AVASTIN 25 mg/mL concentrate for infusion solution

Introduction

Package Leaflet: Information for the Patient

Avastin 25mg/ml concentrate for solution for infusion

bevacizumab

Read all of this leaflet carefully before you start using this medicine because it contains important information for you.

• Keep this leaflet, you may need to read it again.
• If you have any further questions, ask your doctor, pharmacist, or nurse.
• If you experience any side effects, talk to your doctor, pharmacist, or nurse, even if they are not listed in this leaflet. See section 4.

Contents of the pack:

1. What Avastin is and what it is used for
2. What you need to know before you use Avastin
3. How to use Avastin
4. Possible side effects
5. Storage of Avastin
6. Contents of the pack and other information

1. What Avastin is and what it is used for

The active substance of Avastin is bevacizumab, a humanized monoclonal antibody (a type of protein that is normally produced by the immune system to help the body defend itself against infections and cancer). Bevacizumab selectively binds to a protein called vascular endothelial growth factor (VEGF), which is located on the walls of blood and lymphatic vessels in the body. The VEGF protein causes blood vessels to grow into the tumor, supplying it with nutrients and oxygen. When bevacizumab binds to VEGF, it prevents tumor growth by blocking the growth of blood vessels, which provide the necessary nutrients and oxygen for the tumor.

Avastin is a medicine used to treat adult patients with advanced colon or rectal cancer. Avastin will be given in combination with a chemotherapy treatment that contains a fluoropyrimidine medicine.

Avastin is also used to treat adult patients with metastatic breast cancer. When used in patients with breast cancer, it will be given with a chemotherapy medicine called paclitaxel or capecitabine.

Avastin is also used to treat adult patients with advanced non-small cell lung cancer. Avastin will be given along with a platinum-based chemotherapy regimen.

Avastin is also used to treat adult patients with advanced non-small cell lung cancer when the cancer cells have specific mutations in a protein called epidermal growth factor receptor (EGFR). Avastin will be given in combination with erlotinib.

Avastin is also used to treat adult patients with advanced kidney cancer. When used in patients with kidney cancer, it will be given with another type of medicine called interferon.

Avastin is also used to treat adult patients with advanced epithelial ovarian, fallopian tube, or primary peritoneal cancer. When used in patients with epithelial ovarian, fallopian tube, or primary peritoneal cancer, it will be given in combination with carboplatin and paclitaxel.

When used in adult patients with advanced epithelial ovarian, fallopian tube, or primary peritoneal cancer who have had a recurrence of their disease at least 6 months after their last treatment with a platinum-based chemotherapy regimen, Avastin will be given in combination with carboplatin and gemcitabine or with carboplatin and paclitaxel.

When used in adult patients with advanced epithelial ovarian, fallopian tube, or primary peritoneal cancer who have had a recurrence of their disease at least 6 months after their last treatment with a platinum-based chemotherapy regimen, Avastin will be given in combination with paclitaxel, topotecan, or pegylated liposomal doxorubicin.

Avastin is also used to treat adult patients with persistent, recurrent, or metastatic cervical cancer. Avastin will be given in combination with paclitaxel and cisplatin or, alternatively, paclitaxel and topotecan in patients who cannot receive platinum-based therapy.

2. What you need to know before you use Avastin

Do not use Avastin

• if you are allergic (hypersensitive) to bevacizumab or any of the other ingredients of this medicine (listed in section 6).
• if you are allergic (hypersensitive) to products derived from Chinese Hamster Ovary (CHO) cells or to other recombinant human or humanized antibodies.
• if you are pregnant.

Warnings and precautions

Talk to your doctor, pharmacist, or nurse before you start using Avastin

• Avastin may increase the risk of perforation of the intestine wall. If you have any disease that causes inflammation in the abdomen (e.g., diverticulitis, stomach ulcer, chemotherapy-induced colitis), consult your doctor.

