- Approval Id
- b56bc074507120d3
- Drug Approval Emc Name
- Letrozole 2.5 mg film-coated tablets
- Drug Name
- Letrozole 2.5 mg film-coated tablets
- Company Name
- Cipla EU Ltd
- Company Address
- Dixcart House, Addlestone Road, Bourne Business Park, Addlestone,, KT15 2LE, UK
- Company Website
- http://www.cipla.com
- Company Telephone
- +44 (0)1932 264688
- Company Medical Info Direct Line
- 0800 0472144
- Company Medical Info Email
- Drugsafety@cipla.com
- Company Customer Care Direct Line
- +44 (0)207 399 4883
- Atc Code
- L02BG04
- Legal Category
- Prescription only medicine
- Authorisation Holder
- Cipla (EU) Limited,
Dixcart House, Addlestone Road,
Bourne Business Park, Addlestone,
Surrey, KT15 2LE,
United Kingdom
- Authorisation Number
- PLGB 36390/0338
- Authorisation Date
- 11/12/2024
- Instruction Authorisation Holder
- Cipla (EU) Limited,
Dixcart House, Addlestone Road,
Bourne Business Park, Addlestone,
Surrey, KT15 2LE,
United Kingdom
- Instruction Authorisation Number
- PLGB 36390/0338
- Instruction Authorisation Date
- 11/12/2024
- Instruction Composition
- Each film-coated tablet contains 2.5 mg letrozole.
\*\*Excipient with known effect\*\*
Each film-coated tablet contains 45 mg of lactose monohydrate.
For the full list of excipients, see section 6.1.
- Instruction Dosage Form
- Film-coated tablet.
Yellow, circular, biconvex film-coated tablets, plain on both sides.
- Instruction Clinical Particulars
- 4.1 Therapeutic indications
Adjuvant treatment of postmenopausal women with hormone receptor positive invasive early breast cancer.
Extended adjuvant treatment of hormone-dependent early invasive breast cancer in postmenopausal women who have received prior standard adjuvant tamoxifen therapy for 5 years.
First-line treatment in postmenopausal women with hormone-dependent advanced breast cancer.
Advanced breast cancer after relapse or disease progression, in women with natural or artificially induced postmenopausal endocrine status, who have previously been treated with antioestrogens.
Neoadjuvant treatment of postmenopausal women with hormone receptor positive, HER-2 negative breast cancer where chemotherapy is not suitable and immediate surgery not indicated.
Efficacy has not been demonstrated in patients with hormone receptor negative breast cancer.4.2 Posology and method of administration
\*\*Posology\*\*
\*Adult and elderly patients\*
The recommended dose of Letrozole tablet is 2.5 mg once daily.
In patients with advanced or metastatic breast cancer, treatment with letrozole tablets should continue until tumour progression is evident.
In the adjuvant and extended adjuvant setting, treatment with Letrozole tablets should continue for 5 years or until tumour relapse occurs, whichever is first.
In the neoadjuvant setting, treatment with letrozole tablets could be continued for 4 to 8 months in order to establish optimal tumour reduction. If the response is not adequate, treatment with letrozole tablets should be discontinued and surgery scheduled and/or further treatment options discussed with the patient.
Following standard adjuvant tamoxifen therapy, treatment with letrozole tablets should continue for 5 years or until tumour relapse occurs, whichever comes first. In patients with metastatic disease, treatment with letrozole tablets should continue until tumour progression is evident. Regular monitoring to observe progression during the pre-operative treatment period is recommended (see section 5.1). No dose adjustment is required for elderly patients.
\*Paediatric population\*
Letrozole tablets is not recommended for use in children and adolescents. The safety and efficacy of letrozole tablets in children and adolescents aged up to 17 years have not been established. Limited data are available and no recommendation on a posology can be made.
\*Renal impairment\*
No dosage adjustment of letrozole tablets is required for patients with renal insufficiency with creatinine clearance ≥10 ml/min. Insufficient data are available in cases of renal insufficiency with creatinine clearance lower than 10 ml/min (see sections 4.4 and 5.2).
\*Hepatic impairment\*
No dosage adjustment of letrozole tablets is required for patients with mild to moderate hepatic insufficiency (Child-Pugh grade A or B). Insufficient data are available for patients with severe hepatic impairment. Patients with severe hepatic impairment (Child-Pugh C) require close supervision (see sections 4.4 and 5.2).
\*\*Method of administration\*\*
Letrozole tablets should be taken orally and can be taken with or without food.
A missed dose should be taken as soon as the patient remembers. However, if it is almost time for the next dose (within 2 or 3 hours), the missed dose should be skipped, and the patient should go back to her regular dosage schedule. Doses should not be doubled because with daily doses over the 2.5 mg recommended dose, over-proportionality in systemic exposure was observed (see section 5.2).4.3 Contraindications
• Hypersensitivity to the active substance or to any of the excipients listed in section 6.1
• Premenopausal endocrine status
• Premenopausal, pregnant or lactating women (see section 4.6).4.4 Special warnings and precautions for use
\*\*Menopausal status\*\*
In patients whose menopausal status is unclear, luteinising hormone (LH), follicle-stimulating hormone (FSH) and/or oestradiol levels should be measured before initiating treatment with letrozole. Only women of postmenopausal endocrine status should receive letrozole.
\*\*Renal impairment\*\*
Letrozole has not been investigated in a sufficient number of patients with a creatinine clearance lower than 10 ml/min. The potential risk/benefit to such patients should be carefully considered before administration of letrozole.
\*\*Hepatic impairment\*\*
In patients with severe hepatic impairment (Child-Pugh C), systemic exposure and terminal half-life were approximately doubled compared to healthy volunteers. Such patients should therefore be kept under close supervision (see section 5.2).
\*\*Bone effects\*\*
Letrozole is a potent oestrogen-lowering agent. Women with a history of osteoporosis and/or fractures, or who are at increased risk of osteoporosis, should have their bone mineral density formally assessed prior to the commencement of adjuvant and extended adjuvant treatment and monitored during and following treatment with letrozole. Treatment or prophylaxis for osteoporosis should be initiated as appropriate and carefully monitored. In the adjuvant setting a sequential treatment schedule (letrozole 2 years followed by tamoxifen 3 years) could also be considered depending on the patient`s safety profile (see sections 4.2, 4.8 and 5.1).
\*\*Tendonitis and tendon rupture\*\*
Tendonitis and tendon ruptures (rare) may occur. Close monitoring of the patients and appropriate measures (e.g. immobilisation) must be initiated for the affected tendon (see section 4.8).
\*\*Other warnings\*\*
Co-administration of letrozole with tamoxifen, other anti-oestrogens or oestrogen-containing therapies should be avoided as these substances may diminish the pharmacological action of letrozole (see section 4.5).
\*\*Lactose\*\*
Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicine.
\*\*Sodium\*\*
This medicine contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially 'sodium-free'.4.5 Interaction with other medicinal products and other forms of interaction
Metabolism of letrozole is partly mediated via CYP2A6 and CYP3A4. Clinical interaction studies with cimetidine and warfarin indicated that the co-administration of letrozole with these drugs does not result in clinically significant drug interactions, even though cimetidine is a known weak inhibitor of one of the cytochrome P450 isoenzymes capable of metabolising letrozole \*in vitro\* (See section 5.2 Metabolism and elimination).
There was no evidence of other clinically relevant interaction in patients receiving other commonly prescribed drugs (e.g. benzodiazepines; barbiturates; NSAIDs such as diclofenac sodium, ibuprofen; paracetamol; furosemide; omeprazole).
There is no clinical experience to date on the use of letrozole in combination with oestrogens or other anticancer agents, other than tamoxifen. Tamoxifen, other anti-oestrogens or oestrogen-containing therapies may diminish the pharmacological action of letrozole. In addition, co-administration of tamoxifen with letrozole has been shown to substantially decrease plasma concentrations of letrozole. Co-administration of letrozole with tamoxifen, other anti-oestrogens or oestrogens should be avoided.
Letrozole inhibits \*in vitro\* the cytochrome P450-isoenzymes 2A6 and moderately 2C19, however, CYP2A6 does not play a major role in drug metabolism. In \*in vitro\* experiments, letrozole was not able to substantially inhibit the metabolism of diazepam (a substrate of CYP2C19) at concentrations approximately 100-fold higher than those observed in plasma at steady-state. Thus, clinically relevant interactions with CYP2C19 are unlikely to occur. Nevertheless, caution should be used in the concomitant administration of drugs whose disposition is mainly dependent on these isoenzymes and whose therapeutic index is narrow (e.g phenytoin, clopidrogel).4.6 Fertility, pregnancy and lactation
\*\*Women of perimenopausal status or child-bearing potential\*\*
Letrozole should only be used in women with a clearly established postmenopausal status (see section 4.4). As there are reports of women regaining ovarian function during treatment with letrozole despite a clear postmenopausal status at start of therapy, the physician needs to discuss adequate contraception when necessary.
\*\*Pregnancy\*\*
Based on human experience in which there have been isolated cases of birth defects (labial fusion, ambiguous genitalia), letrozole may cause congenital malformations when administered during pregnancy. Studies in animals have shown reproductive toxicity (see section 5.3).
Letrozole is contraindicated during pregnancy (see section 4.3 and 5.3).
\*\*Breast-feeding\*\*
It is unknown whether letrozole and its metabolites are excreted in human milk. A risk to the newborns/infants cannot be excluded.
Letrozole is contraindicated during breast-feeding (see section 4.3).
\*\*Fertility\*\*
The pharmacological action of letrozole is to reduce oestrogen production by aromatase inhibition. In premenopausal women, the inhibition of oestrogen synthesis leads to feedback increases in gonadotropin (LH, FSH) levels. Increased FSH levels in turn stimulate follicular growth, and can induce ovulation.4.7 Effects on ability to drive and use machines
Letrozole has minor influence on the ability to drive and use machines. Since fatigue and dizziness have been observed with the use of letrozole and somnolence has been reported uncommonly, caution is advised when driving or using machines.4.8 Undesirable effects
\*\*Summary of the safety profile\*\*
The frequencies of adverse reactions for letrozole are mainly based on data collected from clinical trials.
Up to approximately one third of the patients treated with letrozole in the metastatic settings and approximately 80% of the patients in the adjuvant setting as well as in the extended adjuvant setting experienced adverse reactions. The majority of the adverse reactions occurred during the first few weeks of treatment.
The most frequently reported adverse reactions in clinical studies were hot flushes, hypercholesterolaemia, arthralgia, fatigue, increased sweating and nausea.
Important additional adverse reactions that may occur with letrozole are: skeletal events such as osteoporosis and/or bone fractures and cardiovascular events (including cerebrovascular and thromboembolic events). The frequency category for these adverse reactions is described in Table 1.
\*\*Tabulated list of adverse reactions\*\*
The frequencies of adverse reactions for letrozole are mainly based on data collected from clinical trials.
The following adverse drug reactions, listed in Table 1, were reported from clinical studies and from post-marketing experience with letrozole tablets.
