GEMCITABINE injection, solution

GEMCITABINE by

Drug Labeling and Warnings

GEMCITABINE by is a Prescription medication manufactured, distributed, or labeled by Accord Healthcare Inc., Intas Pharmaceuticals Limited. Drug facts, warnings, and ingredients follow.

Drug Details [pdf]

  • 1 INDICATIONS AND USAGE

    1.1 Ovarian Cancer

    Gemcitabine Injection in combination with carboplatin is indicated for the treatment of patients with advanced ovarian cancer that has relapsed at least 6 months after completion of platinum-based therapy.

    1.2 Breast Cancer

    Gemcitabine Injection in combination with paclitaxel is indicated for the first-line treatment of patients with metastatic breast cancer after failure of prior anthracycline-containing adjuvant chemotherapy, unless anthracyclines were clinically contraindicated.

    1.3 Non-Small Cell Lung Cancer

    Gemcitabine Injection in combination with cisplatin is indicated for the first-line treatment of patients with inoperable, locally advanced (Stage IIIA or IIIB) or metastatic (Stage IV) non-small cell lung cancer (NSCLC).

    1.4 Pancreatic Cancer

    Gemcitabine Injection is indicated as first-line treatment for patients with locally advanced (nonresectable Stage II or Stage III) or metastatic (Stage IV) adenocarcinoma of the pancreas. Gemcitabine Injection is indicated for patients previously treated with fluorouracil.

  • 2 DOSAGE AND ADMINISTRATION

    2.1 Ovarian Cancer

    Recommended Dose and Schedule

    The recommended dosage of Gemcitabine Injection is 1000 mg/m 2 intravenously over 30 minutes on Days 1 and 8 of each 21-day cycle in combination with carboplatin AUC 4 administered intravenously on Day 1 after Gemcitabine Injection administration. Refer to carboplatin prescribing information for additional information.

    Dosage Modifications

    Recommended Gemcitabine Injection dosage modifications for myelosuppression are described in Table 1 and 2[see Warnings and Precautions ( 5.2)]. Refer to the recommended dosage modifications for non-hematologic adverse reactions [see Dosage and Administration ( 2.5)].

    Table 1: Recommended Dosage Modifications for Gemcitabine Injection for Myelosuppression on Day of Treatment in Ovarian Cancer
    Treatment DayAbsolute Neutrophil Count
    (x 10 6/L)     		Platelet Count
    (x 10 6/L)     		Dosage Modification
    Day 1Greater than or equal to 1500
    Less than 1500     		and
    or     		Greater than or equal to 100,000
    Less than 100,000     		None
    Delay Treatment Cycle
    Day 8Greater than or equal to 1500
    1000 to 1499
    Less than 1000     		and
    or
    or     		Greater than or equal to 100,000
    75,000 to 99,999
    Less than 75,000     		None
    50% of full dose
    Hold
    Table 2: Recommended Dosage Modifications for Gemcitabine Injection for Myelosuppression in Previous Cycle in Ovarian Cancer
    OccurrenceMyelosuppression During Treatment CycleDosage Modification
    Initial Occurrence
    • Absolute neutrophil count less than 500 x 10 6/L for more than 5 days or
    • Absolute neutrophil count less than 100 x 10 6/L for more than 3 days or
    • Febrile neutropenia or
    • Platelets less than 25,000x10 6/L or
    • Cycle delay for more than one week due to toxicity
    		Permanently reduce Gemcitabine Injection to 800 mg/m 2 on Days 1 and 8
    Subsequent OccurrenceIf any of the above toxicities occur after the initial dose reductionPermanently reduce Gemcitabine Injection to 800 mg/m 2 on Day 1 only

    2.2 Breast Cancer

    Recommended Dose and Schedule

    The recommended dosage of Gemcitabine Injection is 1250 mg/m 2 m2 intravenously over 30 minutes on Days 1 and 8 of each 21-day cycle in combination with paclitaxel 175 mg/m 2 administered as a 3-hour intravenous infusion on Day 1 before Gemcitabine Injection administration. Refer to paclitaxel prescribing information for additional information.

    Dosage Modifications

    Recommended Gemcitabine Injection dosage modifications for myelosuppression are described in Table 3 [see Warnings and Precautions ( 5.2)]. Refer to the recommended dosage modifications for non-hematologic adverse reactions [see Dosage and Administration ( 2.5)].

    Table 3: Recommended Dosage Modifications for Gemcitabine Injection for Myelosuppression on Day of Treatment in Breast Cancer
    Treatment DayAbsolute Neutrophil Count
    (x 10 6/L)     		Platelet Count
    (x 10 6/L)     		Dosage Modification
    Day 1Greater than or equal to 1500andGreater than or equal to 100,000None
    Less than 1500orLess than 100,000Hold
    Day 8Greater than or equal to 1200andGreater than 75,000None
    1000 to 1199or50,000 to 75,00075% of full dose
    700 to 999andGreater than or equal to 50,00050% of full dose
    Less than 700orLess than 50,000Hold

    2.3 Non-Small Cell Lung Cancer

    Recommended Dose and Schedule

    28-day schedule

    The recommended dosage of Gemcitabine Injection is 1000 mg/m 2 m2 intravenously over 30 minutes on Days 1, 8, and 15 of each 28-day cycle in combination with cisplatin 100 mg/m 2 administered intravenously on Day 1 after Gemcitabine Injection administration.

    21-day schedule

    The recommended dosage of Gemcitabine Injection is 1250 mg/m 2 intravenously over 30 minutes on Days 1 and 8 of each 21-day cycle in combination with cisplatin 100 mg/m 2 administered intravenously on Day 1 after Gemcitabine Injection administration.

    Refer to cisplatin prescribing information for additional information.

    Dosage Modifications

    Recommended dosage modifications for Gemcitabine Injection myelosuppression are described in Table 4[see Warnings and Precautions ( 5.2)]. Refer to the recommended dosage modifications for non-hematologic adverse reactions [see Dosage and Administration ( 2.5)].

    2.4 Pancreatic Cancer

    Recommended Dose and Schedule

    The recommended dosage of Gemcitabine Injection is 1000 mg/m 2 intravenously over 30 minutes. The recommended treatment schedule is as follows:

    • Weeks 1 to 8: weekly dosing for the first 7 weeks followed by one week rest.
    • After week 8: weekly dosing on Days 1, 8, and 15 of each 28-day cycle.

    Dosage Modifications

    Recommended dosage modifications for Gemcitabine Injection for myelosuppression are described in Table 4[see Warnings and Precautions ( 5.2)]. Refer to the recommended dosage modifications for non-hematologic adverse reactions [see Dosage and Administration ( 2.5)].

    Table 4: Recommended Dosage Modifications for Gemcitabine Injection for Myelosuppression in Pancreatic Cancer and Non-Small Cell Lung Cancer
    Absolute Neutrophil Count
    (x10 6/L)     		Platelet Count
    (x10 6/L)     		Dosage Modification
    Greater than or equal to 1000andGreater than or equal to 100,000None
    500 to 999or50,000 to 99,99975% of full dose
    Less than 500orLess than 50,000Hold

    2.5 Dosage Modifications for Non-Hematologic Adverse Reactions

    Permanently discontinue Gemcitabine Injection for any of the following:

    • Unexplained dyspnea or evidence of severe pulmonary toxicity [see Warnings and Precautions ( 5.3)]
    • Hemolytic uremic syndrome (HUS) or severe renal impairment [see Warnings and Precautions ( 5.4)]
    • Severe hepatic toxicity [see Warnings and Precautions ( 5.5)]
    • Capillary leak syndrome (CLS) [see Warnings and Precautions ( 5.8)]
    • Posterior reversible encephalopathy syndrome (PRES) [see Warnings and Precautions ( 5.9)]

    Withhold Gemcitabine Injection or reduce dose by 50% for other Grade 3 or 4 non-hematological adverse reactions until resolved. No dose modifications are recommended for alopecia, nausea, or vomiting.

    2.6 Preparation and Administration

    Gemcitabine Injection is a cytotoxic drug. Follow applicable special handling and disposal procedures. 1

    Exercise caution and wear gloves when preparing Gemcitabine Injection solutions. Immediately wash the skin thoroughly or rinse the mucosa with copious amounts of water if Gemcitabine Injection contacts the skin or mucus membranes. Death has occurred in animal studies due to dermal absorption.

    Preparation

    • Inspect solution and discard vial if particulate matter or discoloration is observed.
    • Dilute Gemcitabine Injection with 0.9% Sodium Chloride Injection to a minimum final concentration of at least 0.1 mg/mL.
    • Mix diluted solution by gentle inversion. Do not shake.

    After dilution with 0.9% Sodium Chloride Injection, inspect the diluted Gemcitabine Injection solution visually for particulate matter and discoloration. Discard if particulate matter or discoloration is found.

    Storage

    • After initial withdrawal with a needle, use the remaining portion in the vial or discard within 28 days.
    • Store diluted Gemcitabine Injection solution at controlled room temperature 20°C to 25°C (68°F to 77°F). Discard the diluted solution after 24 hours.

