Surgery News - February 2009 - (Page 12) ONCOLOGY FEBRUARY 2009 • SURGERY NEWS Preop MRI in Breast Cancer Patients Not Beneficial BY BRUCE JANCIN Else vier Global Medical Ne ws S A N A N T O N I O — Preoperative evaluation by breast MRI did not reduce reoperation or mastectomy rates following planned wide local excision for breast cancer in the randomized U.K. COMICE trial. COMICE (the Comparative Effectiveness of Magnetic Resonance Imaging in Breast Cancer) was a large multicenter technology assessment study undertaken at the request of the U.K. National Health Service, which sought to determine whether preoperative MRI in patients diagnosed with breast cancer is cost effective. “This was a simple study that asked a very simple question, and here is the answer: There was no reduction in reoperation rates. End of story,” Dr. Phil Drew declared at the San Antonio Breast Cancer Symposium. BRIEF SUMMARY COMICE involved 1,623 breast cancer patients who were scheduled at 45 medical centers for wide local excision based upon standard triple assessment by physical exam, mammography, and ultrasound. On a randomized basis, half of them underwent preoperative contrastenhanced MRI. Unlike prior retrospective studies of the utility of breast MRI for preoperative cancer staging, COMICE was an inclusive study not limited to specialized centers. ENTEREG® (alvimopan) Capsules The following is a brief summary only; see full prescribing information for complete product information. WARNING: FOR SHORT-TERM HOSPITAL USE ONLY ENTEREG is available only for short-term (15 doses) use in hospitalized patients. Only hospitals that have registered in and met all of the requirements for the ENTEREG Access Support and Education (E.A.S.E.) program may use ENTEREG. [see Warnings and Precautions (5.1 and 5.2)] 4 CONTRAINDICATIONS ENTEREG is contraindicated in patients who have taken therapeutic doses of opioids for more than 7 consecutive days immediately prior to taking ENTEREG. 5 WARNINGS AND PRECAUTIONS 5.1 Myocardial Infarction in a 12-Month Study in Patients treated with Opioids for Chronic Pain There were more reports of myocardial infarctions in patients treated with alvimopan 0.5 mg twice daily compared with placebo-treated patients in a 12-month study of patients treated with opioids for chronic pain. In this study, the majority of myocardial infarctions occurred between 1 and 4 months after initiation of treatment. This imbalance has not been observed in other studies of alvimopan, including studies in patients undergoing bowel resection surgery who received alvimopan 12 mg twice daily for up to 7 days. A causal relationship with alvimopan has not been established. 5.2 Distribution Program for ENTEREG ENTEREG is available only to hospitals that enroll in the E.A.S.E. program. To enroll in the E.A.S.E. program, the hospital must acknowledge that: hospital staff who prescribe, dispense, or administer ENTEREG have been provided the educational materials on the need to limit use of ENTEREG to short-term, inpatient use; patients will not receive more than 15 doses of alvimopan; and ENTEREG will not be dispensed to patients after they have been discharged from the hospital. Contact the E.A.S.E. program at 1-866-4ADOLOR (1-866-423-6567). 5.3 Opioid Tolerance and Gastrointestinal-Related Adverse Effects Patients recently exposed to opioids are expected to be more sensitive to the effects of µ-opioid receptor antagonists. Since ENTEREG acts peripherally, clinical signs and symptoms of increased sensitivity would likely be limited to the gastrointestinal tract (e.g., abdominal pain, nausea and vomiting, diarrhea). Patients receiving more than 3 doses of an opioid within the week prior to surgery were not studied in the postoperative ileus clinical trials; therefore, ENTEREG 12 mg capsules should be administered with caution to these patients. 5.4 Severe Hepatic Impairment In patients with severe hepatic impairment, there is a potential for 10-fold higher plasma levels of drug [see Clinical Pharmacology (12.3) of full prescribing information]. There are no studies of ENTEREG in patients with severe hepatic impairment undergoing bowel resection. Because of the limited data available, ENTEREG is not recommended for use in patients with severe hepatic impairment. 5.5 End-Stage Renal Disease No studies have been conducted with end-stage renal disease. ENTEREG is not recommended for use in these patients. 5.6 Bowel Obstruction Use of ENTEREG in patients undergoing surgery for correction of complete bowel obstruction is not recommended. 6 6.1 ADVERSE REACTIONS Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice. The adverse event information from clinical trials does, however, provide a basis for identifying the adverse events that appear to be related to drug use and for approximating rates. The data described below reflect exposure to ENTEREG in 1,650 patients in 9 placebo-controlled studies worldwide. The population was 19 to 97 years old, 68% were female, and 83% were Caucasian; 61% were undergoing bowel resection surgery. The first dose of ENTEREG was administered 30 minutes to 5 hours before the scheduled start of surgery and then twice daily until hospital discharge (or for a maximum of 7 days of postoperative treatment). Table 1 presents treatment-emergent adverse reactions reported in ≥3% patients treated with ENTEREG and for which the rate for ENTEREG was ≥1% than placebo. Treatment-emergent adverse reactions are those events