Octreotide for Injectable Suspension Product Monograph

RECENT MAJOR LABEL CHANGES

TABLE OF CONTENTS

Sections or subsections that are not applicable at the time of authorization are not listed.

RECENT MAJOR LABEL CHANGES ............................................................................... 2

TABLE OF CONTENTS....................................................................................................... 2

PART I: HEALTH PROFESSIONAL INFORMATION ....................................................... 4

1 INDICATIONS .................................................................................................................... 4

1.1 Pediatrics.................................................................................................................... 4

1.2 Geriatrics .................................................................................................................... 4

2 CONTRAINDICATIONS ...................................................................................................... 4

4 DOSAGE AND ADMINISTRATION ....................................................................................... 5

4.1 Dosing Considerations .................................................................................................. 5

4.2 Recommended Dose and Dosage Adjustment .................................................................. 5

4.4 Administration.............................................................................................................. 7

4.5 Missed Dose ..............................................................................................................12

5 OVERDOSAGE.................................................................................................................12

6 DOSAGE FORMS, STRENGTHS, COMPOSITION AND PACKAGING .....................................13

7 WARNINGS AND PRECAUTIONS.......................................................................................13

7.1 Special Populations .....................................................................................................18

7.1.1 Pregnant Women .....................................................................................................18

7.1.2 Breast-feeding .........................................................................................................18

7.1.3 Pediatrics ...............................................................................................................18

7.1.4 Geriatrics ................................................................................................................18

8 ADVERSE REACTIONS.....................................................................................................19

8.1 Adverse Reaction Overview ..........................................................................................19

8.2 Clinical Trial Adverse Reactions ....................................................................................19

8.3 Less Common Clinical Trial Adverse Reactions ...............................................................22

8.5 Post-Market Adverse Reactions .........................................................................................23

9 DRUG INTERACTIONS......................................................................................................24

9.2 Drug interactions overview ...............................................................................................24

9.4 Drug-Drug Interactions .................................................................................................24

9.5 Drug-Food Interactions ................................................................................................25

9.6 Drug-Herb Interactions .................................................................................................25

9.7 Drug-Laboratory Test Interactions..................................................................................25

10 CLINICAL PHARMACOLOGY ............................................................................................25

10.1 Mechanism of Action ...................................................................................................25

10.2 Pharmacodynamics .....................................................................................................26

10.3 Pharmacokinetics........................................................................................................26

11 STORAGE, STABILITY AND DISPOSAL .............................................................................27

12 SPECIAL HANDLING INSTRUCTIONS ................................................................................27

PART II: SCIENTIFIC INFORMATION ............................................................................. 28

13 PHARMACEUTICAL INFORMATION...................................................................................28

14 CLINICAL TRIALS ............................................................................................................29

14.1 Trial Design and Study Demographics............................................................................29

14.2 Study Results .............................................................................................................29

14.3 Comparative Bioavailability Studies................................................................................32

15 MICROBIOLOGY ..............................................................................................................32

16 NON-CLINICAL TOXICOLOGY ...........................................................................................33

17 SUPPORTING PRODUCT MONOGRAPHS ..........................................................................40

PATIENT MEDICATION INFORMATION ......................................................................... 41

PART I: HEALTH PROFESSIONAL INFORMATION

1 INDICATIONS

Acromegaly

OCTREOTIDE for INJECTABLE SUSPENSION (octreotide acetate) is indicated for acromegalic patients who are adequately controlled with octreotide acetate injection administered subcutaneously, including those in whom surgery, radiotherapy or dopamine agonist treatment is inappropriate or ineffective, or in the interim period until radiotherapy becomes fully effective (see 4 DOSAGE AND ADMINISTRATION).

In most patients, octreotide acetate for injectable suspension markedly reduces the clinical symptoms of the disease, such as headache, perspiration, paresthesia, fatigue, osteoarthralagia and carpal tunnel syndrome.

Carcinoid Tumours

OCTREOTIDE for INJECTABLE SUSPENSION is indicated for the treatment of the severe diarrhea and flushing episodes associated with carcinoid tumours in patients in whom symptoms are adequately controlled on subcutaneous treatment with octreotide acetate injection.

Vasoactive Intestinal Peptide Tumours (VIPomas)

OCTREOTIDE for INJECTABLE SUSPENSION is indicated for the treatment of the profuse watery diarrhea associated with VIP-secreting tumours in patients in whom symptoms are adequately controlled on subcutaneous treatment with octreotide acetate injection.

In patients with carcinoid syndrome and VIPomas, the effect of octreotide acetate for injectable suspension on tumour size and rate of growth has not been determined. In patients with carcinoid syndrome and VIPomas, the effect of octreotide acetate for injectable suspension on development of metastases has not been determined.

1.1 Pediatrics

Pediatrics (between birth and 18 years of age): No data are available to Health Canada; therefore, Health Canada has not authorized an indication for pediatric use (see 7 WARNINGS AND PRECAUTIONS, 7.4.3 Pediatrics).

1.2 Geriatrics

Information specific to the geriatric population is not available for this drug product.

2 CONTRAINDICATIONS

OCTREOTIDE for INJECTABLE SUSPENSION (as acetate) is contraindicated in patients who are hypersensitive to this drug or to any ingredient in the formulation, including any non-medicinal ingredient, or component of the container. For a complete listing, see 6 DOSAGE FORMS, STRENGTHS, COMPOSITION AND PACKAGING.

4 DOSAGE AND ADMINISTRATION

4.1 Dosing Considerations

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration. Do not use if particulates and/or discoloration are observed.

4.2 Recommended Dose and Dosage Adjustment

OCTREOTIDE for INJECTABLE SUSPENSION may only be administered by deep intragluteal injection. The site of repeat intragluteal injection should be alternated between the left and right gluteal muscle.

OCTREOTIDE for INJECTABLE SUSPENSION should only be administered by a trained healthcare professional. Do not directly inject diluent without preparing the suspension. It is important to closely follow the mixing instructions included in the packaging.

OCTREOTIDE for INJECTABLE SUSPENSION must be administered immediately after mixing.

OCTREOTIDE for INJECTABLE SUSPENSION should be administered intragluteally at 4-week intervals. Administration of OCTREOTIDE for INJECTABLE SUSPENSION at intervals greater than 4 weeks is not recommended because there is no adequate information on whether such patients could be satisfactorily controlled. Deltoid injections are to be avoided because of significant discomfort at the injection site when given in that area. OCTREOTIDE for INJECTABLE SUSPENSION should never be administered by the intravenous or subcutaneous routes. The following dosage regimens are recommended.

• Acromegaly

For patients who are adequately controlled with octreotide acetate injection s.c., it is recommended to start treatment with the administration of 20 mg OCTREOTIDE for INJECTABLE SUSPENSION at 4-week intervals for 3 months. Treatment with OCTREOTIDE for INJECTABLE SUSPENSION can be started the day after the last dose of s.c. octreotide acetate injection. Subsequent dosage adjustments should be based upon serum growth hormone (GH) and insulin-like growth factor 1/somatomedin C (IGF 1) concentrations and clinical symptoms.

