GEMCITABINE HYDROCHLORIDE injection, powder, lyophilized, for solution

gemcitabine hydrochloride by

Drug Labeling and Warnings

gemcitabine hydrochloride by is a Prescription medication manufactured, distributed, or labeled by Gland Pharma Limited. Drug facts, warnings, and ingredients follow.

Drug Details [pdf]

  • 1 INDICATIONS AND USAGE

    1.1 Ovarian Cancer

    Gemcitabine for 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 for 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 for 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 for 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 for 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 for Injection is 1000 mg/m2 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 for Injection administration. Refer to carboplatin prescribing information for additional information.

    Dosage Modifications
    Recommended Gemcitabine for Injection dosage modifications for myelosuppression are described in Tables 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 for Injection for Myelosuppression on Day of Treatment in Ovarian Cancer


    Treatment Day
    		Absolute Neutrophil Count
    (x 106/L)

    		Platelet Count
    (x 106/L)
    		Dosage Modification
    Day 1
    		Greater than or equal to 1500
    		And
    		Greater than or equal to 100,000
    		None
    Less than 1500
    		Or
    		Less than 100,000
    		Delay Treatment Cycle
    Day 8
    		Greater than or equal to 1500
    		And
    		Greater than or equal to 100,000
    		None
    1000 to 1499
    		Or
    		75,000 to 99,999
    		50% of full dose
    Less than 1000
    		Or
    		Less than 75,000
    		Hold










    Table 2: Recommended Dosage Modifications for Gemcitabine for Injection for Myelosuppression in Previous Cycle in Ovarian Cancer

    Occurrence
    		Myelosuppression During Treatment Cycle
    		Dosage Modification
    Initial Occurrence
    • Absolute neutrophil count less than 500 x 106/L for more than 5 days or
    • Absolute neutrophil count less than 100 x 106/L for more than 3 days or
    • Febrile neutropenia or
    • Platelets less than 25,000 x 106/L or
    • Cycle delay for more than one week due to toxicity
    		Permanently reduce Gemcitabine for Injection to 800 mg/m2 on Days 1 and 8
    Subsequent Occurrence
    		If any of the above toxicities occur after the initial dose reduction:
    		Permanently reduce Gemcitabine for Injection to 800 mg/m2 on Day 1 only

    2.2 Breast Cancer


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

    Dosage Modifications
    Recommended Gemcitabine for 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 for Injection for Myelosuppression on Day of Treatment in Breast Cancer

    Treatment Day
    		Absolute Neutrophil Count
    (x 106/L)
    		 
    		Platelet Count
    (x 106/L)
    		Dosage Modification
    Day 1
    		Greater than or equal to 1500
    		And
    		Greater than or equal to 100,000
    		None
    Less than 1500
    		Or
    		Less than 100,000
    		Hold
    Day 8
    		Greater than or equal to 1200
    		And
    		Greater than 75,000
    		None
    1000 to 1199
    		Or
    		50,000 to 75,000
    		75% of full dose
    700 to 999
    		And
    		Greater than or equal to 50,000
    		50% of full dose
    Less than 700
    		Or
    		Less than 50,000
    		Hold

    2.3 Non-Small Cell Lung Cancer

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

    21-day schedule
    The recommended dosage of Gemcitabine for Injection is 1250 mg/m2 intravenously over 30 minutes on Days 1 and 8 of each 21-day cycle in combination with cisplatin 100 mg/m2 administered intravenously on Day 1 after Gemcitabine for Injection administration.

    Refer to cisplatin prescribing information for additional information.

    Dosage Modifications
    Recommended dosage modifications for Gemcitabine for 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 for Injection is 1000 mg/m2 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 cycles.

    Dosage Modifications
    Recommended dosage modifications for Gemcitabine for 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 for Injection for Myelosuppression in Pancreatic Cancer and Non-Small Cell Lung Cancer


    Absolute Neutrophil Count
    (x 106/L)

    		Platelet Count
    (x 106/L)
    		Dosage Modification
    Greater than or equal to 1000
    		And
    		Greater than or equal to 100,000
    		None
    500 to 999
    		Or
    		50,000 to 99,999
    		75% of full dose
    Less than 500
    		Or
    		Less than 50,000
    		Hold

    2.5 Dosage Modifications for Non-Hematologic Adverse Reactions


    Permanently discontinue Gemcitabine for 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 for 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


