery of peripheral blood counts (platelets < 100 × 109/L and/or ANC <1×109/L) and resolution of any extramedullary disease. e 7-day treatment-free interval starting on Day 21. Dose modifications Dose modification of BESPONSA may be required based on individual safety and tolerability (see section 4.4). Management of some adverse drug reactions may require dosing interruptions and/or dose reductions, or permanent discontinuation of BESPONSA (see sections 4.4 and 4.8). If the dose is reduced due to BESPONSA-related toxicity, the dose should not be re-escalated. Table 2 and Table 3 show the dose modification guidelines for haematological and non-haematological toxicities, respectively. BESPONSA doses within a treatment cycle (i.e. Days 8 and/or 15) do not need to be interrupted due to neutropenia or thrombocytopenia, but dosing interruptions within a cycle are recommended for non-haematological toxicities. Table 2. Dose modifications for haematological toxicities at the start of a treatment cycle (Day 1) Abbreviation: ANC=absolute neutrophil count. a Platelet count used for dosing must be independent of blood transfusion. Table 3. Dose modifications for non-haematological toxicities at any time during treatment Abbreviations: ALT=alanine aminotransferase; AST=aspartate aminotransferase; ULN=upper limit of normal; VOD/SOS=venoocclusive disease/sinusoidal obstruction syndrome. a Severity grade according to National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE) version 3.0. Table 4 shows the dose modification guidelines depending on the duration of dosing interruptions due to toxicity. Table 4. Dose modifications depending on duration of dosing interruption due to toxicity Special populations Elderly No adjustment to the starting dose is required based on age (see section 5.2). Hepatic impairment No adjustment to the starting dose is required in patients with hepatic impairment defined by total bilirubin ≤ 1.5 × upper limit of normal (ULN) and aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ≤ 2.5 × ULN (see section 5.2). There is limited safety information available in patients with total bilirubin > 1.5 × ULN and AST/ALT > 2.5 × ULN prior to dosing. Interrupt dosing until recovery of total bilirubin to ≤ 1.5 × ULN and AST/ALT to ≤ 2.5 × ULN prior to each dose unless due to Gilbert's syndrome or haemolysis. Permanently discontinue treatment if total bilirubin does not recover to ≤ 1.5 × ULN or AST/ALT does not recover to ≤ 2.5 × ULN (see Table 3 and section 4.4). Renal impairment No adjustment to the starting dose is required in patients with mild, moderate, or severe renal impairment (creatinine clearance [CLcr] 60-89 mL/min, 30-59 mL/min, or 15-29 mL/min, respectively) (see section 5.2). The safety and efficacy of BESPONSA have not been studied in patients with end-stage renal disease. Paediatric population The safety and efficacy of BESPONSA in children aged 0 to <18 years have not been established. No data are available. Method of administration BESPONSA is for intravenous use. The infusion must be administered over 1 hour. BESPONSA should not be administered as an intravenous push or bolus. BESPONSA must be reconstituted and diluted before administration. For instructions on reconstitution and dilution of BESPONSA before administration, see section 6.6. 4.3 Contraindications - Hypersensitivity to the active substance or to any of the excipients listed in section 6.1. - Patients who have experienced prior confirmed severe or ongoing venoocclusive liver disease/sinusoidal obstruction syndrome (VOD/SOS). - Patients with serious ongoing hepatic disease (e.g., cirrhosis, nodular regenerative hyperplasia, active hepatitis). 4.4 Special warnings and precautions for use Traceability In order to improve traceability of biological medicinal products, the trade name and the batch number of the administered product should be clearly recorded in the patient file. Hepatotoxicity, including venoocclusive liver disease/sinusoidal obstruction syndrome (VOD/SOS) Hepatotoxicity, including severe, life-threatening, and sometimes fatal hepatic VOD/SOS, was reported in patients with relapsed or refractory ALL receiving BESPONSA (see section 4.8). BESPONSA significantly increased the risk of VOD/SOS above that of standard chemotherapy regimens in this patient population. This risk was most marked in patients who underwent subsequent HSCT. In the following subgroups, the reported frequency of VOD/SOS post-HSCT was ≥ 50%: - Patients who received a HSCT conditioning regimen containing 2 alkylating agents; - Patients aged ≥ 65 years; and - Patients with a serum bilirubin ≥ ULN prior to HSCT. The use of HSCT conditioning regimens containing 2 alkylating agents should be avoided. The benefit/risk should be carefully considered before administering BESPONSA to patients in whom the future use of HSCT conditioning regimens containing 2 alkylating agents is likely unavoidable. In patients in whom the serum bilirubin is ≥ ULN prior to HSCT, HSCT post BESPONSA treatment should only be undertaken after careful consideration of the benefit/risk. If these patients do proceed to HSCT, signs and symptoms of VOD/SOS should be monitored closely (see section 4.2). Other patient factors that appear to be associated with an increased risk of VOD/SOS after HSCT include a prior HSCT, age ≥ 55 years, a history of liver disease and/or hepatitis before treatment, later salvage lines, and a greater number of treatment cycles. Careful consideration is required before administering BESPONSA to patients who have had a prior HSCT. No patients with relapsed or refractory ALL who were treated with BESPONSA in clinical trials had undergone HSCT within the previous 4 months. Patients with a history of liver disease should be carefully evaluated (e.g., ultrasound scan, viral hepatitis testing) prior to treatment with BESPONSA to exclude serious ongoing hepatic disease (see section 4.3). For patients proceeding to HSCT, the recommended duration of treatment is 2 cycles, with a maximum of 3 cycles, to reduce the risk of VOD/ SOS (see section 4.2). Signs and symptoms of VOD/SOS should be monitored closely in all patients, especially post HSCT. Signs may include elevations in total bilirubin, hepatomegaly (which may be painful), rapid weight gain, and ascites. Monitoring only total bilirubin may not identify all patients at risk of VOD/SOS. In all patients, liver tests should be monitored, including, ALT, AST, total bilirubin, and alkaline phosphatase, prior to and following each dose of BESPONSA. For patients who develop abnormal liver tests, liver tests and clinical signs and symptoms of hepatotoxicity should be monitored more frequently. For patients who proceed to HSCT, liver tests should be monitored closely during the first month post-HSCT, then less frequently thereafter, according to standard medical practice. Elevation of liver tests may require dosing interruption, dose reduction, or permanent discontinuation of BESPONSA (see section 4.2). Treatment should be permanently discontinued if VOD/SOS occurs (see section 4.2). If severe VOD/SOS occurs, the patient should be treated according to standard medical practice. Myelosuppression/cytopenias In patients receiving inotuzumab ozogamicin, neutropenia, thrombocytopenia, anaemia, leukopenia, febrile neutropenia, lymphopenia, and pancytopenia, some of which were life-threatening, have been reported (see section 4.8). In patients receiving inotuzumab ozogamicin, complications associated with neutropenia and thrombocytopenia (including infections and bleeding/haemorrhagic events, respectively) were reported in some patients (see section 4.8). Complete blood counts should be monitored prior to each dose of BESPONSA and signs and symptoms of infection, bleeding/haemorrhage, and other effects of myelosuppression should be monitored during treatment. As appropriate, prophylactic anti-infectives should be administered and surveillance testing should be employed during and after treatment. Management of severe infection, bleeding/haemorrhage and other effects of myelosuppression, including severe neutropenia or thrombocytopenia, may require a dosing interruption, dose reduction, or discontinuation of treatment (see section 4.2). Infusion related reactions In patients receiving inotuzumab ozogamicin, infusion related reactions were reported (see section 4.8). Pre-medication with a corticosteroid, antipyretic, and antihistamine is recommended prior to dosing (see section 4.2). Patients should be monitored closely during and for at least 1 hour after the end of infusion for the potential onset of infusion related reactions, including symptoms such as hypotension, hot flush, or breathing problems. If an infusion related reaction occurs, the infusion should be interrupted and appropriate medical management should be instituted. Depending on the severity of the infusion related reaction, discontinuation of the infusion or administration of steroids and antihistamines should be considered (see section 4.2). For severe or life-threatening infusion reactions, treatment should be permanently discontinued (see section 4.2). Tumour lysis syndrome (TLS) In patients receiving inotuzumab ozogamicin, TLS, which may be life-threatening or fatal, was reported (see section 4.8). Pre-medication to reduce uric acid levels and hydration is recommended prior to dosing for patients with a high tumour burden (see section 4.2). Patients should be monitored for signs and symptoms of TLS and treated according to standard medical practice. QT interval prolongation In patients receiving inotuzumab ozogamicin, QT interval prolongation was observed (see sections 4.8 and 5.2). BESPONSA should be administered with caution in patients who have a history of, or predisposition to QT interval prolongation, who are taking medicinal products that are known to prolong QT interval (see section 4.5) and in patients with electrolyte disturbances. ECG and electrolytes should be obtained prior to the start of treatment and periodically monitored during treatment (see sections 4.8 and 5.2). Increased amylase and lipase In patients receiving inotuzumab ozogamicin, increases in amylase and lipase have been reported (see section 4.8). Patients should be monitored for increases in amylase and lipase. Potential hepatobiliary disease should be evaluated and treated according to standard medical practice. Immunisations The safety of immunisation with live viral vaccines during or following BESPONSA therapy has not been studied. Vaccination with live viral vaccines is not recommended for at least 2 weeks prior to the start of BESPONSA treatment, during treatment, and until recovery of B lymphocytes following the last treatment cycle. 4.5 Interaction with other medicinal products and other forms of interaction No formal clinical drug interaction studies have been performed (see section 5.2). Based on in vitro data, coadministration of inotuzumab ozogamicin with inhibitors or inducers of cytochrome P450 (CYP) or uridine diphosphate-glucuronosyltransferase (UGT) drug metabolising enzymes are unlikely to alter exposure to N-acetyl-gamma-calicheamicin dimethylhydrazide. In addition, inotuzumab ozogamicin and N-acetyl-gamma-calicheamicin dimethylhydrazide are unlikely to alter the exposure of substrates of CYP enzymes, and N-acetyl-gamma-calicheamicin dimethylhydrazide is unlikely to alter the exposure of substrates of UGT enzymes or major drug transporters. In patients receiving inotuzumab ozogamicin, prolonged QT interval was observed (see section 4.4). Therefore, the concomitant use of inotuzumab ozogamicin with medicinal products known to prolong QT interval or to induce Torsades de Pointes should be carefully considered. The QT interval should be monitored in case of combinations of such medicinal products (see sections 4.4, 4.8, and 5.2). 