Indication and Important Safety Information
ALIMTA is indicated in combination with carboplatin (carbo) and pembrolizumab (pembro) for the initial treatment of patients with nonsquamous metastatic non-small cell lung cancer (mNSCLC). This indication is approved under accelerated approval based on tumor response rate and progression-free survival. Continued approval for this indication may be contingent upon verification and description of clinical benefit in the confirmatory trials.
Limitation of Use: ALIMTA is not indicated for the treatment of patients with squamous cell non-small cell lung cancer.
IMPORTANT SAFETY INFORMATION
ALIMTA is contraindicated in patients who have a history of severe hypersensitivity reaction to pemetrexed.
WARNINGS AND PRECAUTIONS
Myelosuppression and Increased Risk of Myelosuppression without Vitamin Supplementation
ALIMTA can cause severe myelosuppression resulting in a requirement for transfusions and which may lead to neutropenic infection. The risk of myelosuppression is increased in patients who do not receive vitamin supplementation.
Prior to treatment with ALIMTA, patients must be instructed to initiate supplementation with oral folic acid. Intramuscular injections of vitamin B12 are also required prior to ALIMTA treatment. Folic acid and vitamin B12 supplementation should be continued during treatment and for 21 days after the last dose of ALIMTA as they may reduce the severity of treatment-related hematologic and gastrointestinal toxicities. Obtain a complete blood count at the beginning of each cycle. Do not administer ALIMTA until the ANC is at least 1500 cells/mm3 and platelet count is at least 100,000 cells/mm3. Permanently reduce ALIMTA in patients with an ANC of less than 500 cells/mm3 or platelet count of less than 50,000 cells/mm3 in previous cycles.
In Studies JMDB and JMCH, among patients who received vitamin supplementation, incidence of Grade 3-4 neutropenia was 15% and 23%, the incidence of Grade 3-4 anemia was 6% and 4%, and incidence of Grade 3-4 thrombocytopenia was 4% and 5%, respectively. In Study JMCH, 18% of patients in the ALIMTA arm required red blood cell transfusions compared to 7% of patients in the cisplatin arm. In Studies JMEN, PARAMOUNT, and JMEI, where all patients received vitamin supplementation, incidence of Grade 3-4 neutropenia ranged from 3% to 5%, and incidence of Grade 3-4 anemia ranged from 3% to 5%.
ALIMTA can cause severe, and sometimes fatal, renal toxicity. Determine creatinine clearance before each dose and periodically monitor renal function during treatment with ALIMTA.
The incidences of renal failure in clinical studies in which patients received ALIMTA with cisplatin were: 2.1% in Study JMDB and 2.2% in Study JMCH. The incidence of renal failure in clinical studies in which patients received ALIMTA as a single agent ranged from 0.4% to 0.6% (Studies JMEN, PARAMOUNT, and JMEI).
Withhold ALIMTA in patients with a creatinine clearance of less than 45 mL/min.
Bullous and Exfoliative Skin Toxicity
Serious and sometimes fatal, bullous, blistering and exfoliative skin toxicity, including cases suggestive of Stevens-Johnson Syndrome/Toxic epidermal necrolysis can occur with ALIMTA. Permanently discontinue ALIMTA for severe and life-threatening bullous, blistering or exfoliating skin toxicity.
Serious interstitial pneumonitis, including fatal cases, can occur with ALIMTA treatment. Withhold ALIMTA for acute onset of new or progressive unexplained pulmonary symptoms such as dyspnea, cough, or fever pending diagnostic evaluation. If pneumonitis is confirmed, permanently discontinue ALIMTA.
Radiation recall can occur with ALIMTA in patients who have received radiation weeks to years previously. Monitor patients for inflammation or blistering in areas of previous radiation treatment. Permanently discontinue ALIMTA for signs of radiation recall.
Increased Risk of Toxicity with Ibuprofen in Patients with Renal Impairment
Exposure to ALIMTA is increased in patients with mild to moderate renal impairment who take concomitant ibuprofen, increasing the risks of adverse reactions of ALIMTA. In patients with creatinine clearances between 45 mL/min and 79 mL/min, avoid administration of ibuprofen for 2 days before, the day of, and 2 days following administration of ALIMTA. If concomitant ibuprofen use cannot be avoided, monitor patients more frequently for ALIMTA adverse reactions, including myelosuppression, renal, and gastrointestinal toxicity.
