2.1 Dosage Adjustment in Renal Impairment

No dosage adjustment is necessary for patients with renal impairment [see Use in Specific Populations (8.7)].

2.2 Dosage Adjustment in Hepatic Impairment

No dosage adjustment is necessary for patients with mild to moderate hepatic impairment. In patients with severe liver impairment (n = 4), although there was a 76% increase in the half-life (5.9 and 10.4 days for normal and impaired patients, respectively) of the active enantiomer of bicalutamide no dosage adjustment is necessary [see Use in Specific Populations (8.6)].

4.1 Hypersensitivity

Bicalutamide tablets are contraindicated in any patient who has shown a hypersensitivity reaction to the drug or any of the tablet’s components. Hypersensitivity reactions including angioneurotic edema and urticaria have been reported [see Adverse Reactions (6.2)].

4.2 Women

Bicalutamide tablets have no indication for women, and should not be used in this population.

4.3 Pregnancy

Bicalutamide tablets may cause fetal harm when administered to a pregnant woman. Bicalutamide tablets are contraindicated in women, including those who are or may become pregnant. There are no studies in pregnant women using bicalutamide tablets. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be appraised of the potential hazard to the fetus [see Use in Specific Populations (8.1)].

5.1 Hepatitis

Rare cases of death or hospitalization due to severe liver injury have been reported post-marketing in association with the use of bicalutamide tablets. Hepatotoxicity in these reports generally occurred within the first 3 to 4 months of treatment. Hepatitis or marked increases in liver enzymes leading to drug discontinuation occurred in approximately 1% of bicalutamide tablets patients in controlled clinical trials.

Serum transaminase levels should be measured prior to starting treatment with bicalutamide tablets, at regular intervals for the first 4 months of treatment, and periodically thereafter. If clinical symptoms or signs suggestive of liver dysfunction occur (e.g., nausea, vomiting, abdominal pain, fatigue, anorexia, “flu-like” symptoms, dark urine, jaundice, or right upper quadrant tenderness), the serum transaminases, in particular the serum ALT, should be measured immediately. If at any time a patient has jaundice, or their ALT rises above two times the upper limit of normal, bicalutamide tablets should be immediately discontinued with close follow-up of liver function.

5.2 Gynecomastia and Breast Pain

In clinical trials with bicalutamide tablets 150 mg as a single agent for prostate cancer, gynecomastia and breast pain have been reported in up to 38% and 39% of patients, respectively.

5.3 Glucose Tolerance

A reduction in glucose tolerance has been observed in males receiving LHRH agonists. This may manifest as diabetes or loss of glycemic control in those with preexisting diabetes. Consideration should therefore be given to monitoring blood glucose in patients receiving bicalutamide tablets in combination with LHRH agonists.

5.4 Laboratory Tests

Regular assessments of serum Prostate Specific Antigen (PSA) may be helpful in monitoring the patient’s response.

If PSA levels rise during bicalutamide tablets therapy, the patient should be evaluated for clinical progression. For patients who have objective progression of disease together with an elevated PSA, a treatment-free period of antiandrogen, while continuing the LHRH analog, may be considered.

6.1 Clinical Trials Experience

In patients with advanced prostate cancer treated with bicalutamide tablets in combination with an LHRH analog, the most frequent adverse reaction was hot flashes (53%).

In the multicenter, double-blind, controlled clinical trial comparing bicalutamide tablets 50 mg once daily with flutamide 250 mg 3 times a day, each in combination with an LHRH analog, the following adverse reactions with an incidence of 5% or greater, regardless of causality, have been reported.

Other adverse reactions (greater than or equal to 2%, but less than 5%) reported in the bicalutamide tablets-LHRH analog treatment group are listed below by body system and are in order of decreasing frequency within each body system regardless of causality.

Body as a Whole: neoplasm; neck pain; fever; chills; sepsis; hernia; cyst

Cardiovascular: angina pectoris; congestive heart failure; myocardial infarct; heart arrest; coronary artery disorder; syncope

Digestive: melena; rectal hemorrhage; dry mouth; dysphagia; gastrointestinal disorder; periodontal abscess; gastrointestinal carcinoma

Metabolic and Nutritional: edema; BUN increased; creatinine increased; dehydration; gout; hypercholesteremia

Musculoskeletal: myalgia; leg cramps

Nervous: hypertonia; confusion; somnolence; libido decreased; neuropathy; nervousness

Respiratory: lung disorder; asthma; epistaxis; sinusitis

Skin and Appendages: dry skin; alopecia; pruritus; herpes zoster; skin carcinoma; skin disorder

Special Senses: cataract specified

Urogenital: dysuria; urinary urgency; hydronephrosis; urinary tract disorder

Abnormal Laboratory Test Values: Laboratory abnormalities including elevated AST, ALT, bilirubin, BUN, and creatinine and decreased hemoglobin and white cell count have been reported in both bicalutamide tablets-LHRH analog treated and flutamide-LHRH analog treated patients.