     Gemcitabine for Injection vials contain no antimicrobial preservatives and are intended for single use only.
     Gemcitabine for Injection is a cytotoxic drug. Follow applicable special handling and disposal procedures.1
     Exercise caution and wear gloves when preparing Gemcitabine for Injection solutions. Immediately wash the skin thoroughly or rinse the mucosa with copious amounts of water if Gemcitabine for
        Injection contacts the skin or mucus membranes. Death has occurred in animal studies due to dermal absorption.
     Reconstitute the 200 mg vial with 5 mL and the 1 gram vial with 25 mL of 0.9% Sodium Chloride Injection, USP to yield a Gemcitabine for Injection concentration of 38 mg/mL. Reconstituted
        Gemcitabine for Injection is a clear, colorless to light straw-colored solution.
     Visually inspect reconstituted product for particulate matter and discoloration. Discard if particulate matter or discoloration is observed.
     Withdraw the calculated dose from the vial and discard any unused portion.
     Prior to administration, dilute the reconstituted solution with 0.9% Sodium Chloride Injection, USP to a minimum final concentration of at least 0.1 mg/mL.
     Store Gemcitabine for Injection solutions (reconstituted and diluted) at controlled room temperature of 20°C to 25°C (68°F to 77°F). Do not refrigerate as crystallization can occur. Discard Gemcitabine for Injection solutions if not used within 24 hours after reconstitution.
     No incompatibilities have been observed with infusion bottles or polyvinyl chloride bags and administration sets.

  • 3 DOSAGE FORMS AND STRENGTHS


    Gemcitabine for Injection, USP is a white to off-white lyophilized powder available in sterile single-dose vials containing 200 mg or 1 gram gemcitabine.

  • 4 CONTRAINDICATIONS


    Gemcitabine for 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 for Injection, 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 for Injection is influenced by the length of the infusion [see Clinical Pharmacology (12.3)]. Refer to the recommended Gemcitabine for 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 for Injection as a single agent and the risks are increased when Gemcitabine for Injection 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 for Injection. 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 for Injection in combination with another drug [see Adverse Reactions (6.1)].

    Prior to each dose of Gemcitabine for Injection, obtain a complete blood count (CBC) with a differential and a platelet count. Modify the 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 for Injection [see Adverse Reactions (6.1, 6.2)].

    Permanently discontinue Gemcitabine for 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 for Injection. 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 other than HUS have been reported with Gemcitabine for Injection [see Adverse Reactions (6.2)].
     

    Assess renal function prior to initiation of Gemcitabine for 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 for 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 for Injection alone or with other potentially hepatotoxic drugs [see Adverse Reactions (6.1, 6.2)]. Administration of Gemcitabine for Injection 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 for Injection and periodically during treatment. Permanently discontinue Gemcitabine for Injection in patients who develop severe hepatic toxicity.

    5.6 Embryo-Fetal Toxicity


    Based on animal data and its mechanism of action, Gemcitabine for 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 for 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 for 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 for Injection 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 for Injection was administered at a dose of 1000 mg/m2 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 for Injection is administered more than 7 days before or after radiation. Radiation recall has been reported in patients who received Gemcitabine for Injection after prior radiation.

    5.8 Capillary Leak Syndrome

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

    5.9 Posterior Reversible Encephalopathy Syndrome


    Posterior reversible encephalopathy syndrome (PRES) has been reported in patients receiving Gemcitabine for Injection 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 for 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 for Injection as a single agent administered at doses between 800 mg/m2 to 1250 mg/m2 intravenously over 30 minutes once weekly in 979 patients with various malignancies. The most common (≥20%) adverse reactions of single agent Gemcitabine for Injection 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 for Injection due to adverse reactions. Adverse reactions resulting in discontinuation of Gemcitabine for Injection in 2% of 979 patients were cardiovascular adverse reactions (myocardial infarction, cerebrovascular accident, arrhythmia, and hypertension) and adverse reactions resulting in discontinuation of Gemcitabine for Injection 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 for Injection 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 for Injectiona


    Adverse Reactionsb
    		Gemcitabine for Injectionc
    All Grades (%)
    		Grade 3 (%)
    		Grade 4 (%)
    Nausea and Vomiting
    		69
    		13
    		1
    Fever
    		41
    		2
    		0
    Rash
    		30
    		<1
    		0
    Dyspnea
    		23
    		3
    		<1
    Diarrhea
    		19
    		1
    		0
    Hemorrhage
    		17
    		<1
    		<1
    Infection
    		16
    		1
    		<1
    Alopecia
    		15
    		<1
    		0
    Stomatitis
    		11
    		<1
    		0
    Somnolence
    		11
    		<1
    		<1
    Paresthesias
    		10
    		<1
    		0

    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.
    Table 6: Selected Laboratory Abnormalities Occurring in Patients Receiving Single Agent Gemcitabine for Injectiona


    Laboratory Abnormalityb
    		Gemcitabine for Injectionc
    All Grades (%)
    		Grade 3 (%)
    		Grade 4 (%)
    Hematologic
    		 
    		 
    		 
          Anemia
    		68
    		7
    		1
          Neutropenia
    		63
    		19
    		6
          Thrombocytopenia
    		24
    		4
    		1
    Hepatic
    		 
    		 
    		 
          Increased ALT
    		68
    		8
    		2
          Increased AST
    		67
    		6
    		2
          Increased Alkaline Phosphatase
    		55
    		7
    		2
          Hyperbilirubinemia
    		13
    		2
    		<1
    Renal
    		 
    		 
    		 
          Proteinuria
    		45
    		<1
    		0
          Hematuria
    		35
    		<1
    		0
          Increased BUN
    		16
    		0
    		0
          Increased Creatinine
    		8
    		<1
    		0

    a  Grade based on criteria from the WHO.
    b  Regardless of causality.
    c  N=699-974; all patients with laboratory or non-laboratory data.

