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palonosetron HCl injection
NAME OF THE DRUG
Palonosetron hydrochloride is a white to off-white crystalline powder. It is freely soluble in water,
soluble in propylene glycol, and slightly soluble in ethanol and 2-propanol.
Chemically, palonosetron hydrochloride is: (3aS)-2-[(S)-1-Azabicyclo[2.2.2]oct-3-yl]-2,3,3a,4,5,6-
hexahydro-1-oxo-1Hbenz[de]isoquinoline hydrochloride. The empirical formula is C
a molecular weight of 332.87. Palonosetron hydrochloride exists as a single isomer.
Chemical Abstracts Service (CAS) registry number:
135729-62-3 Palonosetron Hydrochloride
ALOXI injection is a sterile, clear, colourless, non-pyrogenic, isotonic, buffered solution for intravenous
administration. Each 5 ml vial of ALOXI injection contains 250 µg equivalent palonosetron base
Mannitol 207.5 mg, disodium edetate and citrate buffer in water for intravenous administration. The
pH of the solution is 4.5 to 5.5.
Palonosetron hydrochloride is an antiemetic and antinauseant agent. It is a selective serotonin
subtype 3 (5-HT
) receptor antagonist with a strong binding affinity for this receptor.
Cancer chemotherapy may be associated with a high incidence of nausea and vomiting, particularly
when certain agents, such as cisplatin, are used. 5-HT
receptors are located on the nerve terminals
of the vagus in the periphery and centrally in the chemoreceptor trigger zone of the area postrema. It
is thought that chemotherapeutic agents produce nausea and vomiting by releasing serotonin from
the enterochromaffin cells of the small intestine and that the released serotonin then activates 5-HT
receptors located on vagal afferents to initiate the vomiting reflex.
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The effect of palonosetron on blood pressure, heart rate, and ECG parameters including QTc were
comparable to ondansetron and dolasetron in clinical trials. In non-clinical studies palonosetron
possesses the ability to block ion channels involved in ventricular de- and re-polarization and to
prolong action potential duration. The effect of palonosetron on QTc interval was evaluated in a
double blind, randomized, parallel, placebo and positive (moxifloxacin) controlled trial in adult men
and women. The objective was to evaluate the ECG effects of IV administered palonosetron at single
doses of 0.25, 0.75 or 2.25 mg in 221 healthy subjects. The study demonstrated no effect on QT/QTc
interval duration as well as any other ECG interval at doses up to 2.25 mg. No clinically significant
changes were shown on heart rate, atrioventricular (AV) conduction and cardiac repolarisation.
After intravenous dosing of palonosetron in healthy subjects and cancer patients, an initial decline in
plasma concentrations is followed by a slow elimination from the body. Mean maximum plasma
) and area under the concentration-time curve (AUC
) are generally dose-
proportional over the dose range of 0.3–90 µg/kg in healthy subjects and in cancer patients. Following
single IV dose of palonosetron at 3 µg/kg (or 0.21 mg/70 kg) to six cancer patients, mean (±SD)
maximum plasma concentration was estimated to be 5.6 ± 5.5 ng/mL and mean AUC was 35.8 ± 20.9
Following intravenous administration of palonosetron 0.25 mg once every other day for 3
doses in 11 testicular cancer patients, the mean (± SD) increase in the initial phase of the
plasma concentration-time curve (AUC
) from Day 1 to Day 5 was 42 ± 34 %; how this
finding relates to more conventional measures of systemic exposure is not known.
After intravenous administration of palonosetron 0.25 mg once daily for 3 days in 12 healthy
subjects, the mean (± SD) increase in systemic exposure over 24 hours (AUC
) from Day
1 to Day 3 was 110 ± 45 %.
Drug accumulation may be greater in the 10% of patients with prolonged elimination half-life.
Distribution: Palonosetron has a volume of distribution of approximately 8.3 ± 2.5 L/kg.
Approximately 62% of palonosetron is bound to plasma proteins.