\*\*Table 1\*\*
Adverse reactions are ranked under headings of frequency, the most frequent first, using the following convention: very common (≥ 1/10); common (≥1/100 to <1/10); uncommon (≥ 1/1,000 to < 1/100); rare (≥ 1/10,000 to < 1/1,000); very rare (<1/10,000), not known (cannot be estimated from the available data).
| | | | | | |
| --- | --- | --- | --- | --- | --- |
| \*\*Frequency\*\* | \*\*Very Common\*\* \*\*(≥1/10)\*\* | \*\*Common\*\* \*\*(≥1/100 to <1/10)\*\* | \*\*Uncommon\*\* \*\*(≥1/1,000 to <1/100)\*\* | \*\*Rare\*\* \*\*(≥1/10,000 to <1/1,000)\*\* | \*\*Not known (cannot be estimated from the available data)\*\* |
| \*\*Organ System\*\* |
| Infections and infestations | | | Urinary tract infection | | |
| Neoplasms benign, malignant and unspecified (including cysts and polyps) | | | Tumour pain1 | | |
| Blood and lymphatic system disorders | | | Leucopenia | | |
| Immune system disorders | | | | | Anaphylactic reactions |
| Metabolism and nutrition disorders | Hypercholesterolaemia | Decreased appetite,appetite increase, | | | |
| Psychiatric disorders | | Depression | Anxiety (including nervousness), irritability | | |
| Nervous system disorders | | Headache, dizziness | Somnolence, insomnia, memory impairment, dysaesthesia (including paraesthesia, hypoaesthesia), dysgeusia, cerebrovascular accident, carpal tunnel syndrome | | |
| Eye disorders | | | Cataract, eye irritation, blurred vision | | |
| Cardiac disorders | | Palpitations1 | Tachycardia, ischaemic cardiac events (including new or worsening angina, angina requiring surgery, myocardial infarction and myocardial ischaemia) | | |
| Vascular disorders | Hot flushes | Hypertension | Thrombophlebitis (including superficial and deep vein thrombophlebitis), | Pulmonary embolism, arterial thrombosis, cerebral infarction | |
| Respiratory, thoracic and mediastinal disorders | | | Dyspnoea, cough | | |
| Gastrointestinal disorders | | Nausea, dyspepsia1, constipation, abdominal pain, diarrhoea, vomiting | Dry mouth, stomatitis1 | | |
| Hepatobiliary disorders | | | Increased hepatic enzymes, hyperbilirubinemia, jaundice. | | Hepatitis |
| Skin and subcutaneous tissue disorders | Hyperhidrosis, | Alopecia, rash (including erythematous, maculopapular, psoriaform, and vesicular rash), dry skin | Pruritus, urticaria | | Angioedema,Toxic epidermal necrolysis, erythema multiforme |
| Musculoskeletal and connective tissue disorders | Arthralgia | Myalgia, bone pain1, osteoporosis, bone fractures, arthritis. | Tendonitis | Tendon rupture | Trigger finger |
| Renal and urinary disorders | | | Pollakiuria | | |
| Reproductive system and breast disorders | | Vaginal haemorrhage | Vaginal discharge, vulvovaginal dryness, breast pain | | |
| General disorders and administration site conditions | Fatigue (including asthenia, malaise), | Peripheral oedema, chest pain. | General oedema, pyrexia, mucosal dryness, thirst | | |
| Investigations | | Weight increase | Weight loss | | |
1 Adverse drug reactions reported only in the metastatic setting
Some adverse reactions have been reported with notably different frequencies in the adjuvant treatment setting. The following tables provide information on significant differences in letrozole versus tamoxifen monotherapy and in the letrozole-tamoxifen sequential treatment therapy:
\*\*Table 2 Adjuvant letrozole monotherapy versus tamoxifen monotherapy – adverse events with significant differences\*\*
| | | | | |
| --- | --- | --- | --- | --- |
| | \*\*Letrozole, incidence rate\*\* | | \*\*Tamoxifen, incidence rate\*\* | |
| \*\*N=2448\*\* | | \*\*N=2447\*\* | |
| \*\*During treatment (Median 5y)\*\* | \*\*Any time after randomization (Median 8y)\*\* | \*\*During treatment (Median 5y)\*\* | \*\*Any time after randomization (Median 8y)\*\* |
| Bone fracture | 10.2% | 14.7% | 7.2% | 11.4% |
| Osteoporosis | 5.1% | 5.1% | 2.7% | 2.7% |
| Thromboembolic events | 2.1% | 3.2% | 3.6% | 4.6% |
| Myocardial infarction | 1.0% | 1.7% | 0.5% | 1.1% |
| Endometrial hyperplasia/endometrial cancer | 0.2% | 0.4% | 2.3% | 2.9% |
| Note: “During treatment” includes 30 days after last dose. “Any time” includes follow-up period after completion or discontinuation of study treatment. Differences were based on risk ratios and 95% confidence intervals. | | | | |
\*\*Table 3 Sequential treatment versus letrozole monotherapy – adverse events with significant differences\*\*
| | | | |
| --- | --- | --- | --- |
| | \*\*Letrozole monotherapy\*\* | \*\*Letrozole->tamoxifen\*\* | \*\*Tamoxifen->Letrozole\*\* |
| \*\*N=1535\*\* | \*\*N=1527\*\* | \*\*N=1541\*\* |
| \*\*5 years\*\* | \*\*2 yrs-> 3y\*\* | \*\*2 yrs-> 3y\*\* |
| Bone fractures | 10.0% | 7.7%\\* | 9.7% |
| Endometrial proliferative disorders | 0.7% | 3.4%\\*\\* | 1.7%\\*\\* |
| Hypercholesterolaemia | 52.5% | 44.2%\\* | 40.8%\\* |
| Hot flushes | 37.6% | 41.7%\\*\\* | 43.9%\\*\\* |
| Vaginal bleeding | 6.3% | 9.6%\\*\\* | 12.7%\\*\\* |
| \\* Significantly less than with letrozole monotherapy \\*\\* Significantly more than with letrozole monotherapy Note: Reporting period is during treatment or within 30 days of stopping treatment | | | |
\*\*Description of selected adverse reactions\*\*
\*Cardiac adverse reactions\*
In the adjuvant setting, in addition to the data presented in Table 2, the following adverse events were reported for letrozole and tamoxifen, respectively (at median treatment duration of 60 months plus 30 days): angina requiring surgery (1.0% vs. 1.0%); cardiac failure (1.1% vs. 0.6%); hypertension (5.6% vs. 5.7%); cerebrovascular accident/transient ischaemic attack (2.1% vs. 1.9%).
In the extended adjuvant setting for letrozole (median duration of treatment 5 years) and placebo (median duration of treatment 3 years), respectively: angina requiring surgery (0.8% vs. 0.6%); new or worsening angina (1.4% vs. 1.0%); myocardial infarction (1.0% vs. 0.7%); thromboembolic event\\* (0.9% vs. 0.3%); stroke/transient ischaemic attack\\* (1.5% vs. 0.8%) were reported.
Events marked \\* were statistically significantly different in the two treatment arms.
\*Skeletal adverse reactions\*
For skeletal safety data from the adjuvant setting, please refer to Table 2.
In the extended adjuvant setting, significantly more patients treated with letrozole experienced bone fractures or osteoporosis (bone fractures, 10.4% and osteoporosis, 12.2%) than patients in the placebo arm (5.8% and 6.4%, respectively). Median duration of treatment was 5 years for letrozole, compared with 3 years for placebo.
\*\*Reporting of suspected adverse reactions\*\*
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: https://yellowcard.mhra.gov.uk/or search for MHRA Yellow Card in the Google Play or Apple App Store.4.9 Overdose
There is no clinical experience of overdosage only isolated cases of overdose with letrozole have been reported. In animal studies, letrozole exhibits only a slight degree of acute toxicity. In clinical trials, the highest single and multiple dose tested in healthy volunteers was 30 mg and 5 mg, respectively, the latter also being the highest dose tested in postmenopausal breast cancer patients. Each of these doses was well tolerated. There is no clinical evidence for a particular dose of letrozole resulting in life-threatening symptoms.
There is no specific antidote to letrozole. In general, supportive care, symptomatic treatment and frequent monitoring of vital signs are appropriate.
- Instruction Pharmacology
- 5.1 Pharmacodynamic properties
\*\*Pharmacotherapeutic group\*\*: Endocrine therapy. Hormone antagonist and related agents: aromatase inhibitor; ATC Code: L02BG04.
\*\*Pharmacodynamic effects\*\*
The elimination of oestrogen-mediated growth stimulation is a prerequisite for tumour response in cases where the growth of tumour tissue depends on the presence of oestrogens and endocrine therapy is used. In postmenopausal women, oestrogens are mainly derived from the action of the aromatase enzyme, which converts adrenal androgens - primarily androstenedione and testosterone - to oestrone and oestradiol. The suppression of oestrogen biosynthesis in peripheral tissues and the cancer tissue itself can therefore be achieved by specifically inhibiting the aromatase enzyme.
Letrozole is a non-steroidal aromatase inhibitor. It inhibits the aromatase enzyme by competitively binding to the haem of the aromatase cytochrome P450, resulting in a reduction of oestrogen biosynthesis in all tissues where present.
In healthy postmenopausal women, single doses of 0.1 mg, 0.5 mg and 2.5 mg letrozole suppress serum oestrone and oestradiol by 75%, 78% and 78% from baseline respectively. Maximum suppression is achieved in 48-78 hours.
In postmenopausal patients with advanced breast cancer, daily doses of 0.1 mg to 5 mg suppressed plasma concentration of oestradiol, oestrone, and oestrone sulphate by 75-95% from baseline in all patients treated. With doses of 0.5 mg and higher, many values of oestrone and oestrone sulphate were below the limit of detection in the assays, indicating that higher oestrogen suppression is achieved with these doses. Oestrogen suppression was maintained throughout treatment in all these patients.
Letrozole is highly specific in inhibiting aromatase activity. Impairment of adrenal steroidogenesis has not been observed. No clinically relevant changes were found in the plasma concentrations of cortisol, aldosterone, 11-deoxycortisol, 17-hydroxyprogesterone, and ACTH or in plasma renin activity among postmenopausal patients treated with a daily dose of letrozole 0.1 to 5 mg. The ACTH stimulation test performed after 6 and 12 weeks of treatment with daily doses of 0.1 mg, 0.25 mg, 0.5 mg, 1 mg, 2.5 mg, and 5 mg did not indicate any attenuation of aldosterone or cortisol production. Thus, glucocorticoid and mineralocorticoid supplementation is not necessary.
No changes were noted in plasma concentrations of androgens (androstenedione and testosterone) among healthy postmenopausal women after 0.1 mg, 0.5 mg, and 2.5 mg single doses of letrozole or in plasma concentrations of androstenedione among postmenopausal patients treated with daily doses of 0.1 mg to 5 mg, indicating that the blockade of oestrogen biosynthesis does not lead to accumulation of androgenic precursors. Plasma levels of LH and FSH are not affected by letrozole in patients, nor is thyroid function as evaluated by TSH, T4 and T3 uptake test.
\*\*Adjuvant treatment\*\*
\*\*\*Study BIG 1-98\*\*\*
BIG 1-98 was a multicentre, double-blind study in which over 8,000 postmenopausal women with hormone receptor-positive early breast cancer were randomised to one of the following treatments: A. tamoxifen for 5 years; B. letrozole for 5 years; C. tamoxifen for 2 years followed by letrozole for 3 years; D, letrozole for 2 years followed by tamoxifen for 3 years.
The primary endpoint was disease-free survival (DFS); secondary efficacy endpoints were time to distant metastasis (TDM), distant disease-free survival (DDFS), overall survival (OS), systemic disease-free survival (SDFS), invasive contralateral breast cancer and time to breast cancer recurrence.
\*Efficacy results at a median follow-up of 26 and 60 months\*
Data in Table 4 reflect the results of the Primary Core Analysis (PCA) based on data from the monotherapy arms (A and B) and from the two switching arms (C and D) at a median treatment duration of 24 months and a median follow-up of 26 months and at a median treatment duration of 32 months and a median follow-up of 60 months.