    Administration

    • Inspect the diluted solution for particulate matter and discoloration prior to administration. Do not administer if particulate matter or discoloration is found.

    The compatibility of Gemcitabine Injection with other drugs has not been studied.

    No incompatibilities have been observed with infusion bottles or polyvinyl chloride bags and administration sets.

  • 3 DOSAGE FORMS AND STRENGTHS

    Injection: 100 mg/mL of gemcitabine as a clear, colorless to pale yellow solution in sterile multiple-dose vials:

    • 200 mg/2 mL (100 mg/mL)
    • 1 g/10 mL (100 mg/mL)
    • 1.5 g/15 mL (100 mg/mL)
    • 2 g/20 mL (100 mg/mL)
  • 4 CONTRAINDICATIONS

    Gemcitabine Injection is contraindicated in patients with a known hypersensitivity to gemcitabine. Reactions include anaphylaxis [see Adverse Reactions ( 6.1)].

  • 5 WARNINGS AND PRECAUTIONS

    5.1 Schedule-Dependent Toxicity

    In clinical trials evaluating the maximum tolerated dose of gemcitabine, prolongation of the infusion time beyond 60 minutes or more frequent than weekly dosing resulted in an increased incidence of clinically significant hypotension, severe flu-like symptoms, myelosuppression, and asthenia. The half-life of gemcitabine is influenced by the length of the infusion [see Clinical Pharmacology ( 12.3)] . Refer to the recommended Gemcitabine Injection dosage [see Dosage and Administration ( 2.1, 2.2, 2.3, 2.4)].

    5.2 Myelosuppression

    Myelosuppression manifested by neutropenia, thrombocytopenia, and anemia occurs with gemcitabine as a single agent and the risks are increased when gemcitabine is combined with other cytotoxic drugs. In clinical trials, Grade 3-4 neutropenia, anemia, and thrombocytopenia occurred in 25%, 8%, and 5%, respectively of the 979 patients who received single agent gemcitabine. The frequencies of Grade 3-4 neutropenia, anemia, and thrombocytopenia varied from 48% to 71%, 8% to 28%, and 5% to 55%, respectively, in patients receiving gemcitabine in combination with another drug [see Adverse Reactions ( 6.1)] .

    Prior to each dose of Gemcitabine Injection, obtain a complete blood count (CBC), with a differential and a platelet count. Modify the Gemcitabine Injection dosage as recommended [see Dosage and Administration ( 2.1, 2.2, 2.3, 2.4)] .

    5.3 Pulmonary Toxicity and Respiratory Failure

    Pulmonary toxicity, including interstitial pneumonitis, pulmonary fibrosis, pulmonary edema, and adult respiratory distress syndrome (ARDS), has been reported. In some cases, these pulmonary events can lead to fatal respiratory failure despite the discontinuation of therapy. The onset of pulmonary symptoms may occur up to 2 weeks after the last dose of gemcitabine [see Adverse Reactions ( 6.1, 6.2)] .

    Permanently discontinue Gemcitabine Injection in patients who develop unexplained dyspnea, with or without bronchospasm, or evidence of severe pulmonary toxicity.

    5.4 Hemolytic Uremic Syndrome

    Hemolytic uremic syndrome (HUS), including fatalities from renal failure or the requirement for dialysis, can occur with gemcitabine. In clinical trials, HUS occurred in 0.25% of 2429 patients. Most fatal cases of renal failure were due to HUS [see Adverse Reactions ( 6.1)] . Serious cases of thrombotic microangiopathy (TMA) other than HUS have been reported with gemcitabine [see Adverse Reactions ( 6.2)] .

    Assess renal function prior to initiation of Gemcitabine Injection and periodically during treatment. Consider the diagnosis of HUS in patients who develop anemia with evidence of microangiopathic hemolysis; increased bilirubin or LDH; reticulocytosis; severe thrombocytopenia; or renal failure (increased serum creatinine or BUN). Permanently discontinue Gemcitabine Injection in patients with HUS or severe renal impairment. Renal failure may not be reversible even with the discontinuation of therapy.

    5.5 Hepatic Toxicity

    Drug-induced liver injury, including liver failure and death, has been reported in patients receiving gemcitabine alone or with other potentially hepatotoxic drugs [see Adverse Reactions ( 6.1, 6.2)] . Administration of gemcitabine in patients with concurrent liver metastases or a pre-existing medical history of hepatitis, alcoholism, or liver cirrhosis can lead to exacerbation of the underlying hepatic insufficiency.

    Assess hepatic function prior to initiation of Gemcitabine Injection and periodically during treatment. Permanently discontinue Gemcitabine Injection in patients who develop severe hepatic toxicity.

    5.6 Embryo-Fetal Toxicity

    Based on animal data and its mechanism of action, Gemcitabine Injection can cause fetal harm when administered to a pregnant woman. Gemcitabine was teratogenic, embryotoxic, and fetotoxic in mice and rabbits.

    Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment with Gemcitabine Injection and for 6 months after the final dose. Advise male patients with female partners of reproductive potential to use effective contraception during treatment with Gemcitabine Injection and for 3 months following the final dose [see Use in Specific Populations ( 8.1, 8.3)] .

    5.7 Exacerbation of Radiation Therapy Toxicity

    Gemcitabine is not recommended for use in combination with radiation therapy.

    Concurrent (given together or ≤7 days apart)

    Life-threatening mucositis, especially esophagitis and pneumonitis occurred in a trial in which gemcitabine was administered at a dose of 1000 mg/m 2 to patients with non-small cell lung cancer for up to 6 consecutive weeks concurrently with thoracic radiation.

    Non-concurrent (given >7 days apart)

    Excessive toxicity has not been observed when gemcitabine is administered more than 7 days before or after radiation. Radiation recall has been reported in patients who received gemcitabine after prior radiation.

    5.8 Capillary Leak Syndrome

    Capillary leak syndrome (CLS) with severe consequences has been reported in patients receiving gemcitabine as a single agent or in combination with other chemotherapeutic agents [see Adverse Reactions ( 6.2)] . Permanently discontinue Gemcitabine Injection if CLS develops during therapy.

    5.9 Posterior Reversible Encephalopathy Syndrome

    Posterior reversible encephalopathy syndrome (PRES) has been reported in patients receiving gemcitabine as a single agent or in combination with other chemotherapeutic agents [see Adverse Reactions ( 6.2)] . PRES can present with headache, seizure, lethargy, hypertension, confusion, blindness, and other visual and neurologic disturbances. Confirm the diagnosis of PRES with magnetic resonance imaging (MRI). Permanently discontinue Gemcitabine Injection if PRES develops during therapy.

  • 6 ADVERSE REACTIONS

    The following clinically significant adverse reactions are described elsewhere in the labeling:

    • Hypersensitivity [see Contraindications ( 4)]
    • Schedule-Dependent Toxicity [see Warnings and Precautions ( 5.1)]
    • Myelosuppression [see Warnings and Precautions ( 5.2)]
    • Pulmonary Toxicity and Respiratory Failure [see Warnings and Precautions ( 5.3)]
    • Hemolytic Uremic Syndrome [see Warnings and Precautions ( 5.4)]
    • Hepatic Toxicity [see Warnings and Precautions ( 5.5)]
    • Exacerbation of Radiation Therapy Toxicity [see Warnings and Precautions ( 5.7)]
    • Capillary Leak Syndrome [see Warnings and Precautions ( 5.8)]
    • Posterior Reversible Encephalopathy Syndrome [see Warnings and Precautions ( 5.9)]

    6.1 Clinical Trials Experience

    Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

    Single Agent

    The data described below reflect exposure to gemcitabine as a single agent administered at doses between 800 mg/m 2 to 1250 mg/m 2 intravenously over 30 minutes once weekly in 979 patients with various malignancies. The most common (≥20%) adverse reactions of single agent gemcitabine are nausea/vomiting, anemia, increased alanine aminotransferase (ALT), increased aspartate aminotransferase (AST), neutropenia, increased alkaline phosphatase, proteinuria, fever, hematuria, rash, thrombocytopenia, dyspnea, and edema. The most common (≥5%) Grade 3 or 4 adverse reactions were neutropenia, nausea/vomiting, increased ALT, increased alkaline phosphatase, anemia, increased AST, and thrombocytopenia. Approximately 10% of the 979 patients discontinued gemcitabine due to adverse reactions. Adverse reactions resulting in discontinuation of gemcitabine in 2% of 979 patients were cardiovascular adverse reactions (myocardial infarction, cerebrovascular accident, arrhythmia, and hypertension) and adverse reactions resulting in discontinuation of gemcitabine in < 1% of 979 patients were anemia, thrombocytopenia, hepatic dysfunction, renal dysfunction, nausea/vomiting, fever, rash, dyspnea, hemorrhage, infection, stomatitis, somnolence, flu-like syndrome, and edema.