    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, asthenia 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 for Injection-treated patients and at a higher incidence in the Gemcitabine for Injection with carboplatin arm, reported in a randomized trial (Study 1) of Gemcitabine for Injection 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 for Injection occurred in 10% of patients and Gemcitabine for Injection dose was omitted in 14% of patients in the Gemcitabine for Injection/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 1a


     
     
    Adverse Reactionsb
    		Gemcitabine for Injection/Carboplatin
    (N=175)
    		Carboplatin
    (N=174)
    All Grades
    (%)
    		Grade 3
    (%)
    		Grade 4
    (%)
    		All Grades
    (%)
    		Grade 3
    (%)
    		Grade 4
    (%)
        Nausea
    		69
    		6
    		0
    		61
    		3
    		0
        Alopecia
    		49
    		0
    		0
    		17
    		0
    		0
        Vomiting
    		46
    		6
    		0
    		36
    		2
    		<1
        Constipation
    		42
    		6
    		1
    		37
    		3
    		0
        Fatigue
    		40
    		3
    		<1
    		32
    		5
    		0
        Diarrhea
    		25
    		3
    		0
    		14
    		<1
    		0
       Stomatitis/Pharyngitis
    		22
    		<1
    		0
    		13
    		0
    		0

    a   Grade based on National Cancer Institute CTC Version 2.0.
    b   Regardless of causality.


    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 1a


     
     
    Laboratory Abnormalityb
    		Gemcitabine for Injection/Carboplatin
    (N=175)
    		Carboplatin
    (N=174)
    All Grades
    (%)
    		Grade 3
    (%)
    		Grade 4
    (%)
    		All Grades
    (%)
    		Grade 3
    (%)
    		Grade 4
    (%)
    Hematologic
    		 
    		 
    		 
    		 
    		 
    		 
         Neutropenia
    		90
    		42
    		29
    		58
    		11
    		1
         Anemia
    		86
    		22
    		6
    		75
    		9
    		2
         Thrombocytopenia
    		78
    		30
    		5
    		57
    		10
    		1
         RBC Transfusionsc
    		38
    		-
    		-
    		15
    		-
    		-
         Platelet Transfusionsc
    		9
    		-
    		-
    		3
    		-
    		-

    a Grade based on National Cancer Institute CTC Version 2.0.
    b Regardless of causality.
    c Percent of patients receiving transfusions. Transfusions are not CTC-graded events. Blood transfusions included both packed red blood cells and whole blood.

    Hematopoietic growth factors were administered more frequently in the Gemcitabine for Injection-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 for Injection 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 for Injection-treated patients and at a higher incidence in the Gemcitabine for Injection with paclitaxel arm, reported in a randomized trial (Study 2) of Gemcitabine for Injection 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 for Injection/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 2a



     
     
    Adverse Reactionsb
    		Gemcitabine for Injection/Paclitaxel
    (N=262)
    		Paclitaxel
    (N=259)
    All Grades
    (%)
    		Grade 3
    (%)
    		Grade 4
    (%)
    		All Grades
    (%)
    		Grade 3
    (%)
    		Grade 4
    (%)
    Alopecia
    		90
    		14
    		4
    		92
    		19
    		3
    Neuropathy-Sensory
    		64
    		5
    		<1
    		58
    		3
    		0
    Nausea
    		50
    		1
    		0
    		31
    		2
    		0
    Fatigue
    		40
    		6
    		<1
    		28
    		1
    		<1
    Vomiting
    		29
    		2
    		0
    		15
    		2
    		0
    Diarrhea
    		20
    		3
    		0
    		13
    		2
    		0
    Anorexia
    		17
    		0
    		0
    		12
    		<1
    		0
    Neuropathy-Motor
    		15
    		2
    		<1
    		10
    		<1
    		0
    Stomatitis/Pharyngitis
    		13
    		1
    		<1
    		8
    		<1
    		0
    Fever
    		13
    		<1
    		0
    		3
    		0
    		0
    Rash/Desquamation
    Febrile Neutropenia
    		11
    6
    		<1
    5
    		<1
    <1
    		5
    2
    		0
    1
    		0
    0

    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.