The 5-year DFS rates were 84% for letrozole and 81.4% for tamoxifen.
\*\*Table 4 Primary Core Analysis: Disease-free and overall survival, at a median follow-up of 26 months and at median follow-up of 60 months (ITT population)\*\*
| | | | | | | |
| --- | --- | --- | --- | --- | --- | --- |
| | \*\*Primary Core Analysis\*\* | | | | | |
| \*\*Median follow-up 26 months\*\* | | | \*\*Median follow-up 60 months\*\* | | |
| \*\*Letrozole N=4003\*\* | \*\*Tamoxifen N=4007\*\* | \*\*HR1 (95% CI) \*P\*\*\* | \*\*Letrozole N=4003\*\* | \*\*Tamoxifen N=4007\*\* | \*\*HR1 (95% CI) \*P\*\*\* |
| Disease-free survival (primary)-events (protocol definition2) | 351 | 428 | 0.81 (0.70, 0.93) 0.003 | 585 | 664 | 0.86 (0.77, 0.96) 0.008 |
| Overall survival (secondary) Number of deaths | 166 | 192 | 0.86 (0.70, 1.06) | 330 | 374 | 0.87 (0.75, 1.01) |
HR = Hazard ratio; CI = Confidence interval
1 Log rank test, stratified by randomisation option and use of chemotherapy (yes/no)
2 DFS events: loco-regional recurrence, distant metastasis, invasive contralateral breast cancer, second (non-breast) primary malignancy, death from any cause without a prior cancer event.
\*Results at a median follow-up of 96 months (monotherapy arms only)\*
The Monotherapy Arms Analysis (MAA) long-term update of the efficacy of letrozole monotherapy compared to tamoxifen monotherapy (median duration of adjuvant treatment: 5 years) is presented in Table 5.
\*\*Table 5 Monotherapy Arms Analysis: Disease-free and overall survival at a median follow-up of 96 months (ITT population)\*\*
| | | | | |
| --- | --- | --- | --- | --- |
| | \*\*Letrozole N=2463\*\* | \*\*Tamoxifen N=2459\*\* | \*\*Hazard Ratio1 (95% CI)\*\* | \*\*\*P\* Value\*\* |
| Disease-free survival events (primary) 2 | 626 | 698 | 0.87 (0.78, 0.97) | 0.01 |
| Time to distant metastasis (secondary) | 301 | 342 | 0.86 (0.74, 1.01) | 0.06 |
| Overall survival (secondary) deaths | 393 | 436 | 0.89 (0.77, 1.02) | 0.08 |
| Censored analysis of DFS3 | 626 | 649 | 0.83 (0.74, 0.92) | |
| Censored analysis of OS3 | 393 | 419 | 0.81 (0.70, 0.93) | |
1 Log rank test, stratified by randomisation option and use of chemotherapy (yes/no)
2 DFS events: loco-regional recurrence, distant metastasis, invasive contralateral breast cancer, second (non-breast) primary malignancy, death from any cause without a prior cancer event.
3 Observations in the tamoxifen arm censored at the date of selectively switching to letrozole
\*Sequential Treatments Analysis (STA)\*
The Sequential Treatments Analysis (STA) addresses the second primary question of BIG 1-98, namely whether sequencing of tamoxifen and letrozole would be superior to monotherapy. There were no significant differences in DFS, OS, SDFS, or DDFS from switch with respect to monotherapy (Table 6).
\*\*Table 6 Sequential treatments analysis of disease-free survival with letrozole as initial endocrine agent (STA switch population)\*\*
| | | | | | |
| --- | --- | --- | --- | --- | --- |
| | \*\*N\*\* | \*\*Number of events1\*\* | \*\*Hazard ratio2\*\* | \*\*(97.5% confidence interval)\*\* | \*\*Cox model \*P-\*value\*\* |
| [Letrozole→] Tamoxifen | 1460 | 254 | 1.03 | (0.84, 1.26) | 0.72 |
| Letrozole | 1464 | 249 | | | |
1 Protocol definition, including second non-breast primary malignancies, after switch / beyond two years
2 Adjusted by chemotherapy use
There were no significant differences in DFS, OS, SDFS or DDFS in any of the STA from randomisation pairwise comparisons (Table 7).
\*\*Table 7 Sequential Treatments Analyses from randomisation (STA-R) of disease-free survival (ITT STA-R population)\*\*
| | | |
| --- | --- | --- |
| | \*\*Letrozole→Tamoxifen\*\* | \*\*Letrozole\*\* |
| Number of patients | 1540 | 1546 |
| Number of patients with DFS events (protocol definition) | 330 | 319 |
| Hazard ratio1 (99% CI) | 1.04 (0.85, 1.27) | |
| | \*\*Letrozole→Tamoxifen\*\* | \*\*Tamoxifen2\*\* |
| Number of patients | 1540 | 1548 |
| Number of patients with DFS events (protocol definition) | 330 | 353 |
| Hazard ratio1 (99% CI) | 0.92 (0.75, 1.12) | |
1 Adjusted by chemotherapy use (yes/no)
2 626 (40%) patients selectively crossed to letrozole after tamoxifen arm unblinded in 2005
\*\*Study D2407\*\*
Study D2407 is an open-label, randomised, multicentre post approval safety study designed to compare the effects of adjuvant treatment with letrozole and tamoxifen on bone mineral density (BMD) and serum lipid profiles. A total of 262 patients were assigned either letrozole for 5 years or tamoxifen for 2 years followed by letrozole for 3 years.
At 24 months, there was a statistically significant difference in the primary end-point; the lumbar spine BMD (L2-L4) showed a median decrease of 4.1% for letrozole compared to a median increase of 0.3% for tamoxifen.
No patient with a normal BMD at baseline became osteoporotic during 2 years of treatment and only 1 patient with osteopenia at baseline (T score of -1.9) developed osteoporosis during the treatment period (assessment by central review).
The results for total hip BMD were similar to those for lumbar spine but less pronounced.
There was no significant difference between treatments in the rate of fractures - 15% in the letrozole arm, 17% in the tamoxifen arm.
Median total cholesterol levels in the tamoxifen arm were decreased by 16% after 6 months compared to baseline and this decrease was maintained at subsequent visits up to 24 months. In the letrozole arm, total cholesterol levels were relatively stable over time, giving a statistically significant difference in favour of tamoxifen at each time point.
\*\*\*Extended adjuvant treatment (MA-17)\*\*\*
In a multicentre, double-blind, randomised, placebo-controlled study (MA-17), over 5,100 postmenopausal women with receptor-positive or unknown primary breast cancer who had completed adjuvant treatment with tamoxifen (4.5 to 6 years) were randomised to either letrozole or placebo for 5 years.
The primary endpoint was disease-free survival, defined as the interval between randomisation and the earliest occurrence of loco-regional recurrence, distant metastasis, or contralateral breast cancer.
The first planned interim analysis at a median follow-up of around 28 months (25% of patients being followed-up for at least 38 months), showed that letrozole significantly reduced the risk of breast cancer recurrence by 42% compared with placebo (HR 0.58; 95% CI 0.45, 0.76; \*P\* = 0.00003). The benefit in favour of letrozole was observed regardless of nodal status.There was no significant difference in overall survival: (letrozole 51 deaths; placebo 62; HR 0.82; 95% CI 0.56, 1.19).
Consequently, after the first interim analysis the study was unblinded and continued in an open-label fashion and patients in the placebo arm were allowed to switch to letrozole for up to 5 years. Over 60% of eligible patients (disease-free at unblinding ) opted to switch to letrozole. The final analysis included 1,551 women who switched from placebo to letrozole at a median of 31 months (range 12 to 106 months) after completion of tamoxifen adjuvant therapy. Median duration of letrozole after switch was 40 months.
The final analysis conducted at a median follow-up of 62 months confirmed the significant reduction in the risk of breast cancer recurrence with letrozole.
\*\*Table 8: Disease-free and overall survival (Modified ITT population)\*\*
| | | | | | | |
| --- | --- | --- | --- | --- | --- | --- |
| | \*\*Median follow-up 28 months1\*\* | | | \*\*Median follow-up 62 months\*\* | | |
| \*\*Letrozole\*\* | \*\*Placebo\*\* | \*\*HR2 (95% CI) 2\*\* | \*\*Letrozole\*\* | \*\*Placebo\*\* | \*\*HR (95% CI) 2\*\* |
| \*\*N = 2582\*\* | \*\*N = 2586\*\* | \*\*\*P\* value\*\* | \*\*N = 2582\*\* | \*\*N = 2586\*\* | \*\*\*P\* value\*\* |
| \*\*Disease-free survival3\*\* | | | | | | |
| Events | 92 (3.6 %) | 155 (6.0 %) | 0.58 (0.45, 0.76) 0.00003 | 209 (8.1 %) | 286 (11.1%) | 0.75 (0.63, 0.89) |
| 4-year DFS rate | 94.4% | 89.8% | | 94.4% | 91.4% | |
| \*\*Disease-free survival3 including deaths from any cause\*\* | | | | | | |
| Events | 122 (4.7%) | 193 (7.5%) | 0.62 (0.49, 0.78) | 344 (13.3%) | 402 (15.5%) | 0.89 (0.77, 1.03) |
| 5-year DFS rate | 90.5% | 80.8% | | 88.8% | 86.7% | |
| \*\*Distant metastases\*\* | | | | | | |
| Events | 57 (2.2%) | 93 (3.6%) | 0.61 (0.44, 0.84) | 142 (5.5%) | 169 (6.5%) | 0.88 (0.70, 1.10) |
| \*\*Overall survival\*\* | | | | | | |
| Deaths | 51 (2.0%) | 62 (2.4%) | 0.82 (0.56, 1.19) | 236 (9.1%) | 232 (9.0%) | 1.13 (0.95, 1.36) |
| Deaths 4 | --- | --- | --- | 2365 (9.1%) | 1706 (6.6%) | 0.78 (0.64, 0.96) |
| HR = Hazards ratio; CI = Confidence interval 1 When the study was unblinded in 2003, 1551 patients in the randomised placebo arm (60% of those eligible to switch – i.e. who were disease-free) switched to letrozole at a median 31 months after randomisation. The analyses presented here ignore the selective crossover 2 Stratified by receptor status, nodal status and prior adjuvant chemotherapy 3 Protocol definition of disease-free survival events: loco-regional recurrence, distant metastasis or contralateral breast cancer 4 Exploratory analysis, censoring follow-up times at the date of switch (if it occurred) in the placebo arm. 5 Median follow-up 62 months 6 Median follow-up until switch (if it occurred) 37 months | | | | | | |
In the MA-17 bone substudy in which concomitant calcium and vitamin D were given, greater decreases in BMD compared to baseline occurred with letrozole compared with placebo. The only statistically significant difference occurred at 2 years and was in total hip BMD (letrozole median decrease of 3.8% vs placebo median decrease of 2.0%).
In the MA-17 lipid substudy there were no significant differences between letrozole and placebo in total cholesterol or in any lipid fraction.
In the updated quality of life substudy there were no significant differences between treatments in physical component summary score or mental component summary score, or in any domain score in the SF-36 scale. In the MENQOL scale, significantly more women in the letrozole arm than in the placebo arm were most bothered (generally in the first year of treatment) by those symptoms deriving from oestrogen deprivation – hot flushes and vaginal dryness. The symptom that bothered most patients in both treatment arms was aching muscles, with a statistically significant difference in favour of placebo.