    Tables 5 and 6 present the incidence of selected adverse reactions and laboratory abnormalities reported in patients with various malignancies receiving single agent gemcitabine across 5 clinical trials. Additional clinically significant adverse reactions are provided following Table 6.

    Table 5: Selected Adverse Reactions Occurring in ≥10% of Patients Receiving Single Agent Gemcitabine a
    Gemcitabine b
    Adverse Reactions bAll Grades (%)Grade 3 (%)Grade 4 (%)

    a Grade based on criteria from the World Health Organization (WHO).

    b For approximately 60% of patients, non-laboratory adverse reactions were graded only if assessed to be possibly drug-related.

    c N=699-974; all patients with laboratory or non-laboratory data.

    Nausea and Vomiting 69131
    Fever 4120
    Rash 30<10
    Dyspnea 233<1
    Diarrhea 1910
    Hemorrhage 17<1<1
    Infection 161<1
    Alopecia 15<10
    Stomatitis 11<10
    Somnolence 11<1<1
    Paresthesias 10<10
    Table 6: Selected Laboratory Abnormalities Occurring in Patients Receiving Single Agent Gemcitabine a
    Gemcitabine c
    Laboratory Abnormality bAll Grades (%)Grade 3 (%)Grade 4 (%)

    a Grade based on criteria from the WHO.

    b Regardless of causality.

    c N=699-974; all patients with laboratory or non-laboratory data

    Hematologic
    Anemia 6871
    Neutropenia 63196
    Thrombocytopenia 2441
    Hepatic
    Increased ALT 6882
    Increased AST 6762
    Increased alkaline phosphatase 5572
    Hyperbilirubinemia 132<1
    Renal
    Proteinuria 45<10
    Hematuria 35<10
    Increased BUN 1600
    Increased creatinine 8<10

    Additional adverse reactions include the following:

    • Transfusion requirements: Red blood cell transfusions (19%); platelet transfusions (<1%)
    • Edema: Edema (13%), peripheral edema (20%), generalized edema (<1%)
    • Flu-like Symptoms: Fever, asthenia, anorexia, headache, cough, chills, myalgia, insomnia, rhinitis, sweating and/or malaise (19%)
    • Infection: Sepsis (<1%)
    • Extravasation: Injection-site reactions (4%)
    • Allergic: Bronchospasm (<2%); anaphylactoid reactions

    Ovarian Cancer

    Tables 7 and 8 present the incidence of selected adverse reactions and laboratory abnormalities, occurring in ≥10% of gemcitabine-treated patients and at a higher incidence in the gemcitabine with carboplatin arm, reported in a randomized trial (Study 1) of gemcitabine with carboplatin (n=175) compared to carboplatin alone (n=174) for the second-line treatment of ovarian cancer in women with disease that had relapsed more than 6 months following first-line platinum-based chemotherapy [see Clinical Studies ( 14.1)] .

    Additional clinically significant adverse reactions, occurring in <10% of patients, are provided following table 8.

    The proportion of patients with dose adjustments for carboplatin (1.8% versus 3.8%), doses of carboplatin omitted (0.2% versus 0) and discontinuing treatment for adverse reactions (11% versus 10%), were similar between arms. Dose adjustment for gemcitabine occurred in 10% of patients and gemcitabine dose was omitted in 14% of patients in the gemcitabine/carboplatin arm.

    Table 7: Adverse Reactions Occurring in >10% of Patients Receiving Gemcitabine with Carboplatin and at Higher Incidence than in Patients Receiving Single Agent Carboplatin [Between Arm Difference of ≥5% (All Grades) or ≥2% (Grades 3-4)] in Study 1 a

    a Grade based on National Cancer Institute CTC Version 2.0.

    b Regardless of causality.

    Adverse Reactions bGemcitabine/Carboplatin
    (N=175)     		Carboplatin
    (N=174)
    All Grades
    (%)     		Grade 3
    (%)     		Grade 4
    (%)     		All Grades
    (%)     		Grade 3
    (%)     		Grade 4
    (%)
    Nausea69606130
    Alopecia49001700
    Vomiting4660362<1
    Constipation42613730
    Fatigue403<13250
    Diarrhea253014<10
    Stomatitis/pharyngitis22<101300
    Table 8: Laboratory Abnormalities Occurring in Patients Receiving Gemcitabine with Carboplatin and at Higher Incidence than in Patients Receiving Single Agent Carboplatin [Between Arm Difference of ≥5% (All Grades) or ≥2% (Grades 3-4)] in Study 1 a

    a Grade based on National Cancer Institute CTC Version 2.0.

    b Regardless of causality.

    c Percent of patients receiving a transfusion. Transfusions are not CTC-graded events. Blood transfusions included both packed red blood cells and whole blood.

    Laboratory Abnormality bGemcitabine/Carboplatin
    (N=175)     		Carboplatin
    (N=174)
    All Grades
    (%)     		Grade 3
    (%)     		Grade 4
    (%)     		All Grades
    (%)     		Grade 3
    (%)     		Grade 4
    (%)
    Hematologic
    Neutropenia90422958111
    Anemia862267592
    Thrombocytopenia7830557101
    RBC Transfusions c38--15--
    Platelet Transfusions c9--3--

    Hematopoietic growth factors were administered more frequently in the gemcitabine-containing arm: leukocyte growth factor (24% and 10%) and erythropoiesis-stimulating agent (7% and 3.9%).

    The following clinically relevant, Grade 3 and 4 adverse reactions occurred more frequently in the gemcitabine with carboplatin arm: dyspnea (3.4% versus 2.9%), febrile neutropenia (1.1% versus 0), hemorrhagic event (2.3% versus 1.1 %), motor neuropathy (1.1% versus 0.6%), and rash/desquamation (0.6% versus 0).

    Breast Cancer

    Tables 9 and 10 present the incidence of selected adverse reactions and laboratory abnormalities, occurring in ≥10% of gemcitabine treated patients and at a higher incidence in the gemcitabine with paclitaxel arm, reported in a randomized trial (Study 2) of gemcitabine with paclitaxel (n=262) compared to paclitaxel alone (n=259) for the first-line treatment of metastatic breast cancer (MBC) in women who received anthracycline-containing chemotherapy in the adjuvant/neo-adjuvant setting or for whom anthracyclines were contraindicated [see Clinical Studies ( 14.2)] . Additional clinically significant adverse reactions, occurring in <10% of patients, are provided following Table 10.

    The requirement for dose reduction of paclitaxel were higher for patients in the gemcitabine/paclitaxel arm (5% versus 2%). The number of paclitaxel doses omitted (<1%), the proportion of patients discontinuing treatment for adverse reactions (7% versus 5%) and the number of treatment-related deaths (1 patient in each arm) were similar between the two arms.

    Table 9: Selected Adverse Reactions Occurring in Patients Receiving Gemcitabine with Paclitaxel and at Higher Incidence than in Patients Receiving Single Agent Paclitaxel [Between Arm Difference of ≥5% (All Grades) or ≥2% (Grades 3-4)] in Study 2 a

    a Grade based on National Cancer Institute CTC Version 2.0.

    b Non-laboratory events were graded only if assessed to be possibly drug-related

    Adverse Reactions bGemcitabine/Paclitaxel (N=262)Paclitaxel (N=259)
    All Grades
    (%)     		Grade 3
    (%)     		Grade 4
    (%)     		All Grades
    (%)     		Grade 3
    (%)     		Grade 4
    (%)
    Alopecia9014492193
    Neuropathy–Sensory645<15830
    Nausea50103120
    Fatigue406<1281<1
    Vomiting29201520
    Diarrhea20301320
    Anorexia170012<10
    Neuropathy–Motor152<110<10
    Stomatitis/Pharyngitis131<18<10
    Fever13<10300
    Rash/Desquamation11<1<1500
    Febrile Neutropenia65<1210
    Table 10: Selected Laboratory Abnormalities Occurring in >10% of Patients Receiving Gemcitabine with Paclitaxel and at a Higher Incidence than Patients Receiving Single Agent Paclitaxel [Between Arm Difference of ≥5% (All Grades) or ≥2% (Grades 3-4)] in Study 2 a

    a Grade based on National Cancer Institute CTC Version 2.0.

    b Regardless of causality.

    Laboratory Abnormality bGemcitabine/Paclitaxel (N=262)Paclitaxel (N=259)
    All Grades
    (%)     		Grade 3
    (%)     		Grade 4
    (%)     		All Grades
    (%)     		Grade 3
    (%)     		Grade 4
    (%)
    Hematologic
    Anemia6961513<1
    Neutropenia6931173147
    Thrombocytopenia265<17<1<1
    Hepatobiliary
    Increased ALT185<16<10
    Increased AST16205<10

    Clinically relevant Grade 3 or 4 dyspnea occurred with a higher incidence in the gemcitabine with paclitaxel arm compared with the paclitaxel arm (1.9% versus 0).