occurring after the first dose of study medication treatment and within 7 days of the last dose of study medication or those events present at baseline that increased in severity after the start of study medication treatment. Table 1. Treatment-Emergent Adverse Reactions That Were Reported in ≥3% of Either Bowel Resection Patients Treated With ENTEREG or All Surgical Patients Treated With ENTEREG and for Which the Rate for ENTEREG Was ≥1% Than Placebo Bowel Resection Patients Placebo ENTEREG (n = 986) (n = 999) % % 4.2 3.9 4.6 4.5 8.5 1.7 2.1 5.2 4.0 7.0 3.1 9.5 3.3 3.2 All Surgical Patients Placebo ENTEREG (n = 1,365) (n = 1,650) % % 5.4 7.6 4.8 7.7 7.5 2.6 2.3 5.4 9.7 5.9 8.7 6.9 3.4 3.5 Coadministration of alvimopan does not appear to alter the pharmacokinetics of morphine and its metabolite, morphine-6-glucuronide, to a clinically significant degree when morphine is administered intravenously. Dosage adjustment for intravenously administered morphine is not necessary when it is coadministered with alvimopan. 8 8.1 USE IN SPECIFIC POPULATIONS Pregnancy Teratogenic Effects: Pregnancy Category B: Reproduction studies have been performed in pregnant rats at about 68 to 136 times the recommended human oral dose based on the body surface area and intravenous doses of about 3.4 to 6.8 times the recommended human oral dose based on the body surface area and in pregnant rabbits at intravenous doses at about 5 to 10 times the recommended human oral dose based on the body surface area and have revealed no evidence of impaired fertility or harm to the fetus due to alvimopan. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed. 8.2 Nursing Mothers Alvimopan and its ‘metabolite’ are detected in the milk of lactating rats. It is not known whether alvimopan is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when ENTEREG is administered to a nursing woman. 8.3 Pediatric Use Safety and effectiveness in pediatric patients have not been established. 8.4 Geriatric Use Of the total number of patients in 5 clinical efficacy studies treated with ENTEREG or placebo, 45% were 65 years of age and over, while 18% were 75 years of age and over. No overall differences in safety or effectiveness were observed between these patients and younger patients, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. No dosage adjustment based on increased age is required [see Clinical Pharmacology (12.3) of full prescribing information]. 8.5 Hepatic Impairment Although there is a potential for higher plasma levels of drug in patients with mild-to-moderate hepatic impairment [see Clinical Pharmacology (12.3)], dosage adjustment in these patients is not required. Patients with mild-to-moderate hepatic impairment should be closely monitored for possible adverse effects (e.g., diarrhea, gastrointestinal pain, cramping) that could indicate high drug or ‘metabolite’ levels, and ENTEREG should be discontinued if adverse events occur. ENTEREG is not recommended for use in patients with severe hepatic impairment. [See Warnings and Precautions (5.4) and Dosage and Administration (2.2) and Clinical Pharmacology (12.3) of full prescribing information] 8.6 Renal Impairment Alvimopan has not been studied in patients with end-stage renal disease and ENTEREG is not recommended for use in these patients. Patients with mild-to-severe renal impairment do not require dosage adjustment, but they should be monitored for adverse effects. [see Dosage and Administration (2.2) and Clinical Pharmacology (12.3) of full prescribing information]. Patients with severe impairment should be closely monitored for possible adverse effects (e.g., diarrhea, gastrointestinal pain, cramping) that could indicate high drug or ‘metabolite’ levels, and ENTEREG should be discontinued if adverse events occur. 9 10 DRUG ABUSE AND DEPENDENCE ENTEREG has no known potential for abuse or dependence. The reoperation rate within 6 months was 18.75%
Table of Contents Feed for the Digital Edition of Surgery News - February 2009 Surgery News - February 2009 Contents The 20/20 Vision ICD-10 Looms News From the College: MedPAC Flak Oncology: Best for Breast General Surgery: Weighty Problem Surgery News - February 2009 Surgery News - February 2009 - Contents (Page 1) Surgery News - February 2009 - Contents (Page 2) Surgery News - February 2009 - Contents (Page 3) Surgery News - February 2009 - Contents (Page 4) Surgery News - February 2009 - The 20/20 Vision ICD-10 Looms (Page 5) Surgery News - February 2009 - The 20/20 Vision ICD-10 Looms (Page 6) Surgery News - February 2009 - The 20/20 Vision ICD-10 Looms (Page 7) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 8) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 9) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 10) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 11) Surgery News - February 2009 - Oncology: Best for Breast (Page 12) Surgery News - February 2009 - Oncology: Best for Breast (Page 13) Surgery News - February 2009 - Oncology: Best for Breast (Page 14) Surgery News - February 2009 - Oncology: Best for Breast (Page 15) Surgery News - February 2009 - Oncology: Best for Breast (Page 16) Surgery News - February 2009 - Oncology: Best for Breast (Page 17) Surgery News - February 2009 - Oncology: Best for Breast (Page 18) Surgery News - February 2009 - General Surgery: Weighty Problem (Page 19) Surgery News - February 2009 - General Surgery: Weighty Problem (Page 20)
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