\*\*Neoadjuvant treatment\*\*
A double blind trial (P024) was conducted in 337 postmenopausal breast cancer patients randomly allocated either letrozole 2.5 mg for 4 months or tamoxifen for 4 months. At baseline all patients had tumours stage T2-T4c, N0-2, M0, ER and/or PgR positive and none of the patients would have qualified for breast-conserving surgery. Based on clinical assessment there were 55% objective responses in the letrozole arm versus 36% for the tamoxifen arm (\*P\*<0.001). This finding was consistently confirmed by ultrasound (letrozole 35% vs tamoxifen 25%, \*P\*=0.04) and mammography (letrozole 34% vs tamoxifen 16%, \*P\*<0.001). In total 45% of patients in the letrozole group versus 35% of patients in the tamoxifen group (\*P\*=0.02) underwent breast-conserving therapy). During the 4-month pre-operative treatment period, 12% of patients treated with letrozole and 17% of patients treated with tamoxifen had disease progression on clinical assessment.
\*\*First-line treatment\*\*
One controlled double-blind trial was conducted comparing letrozole 2.5 mg to tamoxifen 20 mg as first-line therapy in postmenopausal women with advanced breast cancer. In 907 women, letrozole was superior to tamoxifen in time to progression (primary endpoint) and in overall objective response, time to treatment failure and clinical benefit.
The results are summarised in Table 9:
\*\*Table 9 Results at a median follow-up of 32 months\*\*
| | | | |
| --- | --- | --- | --- |
| \*\*Variable\*\* | \*\*Statistic\*\* | \*\*Letrozole\*\* \*\*N=453\*\* | \*\*Tamoxifen\*\* \*\*N=454\*\* |
| Time of progression | Median | 9.4 months | 6.0 months |
| (95% CI for median) | (8.9, 11.6 months) | (5.4, 6.3 months) |
| Hazard ratio (HR) | 0.72 | |
| (95% CI for HR) | (0.62, 0.83) | |
| | \*P\* <0.0001 | |
| Objective response rate (ORR) | CR+PR | 145 (32%) | 95 (21%) |
| (95% CI for rate) | (28, 36%) | (17, 25%) |
| Odds ratio | 1.78 | |
| (95% CI for odds ratio) | (1.32, 2.40) | |
| | \*P\*=0.0002 | |
Time to progression was significantly longer, and response rate significantly higher for letrozole irrespective of whether adjuvant anti-oestrogen therapy had been given or not. Time to progression was significantly longer for letrozole irrespective of dominant site of disease. Median time to progression was 12.1 months for letrozole and 6.4 months for tamoxifen in patients with soft tissue disease only and median 8.3 months for letrozole and 4.6 months for tamoxifen in patients with visceral metastases.
Study design allowed patients to cross over upon progression to the other therapy or discontinue from the study. Approximately 50% of patients crossed over to the opposite treatment arm and crossover was virtually completed by 36 months. The median time to crossover was 17 months (letrozole to tamoxifen) and 13 months (tamoxifen to letrozole).
Letrozole treatment in the first-line therapy of advanced breast cancer resulted in a median overall survival of 34 months compared with 30 months for tamoxifen (logrank test P=0.53, not significant). The absence of an advantage for letrozole on overall survival could be explained by the crossover design of the study.
\*\*Second-line treatment\*\*
Two well-controlled clinical trials were conducted comparing two letrozole doses (0.5 mg and 2.5 mg) to megestrol acetate and to aminoglutethimide, respectively, in postmenopausal women with advanced breast cancer previously treated with anti-oestrogens.
Time to progression was not significantly different between letrozole 2.5 mg and megestrol acetate (\*P\*=0.07). Statistically significant differences were observed in favour of letrozole 2.5 mg compared to megestrol acetate in overall objective tumour response rate (24% vs 16%, \*P\*=0.04), and in time to treatment failure (\*P\*=0.04). Overall survival was not significantly different between the 2 arms (\*P\*=0.2).
In the second study, the response rate was not significantly different between letrozole 2.5 mg and aminoglutethimide (\*P\*=0.06). Letrozole 2.5 mg was statistically superior to aminoglutethimide for time to progression (\*P\*=0.008), time to treatment failure (\*P\*=0.003) and overall survival (\*P\*=0.002).
\*\*Male breast cancer\*\*
Use of letrozole in men with breast cancer has not been studied.5.2 Pharmacokinetic properties
\*\*Absorption\*\*
Letrozole is rapidly and completely absorbed from the gastrointestinal tract (mean absolute bioavailability: 99.9%). Food slightly decreases the rate of absorption (median tmax 1 hour fasted versus 2 hours fed; and mean Cmax 129 ± 20.3 nmol/litre fasted versus 98.7 ± 18.6 nmol/litre fed) but the extent of absorption (AUC) is not changed. The minor effect on the absorption rate is not considered to be of clinical relevance, and therefore letrozole may be taken without regard to mealtimes.
\*\*Distribution\*\*
Plasma protein binding of letrozole is approximately 60%, mainly to albumin (55%). The concentration of letrozole in erythrocytes is about 80% of that in plasma. After administration of 2.5 mg 14C-labelled letrozole, approximately 82% of the radioactivity in plasma was unchanged compound. Systemic exposure to metabolites is therefore low. Letrozole is rapidly and extensively distributed to tissues. Its apparent volume of distribution at steady state is about 1.87 ± 0.47 L/kg.
\*\*Biotransformation\*\*
Metabolic clearance to a pharmacologically inactive carbinol metabolite is the major elimination pathway of letrozole (CLm= 2.1 L/h) but is relatively slow when compared to hepatic blood flow (about 90 L/h). The cytochrome P450 isoenzymes 3A4 and 2A6 were found to be capable of converting letrozole to this metabolite.\*in vitro\*, but their individual contributions to letrozole clearance \*in vivo\* have not been established. In an interaction study co-administration with cimetidine, which is known to inhibit only the 3A4 isoenzyme, did not result in a decrease in letrozole clearance suggesting that \*in vivo\* the 2A6 isoenzyme plays an important part in total clearance. In this study a slight decrease in AUC and increase in Cmax were observed.
Formation of minor unidentified metabolites and direct renal and faecal excretion play only a minor role in the overall elimination of letrozole. Within 2 weeks after administration of 2.5 mg 14C-labelled letrozole to healthy postmenopausal volunteers, 88.2 ± 7.6% of the radioactivity was recovered in urine and 3.8 ± 0.9% in faeces. At least 75% of the radioactivity recovered in urine up to 216 hours (84.7 ± 7.8% of the dose) was attributed to the glucuronide of the carbinol metabolite, about 9% to two unidentified metabolites, and 6% to unchanged Letrozole.
\*\*Elimination\*\*
The apparent terminal elimination half-life in plasma is about 2 to 4 days. After daily administration of 2.5 mg steady-state levels are reached within 2 to 6 weeks. Plasma concentrations at steady state are approximately 7 times higher than concentrations measured after a single dose of 2.5 mg, while they are 1.5 to 2 times higher than the steady-state values predicted from the concentrations measured after a single dose, indicating a slight non-linearity in the pharmacokinetics of letrozole upon daily administration of 2.5 mg. Since steady-state levels are maintained over time, it can be concluded that no continuous accumulation of letrozole occurs.
\*\*Linearity/non-linearity\*\*
The pharmacokinetics of letrozole were dose proportional after single oral doses up to 10 mg (dose range: 0.01 to 30 mg) and after daily doses up to 1.0 mg (dose range: 0.1 to 5mg). After a 30 mg single oral dose there was a slightly dose over-proportional increase in AUC value. The dose over-proportionality is likely to be the result of a saturation of metabolic elimination processes. Steady levels were reached after 1 to 2 months at all dosage regimens tested (0.1-5.0 mg daily).
\*\*Special populations\*\*
\*Elderly\*
Age had no effect on the pharmacokinetics of letrozole.
\*\*Special populations\*\*
\*Renal impairment\*
In a study involving 19 volunteers with varying degrees of renal function (24 hour creatinine clearance 9-116 ml/min) no effect on the pharmacokinetics of letrozole or the urinary excretion of the glucoronide of its carbinol metabolite was found after a single dose of 2.5 mg. In addition to the above study assessing the influence of renal impairment on letrozole, a covariate analysis was performed on the data of two pivotal studies (Study AR/BC2 and Study AR/BC3). Calculated creatinine clearance (CLcr) [Study AR/BC2 range: 19 to 187 mL/min; Study AR/BC3 range: 10 to 180 mL/min] showed no statistically significant association between letrozole plasma trough levels at steady-state (Cmin). Futhermore, data of Study AR/BC2 and Study AR/BC3 in second-line metastatic breast cancer showed no evidence of an adverse effect of letrozole on CLcr or an impairment of renal function.
Therefore, no dose adjustment is required for patients with renal impairment (CLcr ≥10 mL/min). Little information is available in patients with severe impairment of renal function (CLcr <10 mL/min).
\*Hepatic impairment\*
The Cmax, AUC and half-life of the metabolite have not been determined. In a similar study involving subjects with varying degrees of hepatic function, the mean AUC values of the volunteers with moderate hepatic impairment (Child-Pugh B) was 37% higher than in normal subjects, but still within the range seen in subjects without impaired function. In a study comparing the pharmacokinetics of letrozole after a single oral dose in eight male subjects with liver cirrhosis and severe hepatic impairment (Child-Pugh C) to those in healthy volunteers (N=8), AUC and t½ increased by 95 and 187%, respectively. Thus, letrozole should be administered with caution to patients with severe hepatic impairment and after consideration of the risk/benefit in the individual patient.5.3 Preclinical safety data
In a variety of preclinical safety studies conducted in standard animal species, there was no evidence of systemic or target organ toxicity.
Letrozole showed a low degree of acute toxicity in rodents exposed up to 2000 mg/kg. In dogs, letrozole caused signs of moderate toxicity at 100 mg/kg.
In repeated-dose toxicity studies in rats and dogs up to 12 months, the main findings observed can be attributed to the pharmacological action of the compound. The no-adverse-effect level was 0.3 mg/kg in both species.
Oral administration of letrozole to female rats resulted in decreases in mating and pregnancy ratios and increases in pre-implantation loss
Both \*in vitro\* and \*in vivo\* investigations of letrozole's mutagenic potential revealed no indications of any genotoxicity.
In a 104-week rat carcinogenicity study, no treatment-related tumours were noted in male rats. In female rats, a reduced incidence of benign and malignant mammary tumours at all the doses of letrozole was found.
In a 104-week mouse carcinogenicity studies, no treatment-related tumours were noted in male mice. In female mice, a generally dose-related increase in the incidence of benign ovarian granulosa theca cell tumors was observed at all doses of letrozole tested. These tumors were considered to be related to the pharmacological inhibition of estrogen synthesis and may be due to increased LH resulting from the decrease in circulating estrogen.
Letrozole was embryotoxic and foetotoxic in pregnant rats and rabbits following oral administration at clinically relevant doses. In rats that had live foetuses, there was an increase in the incidence of foetal malformations including domed head and cervical/centrum vertebral fusion. An increased incidence of foetal malformations was not seen in the rabbit. It is not known whether this was an indirect consequence of the pharmacological properties (inhibition of oestrogen biosynthesis) or a direct drug effect (see sections 4.3 and 4.6).
Preclinical observations were confined to those associated with the recognised pharmacological action, which is the only safety concern for human use derived from animal studies.
- Instruction Pharmaceutical Particulars
- 6.1 List of excipients
\*\*Tablet core:\*\*
Lactose monohydrate,
Sodium starch glycolate,
Microcrystalline cellulose,
Hypromellose 6 cP,
Colloidal anhydrous silica,
Magnesium stearate (E572).