4.6 Fertility, pregnancy and lactation Women of childbearing potential/Contraception in males and females Women of childbearing potential should avoid becoming pregnant while receiving BESPONSA. Women should use effective contraception during treatment with BESPONSA and for at least 8 months after the last dose. Men with female partners of childbearing potential should use effective contraception during treatment with BESPONSA and for at least 5 months after the last dose. Pregnancy There are no data in pregnant women using inotuzumab ozogamicin. Based on non-clinical safety findings, inotuzumab ozogamicin can cause embryo-foetal harm when administered to a pregnant woman. Studies in animals have shown reproductive toxicity (see section 5.3). BESPONSA must not be used during pregnancy unless the potential benefit to the mother outweighs the potential risks to the foetus. Pregnant women, or patients becoming pregnant while receiving inotuzumab ozogamicin, or treated male patients as partners of pregnant women, must be apprised of the potential hazard to the foetus. Breast-feeding There are no data on the presence of inotuzumab ozogamicin or its metabolites in human milk, the effects on the breast-fed child, or the effects on milk production. Because of the potential for adverse reactions in breast-fed children, women must not breast-feed during treatment with BESPONSA and for at least 2 months after the final dose (see section 5.3). Fertility Based on non-clinical findings, male and female fertility may be compromised by treatment with inotuzumab ozogamicin (see section 5.3). There is no information on fertility in patients. Both men and women must seek advice for fertility preservation before treatment. 4.7 Effects on ability to drive and use machines BESPONSA has moderate influence on the ability to drive and use machines. Patients may experience fatigue during treatment with BESPONSA (see section 4.8). Therefore, caution is recommended when driving or operating machines. 4.8 Undesirable effects Summary of the safety profile The most common (≥ 20%) adverse reactions were thrombocytopenia (51%), neutropenia (49%), infection (48%), anaemia (36%), leukopenia (35%), fatigue (35%), haemorrhage (33%), pyrexia (32%), nausea (31%), headache (28%), febrile neutropenia (26%), increased transaminases (26%), abdominal pain (23%), increased gamma-glutamyltransferase (21%), and hyperbilirubinaemia (21%). In patients who received BESPONSA, the most common (≥ 2%) serious adverse reactions were infection (23%), febrile neutropenia (11%), haemorrhage (5%), abdominal pain (3%), pyrexia (3%), VOD/SOS (2%), and fatigue (2%). Tabulated list of adverse reactions Table 5 shows the adverse reactions reported in patients with relapsed or refractory ALL who received BESPONSA. The adverse reactions are presented by system organ class (SOC) and frequency categories, defined using the following convention: very common (≥ 1/10), common (≥ 1/100 to < 1/10), uncommon (≥ 1/1,000 to < 1/100), rare (≥ 1/10,000 to < 1/1,000), very rare (< 1/10,000), not known (cannot be estimated from the available data). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness. Table 5. Adverse reactions reported in patients with relapsed or refractory B-cell precursor ALL who received BESPONSA Adverse reactions included treatment-emergent, all-causality events that commenced on, or after Cycle 1 Day 1 within 42 days after the last dose of BESPONSA, but prior to the start of a new anticancer treatment (including HSCT). Preferred terms were retrieved by applying the Medical Dictionary for Regulatory Activities (MedDRA) version 18.1. Abbreviations: ALL=acute lymphoblastic leukaemia; ECG=electrocardiogram; GGT=gamma-glutamyltransferase; HSCT=haematopoietic stem cell transplant. a Infection also includes other types of infection (11%). Note: patients may have had > 1 type of infection. b Pancytopenia includes the following reported preferred terms: Bone marrow failure, Febrile bone marrow aplasia, and Pancytopenia. c Haemorrhage also includes other types of haemorrhage (16%). Note: patients may have had > 1 type of haemorrhage. d VOD includes 1 additional patient with Venoocclusive liver disease that occurred at Day 56 with no intervening HSCT. VOD/SOS was also reported in 17 patients after a subsequent HSCT. Description of selected adverse reactions Hepatotoxicity, including venoocclusive liver disease/sinusoidal obstruction syndrome (VOD/SOS) In the pivotal clinical study (N=164), VOD/SOS was reported in 22 (13%) patients including 5 (3%) patients during study therapy or in follow-up without an intervening HSCT. Among the 77 patients who proceeded to a subsequent HSCT (6 of whom received additional salvage therapy after treatment with BESPONSA before proceeding to HSCT), VOD/SOS was reported in 17 (22%) patients. Five of the 17 VOD/SOS events that occurred post-HSCT were fatal. VOD/SOS was reported up to 56 days after the last dose of inotuzumab ozogamicin without an intervening HSCT. The median time from HSCT to onset of VOD/SOS was 15 days (range: 3-57 days). Of the 5 patients who experienced VOD/SOS during treatment with inotuzumab ozogamicin but without an intervening HSCT, 2 patients had also received an HSCT before BESPONSA treatment. Among patients who proceeded to HSCT after BESPONSA treatment, VOD/SOS was reported in 5/11 (46%) patients who received an HSCT both prior to and after BESPONSA treatment and 12/66 (18%) patients who only received an HSCT after BESPONSA treatment. Regarding other risk factors, VOD/ SOS was reported in 6/11 (55%) patients who received a HSCT conditioning regimen containing 2 alkylating agents and 8/52 (15%) patients who received a HSCT conditioning regimen containing 1 alkylating agent, 7/17 (41%) patients who were ≥ 55 years old and 10/60 (17%) patients who were < 55 years old, and 7/12 (58%) patients with a serum bilirubin ≥ ULN prior to HSCT and in 10/65 (15%) patients with a serum bilirubin < ULN prior to HSCT. In the pivotal study (N=164), hyperbilirubinaemia and increased transaminases were reported in 35 (21%) and 43 (26%) patients, respectively. Grade ≥ 3 hyperbilirubinaemia and increased transaminases were reported in 9 (6%) and 11 (7%) patients, respectively. The median time to onset of hyperbilirubinaemia and increased transaminases was 73 days and 29 days, respectively. For clinical management of hepatotoxicity, including VOD/SOS, see section 4.4. Myelosuppression/cytopenias In the pivotal study (N=164), thrombocytopenia and neutropenia were reported in 83 (51%) and 81 (49%) patients, respectively. Grade 3 thrombocytopenia and neutropenia were reported in 23 (14%) and 33 (20%) patients, respectively. Grade 4 thrombocytopenia and neutropenia were reported in 46 (28%) and 45 (27%) patients, respectively. Febrile neutropenia, which may be life-threatening, was reported