For patients in whom, within this 3-month period, clinical symptoms and biochemical parameters (GH, IGF 1) are not fully controlled (GH concentrations still above 2.5 mcg/L) the dose may be increased to 30 mg every four weeks.

For patients whose serum GH concentrations are consistently below 1 mcg/L, whose IGF 1 serum concentrations normalized, and in whom most reversible signs/symptoms of acromegaly have disappeared after 3 months of treatment with 20 mg, 10 mg OCTREOTIDE for INJECTABLE SUSPENSION may be administered every 4 weeks. However, particularly in this group of patients, it is recommended to closely monitor adequate control of serum GH and IGF 1 concentrations and clinical signs/symptoms at this low dose of OCTREOTIDE for INJECTABLE SUSPENSION.

For patients in whom surgery, radiotherapy or dopamine agonist treatment is inappropriate, or in the interim period until radiotherapy becomes fully effective, a short test dosing of octreotide acetate injection s.c. is recommended to assess the response and systemic tolerability of octreotide prior to initiating treatment with OCTREOTIDE for INJECTABLE SUSPENSION as described above.

• Carcinoid tumours and VIPomas

Patients not currently treated with octreotide acetate injection s.c. should begin therapy with octreotide acetate injection s.c. The suggested daily dose during the first 2 weeks of therapy ranges from 100-600 mcg/day in 2-4 divided doses (mean daily dose is 300 mcg). Some patients may require doses up to 1500 mcg/day. The suggested daily dose for VIPomas is 200-300 mcg in 2-4 divided doses (range 150-750 mcg); dosage may be adjusted on an individual basis to control symptoms but usually doses above 450 mcg/day are not required.

Octreotide acetate injection s.c. should be continued for at least 2 weeks. Thereafter, patients who are considered “responders” to octreotide acetate and who tolerate the drug may be switched to OCTREOTIDE for INJECTABLE SUSPENSION in the dosage regimen described below.

Patients currently receiving octreotide acetate injection s.c. can be switched to OCTREOTIDE for INJECTABLE SUSPENSION in a dosage of 20 mg intragluteally at 4-week intervals for 2 months. Gluteal injection sites should be alternated to avoid irritation. Because of the need for serum octreotide to reach therapeutically effective levels following initial injection of OCTREOTIDE for INJECTABLE SUSPENSION, carcinoid tumour and VIPoma patients should continue to receive octreotide acetate injection s.c. for at least 2 weeks in the same dosage they were taking before the switch. Failure to continue s.c. injections for this period may result in exacerbation of symptoms. Some patients may require 3 or 4 weeks of such therapy.

After 2 months of a 20 mg dosage of OCTREOTIDE for INJECTABLE SUSPENSION, dosage may be increased to 30 mg every 4 weeks if symptoms are not adequately controlled. Patients who achieve good control on a 20 mg dose may have their dose lowered to 10 mg for a trial period. If symptoms recur, dosage should then be increased to 20 mg every 4 weeks. A dose of 10 mg is not recommended as a starting dose, however, because therapeutically effective levels of octreotide are reached more rapidly with a 20 mg dose.

Dosages higher than 30 mg are not recommended because there is no information on their usefulness.

Despite good overall control of symptoms, patients with carcinoid tumours and VIPomas often experience periodic exacerbation of symptoms (regardless of whether they are being maintained on octreotide acetate injection s.c. or octreotide acetate for injectable suspension). During these periods they may be given octreotide acetate injection s.c. for a few days at the dosage they were receiving prior to switching to OCTREOTIDE for INJECTABLE SUSPENSION. When symptoms are again controlled, octreotide acetate injection s.c. can be discontinued.

Health Canada has not authorized an indication for pediatric use.

4.4 Administration

Preparation of OCTREOTIDE for INJECTABLE SUSPENSION:

OCTREOTIDE for INJECTABLE SUSPENSION is supplied in kits containing:

• a. One vial of OCTREOTIDE for INJECTABLE SUSPENSION 10 mg, 20 mg or 30 mg octreotide (as acetate) for injectable suspension
• b. One prefilled syringe containing the diluent (showing the peel-off outer syringe label)
• c. One vial adapter for drug product reconstitution
• d. One 19G x 1.5”safety injection needle
• e. The package insert with administration instructions.

Follow the instructions below carefully to ensure proper reconstitution of OCTREOTIDE for INJECTABLE SUSPENSION before deep intragluteal injection.

There are 3 critical steps in the reconstitution of OCTREOTIDE for INJECTABLE SUSPENSION. Not following them could result in failure to deliver the drug appropriately.

• The kit must reach room temperature. Remove the kit from the fridge and let the kit stand at room temperature for a minimum of 30 minutes before reconstitution, but do not exceed 24 hours.
• After adding the diluent, ensure that the powder is fully saturated by letting the vial stand for 5 minutes.

• After saturation, shake the vial moderately in a horizontal direction for a minimum of

  30 seconds until a uniform suspension is formed. The OCTREOTIDE for INJECTABLE SUSPENSION must only be prepared immediately before administration. As with all parenteral admixtures, the constituted product should be examined for the presence of foreign particulate matter, agglomeration or discolouration. Any defective units should be discarded.

OCTREOTIDE for INJECTABLE SUSPENSION should only be administered by a trained health care professional.

	Step 1 Remove the OCTREOTIDE for INJECTABLE SUSPENSION kit from refrigerated storage. ATTENTION: It is essential to start the reconstitution process only after the kit reaches room temperature. Let the kit stand at room temperature for a minimum of 30 minutes before reconstitution, but do not exceed 24 hours. Note: The injection kit can be re-refrigerated if needed.
	Step 2 Remove the plastic cap from the vial and clean the rubber stopper of the vial with an alcohol wipe.
	Peel the blister film and remove the vial adapter from its packaging, by holding between the white luer cap and the skirt. DO NOT touch the tip of the access device at any place.

	Place the vial on a flat surface. Position the vial adapter on top of the vial and push it fully down so that it snaps in place, confirmed by an audible “click“. Clean the tip of the vial adapter with an alcohol wipe.
	Step 3 Snap off the smooth white cap from the syringe prefilled with diluent solution and screw the syringe onto the vial adapter.
	Slowly push the plunger all the way down to transfer all the diluent into the vial.
	Step 4 ATTENTION: It is essential to let the vial stand for 5 minutes to ensure that the diluent has fully saturated the powder. Note: It is normal if the plunger rod moves up as there might be a slight overpressure in the vial. At this stage prepare the patient for injection.
	Step 5 After the saturation period, make sure that the plunger is pushed all the way down in the syringe. ATTENTION: Keep the plunger pressed and shake the vial moderately in a horizontal direction for a minimum of 30 seconds so

	that the powder is completely suspended (uniform milky suspension). Repeat moderate shaking for another 30 seconds if the powder is not completely suspended.
	Step 6 Turn syringe and vial upside down, slowly pull the plunger back and draw the entire contents from the vial into the syringe.
	Unscrew the syringe from the vial adapter.
	Step 7 The product in the syringe now consists of reconstituted OCTREOTIDE for INJECTABLE SUSPENSION. To avoid confusion, peel off the outer syringe label which corresponds only with the diluent. It is no longer a correct representation of the current contents of the syringe.

