Herzuma

Trastuzumab.

Active ingredient: trastuzumab.
Dosage preparations: 150 mg single-dose vials, and 440 mg multidose vials containing powder for concentrate for solution for infusion. Reconstituted trastuzumab concentrate contains 21 mg/ml of trastuzumab.

Pharmacotherapeutic Group: Antineoplastic agent. ATC code: LO1 XC03.
Pharmacology: Pharmacodynamics: Mechanism of Action: Trastuzumab is a recombinant humanised monoclonal antibody that selectively targets the extracellular domain of the human epidermal growth factor receptor 2 protein (HER2). The antibody is an IgG, isotype that contains human framework regions with the complementarity-determining regions of a murine anti-p185 HER2 antibody that binds to human HER2.
The HER2 proto-oncogene or c-erbB2 encodes for a single transmembrane spanning, receptor-like protein of 185 kDa, which is structurally related to the epidermal growth factor receptor. Overexpression of HER2 is observed in 15%-20% of primary breast. The overall rate of HER2 positivity in advanced gastric cancers as observed during screening for study BO18255 is 15% for IHC3+ and IHC2+/FISH+ or 22.1% when applying the broader definition of IHC3+ or FISH+. A consequence of HER2 gene amplification is an increase in HER2 protein expression on the surface of these tumour cells, which results in a constitutively activated HER2 protein.
Studies indicate that breast cancer patients whose tumours have amplification or overexpression of HER2 have a shortened disease-free survival compared to patients whose tumours do not have amplification or overexpression of HER2.
Trastuzumab has been shown, both in in-vitro assays and in animals, to inhibit the proliferation of human tumour cells that overexpress HER2. In vitro, trastuzumab-mediated antibody-dependent cell-­mediated cytotoxicity (ADCC) has been shown to be preferentially exerted on HER2 overexpressing cancer cells compared with cancer cells that do not overexpress HER2.
Clinical/ Efficacy Studies: Metastatic Breast Cancer: Trastuzumab monotherapy has been used in clinical trials for patients with metastatic breast cancer who have tumours that overexpress HER2 and who have failed one or more chemotherapy regimens for their metastatic disease.
Trastuzumab has also been used in clinical trials in combination with paclitaxel or an anthracycline (doxorubicin or epirubicin) + cyclophosphamide as first line therapy for patients with metastatic breast cancer who have tumours that overexpress HER2.
Patients who had previously received anthracycline-based adjuvant chemotherapy were treated with paclitaxel (175 mg/m² infused over 3 hours) with or without trastuzumab. Patients could be treated with trastuzumab until progression of disease.
Trastuzumab monotherapy, when used as second- or third-line treatment of women with metastatic breast cancer which overexpresses HER2, results in an overall tumour response rate of 15% and a median survival of 13 months. The use of trastuzumab in combination with paclitaxel as first-line treatment of women with metastatic breast cancer that overexpresses HER2 significantly prolongs the median time to disease progression, compared with patients treated with paclitaxel alone. The increase in median time to disease progression for patients treated with trastuzumab and paclitaxel is 3.9 months (6.9 months versus 3.0 months). Tumour response and one year survival rate are also increased for trastuzumab in combination with paclitaxel versus paclitaxel alone.
Trastuzumab has also been studied in a randomised, controlled trial, in combination with docetaxel, as first-line treatment of women with metastatic breast cancer. The combination of trastuzumab and docetaxel significantly increased response rate (61% versus 34%) and prolonged the median time to disease progression (by 5.6 months), compared with patients treated with docetaxel alone. Median survival was also significantly increased in patients receiving the combination, compared with those receiving docetaxel alone (31.2 months versus 22.7 months).
Combination treatment with trastuzumab and anastrozole: Trastuzumab has been studied in combination with anastrozole for first line treatment of metastatic breast cancer in HER2 overexpressing, hormone-receptor [i.e. oestrogen-receptor (ER) and/or progesterone-receptor (PR)] positive patients. Progression-free survival was doubled in the trastuzumab + anastrozole arm compared to anastrozole (4.8 months versus 2.4 months). For the other parameters the improvements seen for the combination were: for overall response (16.5% versus 6.7%); clinical benefit rate (42.7% versus 27.9%); time to progression (4.8 months versus 2.4 months). For time to response and duration of response no difference could be recorded between the arms. The median overall survival was extended by 4.6 months for patients in the combination arm. The difference was not statistically significant; however, more than half of the patients in the anastrozole alone arm crossed over to a trastuzumab containing regimen after progression of disease. Fifty two percent of the patients taking trastuzumab + anastrozole survived for at least 2 years compared to 45% taking anastrozole alone.
Early Breast Cancer: In the adjuvant setting, trastuzumab was investigated in 4 large multicentre, randomised, phase 3 trials: The Study BO16348 was designed to compare one and two years of three-weekly trastuzumab treatment versus observation in patients with HER2 positive early breast cancer following surgery, established chemotherapy and radiotherapy (if applicable). In addition, a comparison of two years trastuzumab treatment versus one year trastuzumab treatment was performed. Patients assigned to receive trastuzumab were given an initial loading dose of 8 mg/kg, followed by 6 mg/kg every three weeks for either one or two years.
Studies NSAPB B-31 and NCCTG N9831 that comprise the joint analysis were designed to investigate the clinical utility of combining trastuzumab treatment with paclitaxel following AC chemotherapy; additionally the NCCTG N9831 study investigated adding trastuzumab sequentially to AC-paclitaxel chemotherapy in patients with HER2-positive early breast cancer following surgery. Study BCIRG 006 was designed to investigate combining trastuzumab treatment with docetaxel either following AC chemotherapy or in combination with docetaxel and carboplatin in patients with HER2-positive early breast cancer following surgery.
Study BCIRG 006 was designed to investigate combining trastuzumab treatment with docetaxel either following AC chemotherapy or in combination with docetaxel and carboplatin in patients with HER2-positive early breast cancer following surgery.
Early breast cancer in the BO16348 study was limited to operable, primary, invasive adenocarcinoma of the breast, with axillary nodes-positive or axillary nodes-negative tumours of at least 1 cm in diameter.
The efficacy results from the BO16348 study are summarized in the following table: See Table 1.