    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 2a



     
     
    Laboratory Abnormalityb
    		Gemcitabine for Injection/ Paclitaxel
    (N=262)
    		Paclitaxel
    (N=259)
    All Grades
    (%)
    		Grade 3
    (%)
    		Grade 4
    (%)
    		All Grades
    (%)
    		Grade 3
    (%)
    		Grade 4
    (%)
    Hematologic
    		 
    		 
    		 
    		 
    		 
    		 
         Anemia
    		69
    		6
    		1
    		51
    		3
    		<1
         Neutropenia
    		69
    		31
    		17
    		31
    		4
    		7
         Thrombocytopenia
    		26
    		5
    		<1
    		7
    		<1
    		<1
    Hepatobiliary
    		 
    		 
    		 
    		 
    		 
    		 
         Increased ALT
    		18
    		5
    		<1
    		6
    		<1
    		0
         Increased AST
    		16
    		2
    		0
    		5
    		<1
    		0

    a  Grade based on National Cancer Institute CTC Version 2.0.
    b  Regardless of causality.

    Clinically relevant Grade 3 or 4 dyspnea occurred with a higher incidence in the Gemcitabine for Injection 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 for Injection-treated patients and at a higher incidence in the Gemcitabine for Injection with cisplatin arm, reported in a randomized trial (Study 3) of Gemcitabine for Injection 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 for Injection 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 for Injection 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 for Injection 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 3a


     
    Adverse Reactionsb
    		Gemcitabine for Injection/Cisplatinc
    		Cisplatind
    All Grades (%)
    		Grade 3 (%)
    		Grade 4 (%)
    		All Grades (%)
    		Grade 3 (%)
    		Grade 4 (%)
        Nausea
    		93
    		25
    		2
    		87
    		20
    		<1
        Vomiting
    		78
    		11
    		12
    		71
    		10
    		9
        Alopecia
    		53
    		1
    		0
    		33
    		0
    		0
        Neuro Motor
    		35
    		12
    		0
    		15
    		3
    		0
        Diarrhea
    		24
    		2
    		2
    		13
    		0
    		0
        Neuro Sensory
    		23
    		1
    		0
    		18
    		1
    		0
        Infection
    		18
    		3
    		2
    		12
    		1
    		0
        Fever
    		16
    		0
    		0
    		5
    		0
    		0
        Neuro Cortical
    		16
    		3
    		1
    		9
    		1
    		0
        Neuro Mood
    		16
    		1
    		0
    		10
    		1
    		0
        Local
    		15
    		0
    		0
    		6
    		0
    		0
        Neuro Headache
    		14
    		0
    		0
    		7
    		0
    		0
        Stomatitis
    		14
    		1
    		0
    		5
    		0
    		0
        Hemorrhage
    		14
    		1
    		0
    		4
    		0
    		0
        Hypotension
    		12
    		1
    		0
    		7
    		1
    		0
        Rash
    		11
    		0
    		0
    		3
    		0
    		0

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


    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 3a


     
     
    Laboratory Abnormalityb
    		Gemcitabine for Injection/Cisplatin
    		Cisplatin
    All Grades (%)
    		Grade 3 (%)
    		Grade 4 (%)
    		All Grades (%)
    		Grade 3 (%)
    		Grade 4 (%)
    Hematologic
    		 
    		 
    		 
    		 
    		 
    		 
         Anemia
    		89
    		22
    		3
    		67
    		6
    		1
         Thrombocytopenia
    		85
    		25
    		25
    		13
    		3
    		1
         Neutropenia
    		79
    		22
    		35
    		20
    		3
    		1
         Lymphopenia
         RBC Transfusionse
         Platelet Transfusionse
    		75
    39
    21
    		25
    -
    -
    		18
    -
    -
    		51
    13
    <1
    		12
    -
    -
    		5
    -
    -
    Hepatic
    		 
    		 
    		 
    		 
    		 
    		 
         Increased Transaminases
    		22
    		2
    		1
    		10
    		1
    		0
         Increased Alkaline
         Phosphatase
    		19
    		1
    		0
    		13
    		0
    		0
    Renal
         Increased Creatinine
    		 
    38
    		 
    4
    		 
    <1
    		 
    31
    		 
    2
    		 
    <1
         Proteinuria
    		23
    		0
    		0
    		18
    		0
    		0
         Hematuria
    		15
    		0
    		0
    		13
    		0
    		0
    Other Laboratory
    		 
    		 
    		 
    		 
    		 
    		 
         Hyperglycemia
    		30
    		4
    		0
    		23
    		3
    		0
         Hypomagnesemia
    		30
    		4
    		3
    		17
    		2
    		0
         Hypocalcemia
    		18
    		2
    		0
    		7
    		0
    		<1

    a  Grade based on National Cancer Institute CTC.
    b  Regardless of causality.
    c  N=217-253; all Gemcitabine for Injection/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 transfusions. Percent transfusions are not CTC-graded events.