	Step 8 Prepare the injection site with an alcohol wipe. Screw the safety injection needle onto the syringe. Gently re-shake the syringe to ensure a milky uniform suspension.
	Pull the protective cover straight off the needle Gently tap the syringe to remove any visible bubbles and expel them from the syringe. Proceed immediately to Step 9 for administration to the patient. Any delay may result in sedimentation.
	Step 9 OCTREOTIDE for INJECTABLE SUSPENSION must be given only by deep intragluteal injection, NEVER intravenously. Insert the needle fully into the left or right gluteus at a 90° angle to the skin. Slowly pull back the plunger to check that no blood vessel has been penetrated (reposition if a blood vessel has been penetrated). Depress the plunger with steady pressure until the syringe is empty. Withdraw the needle from the injection site and activate the safety guard (as shown in Step 10).

OCTREOTIDE for INJECTABLE SUSPENSION must be given only by deep intragluteal injection, never intravenously. If a blood vessel has been penetrated, another injection site must be selected. The site of repeat intragluteal injection should be alternated between the left and right gluteal muscle. Do not use the same gluteal region each time (every 4 weeks).

4.5 Missed Dose

If a scheduled injection is missed, the missed dose should be administered as soon as possible.

5 OVERDOSAGE

A limited number of accidental overdoses of octreotide acetate for injectable suspension have been reported. The doses ranged from 100 mg to 163 mg/month of octreotide acetate for injectable suspension. The only adverse event reported was hot flushes.

Cancer patients receiving doses of octreotide acetate for injectable suspension up to 60 mg/month and up to 90 mg/2 weeks have been reported. These doses were in general well tolerated; however, the following adverse events have been reported: frequent urination, fatigue, depression, anxiety, and lack of concentration.

The management of overdosage is symptomatic. Patients who received higher than recommended doses of intravenous octreotide are at increased risk of higher degree atrioventricular blocks and should be kept under appropriate cardiac monitoring.

6 DOSAGE FORMS, STRENGTHS, COMPOSITION AND PACKAGING

The reconstituted solution is a milky suspension without aggregates.

OCTREOTIDE for INJECTABLE SUSPENSION is supplied in kits containing:

• One single dose 8 mL glass vial of OCTREOTIDE for INJECTABLE SUSPENSION containing 10, 20 or 30 mg of octreotide (as acetate) slow release
• A pre-filled glass syringe containing 2 mL of diluent
• One vial adapter for drug product reconstitution
• One 19G x 1.5” safety injection needle
• The package insert with administration instructions.

7 WARNINGS AND PRECAUTIONS

General

As GH-secreting pituitary tumours may sometimes expand, causing serious complications (e.g.

visual field defects), it is essential that all patients treated with OCTREOTIDE for INJECTABLE SUSPENSION be carefully monitored. If evidence of tumour expansion appears, alternative procedures may be advisable.

Octreotide alters the balance between the counter-regulatory hormones, insulin, glucagon and growth hormone, which may result in hypoglycemia or hyperglycemia. Octreotide also suppresses secretion of thyroid stimulating hormone, which may result in hypothyroidism. Cardiac conduction abnormalities have also occurred during treatment with octreotide.

Careful instruction in sterile intramuscular injection techniques should be given to the patients and to other persons who may administer OCTREOTIDE for INJECTABLE SUSPENSION (see PATIENT MEDICATION INFORMATION).

Patients with carcinoid tumours and VIPomas should be advised to adhere closely to their scheduled return visits for reinjection in order to minimize exacerbation of symptoms.

Patients with acromegaly should also be urged to adhere to their return visit schedule to help assure steady control of GH and IGF-1 levels.

Carcinogenesis and Mutagenesis

Studies in laboratory animals have demonstrated no mutagenic potential of octreotide acetate.

Cardiovascular

In both acromegalic and carcinoid syndrome patients, bradycardia, arrhythmias and conduction abnormalities have been reported during octreotide therapy. Dose adjustments of drugs such as beta-blockers, calcium channel blockers, or agents to control fluid and electrolyte balance, may be necessary. Other EKG changes were observed such as QT prolongation, axis shifts, early repolarization, low voltage, R/S transition, early R wave progression, and non-specific ST-T wave changes. The relationship of these events to octreotide acetate is not established because many of these patients have underlying cardiac disease. In one acromegalic patient with severe congestive heart failure, initiation of octreotide acetate injection therapy resulted in worsening of CHF with improvement when drug was discontinued. Confirmation of a drug effect was obtained with a positive re-challenge (see 8 ADVERSE REACTIONS).

Endocrine and Metabolism

• Glucose Metabolism

Octreotide acetate injection therapy is occasionally associated with mild transient hypo- or hyperglycemia but may also result in overt diabetes due to alterations in the balance between the counter-regulatory hormones, insulin, glucagon and growth hormone. Patients should be closely observed on introduction of octreotide acetate injection therapy and at each change of dosage for symptomatic evidence of hyper- and hypoglycemia. Insulin requirement of patients with type I diabetes mellitus may be reduced by administration of octreotide acetate injection. In non-diabetics and type II diabetics with partially intact insulin reserves, octreotide acetate injection administration can result in prandial increases in glycemia. Severe hyperglycemia, subsequent pneumonia, and death following initiation of octreotide acetate injection therapy was reported in one patient with no history of hyperglycemia.

Predicting the effect of octreotide acetate injection on glucose tolerance in any given patients is not possible at this time. It is recommended that all acromegalic patients have their serum glucose carefully monitored during initiation and titration of therapy with OCTREOTIDE for INJECTABLE SUSPENSION.

Since following bleeding episodes from esophageal varices, there is an increased risk for the development of insulin-dependent diabetes or for changes in insulin requirement in patients with pre-existing diabetes, an appropriate monitoring of blood glucose is required.

It is therefore recommended that glucose tolerance and antidiabetic treatment be periodically monitored during therapy with OCTREOTIDE for INJECTABLE SUSPENSION.

• Thyroid Function

Data on the effect of chronic therapy with octreotide acetate injection on hypothalamic/pituitary function have not been obtained. A progressive drop in T4 levels has been reported, culminating in clinical and biochemical hypothyroidism after 19 months of therapy in one clinical trial patient (carcinoid) receiving 1500 mcg of octreotide acetate injection s.c. daily. Minimal impairment of thyroid function was recorded in some acromegalic patients following treatment with octreotide acetate for injectable suspension. Therefore, baseline and periodic assessment of thyroid function (TSH, total and/or free T4) should be monitored during chronic therapy with octreotide acetate.