Metabolism: Palonosetron is eliminated by multiple routes with approximately 50% metabolized to
form two primary metabolites: N-oxide-palonosetron and 6-S-hydroxy-palonosetron. These
metabolites each have less than 1% of the 5-HT
receptor antagonist activity of palonosetron. In vitro
metabolism studies have suggested that CYP2D6 and to a lesser extent, CYP3A and CYP1A2 are
involved in the metabolism of palonosetron. However, clinical pharmacokinetic parameters are not
significantly different between poor and extensive metabolizers of CYP2D6 substrates.
Elimination: After a single intravenous dose of 10 µg/kg [
C]-palonosetron, approximately 80% of
the dose was recovered within 144 hours in the urine with palonosetron representing approximately
40% of the administered dose. In healthy subjects the total body clearance of palonosetron was 160
± 35 mL/h/kg and renal clearance was 66.5± 18.2 mL/h/kg . Mean terminal elimination half life is
approximately 40 hours.
Single-dose palonosetron administration
Efficacy of single-dose palonosetron injection in preventing nausea and vomiting induced by
moderately and highly emetogenic chemotherapy was studied in a phase 2 dose-ranging trial and
three phase 3 trials. In the phase 3 trials, the primary efficacy endpoint was complete response rate
(no emetic episodes and no rescue medication). Prevention of nausea was assessed as a secondary
efficacy endpoint. The safety and efficacy of palonosetron in repeated courses of chemotherapy was
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Moderately Emetogenic Chemotherapy
Two Phase 3, double-blind trials involving 1132 patients compared single-dose IV palonosetron with
either single-dose IV ondansetron (study 1) or dolasetron (study 2) given 30 minutes prior to
moderately emetogenic chemotherapy including carboplatin, cisplatin ≤ 50 mg/m², cyclophosphamide
< 1500 mg/m², doxorubicin > 25 mg/m², epirubicin, irinotecan, and methotrexate > 250 mg/m².
Concomitant corticosteroids were not administered prophylactically in study 1 and were only used by
4-6% of patients in study 2. The majority of patients in these studies were women (77%), White
(65%) and naïve to previous chemotherapy (54%). The mean age was 55 years, (age range 18-97).
Highly Emetogenic Chemotherapy
A Phase 2, double-blind, dose-ranging study evaluated the efficacy of single-dose IV palonosetron
from 0.3 to 90 µg/kg (equivalent to < 0.1 mg to 6 mg fixed dose) in 161 chemotherapy-naïve adult
cancer patients receiving highly-emetogenic chemotherapy (either cisplatin ≥ 70 mg/m² or
cyclophosphamide > 1100 mg/m²). Concomitant corticosteroids were not administered
prophylactically. Analysis of data from this trial indicates that 250 µg is the lowest effective dose in
preventing acute nausea and vomiting induced by highly emetogenic chemotherapy.
A Phase 3, double-blind trial involving 667 patients compared single-dose IV palonosetron with single-
dose IV ondansetron (study 3) given 30 minutes prior to highly emetogenic chemotherapy including
cisplatin ≥ 60 mg/m², cyclophosphamide > 1500 mg/m², and dacarbazine. Highly emetogenic
chemotherapy was given only for the first day of the chemotherapy cycle. For the remainder of the
cycle, low to moderately (max grade 3 of Hesketh scale) emetogenic chemotherapy was allowed.
Corticosteroids were co-administered prophylactically before chemotherapy in 67% of patients. Of the
667 patients, 51% were women, 60% White, and 59% naïve to previous chemotherapy. The mean
age was 52 years; (age range 18-86).
Intent-to-treat analyses are presented. The conclusions of the per protocol analyses were similar.
Palonosetron was non-inferior to the comparators in the prevention of acute vomiting (within 24h) after
moderately and highly emetogenic chemotherapy and comparable in the prevention of nausea
(Tables 1-3). Efficacy was greater when corticosteroids were administered concomitantly in the highly
emetogenic setting. The secondary efficacy endpoint of the study assessed delayed onset (24-120h)
nausea and vomiting, the results are shown below (Tables 1-3). The comparative efficacy of
palonosetron 250 µg in multiple cycles of chemotherapy has not been demonstrated.