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The efficacy results from the interim efficacy analysis crossed the protocol pre-specified statistical boundary for the comparison of 1-year of trastuzumab vs. observation. After a median follow-up of 12 months, the hazard ratio (HR) for disease free survival (DFS) was 0.54 (95% CI 0.44, 0.67) which translates into an absolute benefit, in terms of a 2-year disease-free survival rate, of 7.6 percentage points (85.8% versus 78.2%) in favour of the trastuzumab arm.
A final analysis was performed after a median follow-up of 8 years, which showed that 1-year trastuzumab treatment is associated with a 24% risk reduction compared to observation only (HR=0.76, 95% CI 0.67, 0.86). This translates into an absolute benefit in terms of an 8-year disease free survival rate of 6.4 percentage points in favour of 1 year trastuzumab treatment.
In this final analysis, extending trastuzumab treatment for a duration of two years did not show additional benefit over treatment for 1 year [DFS HR in the intent to treat (ITT) population of 2 years versus 1 year=0.99 (95% CI: 0.87, 1.13), p-value = 0.90 and OS HR=0.98 (0.83, 1.15); p-value= 0.78].
The rate of asymptomatic cardiac dysfunction was increased in the 2-year treatment arm (8.1% versus 4.6% in the 1-year treatment arm). More patients experienced at least one Grade 3 or 4 adverse event in the 2-year treatment arm (20.4%) compared with the 1-year treatment arm (16.3%). In the joint analysis of the NSAPB B-31 and NCCTG N9831 studies, early breast cancer was limited to women with operable breast cancer at high risk, defined as HER2-positive and axillary lymph node­-positive or HER2-positive and lymph node-negative with high risk features (tumour size > 1 cm and ER-negative or tumour size > 2 cm, regardless of hormonal status). Trastuzumab was administered in combination with paclitaxel, following AC chemotherapy. Paclitaxel was administered as follows: intravenous paclitaxel - 80 mg/m² as a continuous IV infusion, given every week for 12 weeks, or intravenous paclitaxel - 175 mg/m² as a continuous IV infusion, given every 3 weeks for 4 cycles (day 1 of each cycle). (See Table 2.)

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For the primary endpoint, DFS, the addition of trastuzumab to paclitaxel chemotherapy resulted in a 52% decrease in the risk of disease recurrence. The hazard ratio translates into an absolute benefit, in terms of a 3-year disease-free survival rate, of 11.8 percentage points (87.2% versus 75.4%) in favour of the AC→PH (trastuzumab) arm.
The pre-planned final analysis of OS from the joint analysis of studies NSABP B-31 and NCCTG N9831 was performed when 707 deaths had occurred (median follow-up 8.3 years in the AC→PH group). Treatment with AC→PH resulted in a statistically significant improvement in OS compared with AC->P (stratified HR=0.64; 95% CI [0.55, 0.74); log-rank p-value < 0.0001). At 8 years, the survival rate was estimated to be 86.9% in the AC→PH arm and 79.4% in the AC→P arm, an absolute benefit of 7.4% (95% CI 4.9%, 10.0%).
The final OS results from the joint analysis of studies NSABP B-31 and NCCTG N9831 are summarized in the following table: See Table 3.

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In the BCIRG 006 study, HER2-positive, early breast cancer was limited to either lymph node-positive or high risk node-negative patients, defined as negative (pN0) lymph node involvement, and at least 1 of the following factors: tumour size greater than 2 cm, oestrogen receptor- and progesterone receptor-­negative, histologic and/or nuclear grade 2 - 3, or age < 35 years.
Trastuzumab was administered either in combination with docetaxel, following AC chemotherapy (AC­-DH) or in combination with docetaxel and carboplatin (DCarbH). Docetaxel was administered as follows: intravenously (100 mg/m² as an IV infusion over 1 hour) given every 3 weeks for 4 cycles (day 2 of first docetaxel cycle, then day 1 of each subsequent cycle), or intravenously (75 mg/m² as an IV infusion over 1 hour) given every 3 weeks for 6 cycles (day 2 of cycle 1, then day 1 of each cycle).
Docetaxel therapy was followed by carboplatin (at target AUC = 6 mg/ml/min) administered by IV infusion over 30-60 minutes repeated every 3 weeks for a total of 6 cycles.
The efficacy results from the BCIRG 006 study are summarized in the following tables: See Tables 4 and 5.

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In the BCIRG 006 study for the primary endpoint, DFS, the hazard ratio translates into an absolute benefit, in terms of a 3-year disease-free survival rate, of 5.8 percentage points (86.7% versus 80.9%) in favour of the AC→DH (trastuzumab) arm and 4.6 percentage points (85.5% versus 80.9%) in favour of the DCarbH (trastuzumab) arm compared to AC→D.
For the secondary endpoint overall survival, treatment with AC→DH reduced the risk of death by 42% when compared to AC→D (hazard ratio 0.58 [95% CI: 0.40, 0.83], p = 0.0024, log-rank test), and the risk of death was reduced by 34% for patients treated with DCarbl-1 compared to patients treated with AC→D (hazard ratio 0.66 [95% CI: 0.47, 0.93], p = 0.0182). In the BCIRG 006 study at the second interim analysis, 185 randomised patients had died: 80 patients (7.5%) in the AC→D arm, 49 patients (4.6%) in the AC→DH arm, and 56 patients (5.2%) in the DCarbH arm. The median duration of follow­-up was 2.9 years in the AC→D arm and 3.0 years in both the AC→DH and DCarbH arms.
In the neoadjuvant-adjuvant setting, trastuzumab was evaluated in two phase 3 trials.
Study MO16432 investigated a total of 10 cycles of neoadjuvant chemotherapy [an anthracycline and a taxane (AP+H followed by P+H, followed by CMF+H] concurrently with neoadjuvant­-adjuvant trastuzumab, or neoadjuvant chemotherapy alone, followed by adjuvant trastuzumab for up to a total treatment duration of 1 year) in newly diagnosed locally advanced (Stage III) or inflammatory HER2 positive breast cancer patients.
The efficacy results from MO16432 are summarized in the table as follows. The median duration of follow-­up in the trastuzumab arm was 3.8 years. (See Table 6.)