Gastrointestinal

• Nutrition

There is evidence that octreotide acetate injection therapy may alter absorption of dietary fats in some patients. It is suggested that periodic quantitative 72-hour fecal fat and serum carotene determinations be performed to aid in the assessment of possible drug-induced aggravation of fat malabsorption.

Depressed vitamin B12 levels and abnormal Schilling’s tests have been observed in some patients receiving octreotide therapy, and monitoring of vitamin B12 levels is recommended during therapy with octreotide acetate for injectable suspension.

Octreotide has been investigated for the reduction of excessive fluid loss from the G.I. tract in patients with conditions producing such a loss. If such patients are receiving total parenteral nutrition (TPN), serum zinc may rise excessively when the fluid loss is reversed. Patients on TPN and octreotide should have periodic monitoring of zinc levels.

Hepatic/Biliary/Pancreatic

• Gallbladder and Related Events

Single doses of octreotide acetate injection have been shown to inhibit gallbladder contractility and decrease bile secretion in normal volunteers. In clinical trials with octreotide acetate injection (primarily patients with acromegaly or psoriasis) in patients who had not previously received octreotide, the incidence of biliary tract abnormalities was 63% (27% gallstones, 24% sludge without stones, 12% biliary duct dilatation). The incidence of stones or sludge in patients who received octreotide acetate injection for 12 months or longer was 52%. The incidence of gallbladder abnormalities did not appear to be related to age, sex, or dose, but was related to duration of exposure.

In clinical trials 52% of acromegalic patients, most of whom received octreotide acetate for injectable suspension for 12 months or longer, developed new biliary abnormalities including gallstones, microlithiasis, sediment, sludge, and dilatation. The incidence of new cholelithiasis was 22%, of which 7% were microstones.

In clinical trials 62% of malignant carcinoid patients who received octreotide acetate for injectable suspension for up to 18 months developed new biliary abnormalities including gallstones, sludge, and dilatation. New gallstones occurred in a total of 24% of patients.

Across all trials, a few patients developed acute cholecystitis, ascending cholangitis, biliary obstruction, cholestatic hepatitis, or pancreatitis during octreotide therapy or following its withdrawal. One patient developed ascending cholangitis during octreotide acetate injection therapy and died. Despite the high incidence of new gallstones in patients receiving octreotide, 1% of patients developed acute symptoms requiring cholecystectomy. Additionally, there have been post-marketing reports of cholelithiasis (gallstones) resulting in complications including cholecystitis, cholangitis, pancreatitis, and requiring cholecystectomy in patients taking octreotide acetate.

It is recommended that patients on extended therapy with OCTREOTIDE for INJECTABLE SUSPENSION be evaluated at baseline and periodically (at about 6-month intervals) to assess the presence of gallstones using ultrasound evaluations of the gallbladder and bile ducts (see 7 WARNINGS AND PRECAUTIONS, Monitoring and Laboratory Tests). If complications of cholelithiasis are suspected, discontinue OCTREOTIDE for INJECTABLE SUSPENSION and treat appropriately.

• Liver Impairment

In patients with liver cirrhosis, the half-life of the drug may be increased, necessitating adjustment of the maintenance dosage.

Monitoring and Laboratory Tests

Laboratory tests that may be helpful as biochemical markers in determining and following patient response depend on the specific tumour. Based on diagnosis, measurement of the following substances may be useful in monitoring the progress of therapy:

Carcinoid: 5-HIAA (urinary 5-hydroxyindole acetic acid), plasma serotonin, plasma Substance P

VIPoma: VIP (plasma vasoactive intestinal peptide)

Acromegaly: Growth hormone-IGF-1 (somatomedin C)

Responsiveness to octreotide may be evaluated by determining growth hormone levels at 1-4 hour intervals for 8-12 hours after subcutaneous injection of octreotide acetate injection (not octreotide acetate for injectable suspension). Alternatively, a single measurement of IGF -1 (somatomedin C) level may be made two weeks after initiation of octreotide acetate injection or dosage change. After patients are switched from octreotide acetate injection to octreotide acetate for injectable suspension, GH and IGF-1 determinations may be made after 3 monthly injections of octreotide acetate for injectable suspension. (Steady-state serum levels of octreotide are reached only after a period of 3 months of monthly injections.) Growth hormone can be determined using the mean of 4 assays taken at 1 hour intervals. Somatomedin C can be determined with a single assay. All GH and IGF-1 determinations should be made 4 weeks after the previous octreotide acetate for injectable suspension.

In patients with acromegaly, if no relevant reduction of GH and IGF 1 levels and no improvement of clinical symptoms have been achieved within 3 months of starting treatment with octreotide acetate, therapy should be discontinued.

Patients should undergo a baseline ultrasound examination of the gallbladder and bile ducts prior to commencing octreotide acetate treatment. Periodic ultrasound examination of the gallbladder should be performed, at about 6-month intervals, throughout octreotide acetate treatment. If stones are already present before the start of therapy, the potential benefit of octreotide acetate should be assessed against the potential risks associated with the gallstones. In case of asymptomatic gallstone, octreotide acetate may be continued, depending on re-assessment of the benefit/risk ratio with increased frequency of monitoring. Symptomatic gallstones should receive medical attention and be treated.

Baseline and periodic total and/or free T4 measurements should be performed during chronic therapy (see Endocrine and Metabolism, Thyroid Function).

Renal

• Renal Impairment

In patients with severe renal failure requiring dialysis, the half-life of the drug may be increased, necessitating adjustment of the maintenance dosage.

Reproductive Health: Female and Male Potential

• Fertility

The therapeutic benefits of a reduction in growth hormone (GH) levels and normalization of insulin- like growth factor 1 (IGF-1) concentration in female acromegalic patients could potentially restore fertility. Pregnancy in acromegalic patients may increase the risk of gestational diabetes, hypertension and exacerbation of the underlying cardiac disease, therefore female patients of childbearing potential should be advised to use adequate contraception during treatment with octreotide.

Animal studies in rats and rabbits did not adversely affect reproduction performance following treatment with octreotide acetate injection at doses up to 1 mg/kg/day (see 16 NON-CLINICAL TOXICOLOGY, Reproductive and Developmental Toxicology).

• Teratogenic Risk

There is no direct indication of a teratogenic potential following octreotide acetate injection treatment in animal studies (see 16 NON-CLINICAL TOXICOLOGY, Reproductive and Developmental

Toxicology).

7.1 Special Populations

7.1.1 Pregnant Women

There are no adequate and well-controlled studies in pregnant women. In the post-marketing experience, data on a limited number of pregnancies have been reported in patients on octreotide therapy.

7.1.2 Breast-feeding

It is not known whether octreotide is excreted in human breast milk. Animal studies have shown excretion of octreotide in breast milk. Patients should not breast-feed during octreotide acetate injection treatment.