Table 1: Study - Efficacy after Moderately Emetogenic Chemotherapy
No Nausea (%)
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Table 2: Study 2 - Efficacy after Moderately Emetogenic Chemotherapy
No Nausea (%)
7.3 [not sig]
Table 3: Study 3 - Efficacy after Highly Emetogenic Chemotherapy
No Nausea (%)
The studies were designed to show non-inferiority in complete response. A lower bound > -15% demonstrates non-inferiority
between palonosetron and comparator. Absence of nausea (Likert Scale) was compared using a Chi-square test at p=0.05
Multiple-dose palonosetron administration
Published randomised, controlled studies have not been designed to show, or have not shown,
improvement in primary efficacy endpoints related to nausea and vomiting in patient arms given
ALOXI daily or on alternate days, relative to single dose use, in the context of multiple day
chemotherapy. It has not been clearly established that such repeated dosing provides significant
additional benefit compared to a single dose.
ALOXI is indicated for prevention of nausea and vomiting induced by cytotoxic chemotherapy.
ALOXI is contraindicated in patients known to have hypersensitivity to the drug or any of its
Hypersensitivity reactions may occur in patients who have exhibited hypersensitivity to other selective
receptor antagonists. ALOXI should not be used to prevent or treat nausea and vomiting in the
days following chemotherapy if not associated with another chemotherapy administration.
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There have been reports of serotonin syndrome with the use of 5-HT
antagonists either alone
or in combination with other serotonergic drugs including selective serotonin reuptake
inhibitors (SSRI) and serotonin noradrenaline reuptake inhibitors (SNRIs).
At all dose levels tested, palonosetron did not induce clinically relevant prolongation of the QTc
interval. A specific thorough QT/QTc study was conducted in healthy volunteers for definitive
data demonstrating the effect of palonosetron on QT/QTc (see Pharmacodynamics). However,
as for the other 5-HT
antagonists, caution should be exercised in the concomitant use of
palonosetron with medicinal products that increase the QT interval or in patients who have or are
likely to develop prolongation of the QT interval.
Effects on ability to drive and use machines: No studies on the effects on the ability to drive and
use machines have been performed.
In a 104-week carcinogenicity study in CD-1 mice, animals were treated with oral doses of
palonosetron at 10, 30 and 60 mg/kg/day. Treatment with palonosetron was not tumorigenic.
The highest tested dose produced a systemic exposure to palonosetron (plasma AUC) of > 600
times the human exposure at the recommended intravenous dose of 250 µg.
In a 104-week carcinogenicity study in Sprague-Dawley rats, male and female rats were treated
with oral doses of 15, 30 and 60 mg/kg/day and 15, 45 and 90 mg/kg/day, respectively. The
lowest and highest doses, respectively, produced a systemic exposure to palonosetron (plasma
AUC) of > 25 times and > 500 times the human exposure at the recommended dose.
Treatment with palonosetron produced increased incidences of adrenal benign
pheochromocytoma and combined benign and malignant pheochromocytoma in both male and
female rats, of pancreatic Islet cell adenoma and combined adenoma and carcinoma of
pancreatic acinar cell adenoma and combined adenoma and adenocarcinoma and of pituitary
adenoma in male rats. Increased incidences of skin keratocanthomas and tail squamous cell
papillomas were also observed, mainly in males. In female rats, palonosetron produced
hepatocellular adenoma and combined hepatocellular adenoma and carcinoma, and increased
the incidences of thyroid C-cell adenoma and combined adenoma and carcinoma, and of
mammary gland adrenocarcinoma.
Palonosetron was not genotoxic in the Ames test, the Chinese hamster ovarian cell
(CHO/HGPRT) forward mutation test, the ex vivo hepatocyte unscheduled DNA synthesis test or
the mouse micronucleus test. It was, however, positive for clastogenic effects in the CHO cell
chromosomal aberration test.
Effects on Fertility
Palonosetron at oral doses of up to 60 mg/kg/day (>170 times the recommended human
intravenous dose based on estimated plasma AUC) was found to have no effect on fertility and
reproductive performance of male and female rats. Oral doses of 60 and 120 mg/kg/day given to
male rats for 2 months prior to mating associated with complete infertility at the 120 mg/kg/day
dose. Testicular degeneration was confirmed in a 3 month general toxicity study at oral doses of
60 and 120 mg/kg/day. An IV dose of up to 10 mg/kg/day (>250 times the recommended human
intravenous dose based on plasma AUC) had no effect on male fertility and reproductive
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Geriatrics: Population pharmacokinetic analysis and clinical safety and efficacy data did not
reveal any differences between cancer patients ≥ 65 years of age and younger patients (18 to 64
years). No dose adjustment is required for these patients.