    Tables 13 and 14 present the incidence of selected adverse reactions and laboratory abnormalities occurring in ≥10% of Gemcitabine for Injection-treated patients and at a higher incidence in the Gemcitabine for Injection with cisplatin arm, reported in a randomized trial (Study 4) of Gemcitabine for Injection 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 for Injection/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 4a



    Adverse Reactionsb
    		Gemcitabine for Injection/Cisplatinc
    		Etoposide/Cisplatind
    All Grades
    (%)
    		Grade 3
    (%)
    		Grade 4
    (%)
    		All Grades
    (%)
    		Grade 3
    (%)
    		Grade 4
    (%)
        Nausea and Vomiting
    		96
    		35
    		4
    		86
    		19
    		7
        Alopecia
    		77
    		13
    		0
    		92
    		51
    		0
        Paresthesias
    		38
    		0
    		0
    		16
    		2
    		0
        Infection
    		28
    		3
    		1
    		21
    		8
    		0
        Stomatitis
    		20
    		4
    		0
    		18
    		2
    		0
        Diarrhea
    		14
    		1
    		1
    		13
    		0
    		2
        Edemae
    		12
    		-
    		-
    		2
    		-
    		-
        Rash
    		10
    		0
    		0
    		3
    		0
    		0
        Hemorrhage
    		9
    		0
    		3
    		3
    		0
    		3
        Fever
    		6
    		0
    		0
    		3
    		0
    		0
        Somnolence
    		3
    		0
    		0
    		3
    		2
    		0
        Flu-like Syndromee
    		3
    		-
    		-
    		0
    		-
    		-
        Dyspnea
    		1
    		0
    		1
    		3
    		0
    		0

    a Grade based on criteria from the WHO.
    b Non-laboratory events were graded only if assessed to be possibly drug-related. Pain data were not collected.
    c N=67-69; all Gemcitabine for Injection/cisplatin patients with laboratory or non-laboratory data.
    d N=57-63; all Etoposide/cisplatin patients with laboratory or non-laboratory data.
    e Flu-like syndrome and edema were not graded.
    Table 14: Selected Laboratory Abnormalities Occurring in Patients Receiving Gemcitabine with Cisplatin in Study 4a



     
     
    Laboratory Abnormalityb
    		Gemcitabine for Injection/ Cisplatinc
    		Etoposide/Cisplatind
    All Grades
    (%)
    		Grade 3
    (%)
    		Grade 4
    (%)
    		All Grades
    (%)
    		Grade 3
    (%)
    		Grade 4
    (%)
    Hematologic
    		 
    		 
    		 
    		 
    		 
    		 
         Anemia
    		88
    		22
    		0
    		77
    		13
    		2
         Neutropenia
    		88
    		36
    		28
    		87
    		20
    		56
         Thrombocytopenia
    		81
    		39
    		16
    		45
    		8
    		5
         RBC Transfusionse
    		29
    		-
    		-
    		21
    		-
    		-
         Platelet Transfusionse
    		3
    		-
    		-
    		8
    		-
    		-
    Hepatic
    		 
    		 
    		 
    		 
    		 
    		 
         Increased Alkaline
         Phosphatase
    		16
    		0
    		0
    		11
    		0
    		0
         Increased ALT
    		6
    		0
    		0
    		12
    		0
    		0
         Increased AST
    		3
    		0
    		0
    		11
    		0
    		0
    Renal
    		 
    		 
    		 
    		 
    		 
    		 
         Hematuria
    		22
    		0
    		0
    		10
    		0
    		0
         Proteinuria
    		12
    		0
    		0
    		5
    		0
    		0
         Increased BUN
    		6
    		0
    		0
    		4
    		0
    		0
         Increased Creatinine
    		2
    		0
    		0
    		2
    		0
    		0

    a Grade based on criteria from the WHO.
    b Regardless of causality.
    c N=67-69; all Gemcitabine for Injection/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.

    6.2 Postmarketing Experience


    The following adverse reactions have been identified during post approval use of Gemcitabine for Injection. 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: Thrombotic microangiopathy (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)

  • DRUG INTERACTIONS

  • 8 USE IN SPECIFIC POPULATIONS

    8.1 Pregnancy


    Risk Summary
    Based on animal data and its mechanism of action, Gemcitabine for 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 for Injection 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 to 4% and 15 to 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/m2 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/m2 clinical dose based on BSA).

    8.2 Lactation

    Risk Summary
    There is no information regarding the presence of Gemcitabine for Injection 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 from Gemcitabine for Injection, advise women not to breastfeed during treatment with Gemcitabine for 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 for Injection [see Use in Specific Populations (8.1)].

    Contraception
    Gemcitabine for 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 for Injection and for 6 months after the final dose of Gemcitabine for Injection.

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

    Infertility
    Males
    Based on animal studies, Gemcitabine for Injection 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 for Injection 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/m2/min for 360 minutes weekly for three weeks followed by a one-week rest period.

    The safety and activity of Gemcitabine for Injection 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 for Injection, 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 for Injection 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 for Injection clearance is affected by age; however, there are no recommended dose adjustments based on patient's age [see Clinical Pharmacology (12.3)].

