Tagrisso Special Precautions

Assessment of EGFR mutation status: When considering the use of TAGRISSO as an adjuvant therapy after complete tumour resection in patients with NSCLC, it is important that the EGFR mutation positive status exon 19 deletions (Ex19del) or exon 21 L858R substitution mutations (L858R) indicates treatment eligibility. A validated test should be performed in a clinical laboratory using tumour tissue DNA from biopsy or surgical specimen.
When considering the use of TAGRISSO as a treatment for locally advanced or metastatic NSCLC, it is important that the EGFR mutation positive status is determined. A validated test should be performed using either tumour DNA derived from a tissue sample or circulating tumour DNA (ctDNA) obtained from a plasma sample.
Positive determination of EGFR mutation status activating EGFR mutations for first-line treatment, exon 19 deletion or exon 21 (L858R) substitution mutations when TAGRISSO is given in combination with pemetrexed and platinum-based chemotherapy for first-line treatment or T790M mutations following progression on or after EGFR TKI therapy) using either a tissue-based or plasma-based test indicates eligibility for treatment with TAGRISSO. However, if a plasma-based ctDNA test is used and the result is negative, it is advisable to follow-up with a tissue test wherever possible due to the potential for false negative results using a plasma-based test.
Only robust, reliable and sensitive tests with demonstrated utility for the determination of EGFR mutation status should be used.
Interstitial Lung Disease (ILD): Severe, life-threatening or fatal ILD or ILD-like adverse reactions (e.g. pneumonitis) have been observed in patients treated with TAGRISSO in clinical studies. Most cases improved or resolved with interruption of treatment. Patients with a past medical history of ILD, drug-induced ILD, radiation pneumonitis that required steroid treatment, or any evidence of clinically active ILD were excluded from clinical studies (see Adverse Reactions).
ILD or ILD-like adverse reactions were reported in 4.0% of the 1813 patients who received TAGRISSO monotherapy in the ADAURA, FLAURA, FLAURA2 and AURA studies. Seven fatal cases were reported in the locally advanced or metastatic setting. No fatal cases were reported in the adjuvant setting. The incidence of ILD was 11.2% in patients of Japanese ethnicity, 2.3% in patients of non-Japanese Asian ethnicity and 2.7% in non-Asian patients (see Adverse Reactions).
ILD or ILD-like adverse reactions were reported in 3.3% and were fatal in 0.4% (n=1) of the 276 patients who received TAGRISSO in combination with pemetrexed and platinum-based chemotherapy in FLAURA2. The incidence of ILD was 14.9% in patients of Japanese ethnicity and 1.7% in non-Asian patients; no patients of non-Japanese Asian ethnicity had an event of ILD in the FLAURA2 combination arm. The median time from first dose to onset of ILD or ILD-like adverse reactions was 161 days.
Careful assessment of all patients with an acute onset and/or unexplained worsening of pulmonary symptoms (dyspnoea, cough, fever) should be performed to exclude ILD. Treatment with this medicinal product should be interrupted pending investigation of these symptoms. If ILD is diagnosed, TAGRISSO should be discontinued and appropriate treatment initiated as necessary. Reintroduction of TAGRISSO should be considered only after careful consideration of the individual patient's benefits and risk.
Severe Cutaneous Adverse Reactions (SCARs): Case reports of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) have been reported with frequency categories of rare and not known, respectively, in association with TAGRISSO treatment. Before initiating treatment, patients should be advised of signs and symptoms of SJS and TEN. If signs and symptoms suggestive of SJS or TEN appear, TAGRISSO should be interrupted. TAGRISSO should be discontinued immediately if SJS or TEN are diagnosed.
QTc interval prolongation: QTc interval prolongation occurs in patients treated with TAGRISSO. QTc interval prolongation may lead to an increased risk for ventricular tachyarrhythmias (e.g. torsade de pointes) or sudden death. No QTc related arrythmias were reported in ADAURA, FLAURA, FLAURA2, or AURA studies (see Adverse Reactions). Patients with clinically important abnormalities in rhythm and conduction as measured by resting electrocardiogram (ECG) (e.g. QTc interval greater than 470 ms) were excluded from these studies (see Adverse Reactions).
When possible, the use of TAGRISSO in patients with congenital long QT syndrome should be avoided. Periodic monitoring with electrocardiograms (ECGs) and electrolytes should be considered in patients with congestive heart failure, electrolyte abnormalities, or those who are taking medicinal products that are known to prolong the QTc interval. Treatment should be withheld in patients who develop a QTc interval greater than 500 msec on at least 2 separate ECGs until the QTc interval is less than 481 msec or recovery to baseline if the QTc interval is greater than or equal to 481 msec, then resume TAGRISSO at a reduced dose as described in Table 8. TAGRISSO should be permanently discontinued in patients who develop QTc interval prolongation in combination with any of the following: Torsade de pointes, polymorphic ventricular tachycardia, signs/symptoms of serious arrhythmia.
Changes in cardiac contractility: Across clinical studies, left ventricular ejection fraction (LVEF) decreases greater than or equal to 10 percentage points and a drop to less than 50% occurred in 4.2% (65/1557) of patients treated with TAGRISSO monotherapy who had baseline and at least one follow-up LVEF assessment. In patients with cardiac risk factors and those with conditions that can affect LVEF, cardiac monitoring, including an assessment of LVEF at baseline and during treatment, should be considered. In patients who develop relevant cardiac signs/symptoms during treatment, cardiac monitoring including LVEF assessment should be considered. In an adjuvant placebo-controlled study (ADAURA), 1.5% (5/325) of patients treated with TAGRISSO and 1.5% (5/331) of patients treated with placebo experienced LVEF decreases greater than or equal to 10 percentage points and a drop to less than 50%. In the FLAURA2 study, 8.0% (21/262) of patients treated with TAGRISSO in combination with pemetrexed and platinum-based chemotherapy, who had baseline and at least one follow-up LVEF assessment, experienced LVEF decreases greater than or equal to 10 percentage points and a drop to less than 50%.
Keratitis: Keratitis was reported in 0.6% (n=10) of the 1813 patients treated with TAGRISSO monotherapy in the ADAURA, FLAURA, FLAURA2 and AURA studies. Patients presenting with signs and symptoms suggestive of keratitis such as acute or worsening: eye inflammation, lacrimation, light sensitivity, blurred vision, eye pain and/or red eye should be referred promptly to an ophthalmology specialist (see Table 8 under Dosage & Administration).
Aplastic anaemia: Rare cases of aplastic anaemia, including fatal events, have been reported in association with TAGRISSO treatment. Some cases had a fatal outcome. Before initiating treatment, patients should be advised of signs and symptoms of aplastic anaemia including but not limited to persistent fever, bruising, bleeding, pallor, infection and fatigue. If signs and symptoms suggestive of aplastic anaemia develop, close patient monitoring and drug interruption or discontinuation of TAGRISSO should be considered. TAGRISSO should be discontinued in patients with confirmed aplastic anaemia (see Dosage & Administration).
Sodium: This medicinal product contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially "sodium-free".
Effects on ability to drive and use machines: TAGRISSO has no or negligible influence on the ability to drive and use machines.
Use in the Elderly: Elderly patients (>65 years) or patients with low body weight (<50 kg) may be at increased risk of developing adverse events of Grade 3 or higher. Close monitoring is recommended in these patients (see Adverse Reactions).