\*\*Film coat\*\* (Opadry 04F52158 Yellow):
Hypromellose 15 cP (E464),
PEG 6000.
Titanium dioxide, (E171),
Iron oxide yellow E172 (iii),
Iron oxide red, E172 (ii),
FD&C yellow #5 Aluminium lake, (E102).6.2 Incompatibilities
None known.6.3 Shelf life
2 years6.4 Special precautions for storage
Store in in the original package6.5 Nature and contents of container
PVC/PE/PVDC Aliminium blister packs of 14 or 28 tablets.6.6 Special precautions for disposal and other handling
No specific instructions for use/handling.
- Instruction Content
- ## Composition
Each film-coated tablet contains 2.5 mg letrozole.
\*\*Excipient with known effect\*\*
Each film-coated tablet contains 45 mg of lactose monohydrate.
For the full list of excipients, see section 6.1.
## Pharmaceutical Form
Film-coated tablet.
Yellow, circular, biconvex film-coated tablets, plain on both sides.
## Clinical Particulars
4.1 Therapeutic indications
Adjuvant treatment of postmenopausal women with hormone receptor positive invasive early breast cancer.
Extended adjuvant treatment of hormone-dependent early invasive breast cancer in postmenopausal women who have received prior standard adjuvant tamoxifen therapy for 5 years.
First-line treatment in postmenopausal women with hormone-dependent advanced breast cancer.
Advanced breast cancer after relapse or disease progression, in women with natural or artificially induced postmenopausal endocrine status, who have previously been treated with antioestrogens.
Neoadjuvant treatment of postmenopausal women with hormone receptor positive, HER-2 negative breast cancer where chemotherapy is not suitable and immediate surgery not indicated.
Efficacy has not been demonstrated in patients with hormone receptor negative breast cancer.4.2 Posology and method of administration
\*\*Posology\*\*
\*Adult and elderly patients\*
The recommended dose of Letrozole tablet is 2.5 mg once daily.
In patients with advanced or metastatic breast cancer, treatment with letrozole tablets should continue until tumour progression is evident.
In the adjuvant and extended adjuvant setting, treatment with Letrozole tablets should continue for 5 years or until tumour relapse occurs, whichever is first.
In the neoadjuvant setting, treatment with letrozole tablets could be continued for 4 to 8 months in order to establish optimal tumour reduction. If the response is not adequate, treatment with letrozole tablets should be discontinued and surgery scheduled and/or further treatment options discussed with the patient.
Following standard adjuvant tamoxifen therapy, treatment with letrozole tablets should continue for 5 years or until tumour relapse occurs, whichever comes first. In patients with metastatic disease, treatment with letrozole tablets should continue until tumour progression is evident. Regular monitoring to observe progression during the pre-operative treatment period is recommended (see section 5.1). No dose adjustment is required for elderly patients.
\*Paediatric population\*
Letrozole tablets is not recommended for use in children and adolescents. The safety and efficacy of letrozole tablets in children and adolescents aged up to 17 years have not been established. Limited data are available and no recommendation on a posology can be made.
\*Renal impairment\*
No dosage adjustment of letrozole tablets is required for patients with renal insufficiency with creatinine clearance ≥10 ml/min. Insufficient data are available in cases of renal insufficiency with creatinine clearance lower than 10 ml/min (see sections 4.4 and 5.2).
\*Hepatic impairment\*
No dosage adjustment of letrozole tablets is required for patients with mild to moderate hepatic insufficiency (Child-Pugh grade A or B). Insufficient data are available for patients with severe hepatic impairment. Patients with severe hepatic impairment (Child-Pugh C) require close supervision (see sections 4.4 and 5.2).
\*\*Method of administration\*\*
Letrozole tablets should be taken orally and can be taken with or without food.
A missed dose should be taken as soon as the patient remembers. However, if it is almost time for the next dose (within 2 or 3 hours), the missed dose should be skipped, and the patient should go back to her regular dosage schedule. Doses should not be doubled because with daily doses over the 2.5 mg recommended dose, over-proportionality in systemic exposure was observed (see section 5.2).4.3 Contraindications
• Hypersensitivity to the active substance or to any of the excipients listed in section 6.1
• Premenopausal endocrine status
• Premenopausal, pregnant or lactating women (see section 4.6).4.4 Special warnings and precautions for use
\*\*Menopausal status\*\*
In patients whose menopausal status is unclear, luteinising hormone (LH), follicle-stimulating hormone (FSH) and/or oestradiol levels should be measured before initiating treatment with letrozole. Only women of postmenopausal endocrine status should receive letrozole.
\*\*Renal impairment\*\*
Letrozole has not been investigated in a sufficient number of patients with a creatinine clearance lower than 10 ml/min. The potential risk/benefit to such patients should be carefully considered before administration of letrozole.
\*\*Hepatic impairment\*\*
In patients with severe hepatic impairment (Child-Pugh C), systemic exposure and terminal half-life were approximately doubled compared to healthy volunteers. Such patients should therefore be kept under close supervision (see section 5.2).
\*\*Bone effects\*\*
Letrozole is a potent oestrogen-lowering agent. Women with a history of osteoporosis and/or fractures, or who are at increased risk of osteoporosis, should have their bone mineral density formally assessed prior to the commencement of adjuvant and extended adjuvant treatment and monitored during and following treatment with letrozole. Treatment or prophylaxis for osteoporosis should be initiated as appropriate and carefully monitored. In the adjuvant setting a sequential treatment schedule (letrozole 2 years followed by tamoxifen 3 years) could also be considered depending on the patient`s safety profile (see sections 4.2, 4.8 and 5.1).
\*\*Tendonitis and tendon rupture\*\*
Tendonitis and tendon ruptures (rare) may occur. Close monitoring of the patients and appropriate measures (e.g. immobilisation) must be initiated for the affected tendon (see section 4.8).
\*\*Other warnings\*\*
Co-administration of letrozole with tamoxifen, other anti-oestrogens or oestrogen-containing therapies should be avoided as these substances may diminish the pharmacological action of letrozole (see section 4.5).
\*\*Lactose\*\*
Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicine.
\*\*Sodium\*\*
This medicine contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially 'sodium-free'.4.5 Interaction with other medicinal products and other forms of interaction
Metabolism of letrozole is partly mediated via CYP2A6 and CYP3A4. Clinical interaction studies with cimetidine and warfarin indicated that the co-administration of letrozole with these drugs does not result in clinically significant drug interactions, even though cimetidine is a known weak inhibitor of one of the cytochrome P450 isoenzymes capable of metabolising letrozole \*in vitro\* (See section 5.2 Metabolism and elimination).
There was no evidence of other clinically relevant interaction in patients receiving other commonly prescribed drugs (e.g. benzodiazepines; barbiturates; NSAIDs such as diclofenac sodium, ibuprofen; paracetamol; furosemide; omeprazole).
There is no clinical experience to date on the use of letrozole in combination with oestrogens or other anticancer agents, other than tamoxifen. Tamoxifen, other anti-oestrogens or oestrogen-containing therapies may diminish the pharmacological action of letrozole. In addition, co-administration of tamoxifen with letrozole has been shown to substantially decrease plasma concentrations of letrozole. Co-administration of letrozole with tamoxifen, other anti-oestrogens or oestrogens should be avoided.
Letrozole inhibits \*in vitro\* the cytochrome P450-isoenzymes 2A6 and moderately 2C19, however, CYP2A6 does not play a major role in drug metabolism. In \*in vitro\* experiments, letrozole was not able to substantially inhibit the metabolism of diazepam (a substrate of CYP2C19) at concentrations approximately 100-fold higher than those observed in plasma at steady-state. Thus, clinically relevant interactions with CYP2C19 are unlikely to occur. Nevertheless, caution should be used in the concomitant administration of drugs whose disposition is mainly dependent on these isoenzymes and whose therapeutic index is narrow (e.g phenytoin, clopidrogel).4.6 Fertility, pregnancy and lactation
\*\*Women of perimenopausal status or child-bearing potential\*\*
Letrozole should only be used in women with a clearly established postmenopausal status (see section 4.4). As there are reports of women regaining ovarian function during treatment with letrozole despite a clear postmenopausal status at start of therapy, the physician needs to discuss adequate contraception when necessary.
\*\*Pregnancy\*\*
Based on human experience in which there have been isolated cases of birth defects (labial fusion, ambiguous genitalia), letrozole may cause congenital malformations when administered during pregnancy. Studies in animals have shown reproductive toxicity (see section 5.3).
Letrozole is contraindicated during pregnancy (see section 4.3 and 5.3).
\*\*Breast-feeding\*\*
It is unknown whether letrozole and its metabolites are excreted in human milk. A risk to the newborns/infants cannot be excluded.
Letrozole is contraindicated during breast-feeding (see section 4.3).
\*\*Fertility\*\*
The pharmacological action of letrozole is to reduce oestrogen production by aromatase inhibition. In premenopausal women, the inhibition of oestrogen synthesis leads to feedback increases in gonadotropin (LH, FSH) levels. Increased FSH levels in turn stimulate follicular growth, and can induce ovulation.4.7 Effects on ability to drive and use machines
Letrozole has minor influence on the ability to drive and use machines. Since fatigue and dizziness have been observed with the use of letrozole and somnolence has been reported uncommonly, caution is advised when driving or using machines.4.8 Undesirable effects
\*\*Summary of the safety profile\*\*
The frequencies of adverse reactions for letrozole are mainly based on data collected from clinical trials.
Up to approximately one third of the patients treated with letrozole in the metastatic settings and approximately 80% of the patients in the adjuvant setting as well as in the extended adjuvant setting experienced adverse reactions. The majority of the adverse reactions occurred during the first few weeks of treatment.
The most frequently reported adverse reactions in clinical studies were hot flushes, hypercholesterolaemia, arthralgia, fatigue, increased sweating and nausea.
Important additional adverse reactions that may occur with letrozole are: skeletal events such as osteoporosis and/or bone fractures and cardiovascular events (including cerebrovascular and thromboembolic events). The frequency category for these adverse reactions is described in Table 1.
\*\*Tabulated list of adverse reactions\*\*
The frequencies of adverse reactions for letrozole are mainly based on data collected from clinical trials.
The following adverse drug reactions, listed in Table 1, were reported from clinical studies and from post-marketing experience with letrozole tablets.