    Non-Small Cell Lung Cancer

    Tables 11 and 12 present the incidence of selected adverse reactions and laboratory abnormalities occurring in ≥10% of gemcitabine-treated patients and at a higher incidence in the gemcitabine with cisplatin arm, reported in a randomized trial (Study 3) of gemcitabine with cisplatin (n=260) administered in 28-day cycles as compared to cisplatin alone (n=262) in patients receiving first-line treatment for locally advanced or metastatic NSCLC [see Clinical Studies ( 14.3)] .

    Patients randomized to gemcitabine with cisplatin received a median of 4 cycles of treatment and those randomized to cisplatin alone received a median of 2 cycles of treatment. In this trial, the requirement for dose adjustments (>90% versus 16%), discontinuation of treatment for adverse reactions (15% versus 8%), and the proportion of patients hospitalized (36% versus 23%) were all higher for patients receiving gemcitabine with cisplatin compared to those receiving cisplatin alone. The incidence of febrile neutropenia (3% versus <1%), sepsis (4% versus 1%), Grade 3 cardiac dysrhythmias (3% versus <1%) were all higher in the gemcitabine with cisplatin arm compared to the cisplatin alone arm. The two-drug combination was more myelosuppressive with 4 (1.5%) possibly treatment-related deaths, including 3 resulting from myelosuppression with infection and one case of renal failure associated with pancytopenia and infection. No deaths due to treatment were reported on the cisplatin arm.

    Table 11: Selected Adverse Reactions Occurring in ≥10% of Patients Receiving Gemcitabine with Cisplatin and at Higher Incidence than in Patients Receiving Single Agent Cisplatin [Between Arm Difference of ≥5% (All Grades) or ≥2% (Grades 3-4)] in Study 3 a

    a Grade based on National Cancer Institute Common Toxicity Criteria (CTC).

    b Non-laboratory events were graded only if assessed to be possibly drug-related.

    c N=217-253; all gemcitabine/cisplatin patients with laboratory or non-laboratory data

    d N=213-248; all cisplatin patients with laboratory or non-laboratory data

    Adverse Reactions bGemcitabine/Cisplatin cCisplatin d
    All Grades
    (%)     		Grade 3
    (%)     		Grade 4
    (%)     		All Grades
    (%)     		Grade 3
    (%)     		Grade 4
    (%)
    Nausea932528720<1
    Vomiting78111271109
    Alopecia53103300
    Neuro Motor351201530
    Diarrhea24221300
    Neuro Sensory23101810
    Infection18321210
    Fever1600500
    Neuro Cortical1631910
    Neuro Mood16101010
    Local1500600
    Neuro Headache1400700
    Stomatitis1410500
    Hemorrhage1410400
    Hypotension1210710
    Rash1100300
    Table 12: Selected Laboratory Abnormalities Occurring in >10% of Patients Receiving Gemcitabine with Cisplatin and at Higher Incidence than in Patients Receiving Single Agent Cisplatin [Between Arm Difference of ≥5% (All Grades) or ≥2% (Grades 3-4)] in Study 3 a

    a Grade based on National Cancer Institute CTC.

    b Regardless of causality.

    c N=217-253; all gemcitabine/cisplatin patients with laboratory or non-laboratory data.

    d N=213-248; all cisplatin patients with laboratory or non-laboratory data.

    e Percent of patients receiving a transfusion. Percent transfusions are not CTC-graded events.

    Laboratory Abnormality bGemcitabine/Cisplatin cCisplatin d
    All Grades
    (%)     		Grade 3
    (%)     		Grade 4
    (%)     		All Grades
    (%)     		Grade 3
    (%)     		Grade 4
    (%)
    Hematologic
    Anemia892236761
    Thrombocytopenia 8525251331
    Neutropenia 7922352031
    Lymphopenia75251851125
    RBC Transfusion e39--13--
    Platelet Transfusion e21--<1--
    Renal
    Increased Creatinine384<1312<1
    Proteinuria23001800
    Hematuria15001300
    Other Laboratory
    Hyperglycemia30402330
    Hypomagnesemia30431720
    Hypocalcemia182070<1
    Hepatic
    Increased Transaminases22211010
    Increased Alkaline Phosphatase19101300

    Tables 13 and 14 present the incidence of selected adverse reactions and laboratory abnormalities occurring in ≥10% of gemcitabine-treated patients and at a higher incidence in the gemcitabine with cisplatin arm, reported in a randomized trial (Study 4) of gemcitabine with cisplatin (n=69) administered in 21-day cycles as compared to etoposide with cisplatin (n=66) in patients receiving first-line treatment for locally advanced or metastatic NSCLC [see Clinical Studies ( 14.3)] . Additional clinically significant adverse reactions are provided following Table 14.

    Patients in the gemcitabine/cisplatin (GC) arm received a median of 5 cycles and those in the etoposide/cisplatin (EC) arm received a median of 4 cycles. The majority of patients receiving more than one cycle of treatment required dose adjustments; 81% in the GC arm and 68% in the EC arm. The incidence of hospitalizations for adverse reactions was 22% in the GC arm and 27% in the EC arm. The proportion of patients who discontinued treatment for adverse reactions was higher in the GC arm (14% versus 8%). The proportion of patients who were hospitalized for febrile neutropenia was lower in the GC arm (7% versus 12%). There was one death attributed to treatment, a patient with febrile neutropenia and renal failure, which occurred in the GC arm.

    Table 13: Selected Adverse Reactions in Patients Receiving Gemcitabine with Cisplatin in Study 4 a

    a Grade based on criteria from the World Health Organization (WHO).

    b Non-laboratory events were graded only if assessed to be possibly drug-related. .

    c N=67-69; all gemcitabine/cisplatin patients with non-laboratory data.

    d N=57-63; all cisplatin plus etoposide patients with non-laboratory data.

    e Flu-like syndrome and edema were not graded.

    Adverse Reactions bGemcitabine/Cisplatin cEtoposide/Cisplatin d
    All Grades
    (%)     		Grade 3
    (%)     		Grade 4
    (%)     		All Grades
    (%)     		Grade 3
    (%)     		Grade 4
    (%)
    Nausea and Vomiting9635486197
    Alopecia7713092510
    Paresthesias38001620
    Infection28312180
    Stomatitis20401820
    Diarrhea14111302
    Edema e12--2--
    Rash1000300
    Hemorrhage 903303
    Fever 600300
    Somnolence 300320
    Flu-like Syndrome e3--0--
    Dyspnea101300
    Table 14: Selected Laboratory Abnormalities Occurring in Patients Receiving Gemcitabine with Cisplatin in Study 4 a

    a Grade based on criteria from the WHO.

    b Regardless of causality.

    c N=67-69; all gemcitabine/cisplatin patients with laboratory or non-laboratory data.

    d N=57-63; all etoposide/cisplatin patients with laboratory or non-laboratory data.

    e WHO grading scale not applicable to proportion of patients with transfusions.

    Laboratory Abnormalities bGemcitabine /Cisplatin cEtoposide /Cisplatin d
    All Grades
    (%)     		Grade 3
    (%)     		Grade 4
    (%)     		All Grades
    (%)     		Grade 3
    (%)     		Grade 4
    (%)
    Hematologic
    Anemia8822077132
    Neutropenia 883628872056
    Thrombocytopenia 8139164585
    Platelet Transfusion e3--8--
    RBC Transfusion e29--21--
    Hepatic
    Increased Alkaline Phosphatase 16001100
    Increased ALT6001200
    Increased AST 3001100
    Renal
    Hematuria22001000
    Proteinuria1200500
    Increased BUN 600400
    Increased Creatinine 200200

    6.2 Postmarketing Experience

    The following adverse reactions have been identified during postapproval use of gemcitabine. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

    Blood and Lymphatic System: TMA

    Cardiovascular: Congestive heart failure, myocardial infarction, arrhythmias, supraventricular arrhythmias

    Vascular: Peripheral vasculitis, gangrene, capillary leak syndrome

    Skin: Cellulitis, pseudocellulitis, severe skin reactions, including desquamation and bullous skin eruptions

    Hepatic: Hepatic failure, hepatic veno-occlusive disease

    Pulmonary: Interstitial pneumonitis, pulmonary fibrosis, pulmonary edema, adult respiratory distress syndrome (ARDS), pulmonary eosinophilia

    Nervous System: Posterior reversible encephalopathy syndrome (PRES)

  • 8 USE IN SPECIFIC POPULATIONS

    8.1 Pregnancy

    Risk Summary

    Based on animal data and its mechanism of action, Gemcitabine Injection can cause fetal harm when administered to a pregnant woman [see Clinical Pharmacology ( 12.1)] . There are no available data on the use of gemcitabine in pregnant women. In animal reproduction studies, gemcitabine was teratogenic, embryotoxic, and fetotoxic in mice and rabbits (see Data). Advise pregnant women of the potential risk to a fetus [see Use in Special Populations ( 8.3)] .

    In the U.S. general population, the estimated background risk of major birth defects and miscarriages in clinically recognized pregnancies is 2-4% and 15-20% respectively.