in 43 (26%) patients. For clinical management of myelosuppression/cytopenias, see section 4.4. Infections In the pivotal study (N=164), infections, including serious infections, some of which were life-threatening or fatal, were reported in 79 (48%) patients. The frequencies of specific infections were: sepsis and bacteraemia (16%), lower respiratory tract infection (12%), upper respiratory tract infection (12%), fungal infection (9%), viral infection (8%), gastrointestinal infection (4%), skin infection (4%), and bacterial infection (1%). Fatal infections, including pneumonia, neutropenic sepsis, sepsis, septic shock, and pseudomonal sepsis, were reported in 8 (5%) patients. For clinical management of infections, see section 4.4. Bleeding/haemorrhage In the pivotal clinical study (N=164), bleeding/haemorrhagic events, mostly mild in severity, were reported in 54/ (33%) patients. The frequencies of specific bleeding/haemorrhagic events were: epistaxis (15%), upper gastrointestinal haemorrhage (5%), lower gastrointestinal haemorrhage (4%), and central nervous system (CNS) haemorrhage (1%). Grade 3/4 bleeding/haemorrhagic events were reported in 8/164 (5%) patients. One Grade 5 bleeding/haemorrhagic event (intra-abdominal haemorrhage) was reported. For clinical management of bleeding/haemorrhagic events, see section 4.4. Infusion related reactions In the pivotal study (N=164), infusion related reactions were reported in 17 (10%) patients. All events were Grade ≤ 2 in severity. Infusion related reactions generally occurred in Cycle 1 and shortly after the end of the inotuzumab ozogamicin infusion and resolved spontaneously or with medical management. For clinical management of infusion related reactions, see section 4.4. Tumour lysis syndrome (TLS) In the pivotal study (N=164), TLS, which may be life-threatening or fatal, was reported in 4/164 (2%) patients. Grade 3/4 TLS was reported in 3 (2%) patients. TLS occurred shortly after the end of the inotuzumab ozogamicin infusion and resolved with medical management. For clinical management of TLS, see section 4.4. QT interval prolongation In the pivotal study (N=164), increases in QT interval corrected for heart rate using the Fridericia formula (QTcF) ≥ 60 msec from baseline were measured in 4/162 (3%) patients. No patients had QTcF values > 500 msec. Grade 2 QT prolongation was reported in 2/164 (1%) patients. No Grade ≥ 3 QT prolongation or events of Torsades de Pointes were reported. For periodic monitoring of ECG and electrolyte levels, see section 4.4. Increased amylase and lipase In the pivotal study (N=164), increases in amylase and lipase were reported in 8 (5%) and 15 (9%) patients, respectively. Increases in Grade ≥ 3 amylase and lipase were reported in 3 (2%) and 7 (4%) patients, respectively. For periodic monitoring of increased amylase and lipase, see section 4.4. Immunogenicity In clinical studies of BESPONSA in patients with relapsed or refractory ALL, 7/236 (3%) patients tested positive for anti-inotuzumab ozogamicin antibodies. No patients tested positive for neutralising anti-inotuzumab ozogamicin antibodies. In patients who tested positive for anti-inotuzumab ozogamicin antibodies, no effect on clearance of BESPONSA was detected based on population-pharmacokinetic analysis. The number of patients was too small to assess the impact of anti-inotuzumab ozogamicin antibodies on efficacy and safety. 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. United Kingdom Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at www.mhra.gov.uk/yellowcard. Ireland Healthcare professionals are asked to report any suspected adverse reactions via HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: medsafety@hpra.ie. 4.9 Overdose In clinical studies in patients with relapsed or refractory ALL, the maximum single and multiple doses of inotuzumab ozogamicin were 0.8 mg/m2 and 1.8 mg/m2, respectively, per cycle, given as 3 divided doses on Days 1 (0.8 mg/m2), 8 (0.5 mg/m2), and 15 (0.5 mg/m2) (see section 4.2). Overdoses may result in adverse reactions that are consistent with the reactions observed at the recommended therapeutic dose (see section 4.8). In the event of an overdose, the infusion should be temporarily interrupted and patients should be monitored for liver and haematological toxicities (see section 4.2). Re-initiation of BESPONSA at the correct therapeutic dose should be considered when all toxicities have resolved. 5. Pharmacological properties 5.1 Pharmacodynamic properties Pharmacotherapeutic group: Antineoplastic agents, other Antineoplastic agent, monoclonal antibodies, ATC code: L01XC26. Mechanism of action Inotuzumab ozogamicin is an ADC composed of a CD22-directed monoclonal antibody that is covalently linked to N-acetyl-gamma-calicheamicin dimethylhydrazide. Inotuzumab is a humanised immunoglobulin class G subtype 4 (IgG4) antibody that specifically recognises human CD22. The small molecule, N-acetyl-gamma-calicheamicin, is a cytotoxic product. N-acetyl-gamma-calicheamicin is covalently attached to the antibody via an acid-cleavable linker. Nonclinical data suggest that the anticancer activity of BESPONSA is due to the binding of the ADC to CD22-expressing tumour cells, followed by internalisation of the ADC-CD22 complex, and the intracellular release of N-acetyl-gamma-calicheamicin dimethylhydrazide via hydrolytic cleavage of the linker. Activation of N-acetyl-gamma-calicheamicin dimethylhydrazide induces double-stranded DNA breaks, subsequently inducing cell cycle arrest and apoptotic cell death. Clinical efficacy and safety Patients with relapsed or refractory ALL who have received 1 or 2 prior treatment regimens for ALL - Study 1 The safety and efficacy of BESPONSA in patients with relapsed or refractory CD22-positive ALL were evaluated in an open-label, international, multicentre, Phase 3 study (Study 1) in which patients were randomised to receive BESPONSA (N=164 [164 received treatment) or Investigator's choice of chemotherapy (N=162 [143 received treatment]), specifically fludarabine plus cytarabine plus granulocyte colony-stimulating factor (FLAG) (N=102 [93 received treatment]), mitoxantrone/cytarabine (MXN/Ara-C) (N=38 [33 received treatment]), or high dose cytarabine (HIDAC) (N=22 [17 received treatment]). Eligible patients were ≥ 18 years of age with Philadelphia chromosome negative (Ph-) or Ph+ relapsed or refractory B-cell CD22-positive precursor ALL. CD22 expression was assessed using flow cytometry based on bone marrow aspirate. In patients with an inadequate bone marrow aspirate sample, a peripheral blood sample was tested. Alternatively, CD22 expression was assessed using immunohistochemistry in patients with an inadequate bone marrow aspirate and insufficient circulating blasts. In the clinical study, the sensitivity of some local tests was lower than the central laboratory test. Therefore only validated tests with demonstrated high sensitivity should be used. All patients were required to have ≥ 5% bone marrow blasts and to have received 1 or 2 prior induction chemotherapy regimens for ALL. Patients with Ph+ B-cell precursor ALL were required to have failed treatment with at least 1 second or third generation TKI and standard chemotherapy. Table 1 (see section 4.2) shows the dosing regimen used to treat patients. The co-primary endpoints were CR/CRi, assessed by a blinded independent endpoint adjudication committee (EAC), and overall survival (OS). The secondary endpoints included MRD negativity (see Table 1 in section 4.2), duration of remission (DoR), HSCT rate, and progression-free survival (PFS). The primary analysis of CR/CRi and MRD negativity was conducted in the initial 218 randomised patients and the analysis of OS, PFS, DoR, and HSCT rate was conducted in all 326 randomised patients. Among all 326 randomised patients (ITT population), 215 (66%) patients had received 1 prior treatment regimen and 108 (33%) patients had received 2 prior treatment regimens for ALL. The median age was 47 years (range: 18-79 years), 206 (63%) patients had a duration of first remission < 12 months, and 55 (17%) patients had undergone an HSCT prior to receiving BESPONSA or Investigator's choice of chemotherapy. A total of 276 (85%) patients had Ph- ALL. Of the 49 (15%) patients with Ph+ ALL, 4 patients did not receive a prior TKI, 28 patients received 1 prior TKI, and 17 patients received 2 prior TKIs. Dasatinib was the most commonly received TKI (42 patients) followed by imatinib (24 patients). Baseline characteristics were similar in the initial 218 patients randomised. Of the 326 patients (ITT population), 253 patients had samples that were evaluable for CD22 testing by both local and central laboratory. By central and local laboratory tests, 231/253 (91.3%) patients and 130/253 (51.4%) patients, respectively, had ≥ 70% CD22-positive leukaemic blasts at baseline. Table 6 shows the efficacy results from this study. Table 6. Study 1: Efficacy results in patients ≥ 18 years of age with relapsed or refractory B-cell precursor ALL who received 1 or 2 prior treatment regimens for ALL Abbreviations: ALL=acute lymphoblastic leukaemia; ANC=absolute neutrophil counts; Ara-C=cytarabine; CI=confidence interval; CR=complete remission; CRi=complete remission with incomplete haematological recovery; DoR=duration of remission; EAC=Endpoint Adjudication Committee; FLAG=fludarabine + cytarabine + granulocyte colony-stimulating factor; HIDAC=high dose cytarabine; HSCT=haematopoietic stem cell transplant; ITT=intent-to-treat; MRD=minimal residual disease; MXN=mitoxantrone; N/n=number of patients; OS=overall survival; PFS=progression-free survival. a CR, per EAC, was defined as < 5% blasts in the bone marrow and the absence of peripheral blood leukaemic blasts, full recovery of peripheral blood counts (platelets ≥ 100 × 109/L and ANC ≥ 1 × 109/L) and resolution of any extramedullary disease. b CRi, per EAC, was defined as < 5% blasts in the bone marrow and the absence of peripheral blood leukaemic blasts, partial recovery of peripheral blood counts (platelets < 100 × 109/L and/or ANC < 1 × 109/L) and resolution of any extramedullary disease. c MRD negativity was defined by flow cytometry as leukaemic cells comprising < 1 × 10-4 (< 0.01%) of bone marrow nucleated cells. d Rate was defined as number of patients who achieved MRD negativity divided by the total number of patients who achieved CR/CRi per EAC. e PFS was defined as the time from date of randomisation to earliest date of the following events: death, progressive disease (including objective progression, relapse from CR/CRi, treatment discontinuation due to global deterioration of health status), and start of new induction therapy or post-therapy HSCT without achieving CR/CRi. f In the standard definition of PFS, defined as the time from date of randomisation to earliest date of the following events: death, progressive disease (including objective progression and relapse from CR/CRi), the HR was 0.535 (2-sided p-value<0.0001) and median PFS was 5.6 months and 3.6 months in the BESPONSA and Investigator's choice of chemotherapy arm, respectively. g Duration of remission was defined as the time since first response of CRa or CRib per Investigator's assessment to the date of a PFS event or censoring date if no PFS event was documented. Analysis was based on the ITT population with patients without remission being given a duration of zero and considered an event. Among the initial 218 randomised patients, 64/88 (73%) and 21/88 (24%) of responding patients per EAC achieved a CR/CRi in Cycles 1 and 2, respectively, in the BESPONSA arm. No additional patients achieved CR/CRi after Cycle 3 in the BESPONSA arm. CR/CRi and MRD negativity findings in the initial 218 randomised patients were consistent with those seen in all 326 randomised patients. Among all 326 randomised patients, the survival probability at 24 months was 22.6% in the BESPONSA arm and 9.6% in the Investigator's choice of chemotherapy arm. A total of 77/164 (47.0%) patients in the BESPONSA arm and 33/162 (20.4%) patients in the Investigator's choice of chemotherapy arm had a follow-up HSCT. This included 71 and 18 patients in the BESPONSA and Investigator's choice of chemotherapy arm, respectively, who proceeded directly to HSCT. In those patients who proceeded directly to HSCT, there was a median gap of 4.9 weeks (range: 1-19 weeks) between the last dose of inotuzumab ozogamicin and HSCT. The OS improvement for BESPONSA