• Avastin may increase the risk of developing an abnormal connection between two organs or vessels. The risk of developing a connection between the vagina and any part of the intestine may increase if you have persistent, recurrent, or metastatic cervical cancer.

• This medicine may increase the risk of bleeding or problems with wound healing. If you are going to have surgery, have had major surgery in the last 28 days, or have an unhealed surgical wound, you should not use this medicine.

• Avastin may increase the risk of developing serious skin or deep skin layer infections, especially if you have had perforation of the intestine wall or problems with wound healing.

• Avastin may increase the risk of high blood pressure. If you have uncontrolled high blood pressure, consult your doctor, it is important to ensure that your blood pressure is controlled before starting treatment with Avastin.

• This medicine may increase the risk of having protein in the urine, especially if you already have high blood pressure.

• The risk of developing blood clots or blockages in your arteries (a type of blood vessel) may increase if you are over 65 years old, if you have diabetes, or if you have had blood clots or blockages in your arteries in the past. Consult your doctor, as blood clots or blockages can cause a heart attack and stroke.

• Avastin may also increase the risk of developing blood clots or blockages in your veins (a type of blood vessel).

• This medicine may cause bleeding, especially bleeding related to the tumor. Consult your doctor if you have a tendency or family history of bleeding disorders (bleeding) or are taking medicines that thin your blood for any reason.

• Avastin may cause bleeding in and around your brain. Consult your doctor if you have metastatic cancer that affects your brain.

• Avastin may increase the risk of bleeding in your lungs, including coughing or spitting up blood. Consult your doctor if you have noticed this previously.

• Avastin may increase the risk of your heart becoming weakened. It is important that you inform your doctor if you have ever been treated with anthracyclines (a specific type of chemotherapy used to treat certain types of cancer, such as doxorubicin) or have received radiation therapy to the chest, or if you have heart disease.

• This medicine may cause infections and decrease the number of neutrophils (a type of blood cell important for your protection against bacteria).

• Avastin may cause hypersensitivity (including anaphylactic reactions) and/or infusion-related reactions (reactions related to the injection of the medicine). Consult your doctor, pharmacist, or nurse if you have previously experienced problems after injections, such as dizziness/fainting, difficulty breathing, swelling, or skin rash.

• A rare neurological side effect called posterior reversible encephalopathy syndrome (PRES) has been associated with treatment with Avastin. If you have a headache, changes in vision, confusion, or seizures with or without high blood pressure, consult your doctor.

Please consult your doctor even if any of the above situations affect you or have occurred in the past.

Before starting treatment with Avastin or during treatment with Avastin:

Before you start treatment with Avastin, you may be advised to have a dental check-up.

Children and adolescents

Avastin is not recommended for use in children and adolescents under 18 years of age, as the safety and efficacy in these patients have not been established.

There have been reports of bone tissue death (osteonecrosis) in bones other than the jaw in patients under 18 years of age treated with Avastin.

Other medicines and Avastin

Tell your doctor, pharmacist, or nurse if you are using, have recently used, or might use any other medicines.

The combination of Avastin with another medicine called sunitinib malate (prescribed for kidney or gastrointestinal cancer) may cause serious side effects. Consult your doctor to ensure that you do not combine these medicines.

Consult your doctor if you are receiving platinum-based or taxane-based treatment for metastatic breast or lung cancer. These therapies in combination with Avastin may increase the risk of serious side effects.

Tell your doctor if you have recently received or are receiving radiation therapy.

Pregnancy, breastfeeding, and fertility

Do not use Avastin if you are pregnant. Avastin may harm your unborn baby, as it may prevent the formation of new blood vessels. Your doctor should advise you to use a contraceptive method during treatment with Avastin and for at least 6 months after the last dose of Avastin.

Inform your doctor immediately if you are already pregnant, become pregnant during treatment with Avastin, or plan to become pregnant in the near future.

Do not breastfeed your baby during treatment with Avastin and for at least 6 months after the last dose of Avastin, as this medicine may interfere with the growth and development of your baby.

Avastin may affect female fertility. Consult your doctor for more information.