6.2 Post-Marketing Experience

The following adverse reactions have been identified during postapproval use of bicalutamide tablets. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Uncommon cases of hypersensitivity reactions, including angioneurotic edema and urticaria [see Contraindications (4.1)], and uncommon cases of interstitial lung disease, including interstitial pneumonitis and pulmonary fibrosis, have been reported with bicalutamide tablets.

Reduction in glucose tolerance, manifesting as diabetes or a loss of glycemic control in those with preexisting diabetes, has been reported during treatment with LHRH agonists.

8.1 Pregnancy

8.3 Nursing Mothers

Bicalutamide tablets are not indicated for use in women.

8.4 Pediatric Use

The safety and effectiveness of bicalutamide in pediatric patients have not been established.

Labeling describing pediatric clinical studies for bicalutamide is approved for AstraZeneca Pharmaceuticals LP’s bicalutamide tablet. However, due to AstraZeneca Pharmaceuticals LP’s marketing exclusivity rights, a description of those clinical studies is not approved for this bicalutamide labeling.

8.5 Geriatric Use

In two studies in patients given 50 mg or 150 mg daily, no significant relationship between age and steady-state levels of total bicalutamide or the active R-enantiomer has been shown.

8.6 Hepatic Impairment

Bicalutamide tablets should be used with caution in patients with moderate-to-severe hepatic impairment. Bicalutamide is extensively metabolized by the liver. Limited data in subjects with severe hepatic impairment suggest that excretion of bicalutamide may be delayed and could lead to further accumulation. Periodic liver function tests should be considered for hepatic-impaired patients on long-term therapy [see Warnings and Precautions (5.1)].

No clinically significant difference in the pharmacokinetics of either enantiomer of bicalutamide was noted in patients with mild to moderate hepatic disease as compared to healthy controls. However, the half-life of the R-enantiomer was increased approximately 76% (5.9 and 10.4 days for normal and impaired patients, respectively) in patients with severe liver disease (n = 4).

8.7 Renal Impairment

Renal impairment (as measured by creatinine clearance) had no significant effect on the elimination of total bicalutamide or the active R-enantiomer.

8.8 Women

Bicalutamide has not been studied in women.

12.1 Mechanism of Action

Bicalutamide tablets are a non-steroidal androgen receptor inhibitor. It competitively inhibits the action of androgens by binding to cytosol androgen receptors in the target tissue. Prostatic carcinoma is known to be androgen sensitive and responds to treatment that counteracts the effect of androgen and/or removes the source of androgen.

When bicalutamide tablets are combined with luteinizing hormone releasing hormone (LHRH) analog therapy, the suppression of serum testosterone induced by the LHRH analog is not affected. However, in clinical trials with bicalutamide tablets as a single agent for prostate cancer, rises in serum testosterone and estradiol have been noted.

In a subset of patients who have been treated with bicalutamide tablets and an LHRH agonist, and who discontinue bicalutamide tablets therapy due to progressive advanced prostate cancer, a reduction in Prostate Specific Antigen (PSA) and/or clinical improvement (antiandrogen withdrawal phenomenon) may be observed.

12.3 Pharmacokinetics

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Two-year oral carcinogenicity studies were conducted in both male and female rats and mice at doses of 5, 15 or 75 mg/kg/day of bicalutamide. A variety of tumor target organ effects were identified and were attributed to the antiandrogenicity of bicalutamide, namely, testicular benign interstitial (Leydig) cell tumors in male rats at all dose levels (the steady-state plasma concentration with the 5 mg/kg/day dose is approximately 2/3 human therapeutic concentrations1) and uterine adenocarcinoma in female rats at 75 mg/kg/day (approximately 1 1/2 times the human therapeutic concentrations1). There is no evidence of Leydig cell hyperplasia in patients; uterine tumors are not relevant to the indicated patient population.