versus Investigator's choice of chemotherapy was seen in patients who underwent HSCT. Although there was a higher frequency of early deaths post-HSCT (up to Day 100) in the BESPONSA arm, a late survival benefit was evident for BESPONSA. In patients who underwent a follow-up HSCT, the median OS was 11.9 months (95% CI: 8.6, 20.6) versus 16.7 months (95% CI: 14.6, 27.8) and the survival probability at month 24 was 38.9% (95% CI: 27.6, 50.0) versus 35.7% (95% CI: 16.3, 55.8) for BESPONSA versus Investigator's choice of chemotherapy, respectively. Based on exploratory analyses, patients with more favourable prognostic factors (duration of first remission ≥ 12 months, Salvage 1, age < 55 years, Ph-, no prior HSCT, ≥ 90% leukaemic blasts CD22-positive at baseline, no baseline peripheral blasts, and baseline haemoglobin ≥ 10 g/dL) had a better OS outcome. Patients with mixed-lineage leukaemia (MLL) gene rearrangements, including t(4;11), that generally have lower CD22 expression prior to treatment, had a worse OS outcome following treatment with BESPONSA or Investigator's choice of chemotherapy. For patient-reported outcomes, most functioning and symptom scores were in favour of BESPONSA compared to Investigator's choice of chemotherapy. For patient-reported outcomes measured using the European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30), BESPONSA resulted in significantly better estimated mean postbaseline scores (BESPONSA and Investigator's choice of chemotherapy, respectively) in role functioning (64.7 versus 53.4; p=0.0065), physical functioning (75.0 versus 68.1; p=0.0139), social functioning (68.1 versus 59.8; p=0.0336), and appetite loss (17.6 versus 26.3; p=0.0193) compared to Investigator's choice of chemotherapy. Although not reaching statistical significance, BESPONSA resulted in better estimated mean postbaseline scores (BESPONSA and Investigator's choice of chemotherapy, respectively) in global health status/Quality of Life (QoL) (62.1 versus 57.8; p=0.1572), cognitive functioning (85.3 versus 82.5; p=0.1904), dyspnoea (14.7 versus 19.4; p=0.1281), diarrhoea (5.9 versus 8.9; p=0.1534), fatigue (35.0 versus 39.4; p=0.1789), nausea and vomiting (8.7 versus 10.4; p=0.4578), financial difficulties (29.5 versus 32.0; p=0.4915), insomnia (25.4 versus 27.1; p=0.6207), and pain (21.3 versus 22.0; p=0.8428). Although not reaching statistical significance, BESPONSA resulted in worse estimated mean postbaseline scores (BESPONSA and Investigator's choice of chemotherapy, respectively) in emotional functioning (77.4 versus 79.6; p=0.3307) and constipation (12.1 versus 10.7; p=0.6249). For patient-reported outcomes measured using the EuroQoL 5 Dimension (EQ-5D) questionnaire, although not reaching statistical significance, BESPONSA resulted in better estimated mean postbaseline scores (BESPONSA and Investigator's choice of chemotherapy, respectively) for the EQ-5D index (0.80 versus 0.76; p=0.1710) and the EQ visual analogue scale (EQ-VAS) (67.1 versus 62.5; p=0.1172). Patients with relapsed or refractory ALL who have received 2 or more prior treatment regimens for ALL - Study 2 The safety and efficacy of BESPONSA were evaluated in a single-arm, open-label, multicentre Phase 1/2 study (Study 2). Eligible patients were ≥ 18 years of age with relapsed or refractory B-cell precursor ALL. Of 93 screened patients, 72 patients were assigned to study drug and treated with BESPONSA. The median age was 45 years (range 20-79); 76.4% were Salvage status ≥ 2; 31.9% had received a prior HSCT and 22.2% were Ph+. The most common reasons for treatment discontinuation were: disease progression/relapse (30 [41.7%)], resistant disease (4 [5.6%]); HSCT (18 [25.0%]), and adverse events (13 [18.1%]). In the Phase 1 portion of the study, 37 patients received BESPONSA at a total dose of 1.2 mg/m2 (n=3), 1.6 mg/m2 (n=12), or 1.8 mg/m2 (n=22). The recommended BESPONSA dose was determined to be 1.8 mg/m2/cycle administered at a dose of 0.8 mg/m2 on Day 1 and 0.5 mg/m2 on Days 8 and 15 of a 28-day cycle with a dose reduction upon achieving CR/CRi. In the Phase 2 portion of the study, patients had to have received at least 2 prior treatment regimens for ALL and patients with Ph+ B-cell ALL had to have failed treatment with at least 1 TKI. Of the 9 patients with Ph+ B-cell ALL, 1 patient had received 1 previous TKI and 1 patient had received no prior TKIs. Table 7 shows the efficacy results from this study. Table 7. Study 2: Efficacy results in patients ≥ 18 years of age with relapsed or refractory B-cell precursor ALL who received 2 or more prior treatment regimens for ALL Abbreviations: ALL=acute lymphoblastic leukaemia; ANC=absolute neutrophil counts; CI=confidence interval; CR=complete remission; CRi=complete remission with incomplete haematological recovery; DoR=duration of remission; HSCT=haematopoietic stem cell transplant; MRD=minimal residual disease; N/n=number of patients; OS=overall survival; PFS=progression-free survival. a, b, c, d, e, f For definition, see Table 6 (with the exception that CR/CRi was not per EAC for Study 2) In the Phase 2 portion of the study, 8/35 (22.9%) patients had a follow-up HSCT. Paediatric population The European Medicines Agency has deferred the obligation to submit the results of studies with BESPONSA in 1 or more subsets of the paediatric population for the treatment of relapsed or refractory ALL (see section 4.2 for information on paediatric use). 