Consult your doctor, pharmacist, or nurse before using any medicine.

Driving and using machines

Avastin has not been shown to reduce your ability to drive or use tools or machines. However, somnolence and fainting have been reported with the use of Avastin. If you experience symptoms that affect your vision or concentration, or your reaction ability, do not drive or use machines until the symptoms disappear.

Important information about some of the ingredients of Avastin

Avastin contains sodiumThis medicine contains less than 1 mmol of sodium (23 mg) per vial, which is essentially "sodium-free".

3. How to use Avastin

Dose and frequency of administration

The dose of Avastin needed depends on your weight and the type of cancer being treated. The recommended dose is 5 mg, 7.5 mg, 10 mg, or 15 mg per kilogram of body weight. Your doctor will prescribe the most suitable dose of Avastin for you, and you will be treated with Avastin once every 2 or 3 weeks. The number of infusions you receive will depend on how you respond to treatment and should continue until Avastin no longer slows down tumor growth. Your doctor will discuss these aspects with you.

Form and route of administration

Do not shake the vial.

Avastin is a concentrate for solution for infusion. Depending on the dose prescribed for you, a fraction or all of the contents of the Avastin vial will be diluted with sodium chloride solution before administration. A doctor or nurse will give you this diluted Avastin solution as an intravenous infusion (by drip into your veins). The first infusion will be given over 90 minutes. If you tolerate this infusion well, the second infusion can be given over 60 minutes. Subsequent infusions can be given over 30 minutes.

Administration of Avastin should be temporarily interrupted:

Administration of Avastin should be permanently discontinued if you have:

• severe high blood pressure that cannot be controlled with blood pressure medicines; or if you experience a sudden and severe increase in blood pressure,
• protein in the urine accompanied by swelling of the body,
• a perforation of the intestine wall,
• a fistula (an abnormal connection between two organs or vessels) that your doctor considers serious,
• severe skin or deep skin layer infections,
• blood clots or blockages in your arteries,
• blood clots in the blood vessels of your lungs,
• any severe bleeding.

If you use more Avastin than you should

• you may have severe migraine. If this happens, you should inform your doctor, pharmacist, or nurse immediately.

If you forget to use Avastin

• your doctor will decide when you should receive the next dose of Avastin. You should inform your doctor about the missed dose.

If you stop using Avastin

Stopping treatment with Avastin may reduce its effect on tumor growth. Do not stop treatment with Avastin unless you have discussed it with your doctor.

If you have any further questions on the use of this medicine, ask your doctor, pharmacist, or nurse.

4. Possible Adverse Effects

Like all medicines, this medicine can cause adverse effects, although not all people will experience them.

If you experience adverse effects, consult your doctor, pharmacist, or nurse, even if they are adverse effects that do not appear in this leaflet.

The adverse effects mentioned below have been observed when Avastin is administered with chemotherapy. This does not necessarily mean that these adverse effects were strictly caused by Avastin.

Allergic Reactions

If you have an allergic reaction, consult your doctor or healthcare professional immediately. The signs may include: difficulty breathing or chest pain. You may also experience redness or flushing of the skin or rash, chills and tremors, feeling of dizziness (nausea) or feeling of discomfort (vomiting), swelling, dizziness, rapid heartbeat, loss of consciousness.

You should seek help immediately if you suffer from any of the adverse effects mentioned below.

Severe adverse effects that may be very common(may affect more than 1 in 10 patients) include:

• high blood pressure,
• feeling of numbness or tingling in hands or feet,
• decrease in the number of blood cells, including white blood cells that help fight infections (this may be accompanied by fever), and platelets that help blood clot,
• feeling of weakness and lack of energy,
• fatigue,
• diarrhea, nausea, vomiting, and abdominal pain.