7.1.3 Pediatrics

Experience with octreotide acetate in the pediatric population is limited.

Octreotide acetate injection has been primarily used in patients with congenital hyperinsulinism (also called nesidioblastosis). The youngest patient to receive the drug was 1 month old. At doses of 1-40 mcg/kg body weight/day, the majority of side effects observed were gastrointestinal-steatorrhea, diarrhea, vomiting and abdominal distension. Poor growth has been reported in several patients treated with octreotide acetate injection for more than 1 year; catch-up growth occurred after octreotide acetate injection was discontinued. A 16-month-old male with enterocutaneous fistula developed sudden abdominal pain and increased nasogastric drainage and died 8 hours after receiving a single 100 mcg subcutaneous dose of octreotide acetate injection.

7.1.4 Geriatrics

Clinical studies of octreotide acetate injection did not include sufficient numbers of patients age 65 years and over to determine whether they respond differently from younger patients. Other reported clinical experience has not identified differences in responses between the elderly and younger patients.

In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

8 ADVERSE REACTIONS

8.1 Adverse Reaction Overview

The most frequent adverse reactions reported with octreotide acetate include gastrointestinal disorders, nervous system disorders, hepatobiliary disorders, and metabolism and nutritional disorders.

8.2 Clinical Trial Adverse Reactions

Clinical trials are conducted under very specific conditions. The adverse reaction rates observed in the clinical trials, therefore, may not reflect the rates observed in practice and should not be compared to the rates in the clinical trials of another drug. Adverse reaction information from clinical trials may be useful in identifying and approximating rates of adverse drug reactions in real-world use.

Octreotide acetate for injectable suspension in Acromegaly

No clinical studies have been performed which compare octreotide acetate for injectable suspension to placebo. However, the profile of adverse reactions recorded in acromegalic patients treated with octreotide acetate for injectable suspension was similar to that known for octreotide acetate injection s.c. administration. Local injection site reactions to octreotide acetate injection may occur and are usually mild and of short duration. These reactions include pain, and rarely swelling and rash. In the double blind studies, gastrointestinal side effects following administration of octreotide acetate for injectable suspension were the most frequent adverse events and included abdominal pain, diarrhea (loose stools), flatulence and steatorrheic stools.

Adverse events occurring in ≥ 2% of patients who participated in the major studies in acromegaly (including their long-term extensions of up to 30 months duration) are listed in the table below, by dose group. It should be noted that some patients may appear under multiple dose levels since some patients switched dose levels.

Descriptions of Selected Adverse Reactions

Liver and Biliary

Octreotide acetate injection and other somatostatin analogues have been shown to inhibit gallbladder contractility and decrease bile secretion, which can lead to gallbladder abnormalities or sludge. Prolonged use of octreotide acetate may result in gallstone formation (see 7 WARNINGS AND PRECAUTIONS). Pancreatitis may develop in patients on long-term treatment with octreotide acetate who develop cholelithiasis.

There have been isolated reports of hepatic dysfunctions associated with octreotide acetate administration. These consist of the following:

• acute hepatitis without cholestasis and normalization of transaminase values on withdrawal of octreotide acetate injection s.c. has occurred;
• the slow development of hyperbilirubinemia in association with elevation of alkaline phosphatase, gamma glutamyl transferase and, to a lesser extent, transaminases.

Endocrine

Because of its inhibitory action on growth hormone, glucagon and insulin, octreotide acetate may impair glucose regulation. Postprandial glucose tolerance may be impaired and in some instances, with chronic administration, a state of persistent hyperglycemia may be induced. Hypoglycemia has also been observed.

Pancreatitis

Acute pancreatitis has been reported in rare instances. Generally, this effect is seen within the first hours or days of octreotide acetate injection s.c. treatment and resolves on withdrawal of the drug.

Hypersensitivity and anaphylactic reactions

Hypersensitivity reactions have been reported; most hypersensitivity and allergic reactions affect the skin and rarely affect the mouth and airways.

Isolated reports of anaphylactic reaction have been reported. Octreotide acetate injection administered s.c. and to a much lesser degree by i.v. infusion, can lead to hypersensitivity reaction that may range from generalized pruritus to cardiovascular shock or bronchospasm, with one case of death having been reported.

Cardiac disorder

Cases of bradycardia have been reported (frequency: common). In patients who are predisposed by having relatively low pre-treatment heart rates or whose cardiovascular system is already compromised, as in cirrhotic patients with bleeding esophageal varices, it is of importance that physicians be alerted to the possible undesirable effect of bradycardia. Tachycardia has also been observed (frequency: uncommon).

Other

Rarely, hair loss has been reported in patients receiving octreotide acetate treatment.

Rarely, dehydration has been reported.

8.3 Less Common Clinical Trial Adverse Reactions

Other adverse events (regardless of relationship) occurring at a 1% ≥ incidence <2% reported in the major studies in acromegaly (all doses combined):

Body As a Whole: Edema peripheral, syncope

Cardiovascular: Hypertension aggravated

Central and Peripheral Nervous Systems: Cramps, vertigo, neuralgia, cramps legs, neuropathy, hyperkinesia

Endocrine: Growth hormone overproduction, hypothyroidism, goiter

Gastro-intestinal System: Gastritis, hemorrhoids, gastroenteritis, hemorrhage rectum, hernia, eructation, gastro-intestinal disorder, stomatitis ulcerative

Hearing and Vestibular: Deafness, ear discharge

Heart Rate and Rhythm: Tachycardia

Liver and Biliary: Hepatitis, liver fatty

Metabolic and Nutritional: Weight increase, hypoglycemia

Musculo-skeletal System: Arthrosis, surgery, bone fracture, osteonecrosis

Platelet, Bleeding and Clotting: Epistaxis

Psychiatric: Amnesia, sleep disorder

Red Blood Cell: Anemia hypochromic

Reproductive Disorders: Female: Breast pain female, intermenstrual bleeding, lactation non purperal. Male: prostate disorder

Resistance Mechanism: Moniliasis, otitis media, pharyngitis, tonsilitis, herpes simplex, herpes zoster

Respiratory System: Dyspnea, pneumonia

Skin and Appendages: Skin disorder, skin dry, acne, nail disorder

Urinary System: Urinary tract infection, cystitis, dysuria, micturition frequency

Vascular (Extracardiac): Phlebitis, cerebrovascular, vein varicose

Octreotide for Injectable Suspension in Carcinoid Tumours

No clinical studies have been performed which compare octreotide acetate for injectable suspension to placebo. However, the profile of adverse reactions recorded in patients with carcinoid tumours treated with octreotide acetate for injectable suspension was similar to that known for octreotide acetate injection s.c. administration. In a 6-month study during which patients with carcinoid tumours were treated with either octreotide acetate for injectable suspension i.m. at 4-week intervals or octreotide acetate injection s.c. t.i.d., gastrointestinal side effects were the most frequently reported adverse events in both groups and included abdominal pain, diarrhea (loose stools), constipation, flatulence, nausea, and vomiting. The incidences of these adverse events were similar between the 10, 20, and 30 mg dosages of octreotide acetate for injectable suspension.