A small increase in the incidence of hepatocellular carcinoma in male mice given 75 mg/kg/day of bicalutamide (approximately 4 times human therapeutic concentrations1) and an increased incidence of benign thyroid follicular cell adenomas in rats given 5 mg/kg/day (approximately 2/3 human therapeutic concentrations1) and above were recorded. These neoplastic changes were progressions of non-neoplastic changes related to hepatic enzyme induction observed in animal toxicity studies. Enzyme induction has not been observed following bicalutamide administration in man. There were no tumorigenic effects suggestive of genotoxic carcinogenesis.

A comprehensive battery of both in vitro and in vivo genotoxicity tests (yeast gene conversion, Ames, E. coli, CHO/HGPRT, human lymphocyte cytogenetic, mouse micronucleus, and rat bone marrow cytogenetic tests) has demonstrated that bicalutamide tablets do not have genotoxic activity.

Administration of bicalutamide tablets may lead to inhibition of spermatogenesis. The long-term effects of bicalutamide tablets on male fertility have not been studied.

In male rats dosed at 250 mg/kg/day (approximately 2 times human therapeutic concentrations1), the precoital interval and time to successful mating were increased in the first pairing but no effects on fertility following successful mating were seen. These effects were reversed by 7 weeks after the end of an 11-week period of dosing.

No effects on female rats dosed at 10, 50 and 250 mg/kg/day (approximately 2/3, 1 and 2 times human therapeutic concentrations, respectively1) or their female offspring were observed. Administration of bicalutamide to pregnant females resulted in feminization of the male offspring leading to hypospadias at all dose levels. Affected male offspring were also impotent.

1

Based on a maximum dose of 50 mg/day of bicalutamide for an average 70 kg patient.

14.1 Bicalutamide Tablets 50 mg Daily in Combination with an LHRH-A

In a multicenter, double-blind, controlled clinical trial, 813 patients with previously untreated advanced prostate cancer were randomized to receive bicalutamide tablets 50 mg once daily (404 patients) or flutamide 250 mg (409 patients) 3 times a day, each in combination with LHRH analogs (either goserelin acetate implant or leuprolide acetate depot).

In an analysis conducted after a median follow-up of 160 weeks was reached, 213 (52.7%) patients treated with bicalutamide tablets-LHRH analog therapy and 235 (57.5%) patients treated with flutamide-LHRH analog therapy had died. There was no significant difference in survival between treatment groups (see Figure 1). The hazard ratio for time to death (survival) was 0.87 (95% confidence interval 0.72 to 1.05).

Figure 1 - The Kaplan-Meier Probability of Death for Both Antiandrogen Treatment Groups

Figure 1 - The Kaplan-Meier Probability of Death for Both Antiandrogen Treatment Groups

There was no significant difference in time to objective tumor progression between treatment groups (see Figure 2).

Objective tumor progression was defined as the appearance of any bone metastases or the worsening of any existing bone metastases on bone scan attributable to metastatic disease, or an increase by 25% or more of any existing measurable extraskeletal metastases. The hazard ratio for time to progression of bicalutamide tablets plus LHRH analog to that of flutamide plus LHRH analog was 0.93 (95% confidence interval, 0.79 to 1.10).

Figure 2 - Kaplan-Meier curve for time to progression for both antiandrogen treatment groups

Figure 2 - Kaplan-Meier curve for time to progression for both antiandrogen treatment groups

Quality of life was assessed with self-administered patient questionnaires on pain, social functioning, emotional well being, vitality, activity limitation, bed disability, overall health, physical capacity, general symptoms, and treatment related symptoms. Assessment of the Quality of Life questionnaires did not indicate consistent significant differences between the two treatment groups.

14.2 Safety Data from Clinical Studies Using Bicalutamide Tablets 150 mg

Bicalutamide tablets 150 mg are not approved for use either alone or with other treatments.

Two identical multicenter, randomized, open-label trials comparing bicalutamide tablets 150 mg daily monotherapy to castration were conducted in patients that had locally advanced (T3-4, NX, MO) or metastatic (M1) prostate cancer.

16.1 Storage and Handling

Store at 20° to 25°C (68° to 77°F). [See USP Controlled Room Temperature.]

Manufactured by:
Mylan Pharmaceuticals Inc.
Morgantown, WV 26505

Packaged and Distributed by:
UDL Laboratories, Inc.
Rockford, IL 61103

S-10495
6/09