    Data

    Animal Data

    Gemcitabine is embryotoxic in mice. Daily dosing of gemcitabine to pregnant mice increased the incidence of fetal malformation (cleft palate, incomplete ossification) at doses of 1.5 mg/kg/day [approximately 0.005 times the 1000 mg/m 2 clinical dose based on body surface area (BSA)]. Gemcitabine was embryotoxic and fetotoxic in rabbits. Daily dosing of gemcitabine to pregnant rabbits resulted in fetotoxicity (decreased fetal viability, reduced litter sizes, and developmental delays) and increased the incidence of fetal malformations (fused pulmonary artery, absence of gall bladder) at doses of 0.1 mg/kg/day (approximately 0.002 times the 1000 mg/m 2 clinical dose based on BSA).

    8.2 Lactation

    Risk Summary

    There is no information regarding the presence of gemcitabine or its metabolites in human milk, or their effects on the breastfed infant or on milk production. Due to the potential for serious adverse reactions in breastfed infants, advise women not to breastfeed during treatment with Gemcitabine Injection and for at least one week following the last dose.

    8.3 Females and Males of Reproductive Potential

    Pregnancy Testing

    Verify pregnancy status in females of reproductive potential prior to initiating Gemcitabine Injection [see Use in Specific Populations ( 8.1)].

    Contraception

    Gemcitabine Injection can cause fetal harm when administered to a pregnant woman [see Use in Specific Populations ( 8.1)].

    Females

    Because of the potential for genotoxicity, advise females of reproductive potential to use effective contraception during treatment with Gemcitabine Injection and for 6 months after the final dose.

    Males

    Because of the potential for genotoxicity, advise males with female partners of reproductive potential to use effective contraception during treatment with Gemcitabine Injection and for 3 months after the final dose [see Nonclinical Toxicology ( 13.1)].

    Infertility

    Males

    Based on animal studies, gemcitabine may impair fertility in males of reproductive potential [see Nonclinical Toxicology ( 13.1)]. It is not known whether these effects on fertility are reversible.

    8.4 Pediatric Use

    The safety and effectiveness of gemcitabine have not been established in pediatric patients.

    The safety and pharmacokinetics of gemcitabine were evaluated in a trial in pediatric patients with refractory leukemia. The maximum tolerated dose was 10 mg/m 2/min for 360 minutes weekly for three weeks followed by a one-week rest period.

    The safety and activity of gemcitabine were evaluated in a trial of pediatric patients with relapsed acute lymphoblastic leukemia (22 patients) and acute myelogenous leukemia (10 patients) at a dose of 10 mg/m2/min administered over 360 minutes weekly for three weeks followed by a one-week rest period. Patients with M1 or M2 bone marrow on Day 28 who did not experience unacceptable toxicity were eligible to receive a maximum of one additional four-week course. Toxicities observed included myelosuppression, febrile neutropenia, increased serum transaminases, nausea, and rash/desquamation. No meaningful clinical activity was observed in this trial.

    8.5 Geriatric Use

    In clinical studies which enrolled 979 patients with various malignancies who received single agent gemcitabine, no overall differences in safety were observed between patients aged 65 and older and younger patients, with the exception of a higher rate of Grade 3-4 thrombocytopenia in older patients as compared to younger patients.

    In a randomized trial in women with ovarian cancer (Study 1), 175 women received gemcitabine with carboplatin, of which 29% were age 65 years or older. Similar effectiveness was observed between older and younger women There was significantly higher Grade 3-4 neutropenia in women 65 years of age or older [see Dosage and Administration ( 2.1)] .

    Gemcitabine clearance is affected by age; however, there are no recommended dose adjustments based on patients’ age [see Clinical Pharmacology ( 12.3)] .

    8.6 Gender

    Gemcitabine clearance is decreased in females [see Clinical Pharmacology ( 12.3)] . In single agent studies of gemcitabine, women, especially older women, were more likely not to proceed to a subsequent cycle and to experience Grade 3-4 neutropenia and thrombocytopenia [see Dosage and Administration ( 2.1, 2.2, 2.3, 2.4)] .

  • 10 OVERDOSAGE

    There is no known antidote for overdoses of gemcitabine. Myelosuppression, paresthesias, and severe rash were the principal toxicities seen when a single dose as high as 5700 mg/m 2 was administered by intravenous infusion over 30 minutes every 2 weeks to several patients in a dose-escalation study. In the event of suspected overdose, monitor with appropriate blood counts and provide supportive therapy, as necessary.

  • 11 DESCRIPTION

    Gemcitabine is a nucleoside metabolic inhibitor. Gemcitabine hydrochloride is 2’-deoxy-2’,2’-difluorocytidine monohydrochloride (β-isomer) with the following molecular structure:.

    Structural Formula

    Gemcitabine hydrochloride is a white to off white crystalline powder. The empirical formula for gemcitabine hydrochloride is C 9H 11F 2N 3O 4 HCl and the molecular weight is 299.66.

    Gemcitabine hydrochloride is soluble in water, slightly soluble in methanol, and practically insoluble in ethanol and polar organic solvents.

    Gemcitabine Injection is a sterile, clear colorless to pale yellow solution that is provided in 100 mg/mL multiple-dose vials for intravenous use only. Gemcitabine Injection is available in four presentations: 200 mg/2 mL, 1 g/10 mL, 1.5 g/15 mL or 2 g/20 mL. Each mL contains 100 mg of gemcitabine free base (equivalent to 113.85 mg of gemcitabine hydrochloride), 250 mg PEG-300, 150 mg propylene glycol, and 16 mg sodium hydroxide in dehydrated alcohol. Sodium hydroxide and/or hydrochloric acid may have been added for pH adjustment.

  • 12 CLINICAL PHARMACOLOGY

    12.1 Mechanism of Action

    Gemcitabine kills cells undergoing DNA synthesis and blocks the progression of cells through the G1/S-phase boundary. Gemcitabine is metabolized by nucleoside kinases to diphosphate (dFdCDP) and triphosphate (dFdCTP) nucleosides. Gemcitabine diphosphate inhibits ribonucleotide reductase, an enzyme responsible for catalyzing the reactions that generate deoxynucleoside triphosphates for DNA synthesis, resulting in reductions in deoxynucleotide concentrations, including dCTP. Gemcitabine triphosphate competes with dCTP for incorporation into DNA. The reduction in the intracellular concentration of dCTP by the action of the diphosphate enhances the incorporation of gemcitabine triphosphate into DNA (self-potentiation). After the gemcitabine nucleotide is incorporated into DNA, only one additional nucleotide is added to the growing DNA strands, which eventually results in the initiation of apoptotic cell death.

    12.3 Pharmacokinetics

    The pharmacokinetics of gemcitabine were examined in 353 patients with various solid tumors. Pharmacokinetic parameters were derived using data from patients treated for varying durations of therapy given weekly with periodic rest weeks and using both short infusions (<70 minutes) and long infusions (70 to 285 minutes). The total gemcitabine dose varied from 500 mg/m 2 to 3600 mg/m 2.

    Distribution

    The volume of distribution was increased with infusion length. Volume of distribution of gemcitabine was 50 L/m 2 following infusions lasting <70 minutes. For long infusions, the volume of distribution rose to 370 L/m 2.

    Gemcitabine pharmacokinetics are linear and are described by a 2-compartment model. Population pharmacokinetic analyses of combined single and multiple dose studies showed that the volume of distribution of gemcitabine was significantly influenced by duration of infusion and sex. Gemcitabine plasma protein binding is negligible.

    Elimination

    Metabolism

    The active metabolite, gemcitabine triphosphate, can be extracted from peripheral blood mononuclear cells. The half-life of the terminal phase for gemcitabine triphosphate from mononuclear cells ranges from 1.7 to 19.4 hours.

    Excretion

    Gemcitabine disposition was studied in 5 patients who received a single 1000 mg/m2 of radiolabeled drug as a 30-minute infusion. Within one week, 92% to 98% of the dose was recovered, almost entirely in the urine. Gemcitabine (<10%) and the inactive uracil metabolite, 2’-deoxy-2’,2’-difluorouridine (dFdU) accounted for 99% of the excreted dose. The metabolite dFdU is also found in plasma.

    Specific Populations

    Geriatric Patients

    Clearance of gemcitabine was affected by age. The lower clearance in geriatric patients results in higher concentrations of gemcitabine for any given dose. Differences in either clearance or volume of distribution based on patient characteristics or the duration of infusion result in changes in half-life and plasma concentrations. Table 15 shows plasma clearance and half-life of gemcitabine following short infusions for typical patients by age and sex.

    Table 15: Gemcitabine Clearance and Half-Life for the “Typical” Patient

    a Half-life for patients receiving <70 minute infusion.