Race: Intravenous palonosetron pharmacokinetics was characterized in twenty-four healthy
Japanese subjects over the dose range of 3 – 90 µg/kg. Total body clearance was 25% higher in
Japanese subjects compared to Whites; however, no dose adjustment is required. The
pharmacokinetics of palonosetron in Blacks has not been adequately characterized.
Renal Impairment: Mild to moderate renal impairment does not significantly affect palonosetron
pharmacokinetic parameters. Total systemic exposure increased by approximately 28% in severe
renal impairment relative to healthy subjects. Dosage adjustment is not necessary in patients with any
degree of renal impairment.
Hepatic Impairment: Hepatic impairment does not significantly affect total body clearance of
palonosetron compared to the healthy subjects. Dosage adjustment is not necessary in patients with
any degree of hepatic impairment.
Children: There are no data on efficacy and safety in patients below 18 years.
Use in Pregnancy (Category B1)
Palonosetron had no effect on foetal development at oral doses of up to 18 mg/kg/day in rats and 90
mg/kg/day in rabbits. At 60 and 120 mg/kg/day in rats, foetal weight was reduced. Palonosetron did
not cause foetal abnormalities at these dose levels. However, palonosetron had toxic effects on the
dams at 120 mg/kg in rats and 90 mg/kg/day in rabbits.
Because animal reproduction studies are not always predictive of human response, palonosetron
should not be used during pregnancy unless it is considered essential.
Use during Lactation
It is not known whether palonosetron is excreted in human milk, but some other drugs of the same
class are known to be excreted in rat milk. Because of the potential for serious adverse reactions in
nursing infants, a decision should be made whether to discontinue breastfeeding or to discontinue the
drug, taking into account the importance of the drug to the mother.
INTERACTIONS WITH OTHER MEDICINES
Palonosetron is eliminated from the body through both renal excretion and metabolic pathways with
the latter mediated via multiple CYP enzymes. Further in vitro studies indicated that palonosetron is
not an inhibitor of CYP1A2, CYP2A6, CYP2B6, CYP2C9, CPY2D6, CYP2E1 and CYP3A4/5
(CYP2C19 was not investigated) nor does it induce the activity of CYP1A2, CYP2D6, or CYP3A4/5.
Therefore, the potential for clinically significant drug interactions with palonosetron appears to be low.
A study in healthy volunteers involving single-dose IV palonosetron (0.75 mg) and steady state oral
metoclopramide (10 mg four times daily) demonstrated no significant pharmacokinetic interaction.
In controlled clinical trials, ALOXI injection has been safely administered with corticosteroids,
analgesics, antiemetics/antinauseants, antispasmodics and anticholinergic agents.
Palonosetron did not inhibit the antitumor activity of the five chemotherapeutic agents tested (cisplatin,
cyclophosphamide, cytarabine, doxorubicin and mitomycin C) in murine tumor models.
There have been reports of serotonin syndrome following concomitant use of 5-HT
antagonists and other serotonergic drugs (including SSRIs and SNRIs).
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In clinical trials for the prevention of nausea and vomiting induced by moderately or highly emetogenic
chemotherapy, 1374 adult patients received palonosetron. Adverse reactions were similar in
frequency and severity with ALOXI and ondansetron or dolasetron. Following is a listing of all
adverse reactions reported by ≥ 2% of patients in these trials (Table 4).
Table 4: Adverse Reactions from Chemotherapy-Induced Nausea and Vomiting Studies, ≥ 2% in any
32 mg IV
100 mg IV
3 (< 1%)
1 (< 1%)
2 (< 1%)
1 (< 1%)
In other studies, 2 subjects experienced severe constipation following a single palonosetron dose of
approximately 0.75 mg, three times the recommended dose. One patient received a 10 µg/kg oral
dose in a post-operative nausea and vomiting study and one healthy subject received a 0.75 mg IV
dose in a pharmacokinetic study.