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For the primary endpoint, EFS, the addition of trastuzumab to the neoadjuvant chemotherapy followed by adjuvant trastuzumab for a total duration of 52 weeks resulted in a 35% reduction in the risk of disease recurrence/progression. The hazard ratio translates into an absolute benefit, in terms of 3-year event-free survival rate estimates of 13 percentage points (65% versus 52%) in favour of the trastuzumab arm.
Advanced Gastric Cancer: The efficacy results from the BO18255 study are summarized in table 7. Patients with previously untreated for HER2-positive inoperable locally advanced or recurrent and/or metastatic adenocarcinoma of the stomach or gastro-oesophageal junction not amenable to curative therapy were recruited. The primary endpoint was overall survival which was defined as the time from the date of randomization to the date of death from any cause. At the time of the analysis a total of 349 randomised patients had died: 182 patients (62.8%) in the control arm and 167 patients (56.8%) in the treatment arm. The majority of the deaths were due to events related to the underlying cancer.
The overall survival was significantly improved in the trastuzumab + capecitabine/5-FU and cisplatin arm compared to the capecitabine/5-FU and cisplatin arm (p = 0.0046, log-rank test). The median survival time was 11.1 months with capecitabine/5-FU and cisplatin and 13.8 months with trastuzumab + capecitabine/5-FU and cisplatin. The risk of death was decreased by 26% (hazard ratio [HR] 0.74 95% CI [0.60-0.91]) for patients in the trastuzumab arm compared to the capecitabine/5-FU arm. Post-hoc subgroup analyses indicate that targeting tumours with higher levels of HER2 protein (IHC 2+/FISH+ and IHC 3+/regardless of the FISH status) results in a greater treatment effect. The median overall survival for the high HER2-expressing group was 11.8 months versus 16 months, HR 0.65 (95% CI 0.51-0.83) and the median progression-free survival was 5.5 months versus 7.6 months, HR 0.64 (95% CI 0.51-0.79) for capecitabine/5-FU and cisplatin and trastuzumab + capecitabine/5-FU and cisplatin, respectively.
In a method comparison study a high degree of concordance (> 95%) was observed for SISH and FISH techniques for the detection of HER2 gene amplification in gastric cancer patients. (See Table 7.)

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Pharmacokinetics: The pharmacokinetics of trastuzumab was evaluated in a population pharmacokinetic model analysis using pooled data from 1,582 subjects from 18 Phase I, II and III trials receiving intravenous trastuzumab. A two-compartment model with parallel linear and non-linear elimination pathways from the central compartment was used to describe trastuzumab concentration-time profile. Due to the non-­linear elimination pathway, total clearance increases with decreasing concentrations. Linear elimination clearance was 0.127 l/day for breast cancer (MBC/EBC) and 0.176 l/day for AGC. The nonlinear elimination parameters were 8.81 mg/day for the maximum elimination rate (V_max) and 8.92 mg/l for the Michaelis-Menten constant (K_m). The central compartment volume was 2.62 l for patients with breast cancer and 3.63 l for patients with AGC.
The population predicted PK exposures (with 5th - 95th Percentiles) and PK parameters at clinically relevant concentrations (C_max and C_min) for breast cancer and AGC patients following the approved Q1W and Q3W regimens are shown in Table 8 (Cycle 1) and Table 9 (steady-state) as follows. (See Tables 8 and 9.)

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Pharmacokinetics in Special Populations: Detailed pharmacokinetic studies in the elderly and those with renal or hepatic impairment have not been carried out.
Renal Impairment: Detailed pharmacokinetic studies in patients with renal impairment have not been carried out. In a population pharmacokinetic analysis, renal impairment was shown not to affect trastuzumab disposition.
Elderly: Age has been shown to have no effect on the disposition of trastuzumab (see Dosage & Administration).
Toxicology: Preclinical Safety: Trastuzumab was well tolerated in mice (non-binding species) and cynomolgus monkeys (binding species) in single- and repeat-dose toxicity studies of up to 6 months duration, respectively. There was no evidence of acute or chronic toxicity identified.
Impairment of Fertility: Reproduction studies have been conducted in cynomolgus monkeys at doses up to 25 times that of the weekly human maintenance dose of 2 mg/kg trastuzumab and have revealed no evidence of impaired fertility.
Teratogenicity: Reproduction studies have been conducted in cynomolgus monkeys at doses up to 25 times that of the weekly human maintenance dose of 2 mg/kg trastuzumab and have revealed no evidence of harm to the foetus. However, when assessing the risk of reproductive toxicity to humans, it is also important to consider the significance of the rodent form of the HER2 receptor in normal embryonic development and the embryonic death in mutant mice lacking this receptor. Placental transfer of trastuzumab during the early (days 20-50 of gestation) and late (days 120-150 of gestation) foetal development period was observed.
Other: Lactation: A study conducted in lactating cynomolgus monkeys at doses 25 times that of the weekly human maintenance dose of 2 mg/kg trastuzumab demonstrated that trastuzumab is secreted in the milk. The presence of trastuzumab in the serum of infant monkeys was not associated with any adverse effects on their growth or development from birth to 1 month of age.

Breast Cancer: Metastatic Breast Cancer (MBC): Herzuma is indicated for the treatment of patients with metastatic breast cancer who have tumors that overexpress HER2: a) as monotherapy for the treatment of those patients who have received one or more chemotherapy regimens for their metastatic disease; b) in combination with paclitaxel or docetaxel for the treatment of those patients who have not received chemotherapy for their metastatic disease; c) in combination with an aromatase inhibitor for the treatment of patients with hormone-receptor-positive metastatic breast cancer.
Early Breast Cancer (EBC): Herzuma is indicated for the treatment of patients with HER2-positive early breast cancer following surgery, chemotherapy (neoadjuvant or adjuvant) and radiotherapy (if applicable); following adjuvant chemotherapy with doxorubicin and cyclophosphamide, in combination with paclitaxel or docetaxel; in combination with adjuvant chemotherapy consisting of docetaxel and carboplatin; in combination with neoadjuvant chemotherapy followed by adjuvant Herzuma, for locally advanced (including inflammatory) breast cancer or tumors > 2 cm in diameter.
Advanced Gastric Cancer: Herzuma in combination with capecitabine or intravenous 5-fluorouracil and a platinum agent is indicated for the treatment of patients with HER2-positive advanced adenocarcinoma of the stomach or gastroesophageal junction who have not received prior anticancer treatment for their metastatic disease.