    AgeClearance Men
    (L/hr/m 2)     		Clearance in Women
    (L/hr/m 2)     		Half-Life a Men
    (min)     		Half-Life a Women
    (min)
    2992.269.44249
    4575.757.04857
    6555.141.56173
    7940.730.77994

    Gemcitabine half-life for short infusions ranged from 42 to 94 minutes and for long infusions varied from 245 to 638 minutes, depending on age and sex, reflecting a greatly increased volume of distribution with longer infusions.

    Male and Female Patients

    Females have lower clearance and longer half-lives than male patients as described in Table 15.

    Patients with Renal Impairment

    No clinical studies have been conducted with gemcitabine in patients with decreased renal function.

    Patients with Hepatic Impairment

    No clinical studies have been conducted with gemcitabine in patients with decreased hepatic function.

    Drug Interaction Studies

    When gemcitabine (1250 mg/m 2 on Days 1 and 8) and cisplatin (75 mg/m 2 on Day 1) were administered in patients with NSCLC, the clearance of gemcitabine on Day 1 was 128 L/hr/m 2 and on Day 8 was 107 L/hr/m 2. Data from patients with NSCLC demonstrate that gemcitabine and carboplatin given in combination does not alter the pharmacokinetics of gemcitabine or carboplatin compared to administration of either single agent; however, due to wide confidence intervals and small sample size, interpatient variability may be observed.

    Data from metastatic breast cancer patients shows that gemcitabine has little or no effect on the pharmacokinetics (clearance and half-life) of paclitaxel and paclitaxel has little or no effect on the pharmacokinetics of gemcitabine.

  • 13 NONCLINICAL TOXICOLOGY

    13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

    Long-term animal studies to evaluate the carcinogenic potential of gemcitabine have not been conducted. Gemcitabine was mutagenic in an in vitro mouse lymphoma (L5178Y) assay and was clastogenic in an in vivo mouse micronucleus assay. Gemcitabine intraperitoneal doses of 0.5 mg/kg/day [about 1/700 the 1000 mg/m 2 clinical dose based on body surface area (BSA)] in male mice resulted in moderate to severe hypospermatogenesis, decreased fertility, and decreased implantations. In female mice, fertility was not affected but maternal toxicities were observed at 1.5 mg/kg/day administered intravenously (about 1/200 the 1000 mg/m 2 clinical dose based on BSA) and fetotoxicity or embryolethality was observed at 0.25 mg/kg/day administered intravenously (about 1/1300 the 1000 mg/m 2 clinical dose based on BSA).

  • 14 CLINICAL STUDIES

    14.1 Ovarian Cancer

    The efficacy of gemcitabine was evaluated in a randomized trial (Study 1) conducted in women with advanced ovarian cancer that had relapsed at least 6 months after first-line platinum-based therapy. Patients were randomized to receive either gemcitabine 1000 mg/m2 on Days 1 and 8 of each 21-day cycle with carboplatin AUC 4 on Day 1 after gemcitabine administration (n=178) or carboplatin AUC 5 on Day 1 of each 21-day cycle (n=178). The major efficacy outcome measure was progression-free survival (PFS).

    A total of 356 patients were enrolled. Demographics and baseline characteristics are shown in Table 16.

    Efficacy results are presented in Table 17 and Figure 1. The addition of gemcitabine to carboplatin resulted in statistically significant improvements in PFS and overall response rate. Approximately 75% of patients in each arm received additional chemotherapy for disease progression; 13 of 120 patients in the carboplatin alone arm received gemcitabine for treatment of disease progression. There was no significant difference in overall survival between the treatment arms.

    Table 16: Baseline Demographics and Clinical Characteristics for Study 1

    a 5 patients on gemcitabine with carboplatin arm and 4 patients on carboplatin arm had no baseline Eastern Cooperative Oncology Group (ECOG) performance status.

    b 2 patients on gemcitabine with carboplatin arm and 1 patient on carboplatin arm had platinum-free interval < 6 months.

    Gemcitabine /Carboplatin
    (N=178)     		Carboplatin
    (N=178)
    Median age, years 59 58
         Range 36 to 78 21 to 81
    Baseline ECOG performance status 0-1 a 94% 95%
    Disease Status
         Evaluable 8% 3%
         Bidimensionally measurable 92% 96%
    Platinum-free interval b
         6-12 months 40% 40%
         >12 months 59% 60%
    First-line therapy
         Platinum-taxane combination 70% 71%
         Platinum-non-taxane combination 29% 28%
         Platinum monotherapy 1% 1%
    Table 17: Efficacy Results in Study 1

    a CI=confidence interval.

    b Log rank, unadjusted.

    c Chi square.

    d CR=Complete response.

    e PR plus PRNM=Partial response plus partial response, non-measurable disease.

    f Independently reviewed cohort - gemcitabine/carboplatin (n=121), carboplatin (n=101); independent reviewers unable to measure disease detected by sonography or physical exam.

    Efficacy ParameterGemcitabine /Carboplatin
    (N=178)     		Carboplatin
    (N=178)
    Progression-free Survival
         Median (95% CI a) months 8.6 (8.0, 9.7)5.8 (5.2, 7.1)
         Hazard Ratio (95% CI)0.72 (0.57, 0.90)
         p-value bp=0.0038
    Overall Survival
         Median (95% CI) months18.0 (16.2, 20.3)17.3 (15.2, 19.3)
         Hazard Ratio (95% CI)0.98 (0.78, 1.24)
         p-value bp=0.8977
    Overall Response Rate by investigator 47.2%30.9%
         p-value cp=0.0016
         CR d14.6%6.2%
         PR plus PRNM e32.6%24.7%
    Overall Response Rate f by independent review 46.3%35.6%
         p-value cp=0.11
         CR d9.1%4.0%
         PR plus PRNM e37.2%31.7%

    Figure 1: Kaplan-Meier Curves for Progression Free Survival in Study 1.

    Figure 1

    14.2 Breast Cancer

    The efficacy of gemcitabine was evaluated in a multinational, randomized, open-label trial (Study 2) conducted in women receiving initial treatment for metastatic breast cancer and who have received prior adjuvant/neoadjuvant anthracycline chemotherapy unless clinically contraindicated. Patients were randomized to receive either gemcitabine 1250 mg/m2 on Days 1 and 8 of each 21-day cycle with paclitaxel 175 mg/m 2 administered on Day 1 before gemcitabine administration (n=267) or paclitaxel 175 mg/m2 on Day 1 of each 21-day cycle (n=262). The major efficacy outcome measure was time to documented disease progression.

    A total of 529 patients were enrolled. Demographic and baseline characteristics were similar between treatment arms (Table 18).

    Efficacy results are presented in Table 19 and Figure 2. The addition of gemcitabine to paclitaxel resulted in statistically significant improvement in time to documented disease progression and overall response rate compared to paclitaxel alone. There was no significant difference in overall survival.

    Table 18: Baseline Demographics and Clinical Characteristics for Study 2

    a Karnofsky Performance Status

    Gemcitabine/Paclitaxel (N=267) Paclitaxel (N=262)
    Median age (years) 53 52
         Range 26 to 83 26 to 75
    Metastatic disease 97% 97%
    Baseline KPS a ≥90 70% 74%
    Number of tumor sites
         1-2 57% 59%
         ≥3 43% 41%
    Visceral disease 73% 73%
    Prior anthracycline 97% 96%
    Table 19: Efficacy Results in Study 2

    b These represent reconciliation of investigator and Independent Review Committee assessments according to a predefined algorithm.

    c Based on the ITT population.

    Efficacy ParameterGemcitabine/Paclitaxel (N=267) Paclitaxel (N=262)
    Time to Documented Disease Progression a
    Median (95% CI) in months 5.2 (4.2, 5.6)2.9 (2.6, 3.7)
     Hazard Ratio (95% CI) 0.650 (0.524, 0.805)
     p-value p<0.0001
    Overall Survival b
    Median Survival (95% CI) in months 18.6 (16.5, 20.7) 15.8 (14.1, 17.3)
    Hazard Ratio (95% CI) 0.86 (0.71, 1.04)
    p-value Not Significant
    Overall Response Rate 40.8%22.1%
    (95% CI)(34.9, 46.7)(17.1, 27.2)
    p-valuep<0.0001

    Figure 2: Kaplan-Meier Curves for Time to Documented Disease Progression in Study 2

    Figure 2

    14.3 Non-Small Cell Lung Cancer

    The efficacy of gemcitabine was evaluated in two randomized, multicenter trials.

    Study 3: 28-Day Schedule

    A multinational, randomized trial (Study 3) compared gemcitabine with cisplatin to cisplatin alone in the treatment of patients with inoperable Stage IIIA, IIIB, or IV NSCLC who had not received prior chemotherapy. Patients were randomized to receive either gemcitabine 1000 mg/m2 on Days 1, 8, and 15 of each 28-day cycle with cisplatin 100 mg/m2 on Day 1 after gemcitabine administration (N=260) or cisplatin 100 mg/m2 on Day 1 of each 28-day cycle (N=262). The major efficacy outcome measure was overall survival.