\*\*Table 1\*\*
Adverse reactions are ranked under headings of frequency, the most frequent first, using the following convention: very common (≥ 1/10); common (≥1/100 to <1/10); uncommon (≥ 1/1,000 to < 1/100); rare (≥ 1/10,000 to < 1/1,000); very rare (<1/10,000), not known (cannot be estimated from the available data).
| | | | | | |
| --- | --- | --- | --- | --- | --- |
| \*\*Frequency\*\* | \*\*Very Common\*\* \*\*(≥1/10)\*\* | \*\*Common\*\* \*\*(≥1/100 to <1/10)\*\* | \*\*Uncommon\*\* \*\*(≥1/1,000 to <1/100)\*\* | \*\*Rare\*\* \*\*(≥1/10,000 to <1/1,000)\*\* | \*\*Not known (cannot be estimated from the available data)\*\* |
| \*\*Organ System\*\* |
| Infections and infestations | | | Urinary tract infection | | |
| Neoplasms benign, malignant and unspecified (including cysts and polyps) | | | Tumour pain1 | | |
| Blood and lymphatic system disorders | | | Leucopenia | | |
| Immune system disorders | | | | | Anaphylactic reactions |
| Metabolism and nutrition disorders | Hypercholesterolaemia | Decreased appetite,appetite increase, | | | |
| Psychiatric disorders | | Depression | Anxiety (including nervousness), irritability | | |
| Nervous system disorders | | Headache, dizziness | Somnolence, insomnia, memory impairment, dysaesthesia (including paraesthesia, hypoaesthesia), dysgeusia, cerebrovascular accident, carpal tunnel syndrome | | |
| Eye disorders | | | Cataract, eye irritation, blurred vision | | |
| Cardiac disorders | | Palpitations1 | Tachycardia, ischaemic cardiac events (including new or worsening angina, angina requiring surgery, myocardial infarction and myocardial ischaemia) | | |
| Vascular disorders | Hot flushes | Hypertension | Thrombophlebitis (including superficial and deep vein thrombophlebitis), | Pulmonary embolism, arterial thrombosis, cerebral infarction | |
| Respiratory, thoracic and mediastinal disorders | | | Dyspnoea, cough | | |
| Gastrointestinal disorders | | Nausea, dyspepsia1, constipation, abdominal pain, diarrhoea, vomiting | Dry mouth, stomatitis1 | | |
| Hepatobiliary disorders | | | Increased hepatic enzymes, hyperbilirubinemia, jaundice. | | Hepatitis |
| Skin and subcutaneous tissue disorders | Hyperhidrosis, | Alopecia, rash (including erythematous, maculopapular, psoriaform, and vesicular rash), dry skin | Pruritus, urticaria | | Angioedema,Toxic epidermal necrolysis, erythema multiforme |
| Musculoskeletal and connective tissue disorders | Arthralgia | Myalgia, bone pain1, osteoporosis, bone fractures, arthritis. | Tendonitis | Tendon rupture | Trigger finger |
| Renal and urinary disorders | | | Pollakiuria | | |
| Reproductive system and breast disorders | | Vaginal haemorrhage | Vaginal discharge, vulvovaginal dryness, breast pain | | |
| General disorders and administration site conditions | Fatigue (including asthenia, malaise), | Peripheral oedema, chest pain. | General oedema, pyrexia, mucosal dryness, thirst | | |
| Investigations | | Weight increase | Weight loss | | |
1 Adverse drug reactions reported only in the metastatic setting
Some adverse reactions have been reported with notably different frequencies in the adjuvant treatment setting. The following tables provide information on significant differences in letrozole versus tamoxifen monotherapy and in the letrozole-tamoxifen sequential treatment therapy:
\*\*Table 2 Adjuvant letrozole monotherapy versus tamoxifen monotherapy – adverse events with significant differences\*\*
| | | | | |
| --- | --- | --- | --- | --- |
| | \*\*Letrozole, incidence rate\*\* | | \*\*Tamoxifen, incidence rate\*\* | |
| \*\*N=2448\*\* | | \*\*N=2447\*\* | |
| \*\*During treatment (Median 5y)\*\* | \*\*Any time after randomization (Median 8y)\*\* | \*\*During treatment (Median 5y)\*\* | \*\*Any time after randomization (Median 8y)\*\* |
| Bone fracture | 10.2% | 14.7% | 7.2% | 11.4% |
| Osteoporosis | 5.1% | 5.1% | 2.7% | 2.7% |
| Thromboembolic events | 2.1% | 3.2% | 3.6% | 4.6% |
| Myocardial infarction | 1.0% | 1.7% | 0.5% | 1.1% |
| Endometrial hyperplasia/endometrial cancer | 0.2% | 0.4% | 2.3% | 2.9% |
| Note: “During treatment” includes 30 days after last dose. “Any time” includes follow-up period after completion or discontinuation of study treatment. Differences were based on risk ratios and 95% confidence intervals. | | | | |
\*\*Table 3 Sequential treatment versus letrozole monotherapy – adverse events with significant differences\*\*
| | | | |
| --- | --- | --- | --- |
| | \*\*Letrozole monotherapy\*\* | \*\*Letrozole->tamoxifen\*\* | \*\*Tamoxifen->Letrozole\*\* |
| \*\*N=1535\*\* | \*\*N=1527\*\* | \*\*N=1541\*\* |
| \*\*5 years\*\* | \*\*2 yrs-> 3y\*\* | \*\*2 yrs-> 3y\*\* |
| Bone fractures | 10.0% | 7.7%\\* | 9.7% |
| Endometrial proliferative disorders | 0.7% | 3.4%\\*\\* | 1.7%\\*\\* |
| Hypercholesterolaemia | 52.5% | 44.2%\\* | 40.8%\\* |
| Hot flushes | 37.6% | 41.7%\\*\\* | 43.9%\\*\\* |
| Vaginal bleeding | 6.3% | 9.6%\\*\\* | 12.7%\\*\\* |
| \\* Significantly less than with letrozole monotherapy \\*\\* Significantly more than with letrozole monotherapy Note: Reporting period is during treatment or within 30 days of stopping treatment | | | |
\*\*Description of selected adverse reactions\*\*
\*Cardiac adverse reactions\*
In the adjuvant setting, in addition to the data presented in Table 2, the following adverse events were reported for letrozole and tamoxifen, respectively (at median treatment duration of 60 months plus 30 days): angina requiring surgery (1.0% vs. 1.0%); cardiac failure (1.1% vs. 0.6%); hypertension (5.6% vs. 5.7%); cerebrovascular accident/transient ischaemic attack (2.1% vs. 1.9%).
In the extended adjuvant setting for letrozole (median duration of treatment 5 years) and placebo (median duration of treatment 3 years), respectively: angina requiring surgery (0.8% vs. 0.6%); new or worsening angina (1.4% vs. 1.0%); myocardial infarction (1.0% vs. 0.7%); thromboembolic event\\* (0.9% vs. 0.3%); stroke/transient ischaemic attack\\* (1.5% vs. 0.8%) were reported.
Events marked \\* were statistically significantly different in the two treatment arms.
\*Skeletal adverse reactions\*
For skeletal safety data from the adjuvant setting, please refer to Table 2.
In the extended adjuvant setting, significantly more patients treated with letrozole experienced bone fractures or osteoporosis (bone fractures, 10.4% and osteoporosis, 12.2%) than patients in the placebo arm (5.8% and 6.4%, respectively). Median duration of treatment was 5 years for letrozole, compared with 3 years for placebo.
\*\*Reporting of suspected adverse reactions\*\*
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: https://yellowcard.mhra.gov.uk/or search for MHRA Yellow Card in the Google Play or Apple App Store.4.9 Overdose
There is no clinical experience of overdosage only isolated cases of overdose with letrozole have been reported. In animal studies, letrozole exhibits only a slight degree of acute toxicity. In clinical trials, the highest single and multiple dose tested in healthy volunteers was 30 mg and 5 mg, respectively, the latter also being the highest dose tested in postmenopausal breast cancer patients. Each of these doses was well tolerated. There is no clinical evidence for a particular dose of letrozole resulting in life-threatening symptoms.
There is no specific antidote to letrozole. In general, supportive care, symptomatic treatment and frequent monitoring of vital signs are appropriate.
## Pharmacological Properties
5.1 Pharmacodynamic properties
\*\*Pharmacotherapeutic group\*\*: Endocrine therapy. Hormone antagonist and related agents: aromatase inhibitor; ATC Code: L02BG04.
\*\*Pharmacodynamic effects\*\*
The elimination of oestrogen-mediated growth stimulation is a prerequisite for tumour response in cases where the growth of tumour tissue depends on the presence of oestrogens and endocrine therapy is used. In postmenopausal women, oestrogens are mainly derived from the action of the aromatase enzyme, which converts adrenal androgens - primarily androstenedione and testosterone - to oestrone and oestradiol. The suppression of oestrogen biosynthesis in peripheral tissues and the cancer tissue itself can therefore be achieved by specifically inhibiting the aromatase enzyme.
Letrozole is a non-steroidal aromatase inhibitor. It inhibits the aromatase enzyme by competitively binding to the haem of the aromatase cytochrome P450, resulting in a reduction of oestrogen biosynthesis in all tissues where present.
In healthy postmenopausal women, single doses of 0.1 mg, 0.5 mg and 2.5 mg letrozole suppress serum oestrone and oestradiol by 75%, 78% and 78% from baseline respectively. Maximum suppression is achieved in 48-78 hours.
In postmenopausal patients with advanced breast cancer, daily doses of 0.1 mg to 5 mg suppressed plasma concentration of oestradiol, oestrone, and oestrone sulphate by 75-95% from baseline in all patients treated. With doses of 0.5 mg and higher, many values of oestrone and oestrone sulphate were below the limit of detection in the assays, indicating that higher oestrogen suppression is achieved with these doses. Oestrogen suppression was maintained throughout treatment in all these patients.
Letrozole is highly specific in inhibiting aromatase activity. Impairment of adrenal steroidogenesis has not been observed. No clinically relevant changes were found in the plasma concentrations of cortisol, aldosterone, 11-deoxycortisol, 17-hydroxyprogesterone, and ACTH or in plasma renin activity among postmenopausal patients treated with a daily dose of letrozole 0.1 to 5 mg. The ACTH stimulation test performed after 6 and 12 weeks of treatment with daily doses of 0.1 mg, 0.25 mg, 0.5 mg, 1 mg, 2.5 mg, and 5 mg did not indicate any attenuation of aldosterone or cortisol production. Thus, glucocorticoid and mineralocorticoid supplementation is not necessary.
No changes were noted in plasma concentrations of androgens (androstenedione and testosterone) among healthy postmenopausal women after 0.1 mg, 0.5 mg, and 2.5 mg single doses of letrozole or in plasma concentrations of androstenedione among postmenopausal patients treated with daily doses of 0.1 mg to 5 mg, indicating that the blockade of oestrogen biosynthesis does not lead to accumulation of androgenic precursors. Plasma levels of LH and FSH are not affected by letrozole in patients, nor is thyroid function as evaluated by TSH, T4 and T3 uptake test.
\*\*Adjuvant treatment\*\*
\*\*\*Study BIG 1-98\*\*\*
BIG 1-98 was a multicentre, double-blind study in which over 8,000 postmenopausal women with hormone receptor-positive early breast cancer were randomised to one of the following treatments: A. tamoxifen for 5 years; B. letrozole for 5 years; C. tamoxifen for 2 years followed by letrozole for 3 years; D, letrozole for 2 years followed by tamoxifen for 3 years.
The primary endpoint was disease-free survival (DFS); secondary efficacy endpoints were time to distant metastasis (TDM), distant disease-free survival (DDFS), overall survival (OS), systemic disease-free survival (SDFS), invasive contralateral breast cancer and time to breast cancer recurrence.
\*Efficacy results at a median follow-up of 26 and 60 months\*
Data in Table 4 reflect the results of the Primary Core Analysis (PCA) based on data from the monotherapy arms (A and B) and from the two switching arms (C and D) at a median treatment duration of 24 months and a median follow-up of 26 months and at a median treatment duration of 32 months and a median follow-up of 60 months.
The 5-year DFS rates were 84% for letrozole and 81.4% for tamoxifen.