Severe adverse effects that may be common(may affect up to 1 in 10 patients) include:

• perforation of the intestine,
• bleeding, including hemorrhage in the lungs in patients with non-small cell lung cancer,
• blockage of arteries due to embolism,
• blockage of veins due to embolism,
• blockage of blood vessels in the lungs due to embolism,
• blockage of veins in the legs due to embolism,
• heart failure,
• problems with wound healing after surgery,
• redness, peeling, sensitivity, pain, or blisters on fingers or toes,
• decrease in the number of red blood cells,
• lack of energy,
• stomach and intestine problems,
• muscle and joint pain, muscle weakness,
• dry mouth combined with thirst and/or reduced or dark urine output,
• inflammation of the mucous membrane lining of the mouth and intestine, lungs and airways, reproductive system and urinary tract,
• sores in the mouth and the tube that goes from the mouth to the stomach, which can be painful and cause difficulty swallowing,
• pain, including headache, back pain, pelvic and anal regions,
• localized pus pockets,
• infection, particularly in the blood or bladder,
• decrease in blood flow to the brain or stroke,
• drowsiness,
• nosebleeds,
• increased heart rate (pulse),
• intestinal obstruction,
• abnormal urine test (protein in the urine),
• difficulty breathing or decreased oxygen levels in the blood,
• skin or deep tissue infections,
• fistula: abnormal tubular communication between internal organs and the skin or other tissues that are not normally connected, including communications between the vagina and intestine in patients with cervical cancer.
• allergic reactions (the signs may include difficulty breathing, redness of the face, skin rash, low or high blood pressure, low oxygen levels in the blood, chest pain or nausea/vomiting),

Severe adverse effects that may be rare(may affect up to 1 in 1000 patients) include:

• sudden and severe allergic reaction with difficulty breathing, swelling, dizziness, rapid heartbeat, sweating, and loss of consciousness (anaphylactic shock).

Severe adverse effects of unknown frequency(cannot be estimated from the available data) include:

• severe skin or deep tissue infections, especially if you had intestinal perforations or problems with wound healing,
• negative effect on a woman's ability to have children (see below for more recommendations),
• brain disease with symptoms such as seizures (attacks), headache, confusion, and vision changes (Posterior Reversible Encephalopathy Syndrome or PRES),
• symptoms suggesting changes in normal brain function (headaches, vision changes, confusion, or seizures), and high blood pressure,
• increase and weakening of the wall of a blood vessel or tear of the wall of a blood vessel (aneurysms and arterial dissections).
• blockage of small blood vessels in the kidney,
• abnormally high blood pressure in the blood vessels of the lungs that makes the right side of the heart work harder than normal,
• perforation in the wall of the cartilage that separates the nasal openings,
• perforation in the stomach or intestine,
• ulcer or perforation in the lining of the stomach or small intestine (these signs may include abdominal pain, feeling of bloating, black stools, bloody stools, or blood in vomit),
• bleeding from the lower part of the large intestine,
• lesions in the gums, with the jawbone exposed that do not heal and may be associated with pain and inflammation of the surrounding tissues (for more recommendations, see the list of adverse effects below),
• perforation of the gallbladder (the symptoms and signs may include abdominal pain, fever, nausea, and vomiting).

If you notice any of these adverse effects, seek medical attention as soon as possible.

Adverse effects that are very common(may affect more than 1 in 10 patients) and not severe are:

• constipation,
• loss of appetite,
• fever,
• eye problems (including increased tear production),
• speech problems,
• taste changes,
• nasal discharge,
• dry skin, peeling, and inflammation of the skin, changes in skin color,
• weight loss,
• nosebleeds.

Adverse effects that are common(may affect up to 1 in 10 patients) and not severe are:

• changes in voice and hoarseness.

Patient over 65 years of age have a higher risk of experiencing the following:

• embolism in the arteries that can cause stroke or heart attack,
• reduction in the number of white blood cells and platelets (that help with clotting) in the blood,
• diarrhea,
• discomfort,
• headache,
• fatigue,
• high blood pressure.