HER2 testing is mandatory prior to initiation of Herzuma therapy.
Substitution by any other biological medicinal product requires the consent of the prescribing physician. Herzuma should be administered by a qualified health care professional.
It is important to check the product labels to ensure that the drug about to be administered is consistent with what has been prescribed for the patient.
IV formulation (see Cautions for Usage and Storage): Herzuma IV formulation is not to be used for subcutaneous administration and should be administered as intravenous infusion.
Do not administer as an intravenous push or bolus.
Weekly schedule: The recommended initial loading dose is 4 mg/kg body weight Herzuma administered as a 90-minute IV infusion.
The recommended weekly dose of Herzuma is 2 mg/kg body weight. If the prior dose was well tolerated, the dose can be administered as a 30-minute infusion.
Alternative 3-weekly schedule: Initial loading dose of 8 mg/kg body weight, followed by 6 mg/kg body weight 3 weeks later and then 6 mg/kg repeated at 3-weekly intervals administered as infusions over approximately 90 minutes. If the prior dose was well tolerated, the dose can be administered as a 30-minute infusion.
Duration of treatment: Patients with MBC should be treated with Herzuma until progression of disease.
Patients with EBC should be treated for 1 year or until disease recurrence, whichever occurs first. Extending treatment in EBC beyond one year is not recommended (see Pharmacology: Pharmacodynamics: Clinical/ Efficacy Studies under Actions).
Patients with advanced gastric cancer should be treated with Herzuma IV until progression of disease.
Missed doses: If the patient has missed a dose of Herzuma by one week or less, then the usual maintenance dose (weekly regimen: 2 mg/kg; three-weekly regimen: 6 mg/kg) should be administered as soon as possible. Do not wait until the next planned cycle. Subsequent Herzuma maintenance doses should be administered 7 days or 21 days later according to the weekly or three-weekly schedules, respectively. If the patient has missed a dose of Herzuma by more than one week, a re-loading dose of Herzuma should be administered over approximately 90 minutes (weekly regimen: 4 mg/kg; 3-weekly regimen: 8 mg/kg) as soon as possible. Subsequent Herzuma maintenance doses (weekly regimen: 2 mg/kg; three-weekly regimen 6 mg/kg, respectively) should be administered 7 days or 21 days later according to the weekly or three-weekly schedules, respectively.
Dose reduction: No reductions in the dose of trastuzumab were made during clinical trials. Patients may continue Herzuma therapy during periods of reversible, chemotherapy-induced myelosuppression, but they should be monitored carefully for complications of neutropenia during this time. The specific instructions to reduce or hold the dose of chemotherapy should be followed.
Special Dosage Instructions: Elderly: Data suggest that the disposition of trastuzumab is not altered based on age (see Pharmacology: Pharmacokinetics: Pharmacokinetics in Special Populations under Actions). In clinical trials, elderly patients did not receive reduced doses of trastuzumab.
Children: The safety and efficacy of trastuzumab in paediatric patients have not been established.

There is no experience with overdosage in human clinical trials. Single doses higher than 10 mg/kg have not been tested.

Herzuma is contraindicated in patients with known hypersensitivity to trastuzumab or to any of its excipients.