\*\*Table 4 Primary Core Analysis: Disease-free and overall survival, at a median follow-up of 26 months and at median follow-up of 60 months (ITT population)\*\*
| | | | | | | |
| --- | --- | --- | --- | --- | --- | --- |
| | \*\*Primary Core Analysis\*\* | | | | | |
| \*\*Median follow-up 26 months\*\* | | | \*\*Median follow-up 60 months\*\* | | |
| \*\*Letrozole N=4003\*\* | \*\*Tamoxifen N=4007\*\* | \*\*HR1 (95% CI) \*P\*\*\* | \*\*Letrozole N=4003\*\* | \*\*Tamoxifen N=4007\*\* | \*\*HR1 (95% CI) \*P\*\*\* |
| Disease-free survival (primary)-events (protocol definition2) | 351 | 428 | 0.81 (0.70, 0.93) 0.003 | 585 | 664 | 0.86 (0.77, 0.96) 0.008 |
| Overall survival (secondary) Number of deaths | 166 | 192 | 0.86 (0.70, 1.06) | 330 | 374 | 0.87 (0.75, 1.01) |
HR = Hazard ratio; CI = Confidence interval
1 Log rank test, stratified by randomisation option and use of chemotherapy (yes/no)
2 DFS events: loco-regional recurrence, distant metastasis, invasive contralateral breast cancer, second (non-breast) primary malignancy, death from any cause without a prior cancer event.
\*Results at a median follow-up of 96 months (monotherapy arms only)\*
The Monotherapy Arms Analysis (MAA) long-term update of the efficacy of letrozole monotherapy compared to tamoxifen monotherapy (median duration of adjuvant treatment: 5 years) is presented in Table 5.
\*\*Table 5 Monotherapy Arms Analysis: Disease-free and overall survival at a median follow-up of 96 months (ITT population)\*\*
| | | | | |
| --- | --- | --- | --- | --- |
| | \*\*Letrozole N=2463\*\* | \*\*Tamoxifen N=2459\*\* | \*\*Hazard Ratio1 (95% CI)\*\* | \*\*\*P\* Value\*\* |
| Disease-free survival events (primary) 2 | 626 | 698 | 0.87 (0.78, 0.97) | 0.01 |
| Time to distant metastasis (secondary) | 301 | 342 | 0.86 (0.74, 1.01) | 0.06 |
| Overall survival (secondary) deaths | 393 | 436 | 0.89 (0.77, 1.02) | 0.08 |
| Censored analysis of DFS3 | 626 | 649 | 0.83 (0.74, 0.92) | |
| Censored analysis of OS3 | 393 | 419 | 0.81 (0.70, 0.93) | |
1 Log rank test, stratified by randomisation option and use of chemotherapy (yes/no)
2 DFS events: loco-regional recurrence, distant metastasis, invasive contralateral breast cancer, second (non-breast) primary malignancy, death from any cause without a prior cancer event.
3 Observations in the tamoxifen arm censored at the date of selectively switching to letrozole
\*Sequential Treatments Analysis (STA)\*
The Sequential Treatments Analysis (STA) addresses the second primary question of BIG 1-98, namely whether sequencing of tamoxifen and letrozole would be superior to monotherapy. There were no significant differences in DFS, OS, SDFS, or DDFS from switch with respect to monotherapy (Table 6).
\*\*Table 6 Sequential treatments analysis of disease-free survival with letrozole as initial endocrine agent (STA switch population)\*\*
| | | | | | |
| --- | --- | --- | --- | --- | --- |
| | \*\*N\*\* | \*\*Number of events1\*\* | \*\*Hazard ratio2\*\* | \*\*(97.5% confidence interval)\*\* | \*\*Cox model \*P-\*value\*\* |
| [Letrozole→] Tamoxifen | 1460 | 254 | 1.03 | (0.84, 1.26) | 0.72 |
| Letrozole | 1464 | 249 | | | |
1 Protocol definition, including second non-breast primary malignancies, after switch / beyond two years
2 Adjusted by chemotherapy use
There were no significant differences in DFS, OS, SDFS or DDFS in any of the STA from randomisation pairwise comparisons (Table 7).
\*\*Table 7 Sequential Treatments Analyses from randomisation (STA-R) of disease-free survival (ITT STA-R population)\*\*
| | | |
| --- | --- | --- |
| | \*\*Letrozole→Tamoxifen\*\* | \*\*Letrozole\*\* |
| Number of patients | 1540 | 1546 |
| Number of patients with DFS events (protocol definition) | 330 | 319 |
| Hazard ratio1 (99% CI) | 1.04 (0.85, 1.27) | |
| | \*\*Letrozole→Tamoxifen\*\* | \*\*Tamoxifen2\*\* |
| Number of patients | 1540 | 1548 |
| Number of patients with DFS events (protocol definition) | 330 | 353 |
| Hazard ratio1 (99% CI) | 0.92 (0.75, 1.12) | |
1 Adjusted by chemotherapy use (yes/no)
2 626 (40%) patients selectively crossed to letrozole after tamoxifen arm unblinded in 2005
\*\*Study D2407\*\*
Study D2407 is an open-label, randomised, multicentre post approval safety study designed to compare the effects of adjuvant treatment with letrozole and tamoxifen on bone mineral density (BMD) and serum lipid profiles. A total of 262 patients were assigned either letrozole for 5 years or tamoxifen for 2 years followed by letrozole for 3 years.
At 24 months, there was a statistically significant difference in the primary end-point; the lumbar spine BMD (L2-L4) showed a median decrease of 4.1% for letrozole compared to a median increase of 0.3% for tamoxifen.
No patient with a normal BMD at baseline became osteoporotic during 2 years of treatment and only 1 patient with osteopenia at baseline (T score of -1.9) developed osteoporosis during the treatment period (assessment by central review).
The results for total hip BMD were similar to those for lumbar spine but less pronounced.
There was no significant difference between treatments in the rate of fractures - 15% in the letrozole arm, 17% in the tamoxifen arm.
Median total cholesterol levels in the tamoxifen arm were decreased by 16% after 6 months compared to baseline and this decrease was maintained at subsequent visits up to 24 months. In the letrozole arm, total cholesterol levels were relatively stable over time, giving a statistically significant difference in favour of tamoxifen at each time point.
\*\*\*Extended adjuvant treatment (MA-17)\*\*\*
In a multicentre, double-blind, randomised, placebo-controlled study (MA-17), over 5,100 postmenopausal women with receptor-positive or unknown primary breast cancer who had completed adjuvant treatment with tamoxifen (4.5 to 6 years) were randomised to either letrozole or placebo for 5 years.
The primary endpoint was disease-free survival, defined as the interval between randomisation and the earliest occurrence of loco-regional recurrence, distant metastasis, or contralateral breast cancer.
The first planned interim analysis at a median follow-up of around 28 months (25% of patients being followed-up for at least 38 months), showed that letrozole significantly reduced the risk of breast cancer recurrence by 42% compared with placebo (HR 0.58; 95% CI 0.45, 0.76; \*P\* = 0.00003). The benefit in favour of letrozole was observed regardless of nodal status.There was no significant difference in overall survival: (letrozole 51 deaths; placebo 62; HR 0.82; 95% CI 0.56, 1.19).
Consequently, after the first interim analysis the study was unblinded and continued in an open-label fashion and patients in the placebo arm were allowed to switch to letrozole for up to 5 years. Over 60% of eligible patients (disease-free at unblinding ) opted to switch to letrozole. The final analysis included 1,551 women who switched from placebo to letrozole at a median of 31 months (range 12 to 106 months) after completion of tamoxifen adjuvant therapy. Median duration of letrozole after switch was 40 months.
The final analysis conducted at a median follow-up of 62 months confirmed the significant reduction in the risk of breast cancer recurrence with letrozole.
\*\*Table 8: Disease-free and overall survival (Modified ITT population)\*\*
| | | | | | | |
| --- | --- | --- | --- | --- | --- | --- |
| | \*\*Median follow-up 28 months1\*\* | | | \*\*Median follow-up 62 months\*\* | | |
| \*\*Letrozole\*\* | \*\*Placebo\*\* | \*\*HR2 (95% CI) 2\*\* | \*\*Letrozole\*\* | \*\*Placebo\*\* | \*\*HR (95% CI) 2\*\* |
| \*\*N = 2582\*\* | \*\*N = 2586\*\* | \*\*\*P\* value\*\* | \*\*N = 2582\*\* | \*\*N = 2586\*\* | \*\*\*P\* value\*\* |
| \*\*Disease-free survival3\*\* | | | | | | |
| Events | 92 (3.6 %) | 155 (6.0 %) | 0.58 (0.45, 0.76) 0.00003 | 209 (8.1 %) | 286 (11.1%) | 0.75 (0.63, 0.89) |
| 4-year DFS rate | 94.4% | 89.8% | | 94.4% | 91.4% | |
| \*\*Disease-free survival3 including deaths from any cause\*\* | | | | | | |
| Events | 122 (4.7%) | 193 (7.5%) | 0.62 (0.49, 0.78) | 344 (13.3%) | 402 (15.5%) | 0.89 (0.77, 1.03) |
| 5-year DFS rate | 90.5% | 80.8% | | 88.8% | 86.7% | |
| \*\*Distant metastases\*\* | | | | | | |
| Events | 57 (2.2%) | 93 (3.6%) | 0.61 (0.44, 0.84) | 142 (5.5%) | 169 (6.5%) | 0.88 (0.70, 1.10) |
| \*\*Overall survival\*\* | | | | | | |
| Deaths | 51 (2.0%) | 62 (2.4%) | 0.82 (0.56, 1.19) | 236 (9.1%) | 232 (9.0%) | 1.13 (0.95, 1.36) |
| Deaths 4 | --- | --- | --- | 2365 (9.1%) | 1706 (6.6%) | 0.78 (0.64, 0.96) |
| HR = Hazards ratio; CI = Confidence interval 1 When the study was unblinded in 2003, 1551 patients in the randomised placebo arm (60% of those eligible to switch – i.e. who were disease-free) switched to letrozole at a median 31 months after randomisation. The analyses presented here ignore the selective crossover 2 Stratified by receptor status, nodal status and prior adjuvant chemotherapy 3 Protocol definition of disease-free survival events: loco-regional recurrence, distant metastasis or contralateral breast cancer 4 Exploratory analysis, censoring follow-up times at the date of switch (if it occurred) in the placebo arm. 5 Median follow-up 62 months 6 Median follow-up until switch (if it occurred) 37 months | | | | | | |
In the MA-17 bone substudy in which concomitant calcium and vitamin D were given, greater decreases in BMD compared to baseline occurred with letrozole compared with placebo. The only statistically significant difference occurred at 2 years and was in total hip BMD (letrozole median decrease of 3.8% vs placebo median decrease of 2.0%).
In the MA-17 lipid substudy there were no significant differences between letrozole and placebo in total cholesterol or in any lipid fraction.
In the updated quality of life substudy there were no significant differences between treatments in physical component summary score or mental component summary score, or in any domain score in the SF-36 scale. In the MENQOL scale, significantly more women in the letrozole arm than in the placebo arm were most bothered (generally in the first year of treatment) by those symptoms deriving from oestrogen deprivation – hot flushes and vaginal dryness. The symptom that bothered most patients in both treatment arms was aching muscles, with a statistically significant difference in favour of placebo.
\*\*Neoadjuvant treatment\*\*
A double blind trial (P024) was conducted in 337 postmenopausal breast cancer patients randomly allocated either letrozole 2.5 mg for 4 months or tamoxifen for 4 months. At baseline all patients had tumours stage T2-T4c, N0-2, M0, ER and/or PgR positive and none of the patients would have qualified for breast-conserving surgery. Based on clinical assessment there were 55% objective responses in the letrozole arm versus 36% for the tamoxifen arm (\*P\*<0.001). This finding was consistently confirmed by ultrasound (letrozole 35% vs tamoxifen 25%, \*P\*=0.04) and mammography (letrozole 34% vs tamoxifen 16%, \*P\*<0.001). In total 45% of patients in the letrozole group versus 35% of patients in the tamoxifen group (\*P\*=0.02) underwent breast-conserving therapy). During the 4-month pre-operative treatment period, 12% of patients treated with letrozole and 17% of patients treated with tamoxifen had disease progression on clinical assessment.