Local injection site reactions to octreotide acetate may occur and are usually mild and of short duration. These reactions include pain, and rarely swelling and rash.

8.5 Post-Market Adverse Reactions

Spontaneously reported adverse drug reactions are presented below. Because these events are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or clearly establish a causal relationship to octreotide acetate exposure.

*Most reports of thrombocytopenia were in patients with liver cirrhosis treated with octreotide acetate injection (i.v.) and some reports were with octreotide acetate for injectable suspension. This was reversible.

9 DRUG INTERACTIONS

9.2 Drug interactions overview

Many patients with carcinoid syndrome or VIPomas being treated with octreotide acetate have also been, or are being, treated with many other drugs to control the symptomatology or progression of the disease, generally without serious drug interaction. Included are chemotherapeutic agents, H2 antagonists, antimotility agents, drugs affecting glycemic states, solutions for electrolyte and fluid support or hyperalimentation, antihypertensive diuretics and anti-diarrheal agents.

Where symptoms are severe and octreotide acetate therapy is added to other therapies used to control glycemic states, such as sulfonylureas, insulin and diazoxide, to beta blockers, calcium channel blockers or to agents for the control of fluid and electrolyte balance, patients must be monitored closely and adjustment made in the other therapies as the symptoms of the disease are controlled. Evidence currently available suggests these imbalances in fluid and electrolytes or glycemic states are secondary to correction of pre-existing abnormalities and not to a direct metabolic action of octreotide acetate. Adjustment of the dosage of drugs, such as insulin, affecting glucose metabolism may be required following initiation of octreotide acetate therapy in patients with diabetes.

9.4 Drug-Drug Interactions

Since octreotide acetate has been associated with alterations in nutrient absorption, its effect on absorption of any orally administered drugs should be carefully considered. A single case of transplant rejection episode (renal/whole pancreas) in a patient immunosuppressed with cyclosporine has been reported. Octreotide acetate treatment to reduce exocrine secretion and close a fistula in this patient resulted in decreases in blood levels of cyclosporine and may have contributed to the rejection episode. Octreotide acetate has also been found to delay the intestinal absorption of cyclosporine or cimetidine.

Concomitant administration of octreotide and bromocriptine increases the bioavailability of bromocriptine.

Limited published data indicate that somatostatin analogues might decrease the metabolic clearance of compounds known to be metabolized by cytochrome P450 enzymes, which may be due to the suppression of growth hormone. Since it cannot be excluded that octreotide may have this effect, other drugs mainly metabolized by the CYP 3A4 and which have a low therapeutic index should therefore be used with caution (e.g. cyclosporine).

Concomitant use with radioactive somatostatin analogues

Somatostatin and its analogues, such as octreotide, competitively bind to somatostatin receptors and may interfere with the efficacy of radioactive somatostatin analogues.

The administration of OCTREOTIDE for INJECTABLE SUSPENSION should be discontinued for at least 4 weeks prior to the administration of lutetium (¹⁷⁷Lu) oxodotreotide (LUTATHERA^TM), a radiopharmaceutical binding to somatostatin receptors. If necessary, patients may be treated with short acting somatostatin analogues until 24 hours prior to the administration of lutetium (¹⁷⁷Lu) oxodotreotide.

After administration of lutetium (¹⁷⁷Lu) oxodotreotide, treatment with OCTREOTIDE for INJECTABLE SUSPENSION can be resumed within 4 to 24 hours and should be discontinued again 4 weeks prior to the next administration of lutetium (¹⁷⁷Lu) oxodotreotide.

9.5 Drug-Food Interactions

Interactions with food have not been established.

9.6 Drug-Herb Interactions

Interactions with herbal products have not been established.

9.7 Drug-Laboratory Test Interactions

No known interference exists with clinical laboratory tests, including amine or peptide determinations.

10 CLINICAL PHARMACOLOGY

10.1 Mechanism of Action

General

Octreotide acetate is a synthetic octapeptide analogue of naturally occurring somatostatin with similar pharmacological effects, but with a prolonged duration of action. It inhibits pathologically increased secretion of growth hormone (GH) and of peptides and serotonin produced within the gastro-entero-pancreatic (GEP) endocrine system.

In normal healthy subjects, octreotide acetate has been shown to inhibit:

• Release of growth hormone (GH) stimulated by arginine infusion, exercise and insulin- induced hypoglycemia.
• Postprandial release of insulin, glucagon, gastrin, other peptides of the GEP endocrine system, and arginine-stimulated release of insulin and glucagon.

• Thyrotropin releasing hormone (TRH) stimulated release of thyroid stimulating

  • hormone (TSH). The precise mode of action of octreotide acetate on portal hypertension is still unclear. It is thought to reduce splanchnic blood flow primarily by inhibiting vasoactive gastro-intestinal hormone secretion and exerting a direct vasomotor effect on splanchnic vessels, thus reducing portal blood flow. Using human sephanous veins, it has been shown that vasoconstriction is mediated by type 2 somatostatin receptors.

10.2 Pharmacodynamics

The pharmacological activities of octreotide acetate in man include inhibition of stimulated GH secretion, stimulated TSH levels, insulin and glucagon release, gut hormone secretion, and decreased portal hypertension. This spectrum of activity resembles that obtained with administration of somatostatin in man.

The actions of somatostatin are mediated by receptors. Five somatostatin receptor subtypes have been identified. Octreotide displays a high affinity for type 2 receptors, a moderate affinity for type 3 and 5 receptors and a very low affinity for type 1 and 4 receptors.

10.3 Pharmacokinetics

Octreotide as acetate for injectable suspension

In patients with acromegaly, octreotide acetate for injectable suspension, a galenical formulation of octreotide consisting of microspheres for depot suspension suitable for repeat intramuscular administration at intervals of four weeks, delivers consistent and therapeutic octreotide serum concentrations thus consistently lowering GH and normalizing IGF-1 serum concentrations in the majority of patients.

In patients with carcinoid tumours and Vasoactive Intestinal Peptide Tumours (VIPomas), treatment with octreotide acetate for injectable suspension provides continuous control of symptoms related to the underlying disease.

The pharmacokinetic profile of octreotide acetate after injection of octreotide acetate for injectable suspension reflects the release profile from the polymer matrix and its biodegradation. Once released into the systemic circulation, octreotide distributes according to its known pharmacokinetic properties.

After single intramuscular injections of octreotide acetate for injectable suspension, the serum octreotide concentration reaches a transient initial peak within one hour after administration followed by progressive decrease to a low undetectable octreotide level within 24 hours. After this initial peak on the first day, octreotide remains at sub-therapeutic levels in the majority of patients for the following seven days. Thereafter, octreotide concentrations increase again, and reach plateau concentrations around day 14 and remain relatively constant during the following three to four weeks. The peak level during day 1 is lower than levels during the plateau phase and no more than 0.5% of the total drug release occurs during day 1. After about day 42, the octreotide concentration decreases slowly, concomitantly with the terminal degradation phase of the polymer matrix dosage form.