In clinical trials, the following infrequently reported adverse reactions, assessed by investigators as
treatment-related or causality unknown, occurred following administration of ALOXI to adult patients
receiving concomitant cancer chemotherapy:
Cardiovascular: 1%: non-sustained tachycardia, bradycardia, hypotension, < 1%: hypertension,
myocardial ischemia, extrasystoles, sinus tachycardia, sinus arrhythmia, supraventricular
extrasystoles and QT prolongation. In many cases, the relationship to ALOXI was unclear.
Dermatological: < 1%: allergic dermatitis, pruritic rash.
Hearing and Vision: < 1% motion sickness, tinnitus, eye irritation and amblyopia.
Gastrointestinal system: 1%: diarrhoea, < 1%: dyspepsia, upper abdominal pain, dry mouth,
hiccups and flatulence.
General: 1%: weakness, asthenia < 1%: fatigue, fever, hot flash, flu-like syndrome.
Liver: < 1%: transient, asymptomatic increases in AST and/or ALT and bilirubin. These changes
occurred predominantly in patients receiving highly emetogenic chemotherapy.
Metabolic: 1%: hyperkalemia, < 1%: electrolyte fluctuations, hypocalcemia, hyperglycemia, metabolic
acidosis, glycosuria, appetite decrease, anorexia.
Musculoskeletal: < 1%: arthralgia.
Nervous System: 1%: dizziness, < 1%: somnolence, insomnia, hypersomnia, paresthesia, and
peripheral sensory neuropathy.
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Psychiatric: 1%: anxiety, < 1%: euphoric mood.
Urinary System: < 1%: urinary retention.
Vascular: < 1%: vein discoloration, vein distention.
In post-marketing reports there have been very rare cases of :
Hypersensitivity reactions including anaphylaxis and shock, and
Injection site reactions such as burning, induration, discomfort and pain
DOSAGE AND ADMINISTRATION
Dosage for Adults
The recommended dosage of ALOXI is 250 µg administered as a single dose approximately 30
minutes before the start of chemotherapy.
Drug accumulation was observed in subjects administered ALOXI on consecutive days or once every
two days for three doses (see Pharmacokinetics). Safety and efficacy data available regarding
repeated dosing of ALOXI within a course of multi-day chemotherapy are limited (see Clinical Trials).
Use in Geriatric Patients and in Patients with Impaired Renal or Hepatic Function
No dosage adjustment is recommended.
Dosage for Paediatric Patients
A recommended intravenous dosage has not been established for paediatric patients.
ALOXI should only be used before chemotherapy administration. ALOXI is to be infused intravenously
over 30 seconds.
Instructions for use/handling
This medicinal product must not be mixed with other medicinal products.
Flush the infusion line with normal saline before and after administration of ALOXI.
Contains no antimicrobial agent. ALOXI is for single use in one patient only. Discard any residue.
There is no known antidote to ALOXI. Overdose should be managed with supportive care. Fifty adult
cancer patients were administered palonosetron at a dose of 90 µg/kg (equivalent to 6 mg fixed dose)
as part of a dose ranging study. This is approximately 25 times the recommended dose of 250 µg.
This dose group had a similar incidence of adverse events compared to the other dose groups and no
dose response effects were observed. Dialysis studies have not been performed; however, due to
the large volume of distribution, dialysis is unlikely to be an effective treatment for palonosetron
overdose. A single intravenous dose of palonosetron at 30 mg/kg (947 and 474 times the human
dose for rats and mice, respectively, based on body surface area) was lethal to rats and mice. The
major signs of toxicity were convulsions, gasping, pallor, cyanosis and collapse.
PRESENTATION AND STORAGE CONDITIONS
ALOXI 250 µg / 5 mL solution for injection is sold as a single pack of 1 vial.
Store below 25°C. Protect from light.
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NAME AND ADDRESS OF THE SPONSOR
Specialised Therapeutics Australia
Level 1, 711 High Street
Kew East VIC 3102 Australia
Tel: 1300 798 820 Fax: 1800 798 829
23 Albert Street
POISON SCHEDULE / MEDICINE SCHEDULE
S4 / Prescription Medicine
Date of first inclusion in the Australian register of Therapeutic Goods (ARTG): 26 June 2006
Date of most recent amendment: 10 June 2014
Under licence of Helsinn Healthcare SA, Lugano, Switzerland.