    A total of 522 patients were enrolled. Demographics and baseline characteristics (Table 20) were similar between arms with the exception of histologic subtype of NSCLC, with 48% of patients on the cisplatin arm and 37% of patients on the gemcitabine with cisplatin arm having adenocarcinoma.

    Efficacy results are presented in Table 21 and Figure 3.

    Study 4: 21-Day Schedule

    A randomized (1:1), multicenter trial (Study 4) was conducted in patients with Stage IIIB or IV NSCLC. Patients were randomized to receive either gemcitabine 1250 mg/m 2 on Days 1 and 8 of each 21-day cycle with cisplatin 100 mg/m 2 on Day 1 after gemcitabine administration or etoposide 100 mg/m 2 intravenously on Days 1, 2, and 3 with cisplatin 100 mg/m 2 on Day 1 of each 21 -day cycle. The major efficacy outcome measure was response rate.

    A total of 135 patients were enrolled. Demographics and baseline characteristics are summarized in Table 20.

    Efficacy results are presented in Table 21. There was no significant difference in survival between the two treatment arms. The median survival was 8.7 months for the gemcitabine with cisplatin arm versus 7 months for the etoposide with cisplatin arm. Median time to disease progression for the gemcitabine with cisplatin arm was 5 months compared to 4.1 months on the etoposide with cisplatin arm (Log-rank p=0.015, two-sided). The objective response rate for the gemcitabine with cisplatin arm was 33% compared to 14% on the etoposide with cisplatin arm (Fisher’s Exact p=0.01, two-sided).

    Table 20: Baseline Demographics and Clinical Characteristics for Studies 3 and 4

    a N/A Not Applicable

    b Karnofsky Performance Status.

    Trial28-day Schedule (Study 3)21-day Schedule (Study 4)
    Gemcitabine/Cisplatin (N=260)Cisplatin (N=262)Gemcitabine/Cisplatin (N=69)Etoposide/ Cisplatin (N=66)
    Male70%71%93%92%
    Median age, years 62635860
    Range36 to 8835 to 7933 to 7635 to 75
    Stage IIIA7%7%N/A aN/A a
    Stage IIIB26%23%48%52%
    Stage IV 67%70%52%49%
    Baseline KPS b 70 to 80 41%44%45%52%
    Baseline KPS b 90 to 100 57%55%55%49%
    Table 21: Efficacy Results for Studies 3 and 4

    a CI=confidence intervals

    b p-value two-sided Fisher’s Exact test for difference in binomial proportions; log-rank test for time-to-event analyses.

    Trial28-day Schedule (Study 3)21-day Schedule (Study 4)
    Efficacy ParameterGemcitabine/CisplatinCisplatinGemcitabine/CisplatinEtoposide/Cisplatin
    Survival
     Median (95% CI a) in months 9.0 (8.2, 11.0)7.6 (6.6, 8.8)8.7 (7.8, 10.1)7.0 (6.0, 9.7)
    p-value bp=0.008p=0.18
    Time to Disease Progression
         Median (95% CI a)in months 5.2 (4.2, 5.7)3.7 (3.0, 4.3)5.0 (4.2, 6.4)4.1 (2.4, 4.5)
         p-value bp=0.009p=0.015
    Tumor Response26%10%33%14%
         p-value bp<0.0001p=0.01

    Figure 3: Kaplan-Meier Survival Curves in Study 3

    Figure 3

    14.4 Pancreatic Cancer

    The efficacy of gemcitabine was evaluated in two trials (Studies 5 and 6), a randomized, single-blind, two-arm, active-controlled trial (Study 5) conducted in patients with locally advanced or metastatic pancreatic cancer who had received no prior chemotherapy and in a single-arm, open-label, multicenter trial (Study 6) conducted in patients with locally advanced or metastatic pancreatic cancer previously treated with fluorouracil or a fluorouracil-containing regimen. In Study 5, patients were randomized to receive either gemcitabine 1000 mg/min 2 intravenously over 30 minutes once weekly for 7 weeks followed by a one-week rest, then once weekly for 3 consecutive weeks every 28-days in subsequent cycles (n=63) or fluorouracil 600 mg/m 2 intravenously over 30 minutes once weekly (n=63). In Study 6, all patients received gemcitabine 1000 mg/m 2 intravenously over 30 minutes once weekly for 7 weeks followed by a one-week rest, then once weekly for 3 consecutive weeks every 28-days in subsequent cycles.

    The major efficacy outcome measure in both trials was “clinical benefit response”. A patient was considered to have had a clinical benefit response if either of the following occurred:

    • The patient achieved a ≥50% reduction in pain intensity (Memorial Pain Assessment Card) or analgesic consumption, or a 20-point or greater improvement in performance status (Karnofsky Performance Status) for a period of at least 4 consecutive weeks, without showing any sustained worsening in any of the other parameters. Sustained worsening was defined as 4 consecutive weeks with either any increase in pain intensity or analgesic consumption or a 20-point decrease in performance status occurring during the first 12 weeks of therapy.

    OR

    • The patient was stable on all of the aforementioned parameters and showed a marked, sustained weight gain (≥7% increase maintained for ≥4 weeks) not due to fluid accumulation.

    Study 5 enrolled 126 patients. Demographics and baseline characteristics were similar between the arms (Table 22).

    The efficacy results are shown in Table 23 and Figure 4. Patients treated with gemcitabine had statistically significant increases in clinical benefit response, survival, and time to disease progression compared to those randomized to receive fluorouracil. No confirmed objective tumor responses were observed in either treatment arm.

    Table 22: Baseline Demographics and Clinical Characteristics for Study 5

    a Karnofsky Performance Status.

    Gemcitabine
    (N= 63)     		Fluorouracil
    (N= 63)
    Male54%54%
    Median age, years6261
    Range37 to 7936 to 77
    Stage IV disease71%76%
    Baseline KPS a ≤70 70%68%
    Table 23: Efficacy Results in Study 5

    a p-value for clinical benefit response calculated using the two-sided test for difference in binomial proportions. All other p- values are calculated using log-rank test.

    Efficacy ParameterGemcitabine
    (N= 63)     		Fluorouracil
    (N= 63)
    Clinical Benefit Response22.2%4.8%
    p-value ap=0.004
    Survival
          Median (95% CI) in months5.7 (4.7, 6.9) 4.2 (3.1, 5.1)
          p-value ap=0.0009
    Time to Disease Progression
          Median (95% CI) in months 2.1 (1.9, 3.4) 0.9 (0.9, 1.1)
          p-value ap=0.0013

    Figure 4: Kaplan-Meier Curves for Overall Survival in Study 5

    Figure 4
  • 15 REFERENCES

    1.“OSHA Hazardous Drugs.”OSHA. http://www.osha.gov/SLTC/hazardousdrugs/index.html

  • 16 HOW SUPPLIED/STORAGE AND HANDLING

    Gemcitabine Injection is a clear colorless to pale yellow solution available in sterile multiple-dose vials containing:

    VialNDC number
    200 mg/2 mL (100 mg/mL)
    1 g/10 mL (100 mg/mL)
    1.5 g/15 mL (100 mg/mL)
    2 g/ 20 mL (100 mg/mL)     		16729-391-30
    16729-419-03
    16729-423-33
    16729-426-05

    Store at 20°C to 25°C (68°F to 77°F); excursions permitted between 15° C and 30°C (59°F and 86°F) [see USP Controlled Room Temperature].

    After initial puncture, Gemcitabine Injection multiple-dose vials are stable for 28 days when stored at room temperature.

    Gemcitabine Injection is a cytotoxic drug. Follow applicable special handling and disposal procedures. 1

  • 17 PATIENT COUNSELING INFORMATION

    Myelosuppression

    Advise patients of the risks of myelosuppression. Instruct patients to immediately contact their healthcare provider should any signs or symptoms of infection, including fever, or if bleeding or signs of anemia, occur [see Warnings and Precautions ( 5.2)].

    Pulmonary Toxicity

    Advise patients of the risks of pulmonary toxicity, including respiratory failure and death. Instruct patients to immediately contact their healthcare provider for development of shortness of breath, wheezing, or cough [see Warnings and Precautions ( 5.3)].

    Hemolytic Uremic Syndrome and Renal Failure

    Advise patients of the risks of hemolytic uremic syndrome and associated renal failure. Instruct patients to immediately contact their healthcare provider for changes in the color or volume of urine output or for increased bruising or bleeding [see Warnings and Precautions ( 5.4)].

    Hepatic Toxicity

    Advise patients of the risks of hepatic toxicity including liver failure and death. Instruct patients to immediately contact their healthcare provider for signs of jaundice or for pain/tenderness in the right upper abdominal quadrant [see Warnings and Precautions ( 5.5)].

    Embryo-Fetal Toxicity

    Advise females and males of reproductive potential that Gemcitabine Injection can cause fetal harm. Advise females of reproductive potential to use effective contraception during treatment with Gemcitabine Injection and for 6 months after the final dose. Advise male patients with female partners of reproductive potential to use effective contraception during treatment with Gemcitabine Injection and for 3 months after the final dose [see Warnings and Precaution ( 5.6), Use in Specific Populations ( 8.1, 8.3)].