In patients with acromegaly, plateau octreotide concentrations after single doses of 10 mg, 20 mg and 30 mg of octreotide acetate for injectable suspension are 358, 926 and 1710 pg/mL, respectively. Steady state octreotide concentrations reached after three injections at four week intervals, are higher by a factor of approximately 1.6 to 1.8 reaching 1557 and 2384 pg/mL after multiple injections of 20 and 30 mg octreotide acetate for injectable suspension, respectively. No accumulation of octreotide beyond that expected from overlapping release profiles occurred over a period of up to 28 monthly octreotide acetate for injectable suspension injections.

In patients with carcinoid tumours, the mean octreotide serum concentrations after six doses of 10 mg, 20 mg and 30 mg of octreotide acetate for injectable suspension administered by intramuscular injection every four weeks were 1231 pg/mL, 2620 pg/mL and 3928 pg/mL, respectively. Concentrations were dose proportional and steady-state concentrations were reached after two injections of 20 and 30 mg and after three injections of 10 mg.

11 STORAGE, STABILITY AND DISPOSAL

The OCTREOTIDE for INJECTABLE SUSPENSION vials must be stored at 2 to 8 ºC. Keep vial in the outer carton in order to protect it from light. The vials can remain at room temperature on the day of the injection. However the suspension must only be prepared immediately prior to intramuscular (i.m.) injection.

Store the pre-filled syringe with 2 mL diluent at 2 to 8 ºC. Do not freeze.

The OCTREOTIDE for INJECTABLE SUSPENSION powder, once suspended in the diluent, should be used immediately.

Keep in a safe place out of reach and sight of children and pets.

12 SPECIAL HANDLING INSTRUCTIONS

Not applicable

PART II: SCIENTIFIC INFORMATION

13 PHARMACEUTICAL INFORMATION

Drug Substance

Proper name: octreotide acetate

Chemical name: D-Phenylalanyl-L-hemicystyl-L-phenylalanyl-D-tryptophyl-L-lysyl-L-threonyl-L-hemicystyl-L-threoninol cyclic(2→7) disulfide acetate

Molecular formula: C49H66N10O10S2, xC2H4O2

Molecular mass: 1019.2 g/mol (as free base)

Structural formula:

Physicochemical properties: Octreotide acetate is a bridged octapeptide analogue of somatostatin. It is a white to off-white amorphous powder, which melts with decomposition; it is very hygroscopic. Freely soluble in methanol, water and in 1% acetic acid.

14 CLINICAL TRIALS

14.1 Trial Design and Study Demographics

The clinical trials of octreotide acetate for injectable suspension were performed in patients who had been receiving subcutaneous octreotide acetate for a period of weeks to as long as 10 years. The acromegaly studies with octreotide acetate for injectable suspension described below were performed in patients who achieved GH levels of <10 ng/mL (and, in most cases <5 ng/mL) while on subcutaneous octreotide acetate injection. However, some patients enrolled were partial responders to subcutaneous octreotide acetate injection, i.e., GH levels were reduced by >50% on subcutaneous octreotide acetate injection compared to the untreated state, although not suppressed to <5 ng/mL.

14.2 Study Results

Acromegaly

Octreotide acetate for injectable suspension was evaluated in three clinical trials in acromegalic patients.

In two of the clinical trials, a total of 101 patients were entered who had, in most cases, achieved a GH level <5 ng/mL on octreotide acetate injection given in doses of 100 mcg or 200 mcg t.i.d. Most patients were switched to 20 mg or 30 mg doses of octreotide acetate for injectable suspension given once every 4 weeks for up to 27 to 28 injections. A few patients received doses of 10 mg and a few required doses of 40 mg. Growth hormone and IGF-1 levels were at least as well controlled with octreotide acetate for injectable suspension as they had been on octreotide acetate injection and this level of control remained for the entire duration of the trials.

A third trial was a 12-month study that enrolled 151 patients who had a GH level <10 ng/mL after treatment with octreotide acetate injection (most had levels <5 ng/mL). The starting dose of octreotide acetate for injectable suspension was 20 mg every 4 weeks for 3 doses. Thereafter, patients received 10 mg, 20 mg or 30 mg every 4 weeks, depending upon the degree of GH suppression. (The recommended regimen for these dosage changes is described under 4 DOSAGE AND ADMINISTRATION.) Growth hormone and IGF-1 were at least as well controlled on octreotide acetate for injectable suspension as they had been on octreotide acetate injection s.c.

Table 2 summarizes the data on hormonal control (GH and IGF-1) for those patients in the first two clinical trials who received all 27 to 28 injections of octreotide acetate for injectable suspension.

For the 88 patients in Table 2, a mean GH level of <2.5 ng/mL was observed in 47% receiving octreotide acetate for injectable suspension. Over the course of the trials 42% of patients maintained mean growth hormone levels of <2.5 ng/mL and mean normal IGF-1 levels.

Table 3 summarizes the data on hormonal control (GH and IGF-1) for those patients in the third clinical trial who received all 12 injections of octreotide acetate for injectable suspension.

For the 122 patients in Table 3, who received all 12 injections in the third trial, a mean GH level of <2.5 ng/mL was observed in 66% receiving octreotide acetate for injectable suspension. Over the course of the trial 57% of patients maintained mean growth hormone levels of <2.5 ng/mL and mean normal IGF-1 levels. In comparing the hormonal response in these trials, note that a higher percentage of patients in the third trial suppressed their mean GH to <5 ng/mL on subcutaneous octreotide acetate injection, 95%, compared to 78% across the two previous trials.

In all three trials, GH, IGF-1, and clinical symptoms were similarly controlled on octreotide acetate for injectable suspension as they had been on octreotide acetate injection.

Of the 25 patients who completed the trials and were partial responders to octreotide acetate injection GH >5.0 ng/mL but reduced by >50% relative to untreated levels), 1 patient (4%) responded to octreotide acetate for injectable suspension with a reduction of GH to <2.5 ng/mL and 8 patients (32%) responded with a reduction of GH to <5.0 ng/mL.

Two exploratory open label phase IV studies investigated a 24- and 48-week treatment with octreotide acetate for injectable suspension in previously untreated acromegalic patients. The median reduction in tumour volume was 20.6% in Study B2402 at 24 weeks (n=46) and 29.2% at 48 weeks (n=29), and 24.5% in Study B2401 at 24 weeks (n=91) and 36.2% at 48 weeks (n=84). The percentage change in tumour volume during the course of the investigation was assessed by MRI for the intent-to-treat population. However, the clinical significance has not been established.