General: In order to improve traceability of biological medicinal products, the trade name of the administered product should be clearly recorded (or stated) in the patient file.
Herzuma therapy should only be initiated under supervision of a physician experienced in the treatment of cancer patients.
Infusion/Administration-related reactions (IRRs/ARRs): IRRs/ARRs are known to occur with the administration of trastuzumab (see Adverse Reactions).
IRRs/ARRs may be clinically difficult to distinguish from hypersensitivity reactions.
Pre-medication may be used to reduce risk of occurrence of IRRs.
Serious IRRs/ARRs to trastuzumab including dyspnea, hypotension, wheezing, bronchospasm, tachycardia, reduced oxygen saturation and respiratory distress, supraventricular tachyarrhythmia and urticaria have been reported (see Adverse Reactions). Patients should be observed for IRRs/ARRs. Interruption of an IV infusion may help control such symptoms and the infusion may be resumed when symptoms abate. These symptoms can be treated with an analgesic/antipyretic such as meperidine or paracetamol, or an antihistamine such as diphenhydramine. Serious reactions have been treated successfully with supportive therapy such as oxygen, beta-agonists and corticosteroids. In rare cases, these reactions are associated with a clinical course culminating in a fatal outcome. Patients who are experiencing dyspnea at rest due to complications of advanced malignancy or co-morbidities may be at increased risk of a fatal infusion reaction. Therefore, these patients should be treated with extreme caution and the risk versus the benefit considered for each patient.
Pulmonary reactions: Severe pulmonary events have been reported with the use of trastuzumab in the post-marketing setting. These events have occasionally resulted in fatal outcome and may occur as part of an IRR or with a delayed onset. In addition, cases of interstitial lung disease including lung infiltrates, acute respiratory distress syndrome, pneumonia, pneumonitis, pleural effusion, respiratory distress, acute pulmonary oedema and respiratory insufficiency have been reported.
Risk factors associated with interstitial lung disease include prior or concomitant therapy with other anti-neoplastic therapies known to be associated with it such as taxanes, gemcitabine, vinorelbine and radiation therapy. Patients with dyspnea at rest due to complications of advanced malignancy and co­-morbidities may be at increased risk of pulmonary events. Therefore, these patients should not be treated with trastuzumab.
Cardiac dysfunction: General considerations: Patients treated with trastuzumab are at increased risk of developing congestive heart failure (CHF) (New York Heart Association [NYHA] class II-IV) or asymptomatic cardiac dysfunction. These events have been observed in patients receiving trastuzumab therapy alone or in combination with taxane following anthracycline (doxorubicin or epirubicin)-containing chemotherapy. This may be moderate to severe and has been associated with death (see Adverse Reactions). In addition, caution should be exercised in treating patients with increased cardiac risk, e.g. hypertension, documented coronary artery disease, CHF, diastolic dysfunction, older age.
Population pharmacokinetic model simulations indicate that trastuzumab may persist in the circulation for up to 7 months after stopping trastuzumab treatment (see Pharmacology: Pharmacokinetics under Actions). Patients who receive anthracycline after stopping trastuzumab may also be at increased risk of cardiac dysfunction.
If possible, physicians should avoid anthracycline-based therapy for up to 7 months after stopping trastuzumab. If anthracyclines are used, the patient's cardiac function should be monitored carefully. Candidates for treatment with trastuzumab, especially those with prior exposure to an anthracycline, should undergo baseline cardiac assessment including history and physical examination, and electrocardiogram (ECG), echocardiogram, and/or multigated; acquisition scanning (MUGA). Monitoring may help to identify patients who develop cardiac dysfunction, including signs and symptoms of CHF. Cardiac assessments, as performed at baseline, should be repeated every 3 months during treatment and every 6 months following discontinuation of treatment until 24 months from the last administration of trastuzumab.
If LVEF drops 10 ejection points from baseline and to below 50%, trastuzumab should be withheld and a repeat LVEF assessment performed within approximately 3 weeks. If LVEF has not improved, or declined further, or clinically significant CHF has developed, discontinuation of trastuzumab should be strongly considered, unless the benefits for the individual patient are deemed to outweigh the risks. Patients who develop asymptomatic cardiac dysfunction may benefit from more frequent monitoring (e.g. every 6-8 weeks). If patients have a continued decrease in left ventricular function, but remain asymptomatic, the physician should consider discontinuing therapy if no clinical benefit of trastuzumab therapy has been seen.
The safety of continuation or resumption of trastuzumab in patients who experience cardiac dysfunction has not been prospectively studied. If symptomatic cardiac failure develops during trastuzumab therapy, it should be treated with standard medications for heart failure (HF). In the pivotal trials, most patients who developed HF or asymptomatic cardiac dysfunction improved with standard HF treatment consisting of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) and a-blocker. The majority of patients with cardiac symptoms and evidence of a clinical benefit of trastuzumab treatment continued with trastuzumab without additional clinical cardiac events.
Metastatic breast cancer (MBC): Trastuzumab and anthracyclines should not be given concurrently in the metastatic breast cancer setting.
Early breast cancer (EBC): For patients with EBC, cardiac assessments, as performed at baseline, should be repeated every 3 months during treatment and every 6 months following discontinuation of treatment until 24 months from the last administration of trastuzumab. In patients who receive anthracycline containing chemotherapy further monitoring is recommended, and should occur yearly up to 5 years from the last administration of trastuzumab, or longer if a continuous decrease of LVEF is observed.
Patients with history of myocardial infarction (MI), angina pectoris requiring medication, history of or present CHF (NYHA II-IV), other cardiomyopathy, cardiac arrhythmia requiring medication, clinically significant cardiac valvular disease, poorly controlled hypertension (hypertension controlled by standard medication eligible), and hemodynamic effective pericardial effusion were excluded from adjuvant breast cancer clinical trials with trastuzumab.
Adjuvant treatment: Trastuzumab and anthracyclines should not be given concurrently in the adjuvant treatment setting. In patients with EBC an increase in the incidence of symptomatic and asymptomatic cardiac events was observed when trastuzumab IV was administered after anthracycline-containing chemotherapy compared to administration with a non-anthracycline regimen of docetaxel and carboplatin. The incidence was more marked when trastuzumab IV was administered concurrently with taxanes than when administered sequentially to taxanes. Regardless of the regimen used, most symptomatic cardiac events occurred within the first 18 months.
Risk factors for a cardiac event identified in four large adjuvant studies included advanced age (> 50 years), low level of baseline and declining LVEF (< 55%), low LVEF prior to or following the initiation of paclitaxel treatment, trastuzumab treatment, and prior or concurrent use of antihypertensive medications. In patients receiving trastuzumab after completion of adjuvant chemotherapy the risk of cardiac dysfunction was associated with a higher cumulative dose of anthracycline given prior to initiation of trastuzumab and a high body mass index (BMI > 25 kg/m²).
Neoadjuvant-adjuvant treatment: In patients with EBC eligible for neoadjuvant-adjuvant treatment, trastuzumab concurrently with anthracyclines should be used with caution and only in chemotherapy-naive patients. The maximum cumulative doses of the low-dose anthracycline regimens should not exceed 180 mg/m² (doxorubicin) or 360 mg/m² (epirubicin).
If patients have been treated concurrently with low-dose anthracyclines and trastuzumab in the neoadjuvant setting, no additional cytotoxic chemotherapy should be given after surgery.
Clinical experience in the neoadjuvant-adjuvant setting is limited in patients above 65 years of age.
Benzyl alcohol: Benzyl alcohol, used as a preservative in bacteriostatic water for injection in the 440 mg multidose vial, has been associated with toxicity in neonates and children up to 3 years old. When administering trastuzumab to a patient with a known hypersensitivity to benzyl alcohol, trastuzumab should be reconstituted with water for injection, and only one dose per trastuzumab vial should be used. Any unused portion must be discarded. Sterile water for injection, used to reconstitute the 150 mg single dose vial, does not contain benzyl alcohol.
Renal Impairment: In a population pharmacokinetic analysis, renal impairment was shown not to affect trastuzumab disposition.
Ability to Drive and Use Machines: No studies on the effects on the ability to drive and to use machines have been performed. Patients experiencing infusion-related symptoms should be advised not to drive or use machines until symptoms resolve completely.

Pregnancy: Trastuzumab should be avoided during pregnancy unless the potential benefit for the mother outweighs the potential risk to the foetus. In the post-marketing setting, cases of foetal renal growth and/or function impairment in association with oligohydramnios, some associated with fatal pulmonary hypoplasia of the fetus, have been reported in pregnant women receiving trastuzumab. Women of child-bearing potential should be advised to use effective contraception during treatment with trastuzumab and for 7 months after treatment has been concluded (see Pharmacology: Pharmacokinetics under Actions). Women who become pregnant should be advised of the possibility of harm to the foetus. If a pregnant woman is treated with trastuzumab, or if a patient becomes pregnant while receiving trastuzumab or within 7 months following last dose of trastuzumab, close monitoring by a multidisciplinary team is desirable. It is not known whether trastuzumab can affect reproductive capacity. Animal reproduction studies revealed no evidence of impaired fertility or harm to the foetus (see Pharmacology: Toxicology: Preclinical Safety: Teratogenicity under Actions).
Nursing Mothers: It is not known whether trastuzumab is secreted in human milk. As human IgG is secreted into human milk, and the potential for harm to the infant is unknown, breast-feeding should be avoided during trastuzumab therapy (see Pharmacology: Toxicology: Preclinical Safety: Other under Actions).