Based on findings from animal studies and its mechanism of action, ALIMTA can cause fetal harm when administered to a pregnant woman. In animal reproduction studies, intravenous administration of pemetrexed to pregnant mice during the period of organogenesis was teratogenic, resulting in developmental delays and increased malformations at doses lower than the recommended human dose of 500 mg/m2. Advise pregnant women of the potential risk to the fetus. Advise females of reproductive potential to use effective contraception during treatment with ALIMTA and for 6 months after the final dose. Advise males with female partners of reproductive potential to use effective contraception during treatment with ALIMTA and for 3 months after the final dose.
Ibuprofen increases exposure (AUC) of pemetrexed. In patients with creatinine clearance between 45 mL/min and 79 mL/min:
- Avoid administration of ibuprofen for 2 days before, the day of, and 2 days following administration of ALIMTA.
- Monitor patients more frequently for myelosuppression, renal, and gastrointestinal toxicity, if concomitant administration of ibuprofen cannot be avoided.
Severe adverse reactions (grades 3-4) occurring in patients with metastatic nonsquamous non-small cell lung cancer (NSCLC) receiving ALIMTA and carboplatin in combination with pembrolizumab versus ALIMTA and carboplatin for initial treatment (KEYNOTE-021), respectively, were fatigue (3.4% vs 0%); dyspnea (3.4% vs 0%); nausea (1.7% vs 0%); vomiting (1.7% vs 0%); diarrhea (1.7% vs 1.6%); rash (1.7% vs 1.6%); constipation (0% vs 1.6%); headache (0% vs 1.6%); and arthralgia (0% vs 1.6%).
Common adverse reactions (all grades) occurring in ≥20% of patients with metastatic nonsquamous non-small cell lung cancer (NSCLC) receiving ALIMTA and carboplatin in combination with pembrolizumab versus ALIMTA and carboplatin for initial treatment (KEYNOTE-021), respectively, were fatigue (71% vs 50%); nausea (68% vs 56%); constipation (51% vs 37%); rash (42% vs 21%); vomiting (39% vs 27%); dyspnea (39% vs 21%); diarrhea (37% vs 23%); decreased appetite (31% vs 23%); headache (31% vs 16%); cough (24% vs 18%); dizziness (24% vs 16%); insomnia (24% vs 15%); pruritus (24% vs 4.8%); peripheral edema (22% vs 18%); dysgeusia (20% vs 11%); alopecia (20% vs 3.2%); upper respiratory tract infection (20% vs 3.2%); and arthralgia (15% vs 24%).
USE IN SPECIFIC PATIENT POPULATIONS
Lactation: There is no information regarding the presence of pemetrexed or its metabolites in human milk, the effects on the breastfed infant, or the effects on milk production. Because of the potential for serious adverse reactions in breastfed infants from ALIMTA, advise women not to breastfeed during treatment with ALIMTA and for one week after last dose.
Males of Reproductive Potential: ALIMTA may impair fertility in males of reproductive potential. It is not known whether these effects on fertility are reversible.
Pediatric Use: The safety and effectiveness of ALIMTA in pediatric patients have not been established. Adverse reactions observed in pediatric patients studied were similar to those observed in adults.
Patients with Renal Impairment: ALIMTA is primarily excreted by the kidneys. Decreased renal function results in reduced clearance and greater exposure (AUC) to ALIMTA compared with patients with normal renal function. No dose is recommended for patients with creatinine clearance less than 45 mL/min.
Geriatric:The incidences of Grade 3-4 anemia, fatigue, thrombocytopenia, hypertension, and neutropenia were higher in patients 65 years of age and older as compared to younger patients: in at least one of five randomized clinical trials.
For safety and dosing guidelines for ALIMTA, see complete Warnings and Precautions, Adverse Reactions, and Dosage and Administration sections in the full Prescribing Information and Patient Prescribing Information.
- ALIMTA (pemetrexed for injection) [package insert]. Indianapolis, IN: Eli Lilly and Company; 2018.
- Langer CJ, et al. Lancet Oncol. 2016;17(11):1497-1508.
PP-PM-US-0581 09/2018 © Lilly USA, LLC 2018. All rights reserved.
ALIMTA® is a registered trademark owned or licensed by Eli Lilly and Company, its subsidiaries, or affiliates.