Carcinoid Tumours and Vasoactive Intestinal Peptide Tumours (VIPomas)

A 6-month clinical trial of malignant carcinoid syndrome was performed in 93 patients who had previously been shown to be responsive to octreotide acetate injection. Sixty-seven patients were randomized at baseline to receive, double-blind, doses of 10 mg, 20 mg or 30 mg octreotide acetate for injectable suspension every 28 days and 26 patients continued, unblinded, on their previous octreotide acetate injection regimen (100-300 mcg t.i.d.).

In any given month after steady-state levels of octreotide were reached, approximately 35%-40% of the patients who received octreotide acetate for injectable suspension required supplemental subcutaneous octreotide acetate injection therapy usually for a few days, to control exacerbation of carcinoid symptoms. In any given month the percentage of patients randomized to subcutaneous octreotide acetate injection, who required supplemental treatment with an increased dose of octreotide acetate injection, was similar to the percentage of patients randomized to octreotide acetate for injectable suspension. Over the six-month treatment period approximately 50%-70% of patients who completed the trial on octreotide acetate for injectable suspension required subcutaneous octreotide acetate injection supplemental therapy to control exacerbation of carcinoid symptoms although steady-state serum octreotide acetate for injectable suspension levels had been reached.

Table 4 presents the average number of daily stools and flushing episodes in malignant carcinoid patients.

Overall, mean daily stool frequency was as well controlled on octreotide acetate for injectable suspension as on octreotide acetate injection (approximately 2 to 2.5 stools/day).

Mean daily flushing episodes were similar at all doses of octreotide acetate for injectable suspension and on octreotide acetate injection (approximately 0.5 to 1 episode/day).

In a subset of patients with variable severity of disease, median 24 hour urinary 5-HIAA (5-hydroxyindole acetic acid) levels were reduced by 38%-50% in the groups randomized to octreotide acetate for injectable suspension.

The reductions are within the range reported in the published literature for patients treated with octreotide (about 10%-50%).

14.3 Comparative Bioavailability Studies

BIOAVAILABILITY DATA

Α randomized, two-treatment, parallel, open label, laboratory-blind, single dose bioequivalence study of OCTREOTIDE for INJECTABLE SUSPENSION 30 mg (Teva Canada Limited) and Sandostatin® LAR®- Monatsdepot 30 mg (Octreotide Acetate for Injectable Suspension) (Novartis Pharma GmbH) following a single intramuscular injection in healthy adults (n=240) under fasting conditions. The results from measured data from 238 subjects who completed the study are summarized in the table below.

^* Octreotide for Injectable Suspension (octreotide acetate) 30 mg (Teva Canada Limited)

^†Sandostatin® LAR®- Monatsdepot 30 mg Injectable Suspension (Novartis Pharma GmbH), Country of purchase: Germany

^§ Expressed as median (range)

^€ Expressed as the arithmetic mean (CV%)

15 MICROBIOLOGY

No microbiological information is required for this drug product.

16 NON-CLINICAL TOXICOLOGY

General Toxicology

Single intravenous injections of octreotide acetate were administered to mice and rats. Animals were observed until death occurred or for a period of seven days following administration.

Octreotide acetate caused no unusual effects. Immediately after administration the following signs were observed: numbness, strained and sometimes slower breathing, jumping and roll and stretch cramps. The animals which died did so within one hour, the survivors were without signs after two days.

Subchronic and Chronic Toxicity

Chronic Toxicity Studies with octreotide acetate for injectable suspension

Carcinogenicity

The results of the oncogenicity studies in rats and mice do not indicate a direct carcinogenic effect of octreotide acetate and are not considered an impediment for human use

Genotoxicity

In vitro mutagenicity was tested in Salmonella typhimurium strains TA1535, TA1537, TA1538, TA98 and TA100 in the presence and absence of a rat liver S9 homogenate (Ames test). No mutagenic effect was found.

In vivo mutagenicity was investigated by means of the micronucleus test using adult CD mice (Charles River). Octreotide acetate was administered intravenously twice within 24 hours. Doses were 5, 16 or 50 mg/kg for each treatment. Controls received the diluent only. Micronuclei were evaluated in bone marrow preparations made 48 or 72 hours after the first administration. Octreotide acetate was not mutagenic in this test system.

In a second in vivo mutagenicity test, damage to germ cell DNA was evaluated using the unscheduled DNA systhesis (UDS) technique. Male CD mice were injected intravenously with single doses of either 25 or 50 mg/kg. One hour after the administration of octreotide acetate, the mice received an intra-testicular injection of radioactive marked thymidine. Sperm were taken from the cauda epididymis at various time intervals, counted, and tested for radioactivity in a scintillation counter. In this test system octreotide acetate had no effect on the DNA of germ cells.

The octreotide acetate for injectable suspension microspheres were devoid of mutagenic potential when tested in a validated in vitro bacterial assay.

Reproductive and Developmental Toxicology

Rats and rabbits were treated intravenously with octreotide acetate 0.01, 0.1 or 1 mg/kg/day from day 6 to 15 or 6 to 18 post coitum. Dams and their fetuses were sacrificed at term and examined. In rats and rabbits the 0.01 mg/kg/day dose was well tolerated by the dams but the mid and high doses caused slight dose-dependent weight gain inhibition. No adverse effect on the reproduction data or fetal and placental weight was observed. Morphological findings in fetuses of both species gave no indication of a teratogenic potential of the drug.

In a peri- and post-natal study in rats treated subcutaneously with doses of 0.02, 0.1 or 1.0 mg/kg/day from day 15 post coitum until autopsy on day 21 post-partum, octreotide acetate was well tolerated by the F0 females of all treatment groups, although slightly lower weight gain during pregnancy was noted in the high dose group. The reduced growth observed in rat pups was most likely a direct consequence of the drug's main pharmacological action, i.e. growth hormone inhibition.

In a fertility and general reproduction performance study in female rats treated subcutaneously, once daily, with doses of 0.02, 0.1 or 1 mg/kg/day, octreotide acetate was well tolerated by the F0 dams of the lower and mid dose group. In the high dose group, body weight gain was slightly reduced during the 2 weeks preceding mating and there was localized hair loss at the site of injection. Reproduction performance was normal at all dose levels. Prenatal and post-natal development of F1 offspring was not affected except for some growth retardation. The reproduction performance of F1 animals as well as the development of the F2 offspring were also normal.

Animal studies do not indicate direct or indirect harmful effects with respect to pregnancy, embryonal/foetal development, parturition or postnatal development apart from some transient retardation of physiological growth.

Special Toxicology

Special Toxicity Studies with octreotide acetate for injectable suspension: Local Tolerance

17 SUPPORTING PRODUCT MONOGRAPHS

SANDOSTATIN^® LAR^® (octreotide acetate for injectable suspension, 10 mg, 20 mg, and 30 mg per vial), Submission Control No. 247160, Product Monograph, Novartis Pharmaceuticals Canada Inc.. Date of Revision: APR 19, 2021.