Avastin may also cause changes in laboratory tests that your doctor performs. These changes may include a decrease in the number of white blood cells in the blood, particularly neutrophils (a type of white blood cell that helps fight infections), presence of protein in the urine, decrease in potassium, sodium, or phosphorus in the blood, increase in blood sugar, increase in alkaline phosphatase (an enzyme) in the blood, decrease in hemoglobin (which is found in red blood cells and carries oxygen), which may be severe.

Pain in the mouth, teeth, and/or jaw, swelling or sores in the mouth, numbness or feeling of heaviness of the jaw, or loss of a tooth. These may be signs and symptoms of jawbone damage (osteonecrosis). Inform your doctor and dentist immediately if you experience any of them.

Pre-menopausal women (women who have a menstrual cycle) may notice that their periods become irregular or disappear and may experience fertility problems. If you are thinking of having children, you should consult your doctor before starting treatment.

Avastin has been developed and manufactured to treat cancer by injection into the bloodstream. It has not been developed or manufactured for injection into the eye. Therefore, it is not authorized for use in this way. When Avastin is injected directly into the eye (unapproved use), the following side effects may occur:

• Infection or inflammation of the eyeball,
• Redness of the eye, small particles or spots in the vision (floaters), eye pain,
• Flashes of light with floaters, progressing to partial loss of vision,
• Increased eye pressure,
• Bleeding in the eye.

Reporting of Adverse Effects

If you experience any type of adverse effect, consult your doctor, pharmacist, or nurse, even if it is a possible adverse effect that does not appear in this leaflet. You can also report them directly through the national reporting system included in Appendix V. By reporting adverse effects, you can contribute to providing more information on the safety of this medicine.

5. Storage of Avastin

Keep this medicine out of the sight and reach of children.

Do not use this medicine after the expiration date that appears on the packaging and on the label of the vial after CAD. The expiration date is the last day of the month indicated.

Store in a refrigerator (between 2°C and 8°C).

Do not freeze.

Keep the vial in the outer packaging to protect it from light.

The solution for infusion should be administered immediately after dilution. If it is not administered immediately, the storage times and conditions are the responsibility of the user and would normally not be more than 24 hours at between 2°C and 8°C, unless the infusion solutions have been prepared in a sterile environment. When the dilution has been prepared in a sterile environment, Avastin remains stable for 30 days at between 2°C and 8°C plus an additional 48 hours at between 2°C and 30°C.

Do not use Avastin if you observe foreign particles or discoloration before administration.

Medicines should not be disposed of via wastewater or household waste. Ask your pharmacist how to dispose of the packaging and medicines you no longer need. This will help protect the environment.

6. Package Contents and Additional Information

Composition of Avastin

The active substance is bevacizumab.

• Each ml of concentrate contains 25 mg of bevacizumab, corresponding to 1.4 or 16.5 mg/ml when diluted as recommended.

Each 4 ml vial contains 100 mg of bevacizumab, corresponding to 1.4 mg/ml when diluted as recommended.

Each 16 ml vial contains 400 mg of bevacizumab, corresponding to 16.5 mg/ml when diluted as recommended.

• The other ingredients are trehalose dihydrate, sodium phosphate (see section 2 Important information about some ingredients of Avastin), polysorbate 20, and water for injectable preparations.

Appearance and Package Contents

Avastin is a concentrate for solution for infusion. The concentrate is a clear, colorless to pale brown liquid contained in a glass vial with a rubber stopper. Each vial contains either 100 mg of bevacizumab in 4 ml of solution or 400 mg of bevacizumab in 16 ml of solution. Each package of Avastin contains one vial.

Marketing Authorization Holder

Roche Registration GmbH

Emil-Barell-Strasse 1

79639 Grenzach-Wyhlen

Germany

Manufacturer

Roche Pharma AG

Emil-Barell-Str. 1

79639 Grenzach-Wyhlen

Germany

You can obtain more information about this medicine by contacting the local representative of the marketing authorization holder:

Date of Last Revision of this Leaflet

Other Sources of Information

Detailed information about this medicine is available on the European Medicines Agency website http://www.ema.europa.eu.