Clinical Trials: In this section, the following categories of frequency have been used: very common (2:1/10), common (2:1/100 to <1/10), uncommon (2:1/1,000 to <1/100), rare (2:1/10,000 to <1/1,000), very rare (<110,000), not known (cannot be estimated from the available data). Within each frequency grouping, adverse reactions should be presented in order of decreasing seriousness.
List of adverse reactions: Presented in the following table are adverse reactions that have been reported in association with the use of trastuzumab alone or in combination with chemotherapy in pivotal clinical trials. All the terms included are based on the highest percentage seen in pivotal clinical trials.
As trastuzumab is commonly used with other chemotherapeutic agents and radiotherapy it is often difficult to ascertain the causal relationship of an adverse event to a particular drug/radiotherapy. (See Table 10.)

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Immunogenicity: In the neoadjuvant-adjuvant setting, 7.1% of patients treated with the IV infusion developed antibodies against trastuzumab (regardless of antibody presence at baseline).
The clinical relevance of these antibodies is not known; however, the pharmacokinetics, efficacy [determined by pathological complete response (pCR)] or safety [determined by occurrence of administration related reactions (ARRs)] of trastuzumab IV did not appear to be adversely affected by these ADAs.
Infusion/Administration-related reactions (IRRs/ARRs) and hypersensitivity: IRRs/ARRs such as chills and/or fever, dyspnoea, hypotension, wheezing, bronchospasm, tachycardia, reduced oxygen saturation and respiratory distress were seen in all trastuzumab clinical trials and for the IV formulation (see Precautions).
IRRs/ARRs may be clinically difficult to distinguish from hypersensitivity reactions.
The rate of IRRs/ARRs of all grades varied between studies depending on the indication, whether trastuzumab was given concurrently with chemotherapy or as monotherapy and data collection methodology.
In MBC, the rate of IRRs ranged from 49% to 54% in the trastuzumab containing arm compared to 36% to 58% in the comparator arm (which may have contained other chemotherapy). Severe (grade 3 and above) ranged from 5% to 7% in the trastuzumab containing arm compared to 5 to 6% in the comparator arm.
In EBC, the rate of IRRs/ARRs ranged from 18% to 54% in the trastuzumab containing arm compared to 6% to 50% in the comparator arm (which may have contained other chemotherapy). Severe (grade 3 and above) ranged from 0.5% to 0.6% in the trastuzumab containing arm compared to 0.3 to 5% in the comparator arm.
Anaphylactoid reactions were observed in isolated cases.
Cardiac dysfunction: Congestive heart failure (NYHA II-IV) is a common adverse reaction to trastuzumab. It has been associated with fatal outcome. Signs and symptoms of cardiac dysfunction such as dyspnoea, orthopnoea, increased cough, pulmonary oedema, S gallop, or reduced ventricular ejection fraction, have been observed in patients treated with trastuzumab (see Precautions).
Metastatic Breast Cancer: Depending on the criteria used to define cardiac dysfunction, the incidence in the pivotal metastatic trials varied between 9% and 12% in the trastuzumab + paclitaxel subgroup, compared with 1% - 4% for the paclitaxel alone subgroup. For trastuzumab monotherapy, the rate was 6% - 9%. The highest rate of cardiac dysfunction was seen in patients receiving concurrent trastuzumab + anthracycline/cyclophosphamide (27%), significantly higher than in the anthracycline/cyclophosphamide alone subgroup (7% - 10%). In a subsequent trial with prospective monitoring of cardiac function, the incidence of symptomatic heart failure was 2.2% in patients receiving trastuzumab and docetaxel, compared with 0% in patients receiving docetaxel alone. Most of the patients (79%) who developed cardiac dysfunction in these trials experienced an improvement after receiving standard treatment for CHF.
Early Breast Cancer (adjuvant setting): In three pivotal clinical trials of adjuvant trastuzumab given in combination with chemotherapy the incidence of grade 3/4 cardiac dysfunction (symptomatic CHF) was similar in patients who were administered chemotherapy alone and in patients who were administered trastuzumab sequentially to a taxane (0.3 - 0.4%).
The rate was highest in patients who were administered trastuzumab concurrently with a taxane (2.0%). At 3 years, the cardiac event rate in patients receiving AC->P (doxorubicin plus cyclophosphamide followed by paclitaxel) + H (trastuzumab) was estimated at 3.2%, compared with 0.8% in AC->P treated patients. No increase in the cumulative incidence of cardiac events was seen with further follow­-up at 5 years.
At 5.5 years, the rates of symptomatic cardiac or LVEF events were 1.0%, 2.3%, and 1.1% in the AC->D (doxorubicin plus cyclophosphamide, followed by docetaxel), AC->DH (doxorubicin plus cyclophosphamide, followed by docetaxel plus trastuzumab), and DCarbH (docetaxel, carboplatin and trastuzumab) treatment arms, respectively. For symptomatic CHF (Grade 3 - 4), the 5-year rates were 0.6%, 1.9%, and 0.4% in the AC->D, AC->DH, and DCarbH treatment arms, respectively. The overall risk of developing symptomatic cardiac events was low and similar for patients in AC->D and DCarbH arms; relative to both the AC->D and DCarbH arms there was an increased risk of developing a symptomatic cardiac event for patients in the AC->DH arm, being discernable by a continuous increase in the cumulative rate of symptomatic cardiac or LVEF events up to 2.3% compared to approximately 1% in the two comparator arms (AC->D and DCarbH).
When trastuzumab was administered after completion of adjuvant chemotherapy NYHA class III-IV heart failure was observed in 0.6% of patients in the one-year arm after a median follow-up of 12 months. After a median follow-up of 3.6 years the incidence of severe CHF and left ventricular dysfunction after 1 year trastuzumab therapy remained low at 0.8% and 9.8%, respectively.
In study BO16348, after a median follow-up of 8 years the incidence of severe CHF (NYHA III & IV) in the trastuzumab 1 year treatment was 0.89%, and the rate of mild symptomatic and asymptomatic left ventricular dysfunction was 6.35%.
Reversibility of severe CHF (defined as a sequence of at least two consecutive LVEF values 2: 50% after the event) was evident for 71.4% of trastuzumab-treated patients. Reversibility of mild symptomatic and asymptomatic left ventricular dysfunction was demonstrated for 79.5% of trastuzumab-treated patients. Approximately 17% of cardiac dysfunction related events occurred after completion of trastuzumab.
In the joint analysis of studies NSABP B-31 and NCCTG N9831, with a median follow-up of 8.1 years for the AC->PH group (doxorubicin plus cyclophosphamide, followed by paclitaxel plus trastuzumab), the per patient incidence of new onset cardiac dysfunction, as determined by LVEF, remained unchanged compared to the analysis performed at a median follow up of 2.0 years in the AC->PH group: 18.5% of AC->PH patients with LVEF decreased of 2:10% to below 50%. Reversibility of left ventricular dysfunction was reported in 64.5% of patients who experienced a symptomatic CHF in the AC->PH group being asymptomatic at latest follow up, and 90.3% having full or partial LVEF recovery (88).
Early Breast Cancer (neoadjuvant-adjuvant setting): In the clinical trial setting, when trastuzumab was administered concurrently with neoadjuvant chemotherapy containing three to four cycles of a neoadjuvant anthracycline (cumulative doxorubicin dose 180 mg/m² or epirubicin dose 360 mg/m²) overall, the incidence of symptomatic cardiac dysfunction was up to 1.7% in the trastuzumab arm.
Advanced Gastric Cancer: In the BO18255 study, at screening, the median LVEF value was 64% (range 48%-90%) in the fluoropyrimidine/cisplatin arm (FP) and 65% (range 50%-86%) in the trastuzumab plus fluoropyrimidine/cisplatin arm (H+FP).
The majority of the LVEF decreases noted in BO18255 study were asymptomatic, with the exception of one patient in the trastuzumab-containing arm whose LVEF decrease coincided with cardiac failure. (See Tables 11 and 12.)