    Lactation

    Advise women not to breastfeed during treatment with Gemcitabine Injection and for at least one week after the last dose [see Use in Specific Populations ( 8.2)].

    Infertility

    Advise males of reproductive potential of the potential for reduced fertility with Gemcitabine Injection [see Use in Specific Populations ( 8.3), Nonclinical Toxicology ( 13.1)].

  • SPL UNCLASSIFIED SECTION

    Manufactured For:
    Accord Healthcare, Inc.,
    1009, Slater Road,
    Suite 210-B,
    Durham, NC 27703,
    USA.

    Manufactured By:
    Intas Pharmaceuticals Limited,
    Plot No.: 457, 458, Village – Matoda,
    Bavla Road, Ta.- Sanand,
    Dist.- Ahmedabad – 382 210, INDIA.

    Issued June 2019

  • PRINCIPAL DISPLAY PANEL

    PACKAGE CARTON – 200 mg/2 mL

    NDC 16729- 391-30

    Gemcitabine Injection

    200 mg/2 mL (100 mg/mL)

    For Intravenous Infusion Only

    Must be Diluted Before Use

    Discard 28 days after initial puncture

    CAUTION: Cytotoxic Agent

    Rx only

    Sterile   Multiple-Dose Vial

    Gemcitabine 200 mg carton 1ct
  • PRINCIPAL DISPLAY PANEL

    PACKAGE CONTAINER – 200 mg/2 mL

    NDC 16729- 391-30      Rx only

    Gemcitabine Injection

    200 mg/2 mL (100 mg/mL)

    For Intravenous Infusion Only

    Must be Diluted Before Use

    Multiple-Dose Vial      Sterile

    Gemcitabine 200 mg/2 mL 1ct
  • PRINCIPAL DISPLAY PANEL

    PACKAGE CARTON – 1 g/10 mL

    NDC 16729- 419-03

    Gemcitabine Injection

    1 g/10 mL (100 mg/mL)

    For Intravenous Infusion Only

    Must be Diluted Before Use

    Discard 28 days after initial puncture

    CAUTION: Cytotoxic Agent

    Rx only

    Sterile  Multiple-Dose Vial

    Gemcitabine 1 g/10 mL
  • PRINCIPAL DISPLAY PANEL

    PACKAGE CONTAINER – 1 g/10 mL

    NDC 16729- 419-03      Rx only

    Gemcitabine Injection

    1 g/10 mL (100 mg/mL)

    For Intravenous Infusion Only

    Must be Diluted Before Use

    Multiple-Dose Vial      Sterile

    Gemcitabine 1g/10 mL
  • PRINCIPAL DISPLAY PANEL

    PACKAGE CARTON – 1.5 g/15 mL

    NDC 16729- 423-33

    Gemcitabine Injection

    1.5 g/15 mL (100 mg/mL)

    For Intravenous Infusion Only

    Must be Diluted Before Use

    Discard 28 days after initial puncture

    CAUTION: Cytotoxic Agent

    Rx only

    Sterile   Multiple-Dose Vial

    Gemcitabine 1.5 g/15 mL
  • PRINCIPAL DISPLAY PANEL

    PACKAGE CONTAINER – 1.5 g/15 mL

    NDC 16729- 423-33      Rx only

    Gemcitabine Injection

    1.5 g/15 mL (100 mg/mL)

    For Intravenous Infusion Only

    Must be Diluted Before Use

    Multiple-Dose Vial      Sterile

    Gemcitabine 1.5g/15 mL
  • PRINCIPAL DISPLAY PANEL

    PACKAGE CARTON – 2 g/20 mL

    NDC 16729- 426-05

    Gemcitabine Injection

    2 g/20 mL (100 mg/mL)

    For Intravenous Infusion Only

    Must be Diluted Before Use

    Discard 28 days after initial puncture

    CAUTION: Cytotoxic Agent

    Rx only

    Sterile   Multiple-Dose Vial

    Gemcitabine 2 g/20 mL
  • PRINCIPAL DISPLAY PANEL

    PACKAGE CONTAINER – 2 g/20 mL

    NDC 16729- 426-05      Rx only

    Gemcitabine Injection

    2 g/20 mL (100 mg/mL)

    For Intravenous Infusion Only

    Must be Diluted Before Use

    Multiple-Dose Vial      Sterile

    Gemcitabine 2g/20 mL
  • INGREDIENTS AND APPEARANCE
    GEMCITABINE 
    gemcitabine injection, solution
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC: 16729-391
    Route of AdministrationINTRAVENOUS
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    GEMCITABINE HYDROCHLORIDE (UNII: U347PV74IL) (GEMCITABINE - UNII:B76N6SBZ8R) GEMCITABINE100 mg  in 1 mL
    Inactive Ingredients
    Ingredient NameStrength
    ALCOHOL (UNII: 3K9958V90M)  
    POLYETHYLENE GLYCOL 300 (UNII: 5655G9Y8AQ) 250 mg  in 1 mL
    PROPYLENE GLYCOL (UNII: 6DC9Q167V3) 150 mg  in 1 mL
    SODIUM HYDROXIDE (UNII: 55X04QC32I) 16 mg  in 1 mL
    HYDROCHLORIC ACID (UNII: QTT17582CB)  
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC: 16729-391-302 mL in 1 VIAL, MULTI-DOSE; Type 0: Not a Combination Product01/24/2018
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    NDANDA20960401/24/2018
    GEMCITABINE 
    gemcitabine injection, solution
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC: 16729-419
    Route of AdministrationINTRAVENOUS
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    GEMCITABINE HYDROCHLORIDE (UNII: U347PV74IL) (GEMCITABINE - UNII:B76N6SBZ8R) GEMCITABINE100 mg  in 1 mL
    Inactive Ingredients
    Ingredient NameStrength
    ALCOHOL (UNII: 3K9958V90M)  
    POLYETHYLENE GLYCOL 300 (UNII: 5655G9Y8AQ) 250 mg  in 1 mL
    PROPYLENE GLYCOL (UNII: 6DC9Q167V3) 150 mg  in 1 mL
    SODIUM HYDROXIDE (UNII: 55X04QC32I) 16 mg  in 1 mL
    HYDROCHLORIC ACID (UNII: QTT17582CB)  
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC: 16729-419-0310 mL in 1 VIAL, MULTI-DOSE; Type 0: Not a Combination Product01/25/2018
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    NDANDA20960401/25/2018
    GEMCITABINE 
    gemcitabine injection, solution
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC: 16729-423
    Route of AdministrationINTRAVENOUS
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    GEMCITABINE HYDROCHLORIDE (UNII: U347PV74IL) (GEMCITABINE - UNII:B76N6SBZ8R) GEMCITABINE100 mg  in 1 mL
    Inactive Ingredients
    Ingredient NameStrength
    ALCOHOL (UNII: 3K9958V90M)  
    POLYETHYLENE GLYCOL 300 (UNII: 5655G9Y8AQ) 250 mg  in 1 mL
    PROPYLENE GLYCOL (UNII: 6DC9Q167V3) 150 mg  in 1 mL
    SODIUM HYDROXIDE (UNII: 55X04QC32I) 16 mg  in 1 mL
    HYDROCHLORIC ACID (UNII: QTT17582CB)  
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC: 16729-423-3315 mL in 1 VIAL, MULTI-DOSE; Type 0: Not a Combination Product01/24/2018
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    NDANDA20960401/24/2018
    GEMCITABINE 
    gemcitabine injection, solution
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC: 16729-426
    Route of AdministrationINTRAVENOUS
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    GEMCITABINE HYDROCHLORIDE (UNII: U347PV74IL) (GEMCITABINE - UNII:B76N6SBZ8R) GEMCITABINE100 mg  in 1 mL
    Inactive Ingredients
    Ingredient NameStrength
    PROPYLENE GLYCOL (UNII: 6DC9Q167V3) 150 mg  in 1 mL
    SODIUM HYDROXIDE (UNII: 55X04QC32I) 16 mg  in 1 mL
    HYDROCHLORIC ACID (UNII: QTT17582CB)  
    ALCOHOL (UNII: 3K9958V90M)  
    POLYETHYLENE GLYCOL 300 (UNII: 5655G9Y8AQ) 250 mg  in 1 mL
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC: 16729-426-0520 mL in 1 VIAL, MULTI-DOSE; Type 0: Not a Combination Product08/06/2018
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    NDANDA20960408/06/2018
    Labeler - Accord Healthcare Inc. (604222237)
    Registrant - Accord Healthcare Inc. (604222237)
    Establishment
    NameAddressID/FEIBusiness Operations
    Intas Pharmaceuticals Limited725927649manufacture(16729-391, 16729-419, 16729-423, 16729-426) , analysis(16729-391, 16729-419, 16729-423, 16729-426)
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