\*\*First-line treatment\*\*
One controlled double-blind trial was conducted comparing letrozole 2.5 mg to tamoxifen 20 mg as first-line therapy in postmenopausal women with advanced breast cancer. In 907 women, letrozole was superior to tamoxifen in time to progression (primary endpoint) and in overall objective response, time to treatment failure and clinical benefit.
The results are summarised in Table 9:
\*\*Table 9 Results at a median follow-up of 32 months\*\*
| | | | |
| --- | --- | --- | --- |
| \*\*Variable\*\* | \*\*Statistic\*\* | \*\*Letrozole\*\* \*\*N=453\*\* | \*\*Tamoxifen\*\* \*\*N=454\*\* |
| Time of progression | Median | 9.4 months | 6.0 months |
| (95% CI for median) | (8.9, 11.6 months) | (5.4, 6.3 months) |
| Hazard ratio (HR) | 0.72 | |
| (95% CI for HR) | (0.62, 0.83) | |
| | \*P\* <0.0001 | |
| Objective response rate (ORR) | CR+PR | 145 (32%) | 95 (21%) |
| (95% CI for rate) | (28, 36%) | (17, 25%) |
| Odds ratio | 1.78 | |
| (95% CI for odds ratio) | (1.32, 2.40) | |
| | \*P\*=0.0002 | |
Time to progression was significantly longer, and response rate significantly higher for letrozole irrespective of whether adjuvant anti-oestrogen therapy had been given or not. Time to progression was significantly longer for letrozole irrespective of dominant site of disease. Median time to progression was 12.1 months for letrozole and 6.4 months for tamoxifen in patients with soft tissue disease only and median 8.3 months for letrozole and 4.6 months for tamoxifen in patients with visceral metastases.
Study design allowed patients to cross over upon progression to the other therapy or discontinue from the study. Approximately 50% of patients crossed over to the opposite treatment arm and crossover was virtually completed by 36 months. The median time to crossover was 17 months (letrozole to tamoxifen) and 13 months (tamoxifen to letrozole).
Letrozole treatment in the first-line therapy of advanced breast cancer resulted in a median overall survival of 34 months compared with 30 months for tamoxifen (logrank test P=0.53, not significant). The absence of an advantage for letrozole on overall survival could be explained by the crossover design of the study.
\*\*Second-line treatment\*\*
Two well-controlled clinical trials were conducted comparing two letrozole doses (0.5 mg and 2.5 mg) to megestrol acetate and to aminoglutethimide, respectively, in postmenopausal women with advanced breast cancer previously treated with anti-oestrogens.
Time to progression was not significantly different between letrozole 2.5 mg and megestrol acetate (\*P\*=0.07). Statistically significant differences were observed in favour of letrozole 2.5 mg compared to megestrol acetate in overall objective tumour response rate (24% vs 16%, \*P\*=0.04), and in time to treatment failure (\*P\*=0.04). Overall survival was not significantly different between the 2 arms (\*P\*=0.2).
In the second study, the response rate was not significantly different between letrozole 2.5 mg and aminoglutethimide (\*P\*=0.06). Letrozole 2.5 mg was statistically superior to aminoglutethimide for time to progression (\*P\*=0.008), time to treatment failure (\*P\*=0.003) and overall survival (\*P\*=0.002).
\*\*Male breast cancer\*\*
Use of letrozole in men with breast cancer has not been studied.5.2 Pharmacokinetic properties
\*\*Absorption\*\*
Letrozole is rapidly and completely absorbed from the gastrointestinal tract (mean absolute bioavailability: 99.9%). Food slightly decreases the rate of absorption (median tmax 1 hour fasted versus 2 hours fed; and mean Cmax 129 ± 20.3 nmol/litre fasted versus 98.7 ± 18.6 nmol/litre fed) but the extent of absorption (AUC) is not changed. The minor effect on the absorption rate is not considered to be of clinical relevance, and therefore letrozole may be taken without regard to mealtimes.
\*\*Distribution\*\*
Plasma protein binding of letrozole is approximately 60%, mainly to albumin (55%). The concentration of letrozole in erythrocytes is about 80% of that in plasma. After administration of 2.5 mg 14C-labelled letrozole, approximately 82% of the radioactivity in plasma was unchanged compound. Systemic exposure to metabolites is therefore low. Letrozole is rapidly and extensively distributed to tissues. Its apparent volume of distribution at steady state is about 1.87 ± 0.47 L/kg.
\*\*Biotransformation\*\*
Metabolic clearance to a pharmacologically inactive carbinol metabolite is the major elimination pathway of letrozole (CLm= 2.1 L/h) but is relatively slow when compared to hepatic blood flow (about 90 L/h). The cytochrome P450 isoenzymes 3A4 and 2A6 were found to be capable of converting letrozole to this metabolite.\*in vitro\*, but their individual contributions to letrozole clearance \*in vivo\* have not been established. In an interaction study co-administration with cimetidine, which is known to inhibit only the 3A4 isoenzyme, did not result in a decrease in letrozole clearance suggesting that \*in vivo\* the 2A6 isoenzyme plays an important part in total clearance. In this study a slight decrease in AUC and increase in Cmax were observed.
Formation of minor unidentified metabolites and direct renal and faecal excretion play only a minor role in the overall elimination of letrozole. Within 2 weeks after administration of 2.5 mg 14C-labelled letrozole to healthy postmenopausal volunteers, 88.2 ± 7.6% of the radioactivity was recovered in urine and 3.8 ± 0.9% in faeces. At least 75% of the radioactivity recovered in urine up to 216 hours (84.7 ± 7.8% of the dose) was attributed to the glucuronide of the carbinol metabolite, about 9% to two unidentified metabolites, and 6% to unchanged Letrozole.
\*\*Elimination\*\*
The apparent terminal elimination half-life in plasma is about 2 to 4 days. After daily administration of 2.5 mg steady-state levels are reached within 2 to 6 weeks. Plasma concentrations at steady state are approximately 7 times higher than concentrations measured after a single dose of 2.5 mg, while they are 1.5 to 2 times higher than the steady-state values predicted from the concentrations measured after a single dose, indicating a slight non-linearity in the pharmacokinetics of letrozole upon daily administration of 2.5 mg. Since steady-state levels are maintained over time, it can be concluded that no continuous accumulation of letrozole occurs.
\*\*Linearity/non-linearity\*\*
The pharmacokinetics of letrozole were dose proportional after single oral doses up to 10 mg (dose range: 0.01 to 30 mg) and after daily doses up to 1.0 mg (dose range: 0.1 to 5mg). After a 30 mg single oral dose there was a slightly dose over-proportional increase in AUC value. The dose over-proportionality is likely to be the result of a saturation of metabolic elimination processes. Steady levels were reached after 1 to 2 months at all dosage regimens tested (0.1-5.0 mg daily).
\*\*Special populations\*\*
\*Elderly\*
Age had no effect on the pharmacokinetics of letrozole.
\*\*Special populations\*\*
\*Renal impairment\*
In a study involving 19 volunteers with varying degrees of renal function (24 hour creatinine clearance 9-116 ml/min) no effect on the pharmacokinetics of letrozole or the urinary excretion of the glucoronide of its carbinol metabolite was found after a single dose of 2.5 mg. In addition to the above study assessing the influence of renal impairment on letrozole, a covariate analysis was performed on the data of two pivotal studies (Study AR/BC2 and Study AR/BC3). Calculated creatinine clearance (CLcr) [Study AR/BC2 range: 19 to 187 mL/min; Study AR/BC3 range: 10 to 180 mL/min] showed no statistically significant association between letrozole plasma trough levels at steady-state (Cmin). Futhermore, data of Study AR/BC2 and Study AR/BC3 in second-line metastatic breast cancer showed no evidence of an adverse effect of letrozole on CLcr or an impairment of renal function.
Therefore, no dose adjustment is required for patients with renal impairment (CLcr ≥10 mL/min). Little information is available in patients with severe impairment of renal function (CLcr <10 mL/min).
\*Hepatic impairment\*
The Cmax, AUC and half-life of the metabolite have not been determined. In a similar study involving subjects with varying degrees of hepatic function, the mean AUC values of the volunteers with moderate hepatic impairment (Child-Pugh B) was 37% higher than in normal subjects, but still within the range seen in subjects without impaired function. In a study comparing the pharmacokinetics of letrozole after a single oral dose in eight male subjects with liver cirrhosis and severe hepatic impairment (Child-Pugh C) to those in healthy volunteers (N=8), AUC and t½ increased by 95 and 187%, respectively. Thus, letrozole should be administered with caution to patients with severe hepatic impairment and after consideration of the risk/benefit in the individual patient.5.3 Preclinical safety data
In a variety of preclinical safety studies conducted in standard animal species, there was no evidence of systemic or target organ toxicity.
Letrozole showed a low degree of acute toxicity in rodents exposed up to 2000 mg/kg. In dogs, letrozole caused signs of moderate toxicity at 100 mg/kg.
In repeated-dose toxicity studies in rats and dogs up to 12 months, the main findings observed can be attributed to the pharmacological action of the compound. The no-adverse-effect level was 0.3 mg/kg in both species.
Oral administration of letrozole to female rats resulted in decreases in mating and pregnancy ratios and increases in pre-implantation loss
Both \*in vitro\* and \*in vivo\* investigations of letrozole's mutagenic potential revealed no indications of any genotoxicity.
In a 104-week rat carcinogenicity study, no treatment-related tumours were noted in male rats. In female rats, a reduced incidence of benign and malignant mammary tumours at all the doses of letrozole was found.
In a 104-week mouse carcinogenicity studies, no treatment-related tumours were noted in male mice. In female mice, a generally dose-related increase in the incidence of benign ovarian granulosa theca cell tumors was observed at all doses of letrozole tested. These tumors were considered to be related to the pharmacological inhibition of estrogen synthesis and may be due to increased LH resulting from the decrease in circulating estrogen.
Letrozole was embryotoxic and foetotoxic in pregnant rats and rabbits following oral administration at clinically relevant doses. In rats that had live foetuses, there was an increase in the incidence of foetal malformations including domed head and cervical/centrum vertebral fusion. An increased incidence of foetal malformations was not seen in the rabbit. It is not known whether this was an indirect consequence of the pharmacological properties (inhibition of oestrogen biosynthesis) or a direct drug effect (see sections 4.3 and 4.6).
Preclinical observations were confined to those associated with the recognised pharmacological action, which is the only safety concern for human use derived from animal studies.
## Pharmaceutical Particulars
6.1 List of excipients
\*\*Tablet core:\*\*
Lactose monohydrate,
Sodium starch glycolate,
Microcrystalline cellulose,
Hypromellose 6 cP,
Colloidal anhydrous silica,
Magnesium stearate (E572).
\*\*Film coat\*\* (Opadry 04F52158 Yellow):
Hypromellose 15 cP (E464),
PEG 6000.
Titanium dioxide, (E171),
Iron oxide yellow E172 (iii),
Iron oxide red, E172 (ii),
FD&C yellow #5 Aluminium lake, (E102).6.2 Incompatibilities
None known.6.3 Shelf life
2 years6.4 Special precautions for storage
Store in in the original package6.5 Nature and contents of container
PVC/PE/PVDC Aliminium blister packs of 14 or 28 tablets.6.6 Special precautions for disposal and other handling
No specific instructions for use/handling.