5.2 Pharmacokinetic properties In patients with relapsed or refractory ALL treated with inotuzumab ozogamicin at the recommended starting dose of 1.8 mg/m2/cycle (see section 4.2), steady-state exposure was achieved by Cycle 4. The mean (SD) maximum serum concentration (Cmax) of inotuzumab ozogamicin was 308 ng/mL (362). The mean (SD) simulated total area under the concentration-time curve (AUC) per cycle at steady state was 100 mcg•h/mL (32.9). Distribution In vitro, the binding of the N-acetyl-gamma-calicheamicin dimethylhydrazide to human plasma proteins is approximately 97%. In vitro, N-acetyl-gamma-calicheamicin dimethylhydrazide is a substrate of P-glycoprotein (P-gp). In humans, the total volume of distribution of inotuzumab ozogamicin was approximately 12 L. Biotransformation In vitro, N-acetyl-gamma-calicheamicin dimethylhydrazide was primarily metabolised via nonenzymatic reduction. In humans, serum N-acetyl-gamma-calicheamicin dimethylhydrazide levels were typically below the limit of quantitation (50 pg/mL). Elimination Inotuzumab ozogamicin pharmacokinetics were well characterised by a 2-compartment model with linear and time-dependent clearance components. In 234 patients with relapsed or refractory ALL, the clearance of inotuzumab ozogamicin at steady state was 0.0333 L/h, and the terminal elimination half-life (t½) at the end of Cycle 4 was approximately 12.3 days. Following administration of multiple doses, a 5.3 times accumulation of inotuzumab ozogamicin was observed between Cycles 1 and 4. Based on a population pharmacokinetic analysis in 765 patients, body surface area was found to significantly affect inotuzumab ozogamicin disposition. The dose of inotuzumab ozogamicin is administered based on body surface area (see section 4.2). Age, race, and gender Based on a population pharmacokinetic analysis, age, race, and gender did not significantly affect inotuzumab ozogamicin disposition. Hepatic impairment No formal pharmacokinetic studies of inotuzumab ozogamicin have been conducted in patients with hepatic impairment. Based on a population pharmacokinetic analysis in 765 patients, the clearance of inotuzumab ozogamicin in patients with hepatic impairment defined by National Cancer Institute Organ Dysfunction Working Group (NCI ODWG) category B1 (total bilirubin ≤ ULN and AST > ULN; n=133) or B2 (total bilirubin > 1.0-1.5 × ULN and AST any level; n=17) was similar to patients with normal hepatic function (total bilirubin/AST ≤ ULN; n=611) (see section 4.2). In 3 patients with hepatic impairment defined by NCI ODWG category C (total bilirubin > 1.5-3 × ULN and AST any level) and 1 patient with hepatic impairment defined by NCI ODWG category D (total bilirubin > 3 × ULN and AST any level), inotuzumab ozogamicin clearance did not appear to be reduced. Renal impairment No formal pharmacokinetic studies of inotuzumab ozogamicin have been conducted in patients with renal impairment. Based on population pharmacokinetic analysis in 765 patients, the clearance of inotuzumab ozogamicin in patients with mild renal impairment (CLcr 60-89 mL/min; n=237), moderate renal impairment (CLcr 30-59 mL/min; n=122), or severe renal impairment (CLcr 15-29 mL/min; n=4) was similar to patients with normal renal function (CLcr ≥ 90 mL/min; n=402) (see section 4.2). Inotuzumab ozogamicin has not been studied in patients with end-stage renal disease (see section 4.2). Cardiac electrophysiology Based on a pharmacokinetic exposure-response analysis in 250 patients with relapsed or refractory ALL or other haematological malignancies who received 1.8 mg/m2/cycle inotuzumab ozogamicin administered as 3 divided doses on Days 1 (0.8 mg/m2), 8 (0.5 mg/m2), and 15 (0.5 mg/m2) of a 21- to 28-day cycle or 1.8 mg/m2/cycle administered once every 4 weeks, respectively, the median QTcF increased by 2.53 milliseconds (msec) from baseline (97.5th percentile: 4.92 msec) at the average Cmax estimated for patients with relapsed or refractory ALL (371 ng/mL) and by 3.87 msec from baseline (97.5th percentile: 7.54 msec) at a 1.5 times higher average Cmax (569 ng/mL). In a randomised clinical study in patients with relapsed or refractory ALL (Study 1), increases in QTcF of ≥ 60 msec from baseline were measured in 4/162 (3%) patients in the inotuzumab ozogamicin arm and 3/124 (2%) in the Investigator's choice of chemotherapy arm. Increases in QTcF of > 500 msec were observed in none of the patients in the inotuzumab ozogamicin arm and 1/124 (1%) patients in the Investigator's choice of chemotherapy arm (see section 4.8). Mean (90% CI) maximum QTcF changes from baseline were 16.5 msec (14.3-18.7) in the inotuzumab ozogamicin arm and 10.8 msec (8.0-13.6) in the Investigator's choice of chemotherapy arm. Central tendency analysis of the QTcF interval changes from baseline showed that the highest upper bound of the 2-sided 90% CI for QTcF was 21.1 msec (observed at Cycle 4/Day 1/1 hour) in the inotuzumab ozogamicin arm and 21.2 msec (observed at Cycle 2/Day 1/1 hour) in the Investigator's choice of chemotherapy arm. 5.3 Preclinical safety data Repeat-dose toxicity In animals, the primary target organs included the liver, bone marrow and lymphoid organs with associated haematological changes, kidney, and nervous system. Other observed changes included male and female reproductive organ effects (see below) and preneoplastic and neoplastic liver lesions (see below). Most effects were reversible to partially reversible except for effects in the liver and nervous system. The relevance of the irreversible animal findings to humans is uncertain. Genotoxicity Inotuzumab ozogamicin was clastogenic in vivo in the bone marrow of male mice. This is consistent with the known induction of DNA breaks by calicheamicin and other enediyne antitumour antibiotics. Inotuzumab ozogamicin was not mutagenic in an in vitro bacterial reverse mutation (Ames) assay when tested up to the maximum feasible dose. Carcinogenicity Formal carcinogenicity studies have not been conducted with inotuzumab ozogamicin. In toxicity studies, rats developed oval cell hyperplasia, altered hepatocellular foci, and hepatocellular adenomas in the liver at approximately 0.3 times the human clinical exposure based on AUC. In 1 monkey, a focus of hepatocellular alteration was detected at approximately 3.1 times the human clinical exposure based on AUC at the end of the 26-week dosing period. The relevance of these animal findings to humans is uncertain. Reproductive toxicity Administration of inotuzumab ozogamicin to female rats at the maternally toxic dose (approximately 2.3 times the human clinical exposure based on AUC) prior to mating and during the first week of gestation resulted in embryo-foetal toxicity, including increased resorptions and decreased viable embryos. The maternally toxic dose (approximately 2.3 times the human clinical exposure based on AUC) also resulted in foetal growth retardation, including decreased foetal weights and delayed skeletal ossification. Slight foetal growth retardation in rats