    8.6 Gender


    Gemcitabine for Injection clearance is decreased in females [see Clinical Pharmacology (12.3)]. In single agent studies of Gemcitabine for Injection, 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/m2 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 structural formula:




    fig1

    The empirical formula for gemcitabine hydrochloride is C9H11F2N3O4 HCl. It has a molecular weight of 299.66 g/mol.

    Gemcitabine hydrochloride is soluble in water, slightly soluble in methanol, and practically insoluble in ethanol and polar organic solvents.
     
    Gemcitabine for Injection, USP is a sterile white to off-white lyophilized powder and available as 200 mg and 1 gram single-dose vials for intravenous use only. Each 200 mg vial contains 200 mg gemcitabine (equivalent to 227.7 mg gemcitabine hydrochloride), 200 mg mannitol and 12.5 mg sodium acetate. Each 1 gram vial contains 1 gram gemcitabine (equivalent to 1.139 gram gemcitabine hydrochloride), 1 gram mannitol, and 62.5 mg sodium acetate. Hydrochloric acid and/or sodium hydroxide 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 for Injection dose varied from 500 mg/m2 to 3600 mg/m2.

    Distribution 
    The volume of distribution was increased with infusion length. Volume of distribution of gemcitabine was 50 L/m2 following infusions lasting <70 minutes. For long infusions, the volume of distribution rose to 370 L/m2.

    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



    Age
    Clearance Men (L/hr/m2)
    Clearance Women (L/hr/m2)
    Half-Lifea
    Men (min) 
    Half-LifeaWomen (min) 
    29
    		92.2
    		69.4
    		42
    		49
    45
    		75.7
    		57.0
    		48
    		57
    65
    		55.1
    		41.5
    		61
    		73
    79
    		40.7
    		30.7
    		79
    		94

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

    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 for Injection (1250 mg/m2 on Days 1 and 8) and cisplatin (75 mg/m2 on Day 1) were administered in patients with NSCLC, the clearance of gemcitabine on Day 1 was 128 L/hr/m2 and on Day 8 was 107 L/hr/m2. Data from patients with NSCLC demonstrate that Gemcitabine for Injection 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 for Injection 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 for Injection 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/m2 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/m2 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/m2 clinical dose based on BSA).

  • 14 CLINICAL STUDIES

    14.1 Ovarian Cancer


    The efficacy of Gemcitabine for Injection 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 for Injection 1000 mg/m2 on Days 1 and 8 of each 21-day cycle with carboplatin AUC 4 on Day 1 after Gemcitabine for Injection 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 for Injection 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 Injection 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



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

    a 5 patients on Gemcitabine for Injection with carboplatin arm and 4 patients on carboplatin arm had no baseline Eastern Cooperative Oncology Group (ECOG) performance status.
    b 2 patients on Gemcitabine for Injection with carboplatin arm and 1 patient on carboplatin arm had platinum-free interval <6 months.

    Table 17: Efficacy Results in Study 1




    Efficacy Parameter
    		Gemcitabine for Injection/Carboplatin
    (N=178)
    		Carboplatin
    (N=178)
    Progression-Free Survival
    Median (95% C Ia) in mon ths
    		8 .6 (8 .0, 9 .7)
    		5 .8 (5 .2, 7 .1)
         Hazard Ratio (95% CI)
    		0 .72 (0 .57, 0 .90)
         p-valueb
    		p =0 .0038
    O vera ll Su r v i val
    Median (95% C I) in mon ths
    		18 .0 (16 .2, 20 .3)
    		17 .3 (15 .2, 19 .3)
          Hazard Ratio (95% CI)
    		0 .98 (0 .78, 1 .24)
          p-valueb
    		p =0 .8977
    O vera ll Response Rate by
    I n vest igator Re v i ew
    		47 .2%
    		30 .9%
          p- valuec
    		p =0 .0016
          CRd
    		14 .6%
    		6 .2%
          PR wi th P RNMe
    		32 .6%
    		24 .7%
    O vera ll Response Ratef by
    Independent Re v i ew
    		46 .3%
    		35 .6%
            p- valuec
    		p =0 .11
            CRd
    		9 .1%
    		4 .0%
            PR wi th P RNMe
    		37 .2%
    		31 .7%

    a CI=confidence interval.
    b Log rank, unadjusted.
    c Chi square.
    d CR=Complete response.
    e PR with PRNM=Partial response with partial response, non-measurable disease.
    f Independently reviewed cohort – Gemcitabine for Injection/carboplatin (n=121), carboplatin (n=101); independent reviewers unable to measure disease detected by sonography or physical exam.