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Overall, there were no significant differences in cardiac dysfunction between the treatment arm and the comparator arm.
Haematological toxicity: Breast Cancer: Haematological toxicity is infrequent following the administration of trastuzumab monotherapy in the metastatic setting, WHO Grade 3 leukopenia, thrombocytopenia and anaemia occurring in < 1% of patients. No WHO Grade 4 toxicities were observed. There was an increase in WHO Grade 3 or 4 haematological toxicity in patients treated with the combination of trastuzumab and paclitaxel compared with patients receiving paclitaxel alone (34% versus 21%). Haematological toxicity was also increased in patients receiving trastuzumab and docetaxel, compared with docetaxel alone (32% Grade 3/4 neutropenia versus 22%, using NCI-CTC criteria). The incidence of febrile neutropenia/neutropenic sepsis was also increased in patients treated with trastuzumab + docetaxel (23% versus 17% for patients treated with docetaxel alone).
Using NCI-CTC criteria, in the BO16348 study, 0.4% of trastuzumab-treated patients experienced a shift of 3 or 4 grades from baseline, compared with 0.6% in the observation arm.
Advanced Gastric Cancer: The most frequently reported AEs, of Grade ≥3 occurring with an incidence rate of at least 1% by trial treatment, that were categorised under the Blood and Lymphatic System Disorders SOC are shown as follows: See Table 13.

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The total percentage of patients who experienced an AE of ≥ Grade 3 NCI-CTCAE v3.0 that has been categorized under this SOC were 38% in the FP arm and 40% in the FP + H arm.
Overall, there were no significant differences in haematotoxicity between the treatment arm and the comparator arm.
Hepatic and renal toxicity: Breast Cancer: WHO Grade 3 or 4 hepatic toxicity was observed in 12% of patients following administration of trastuzumab as single agent, in the metastatic setting. This toxicity was associated with progression of disease in the liver in 60% of these patients.
WHO Grade 3 or 4 hepatic toxicity was less frequently observed among patients receiving trastuzumab and paclitaxel than among patients receiving paclitaxel alone (7% compared with 15%). No WHO Grade 3 or 4 renal toxicity was observed.
Advanced Gastric Cancer: In the BO18255 study no significant differences in hepatic and renal toxicity were observed between the two treatment arms.
NCI-CTCAE (version 3.0) Grade ≥ 3 renal toxicity was not significantly higher in patients receiving trastuzumab than those in the F+P arm (3% and 2% respectively).
NCI-CTCAE (version 3.0) Grade ≥ 3 adverse event in the Hepatobiliary Disorders SOC: Hyperbilirubinaemia was the only reported AE and was not significantly higher in patients receiving trastuzumab than those in the F+P arm (1% and < 1% respectively).
Diarrhoea: Breast Cancer: Of patients treated with trastuzumab monotherapy in the metastatic setting 27% experienced diarrhoea. An increase in the incidence of diarrhoea, primarily mild to moderate in severity, has also been observed in patients receiving trastuzumab in combination with paclitaxel compared with patients receiving paclitaxel alone.
In the BO16348 study, 8% of trastuzumab-treated patients experienced diarrhoea during the first year of treatment.
Advanced Gastric Cancer: In the BO18255 study, 109 patients (37%) participating in the trastuzumab-containing treatment arm versus 80 patients (28%) in the comparator arm experienced any grade diarrhoea. Using NCI-CTCAE v3.0 severity criteria, the percentage of patients experiencing Grade ≥ 3 diarrhoea was 4% in the FP arm versus 9% in the FP+H arm.
Infection: An increased incidence of infections, primarily mild upper respiratory infections of minor clinical significance or catheter infections, has been observed in patients treated with trastuzumab.
Post Marketing: See Table 14.

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Adverse Events: Table 15 as follows indicates adverse events that historically have been reported in patients who have received trastuzumab. As no evidence of a causal association has been found between trastuzumab and these events, these events are not considered expected for the purposes of regulatory reporting. (See Table 15.)