also occurred at approximately 0.4 times the human clinical exposure based on AUC (see section 4.6). Inotuzumab ozogamicin is considered to have the potential to impair reproductive function and fertility in men and women based on non-clinical findings (see section 4.6). In repeat dose toxicity studies in rats and monkeys, female reproductive findings included atrophy of ovaries, uterus, vagina, and mammary gland. The no observed adverse effect level (NOAEL) for the effects on female reproductive organs in rats and monkeys was approximately 2.2 and 3.1 times the human clinical exposure based on AUC, respectively. In repeat dose toxicity studies in rats, male reproductive findings included testicular degeneration, associated with hypospermia, and prostatic and seminal vesicle atrophy. The NOAEL was not identified for the effects on male reproductive organs, which were observed at approximately 0.3 times the human clinical exposure based on AUC. 6. Pharmaceutical particulars 6.1 List of excipients Sucrose Polysorbate 80 Sodium chloride Tromethamine 6.2 Incompatibilities In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products except those mentioned in section 6.6. 6.3 Shelf life Unopened vial 2 years Reconstituted solution BESPONSA contains no bacteriostatic preservatives. The reconstituted solution must be used immediately. If the reconstituted solution cannot be used immediately, it may be stored for up to 4 hours in a refrigerator (2 °C-8 °C). Protect from light and do not freeze. Diluted solution The diluted solution must be used immediately or stored at room temperature (20 °C-25 °C) or in a refrigerator (2 °C-8 °C). The maximum time from reconstitution through administration should be ≤ 8 hours, with ≤ 4 hours between reconstitution and dilution. Protect from light and do not freeze. 6.4 Special precautions for storage Store in a refrigerator (2 °C-8 °C). Do not freeze. Store in the original carton in order to protect from light. For storage conditions after reconstitution and dilution, see section 6.3. 6.5 Nature and contents of container Type I amber glass vial with chlorobutyl rubber stopper and crimp seal with flip off cap containing 1 mg of powder. Each carton contains 1 vial. 6.6 Special precautions for disposal and other handling Instructions for reconstitution, dilution, and administration Use appropriate aseptic technique for the reconstitution and dilution procedures. Inotuzumab ozogamicin is light sensitive and should be protected from ultraviolet light during reconstitution, dilution, and administration. The maximum time from reconstitution through the end of administration should be ≤ 8 hours, with ≤ 4 hours between reconstitution and dilution. Reconstitution • Calculate the dose (mg) and number of vials of BESPONSA required. • Reconstitute each 1 mg vial with 4 mL of water for injection, to obtain a single-use solution of 0.25 mg/mL of BESPONSA. • Gently swirl the vial to aid dissolution. Do not shake. • Inspect the reconstituted solution for particulates and discolouration. The reconstituted solution must be clear to slightly cloudy, colourless, and essentially free of visible foreign matter. If particles or discolouration are observed, do not use. • BESPONSA contains no bacteriostatic preservatives. The reconstituted solution must be used immediately. If the reconstituted solution cannot be used immediately, it may be stored in a refrigerator (2 °C-8 °C) for up to 4 hours. Protect from light and do not freeze. Dilution • Calculate the required volume of the reconstituted solution needed to obtain the appropriate dose according to patient body surface area. Withdraw this amount from the vial(s) using a syringe. Protect from light. Discard any unused reconstituted solution left in the vial. • Add the reconstituted solution to an infusion container with sodium chloride 9 mg/mL (0.9%) solution for injection, to a total nominal volume of 50 mL. Protect from light. An infusion container made of polyvinyl chloride (PVC) (di(2-ethylhexyl)phthalate [DEHP]- or non-DEHP-containing), polyolefin (polypropylene and/or polyethylene), or ethylene vinyl acetate (EVA) is recommended. • Gently invert the infusion container to mix the diluted solution. Do not shake. • The diluted solution must be used immediately, stored at room temperature (20 °C-25 °C), or in a refrigerator (2 °C-8 °C). The maximum time from reconstitution through the end of administration should be ≤ 8 hours, with ≤ 4 hours between reconstitution and dilution. Protect from light and do not freeze. Administration • If the diluted solution is stored in a refrigerator (2 °C-8 °C), it must be allowed to equilibrate at room temperature (20 °C-25 °C) for approximately 1 hour prior to administration. • Filtration of the diluted solution is not required. However, if the diluted solution is filtered, polyethersulphone (PES)-, polyvinylidene fluoride (PVDF)-, or hydrophilic polysulphone (HPS)-based filters are recommended. Do not use filters made of nylon or mixed cellulose ester (MCE). • Infuse the diluted solution for 1 hour at a rate of 50 mL/h at room temperature (20 °C-25 °C). Protect from light. Infusion lines made of PVC (DEHP or non-DEHP-containing), polyolefin (polypropylene and/or polyethylene), or polybutadiene are recommended. Do not mix BESPONSA or administer as an infusion with other medicinal products. Table 8 shows the storage times and conditions for reconstitution, dilution, and administration of BESPONSA. Table 8. Storage times and conditions for reconstituted and diluted BESPONSA solution a With ≤4 hours between reconstitution and dilution. Disposal BESPONSA is for single use only. Any unused medicinal product or waste material should be disposed of in accordance with local requirements. 7. Marketing authorisation holder Pfizer Limited Ramsgate Road Sandwich, Kent CT13 9NJ United Kingdom 8. Marketing authorisation number(s) EU/1/17/1200/001 9. Date of first authorisation/renewal of the authorisation Date of first authorisation: 29 June 2017 10. Date of revision of the text 12/2017 Detailed information on this medicinal product is available on the website of the European Medicines Agency http://www.ema.europa.eu. https://www.medicines.org.uk/emc/product/650/smpc