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



    fig2

    14.2 Breast Cancer


    The efficacy of Gemcitabine for Injection 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 for Injection 1250 mg/m2 on Days 1 and 8 of each 21-day cycle with paclitaxel 175 mg/m2 administered on Day 1 before Gemcitabine for Injection 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 for Injection 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


     
    		Gemcitabine for Injection/Paclitaxel
    (N=267)
    		Paclitaxel
    (N=262)
    Median age, years
      Range
    		53
    26 to 83
    		52
    26 to 75
    Metastatic disease
    		97%
    		97%
    Baseline KPSa ≥90
    		70%
    		74%
    Number of tumor sites
          1-2
           ≥3
    		 
    57%
    43%
    		 
    59%
    41%
    Visceral disease
    		73%
    		73%
       Prior anthracycline
    		97%
    		96%

    a Karnofsky Performance Status.

    Table 19: Efficacy Results in Study 2



    Efficacy Parameter
    		Gemcitabine for Injection/Paclitaxel
    (N=267)
    		Paclitaxel
    (N=262)
    T ime to Do cu ment ed D isease Prog ress iona
    Median (95% C I) in mon ths
    		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
    O vera ll Su r v i valb
     Median (95% C I) in mon ths
    		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 Signi fi c ant
    O vera ll Response Rate
    		40 .8%
    		22 .1%
        (95% C I)
    		(34 .9, 46 .7)
    		(17 .1, 27 .2)
        p-value
    		p <0 .0001

    a These represent reconciliation of investigator and Independent Review Committee assessments according to a predefined  algorithm.
    b Based on the ITT population.
     
    Figure 2: Kaplan-Meier Curves for Time to Documented Disease Progression in Study 2



    fig3

    14.3 Non-Small Cell Lung Cancer


    The efficacy of Gemcitabine for Injection was evaluated in two randomized, multicenter trials.

    Study 3: 28-Day Schedule
    A multinational, randomized trial (Study 3) compared Gemcitabine for Injection 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 for Injection 1000 mg/m2 on Days 1, 8, and 15 of each 28-day cycle with cisplatin 100 mg/m2 on Day 1 after Gemcitabine for Injection 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 for Injection 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 for Injection 1250 mg/m2 on Days 1 and 8 of each 21-day cycle with cisplatin 100 mg/m2 on Day 1 after Gemcitabine for Injection administration or etoposide 100 mg/m2 intravenously on Days 1, 2, and 3 with cisplatin 100 mg/m2 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 for Injection with cisplatin arm versus 7 months for the etoposide with cisplatin arm. Median time to disease progression for the Gemcitabine for Injection 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 for Injection 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



    Trial
    		28-day Schedule (Study 3)
    		21-day Schedule (Study 4)
     
    		 Gemcitabine for Injection/Cisplatin
    (N=260)
    		Cisplatin
    (N=262)
    		Gemcitabine for Injection/Cisplatin
    (N=69)
    		Etoposide/
    Cisplatin
    (N=66)
    Male
    Median age, years
    Range
    		70%
    62
    36 to 88
    		71%
    63
    35 to 79
    		93%
    58
    33 to 76
    		92%
    60
    35 to 75
    Stage IIIA
    Stage IIIB
    Stage IV
    		7%
    26%
    67%
    		7%
    23%
    70%
    		N/Aa
    48%
    52%
    		N/Aa
    52%
    49%
    Baseline KPSb 70 to 80
    Baseline KPSb 90 to 100
    		41%
    57%
    		44%
    55%
    		45%
    55%
    		52%
    49%







    a N/A Not applicable.
    b Karnofsky Performance Status.

    Table 21: Efficacy Results for Studies 3 and 4



    Trial
    		28-day Schedule (Study 3)
    		21-day Schedule (Study 4)
    Efficacy Parameter
    		Gemcitabine for Injection/
    Cisplatin
    (N=260)
    		Cisplatin
    (N=262)
    		Gemcitabine for Injection/ Cisplatin
    (N=69)
    		Etoposide/Cisplatin
    (N=66)
    Survival
         Median (95% CIa)
         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-valuef
    		p=0.008
    		p=0.18
    Time to Disease Progression
         Median (95% CIa)
         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-valueb
    		p=0.009
    		p=0.05
    Tumor Response
    		26%
    		10%
    		33%
    		14%
         p-valueb
    		p<0.0001
    		p=0.01

    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.

    Figure 3: Kaplan-Meier Curves for Overall Survival in Study 3


    fig4

    14.4 Pancreatic Cancer


    The efficacy of Gemcitabine for Injection 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 for Injection 1000 mg/m2 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/m2 intravenously over 30 minutes once weekly (n=63). In Study 6, all patients received Gemcitabine for Injection 1000 mg/m2 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 for Injection 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

     
    		Gemcitabine for Injection
    (N=63)
    		Fluorouracil
    (N=63)
          Male
    		54%
    		54%
    Median age, years
    		62
    		61
          Range
    		37 to 79
    		36 to 77
    Stage IV disease
    		71%
    		76%
    Baseline KPSa ≤70
    		70%
    		68%

    a   Karnofsky Performance Status.