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There have been no formal drug interaction studies performed with trastuzumab in humans. Clinically significant interactions between trastuzumab and the concomitant medications used in clinical trials have not been observed (see Pharmacology: Pharmacokinetics under Actions).
In studies where trastuzumab was administered in combination with docetaxel, carboplatin, or anastrozole, the pharmacokinetics of these medications was not altered nor was the pharmacokinetics of trastuzumab altered.
Concentrations of paclitaxel and doxorubicin (and their major metabolites 6-a hydroxyl-paclitaxel, POH, and doxorubicinol, DOL) were not altered in the presence of trastuzumab. However, trastuzumab may elevate the overall exposure of one doxorubicin metabolite, (7-deoxy-13 dihydro-doxorubicinone, D7D). The bioactivity of D7D and the clinical impact of the elevation of this metabolite is unclear. No changes were observed in trastuzumab concentrations in the presence of paclitaxel and doxorubicin.
The results of a small drug interaction substudy evaluating the pharmacokinetics of capecitabine and cisplatin when used with or without trastuzumab suggested that the exposure to the bioactive metabolites (e.g. 5-FU) of capecitabine was not affected by concurrent use of cisplatin or by concurrent use of cisplatin plus trastuzumab. However, capecitabine itself showed higher concentrations and a longer half-life when combined with trastuzumab. The data also suggested that the pharmacokinetics of cisplatin were not affected by concurrent use of capecitabine or by concurrent use of capecitabine plus trastuzumab.

Special Instruction for Use, Handling and Disposal: Appropriate aseptic technique should be used.
IV formulation: Reconstitution: Herzuma should be carefully handled during reconstitution. Causing excessive foaming during reconstitution or shaking the reconstituted Herzuma solution may result in problems with the amount of Herzuma solution that can be withdrawn from the vial.
Instructions for reconstitution – 440 mg vial: Reconstitution is to be performed with bacteriostatic water for injection, containing 1.1% benzyl alcohol, as supplied. This yields a solution for multiple use, containing 21 mg/ml trastuzumab, at a pH of approximately 6.0. Use of other reconstitution solvents should be avoided except for sterile water for injection in case of a patient with a known hypersensitivity to benzyl alcohol.
1. Using a sterile syringe, slowly inject 20 ml of Bacteriostatic Water for Injection into the vial containing the lyophilized Herzuma, directing the stream into the lyophilized cake.
2. Swirl vial gently to aid reconstitution. DO NOT SHAKE!
Instructions for reconstitution – 150 mg vial: 1. Using a sterile syringe, slowly inject 7.2 ml of sterile water for injection into the vial containing the lyophilized Herzuma, directing the stream into the lyophilized cake.
2. Swirl vial gently to aid reconstitution. DO NOT SHAKE!
Slight foaming of the product upon reconstitution is not unusual. Allow the vial to stand undisturbed for approximately 5 minutes. The reconstituted Herzuma results in a colourless to pale yellow transparent solution and should be essentially free of visible particles.
Dilution of the reconstituted solution: Determine the volume of the solution required: based on a loading dose of 4 mg trastuzumab/kg body weight, or a subsequent weekly dose of 2 mg trastuzumab/kg body weight: See Equation 1.

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Based on a loading dose of 8 mg trastuzumab/kg body weight, or a subsequent 3 weekly dose of 6 mg trastuzumab/kg body weight: See Equation 2.

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The appropriate amount of solution should be withdrawn from the vial and added to an infusion bag containing 250 ml of 0.9% sodium chloride. Dextrose (5%) solution should not be used (see Incompatibilities as follows). The bag should be gently inverted to mix the solution in order to avoid foaming. Parenteral drug products should be inspected visually for particulates and discoloration prior to administration. Once the infusion is prepared it should be administered immediately (see Storage).
Disposal of unused/expired medicines: The release of pharmaceuticals in the environment should be minimized. Medicines should not be disposed of via wastewater and disposal through household waste should be avoided. Use established "collection systems", if available in your location.
The following points should be strictly adhered to regarding the use and disposal of syringes and other medicinal sharps: Needles and syringes should never be reused.
Place all used needles and syringes into a sharps container (puncture-proof disposable container).
Dispose of the full container according to local requirements.
Incompatibilities: No incompatibilities between trastuzumab and polyvinylchloride, polyethylene or polypropylene bags have been observed.
Dextrose (5%) solution should not be used since it causes aggregation of the protein.
Trastuzumab should not be mixed or diluted with other drugs.

Vials: Store vials at 2°C-8°C.
440 mg vials (multidose vials): Shelf-life of the reconstituted solution: Reconstituted solutions made with bacteriostatic water for injection for the 440 mg vial of Herzuma, as supplied, are stable for 28 days when stored refrigerated at 2°C - 8°C.
The reconstituted solution contains preservative and is therefore suitable for multiple use. Any remaining reconstituted solution should be discarded after 28 days.
When administering Herzuma to a patient with a known hypersensitivity to benzyl alcohol (see General: Benzyl alcohol under Precautions), Herzuma should be reconstituted with water for injection. In case Herzuma is reconstituted with water for injection, only one dose per Herzuma vial should be used. The reconstituted solution should be used immediately.
Any unused portion must be discarded.
Do not freeze the reconstituted solution.
Shelf-life of the solution for infusion containing the reconstituted product: The infusion solution (0.9% sodium chloride infusion solution) containing the reconstituted product is physically and chemically stable for 48 hours (do not store above 30°C).
From a microbiological point of view, the Herzuma infusion solution should be used immediately.
If not used immediately, in-use storage times and conditions prior to use is the responsibility of the user and would normally not be longer than 24 hours at 2°C to 8°C, unless reconstitution and dilution have taken place in controlled and validated aseptic conditions.
150 mg vial (single-dose vials): Shelf-life of the reconstituted solution: The reconstituted product is physically and chemically stable for 48 hours at 2°C - 8°C after reconstitution with water for injection.
From a microbiological point of view, the reconstituted solution should be further diluted in infusion solution immediately. If not, in-use storage times and conditions prior to use is the responsibility of the user and would normally not be longer than 24 hours at 2°C to 8°C, unless reconstitution has taken place in controlled and validated aseptic conditions.
Do not freeze the reconstituted solution.
Shelf-life of the solution for infusion containing the reconstituted product: The infusion solution (0.9% sodium chloride infusion solution) containing the reconstituted product is physically and chemically stable for 48 hours (do not store above 30°C).
From a microbiological point of view, the Herzuma infusion solution should be used immediately.
If not used immediately, in-use storage times and conditions prior to use is the responsibility of the user and would normally not be longer than 24 hours at 2°C to 8°C, unless reconstitution and dilution have taken place in controlled and validated aseptic conditions.

Targeted Cancer Therapy

L01FD01 - trastuzumab ; Belongs to the class of HER2 (Human Epidermal Growth Factor Receptor 2) inhibitors. Used in the treatment of cancer.

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