    Table 23: Efficacy Results in Study 5


    Efficacy Parameter
    		Gemcitabine for Injection
    (N=63)
    		Fluorouracil
    (N=63)
    Clinical Benefit Response
    		22.2%
    		4.8%
          p-valuea
    		                              p=0.004
    Overall Survival
          Median (95% CI) in months
    		                            5.7 (4.7, 6.9)
    		4.2 (3.1, 5.1)
          p-valuea
    		p=0.0009
    Time to Disease Progression
    		 
          Median (95% CI) in months
    		2.1 (1.9, 3.4)
    		0.9 (0.9, 1.1)
          p-valuea
    		p=0.0013

    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.

    Figure 4: Kaplan-Meier Curves for Overall Survival in Study 5
    image5





  • 15 REFERENCES

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

  • 16 HOW SUPPLIED/STORAGE AND HANDLING

    Gemcitabine for Injection, USP is supplied as follows:


    NDC
    		Gemcitabine for Injection, USP
    		Package Factor
    68083-148-01 
    		200 mg Single-Dose Vial
    		1 vial per carton
    68083-149-01 
    		1 gram Single-Dose Vial
    		1 vial per carton

    Gemcitabine for Injection, USP is a sterile white to off-white lyophilized powder.
    Gemcitabine for Injection, USP is a cytotoxic drug. Follow applicable special handling and disposal procedures.1

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

    Sterile, Nonpyrogenic, Preservative-free, Lyophilized.
    The container closure is not made with natural rubber latex.

  • 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 for Injection can cause fetal harm. Advise females of reproductive potential to use effective contraception during treatment with Gemcitabine for 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 for 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 for 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 for Injection [see Use in Specific Populations (8.3), Nonclinical Toxicology (13.1)].

    Manufactured by:
    Gland Pharma Limited


    Visakhapatnam-530049,
    Andhra Pradesh, India.

    Revised: November 2019




  • PACKAGE LABEL.PRINCIPAL DISPLAY PANEL


    GEMCITABINE FOR INJECTION, USP
    200 mg/vial
    Single-Dose Vial
    Vial label


    gemcitabine-vial-label-200-mg



    GEMCITABINE FOR INJECTION, USP
    200 mg/vial
    Single-Dose Vial
    Carton labelgemcitabine-carton-label-200-mg
    GEMCITABINE FOR INJECTION, USP
    1 g/vial
    Single-Dose Vial
    Vial label


    gemcitabine-vial-label-1-g

    GEMCITABINE FOR INJECTION, USP
    1 g/vial
    Single-Dose Vial
    Carton label
    gemcitabine-carton-label-1-g

  • INGREDIENTS AND APPEARANCE
    GEMCITABINE HYDROCHLORIDE 
    gemcitabine hydrochloride injection, powder, lyophilized, for solution
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC: 68083-148
    Route of AdministrationINTRAVENOUS
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    GEMCITABINE HYDROCHLORIDE (UNII: U347PV74IL) (GEMCITABINE - UNII:B76N6SBZ8R) GEMCITABINE200 mg  in 5 mL
    Inactive Ingredients
    Ingredient NameStrength
    MANNITOL (UNII: 3OWL53L36A) 200 mg  in 5 mL
    SODIUM ACETATE (UNII: 4550K0SC9B) 12.5 mg  in 5 mL
    SODIUM HYDROXIDE (UNII: 55X04QC32I)  
    HYDROCHLORIC ACID (UNII: QTT17582CB)  
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC: 68083-148-011 in 1 CARTON02/01/2016
    15 mL in 1 VIAL; Type 0: Not a Combination Product
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    ANDAANDA20452002/01/2016
    GEMCITABINE HYDROCHLORIDE 
    gemcitabine hydrochloride injection, powder, lyophilized, for solution
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC: 68083-149
    Route of AdministrationINTRAVENOUS
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    GEMCITABINE HYDROCHLORIDE (UNII: U347PV74IL) (GEMCITABINE - UNII:B76N6SBZ8R) GEMCITABINE1 g  in 25 mL
    Inactive Ingredients
    Ingredient NameStrength
    MANNITOL (UNII: 3OWL53L36A) 1 g  in 25 mL
    SODIUM ACETATE (UNII: 4550K0SC9B) 62.5 mg  in 25 mL
    SODIUM HYDROXIDE (UNII: 55X04QC32I)  
    HYDROCHLORIC ACID (UNII: QTT17582CB)  
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC: 68083-149-011 in 1 CARTON02/01/2016
    125 mL in 1 VIAL; Type 0: Not a Combination Product
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    ANDAANDA20452002/01/2016
    Labeler - Gland Pharma Limited (918601238)
    Establishment
    NameAddressID/FEIBusiness Operations
    Gland Pharma Limited650540227ANALYSIS(68083-148, 68083-149) , API MANUFACTURE(68083-148) , MANUFACTURE(68083-148, 68083-149) , PACK(68083-148, 68083-149)
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