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Contra-indications, warnings, etc
Do not use in pregnant or lactating bitches or in dogs intended for breeding.
Do not use in cases of hypersensitivity to the active substance or to any of the excipients.
Do not use in dogs less than 2 years of age or less than 3 kg bodyweight.
Do not use in dogs with gastrointestinal bleeding.
For any mast cell tumour treatable by surgery, surgery should be the first choice of treatment.
Dogs should be carefully monitored. Dose reductions and/or dose interruptions may be needed to manage adverse events. Treatment should be reviewed weekly for the first six weeks and every six weeks thereafter or at intervals deemed appropriate by the veterinarian. Evaluations should include assessment of clinical signs reported by the pet owner.
To appropriately use the dose adjustment table it is advised that a complete blood cell count, serum chemistry panel and urinalysis be conducted prior to initiation of treatment and approximately one month after treatment is initiated; thereafter at approximately six week intervals or as determined by the veterinarian. Periodic monitoring of laboratory variables should be completed in the context of the clinical signs and condition of the animal and results of laboratory variables at prior visits.
The safety of Palladia was evaluated in mast cell tumour-bearing dogs with the following:
Absolute neutrophil count > 1500/microlitre
Haematocrit > 25%
Platelet count > 75,000/microlitre
ALT or AST < 3x upper normal limit
Bilirubin < 1.25x upper normal limit
Creatinine < 2.5 mg/dl
Blood urea nitrogen < 1.5x upper normal limit
Palladia can cause vascular dysfunction which can lead to oedema and thromboembolism, including pulmonary thromboembolism. Discontinue treatment until clinical signs and clinical pathology have normalised. Before performing surgery, discontinue treatment for at least 3 days in order to assure vasculature homeostasis.
If systemic mastocytosis is present, standard pre-emptive care (e.g., H-1 and H-2 blockers) should be implemented prior to initiation of Palladia to avoid or minimize clinically significant mast cell degranulation and subsequent potentially severe systemic side effects.
Palladia has been associated with diarrhoea or gastrointestinal bleeding which may be severe and requires prompt treatment. Dose interruptions and dose reductions may be needed depending upon the severity of clinical signs.
In rare cases, serious and sometimes fatal gastrointestinal complications including gastrointestinal perforation occurred in dogs treated with Palladia. If gastrointestinal ulceration is suspected, whether or not due to Palladia or to mast cell tumour degranulation, stop the administration of Palladia and treat appropriately.
Toceranib is metabolised in the liver and in the absence of any studies on the effects of renal or hepatic impairment, should be used with caution in dogs suffering from hepatic disease.
Treatment should be permanently discontinued if severe adverse events recur or persist despite appropriate supportive care and dose reduction as described in the table on the following page.
Dose adjustment based on clinical signs / pathology
Clinical signs / pathology
Dose adjustment*
Anorexia
< 50% food intake ≥2 days
Discontinue treatment and institute dietary modification ± supportive care until food intake improves, then decrease dose by 0.5 mg/kg
Diarrhoea
< 4 watery stools/day for < 2 days or soft stools
Maintain dose level and institute supportive care
> 4 watery stools/day for ≥ 2 days
Discontinue treatment until formed stools and institute supportive care, then decrease dose by 0.5 mg/kg
Gastrointestinal bleeding
Fresh blood in stool or black tarry stool for >2 days or frank haemorrhage or blood clots in stool
Discontinue treatment and institute supportive care until resolution of all clinical signs of blood in stool, then decrease dose by 0.5 mg/kg
Hypoalbuminemia (albumin)
Albumin < 1.5 g/dl
Discontinue treatment until >1.5 g/dl and clinical signs normal, then decrease dose by 0.5 mg/kg
Neutropenia (neutrophil count)
> 1000/ul
Maintain dose level
< 1000/ul or neutropenic fever or infection
Discontinue treatment until >1000/ul and clinical signs normal, then decrease dose by 0.5 mg/kg
Anaemia (haematocrit)
> 26%
Maintain dose level
< 26%
Discontinue treatment until > 26%, then decrease dose by 0.5 mg/kg
Hepatic toxicity (ALT, AST)
> 1x – 3x upper normal limit
Maintain dose level; discontinue hepatotoxic drugs, if used
> 3x upper normal limit
Discontinue treatment until ≤3X upper normal limit, discontinue hepatotoxic drugs, if used, then decrease dose by 0.5 mg/kg
Renal toxicity (creatinine)
<1.25x upper normal limit
Maintain dose level
≥1.25x upper normal limit
Discontinue treatment until < 1.25x upper normal limit, then decrease dose by 0.5 mg/kg
Concurrent anaemia, azotaemia, hypoalbuminaemia and hyperphosphataemia
Discontinue treatment for 1 to 2 weeks until values have improved and albumin > 2.5 g/dl, then decrease dose by 0.5 mg/kg.
* A 0.5 mg/kg dose decrease is a decrease from 3.25 mg/kg to 2.75 mg/kg, or from 2.75 mg/kg to 2.25 mg/kg. The dose should not be < 2.2 mg/kg.
No interaction studies have been performed with toceranib. No information relating to potential cross resistance with other cytostatic products is available.
As toceranib is eliminated to a large extent by metabolism in the liver, the combination with other drugs capable of inducing or inhibiting liver enzymes should be used with caution.
It is not known to what extent toceranib could affect the elimination of other drugs.
Use non-steroidal anti-inflammatory drugs with caution in conjunction with Palladia due to an increased risk of gastrointestinal ulceration or perforation.
Adverse reactions
Results from the clinical field study involving 151 treated and placebo-treated dogs showed that the clinical signs of the disease (mast cell tumour) and treatment related adverse reactions are very similar in nature.
Very common (more than 1 in 10 animals)
Mild to moderate:
Diarrhoea, neutropenia, weight loss, blood in faeces/haemorrhagic diarrhoea/gastrointestinal bleeding, anorexia, lethargy, vomiting; lameness/musculoskeletal disorder, dehydration, dermatitis, pruritus; increased alanine aminotransferase, thrombocytopenia, decreased albumin, decreased haematocrit.
Common (more than 1 but less than 10 animals in 100 animals)
Severe:
Vomiting, diarrhoea, anorexia, lethargy, dehydration, pyrexia, blood in faeces/haemorrhagic diarrhoea/gastrointestinal bleeding, duodenal ulceration, nausea, septicaemia, skin necrosis, weight loss; increased alanine aminotransferase, decreased haematocrit.Mild to moderate:
Localised or general pain, nausea, tachypnoea, polydipsia, flatulence, pyrexia, nasal depigmentation; changes in coat colour, alopecia, urinary tract infection; increased bilirubin, increased creatinine.
Uncommon (more than 1 but less than 10 animals in 1000 animals)
Severe lameness/musculoskeletal disorder.
Severe circulatory shock.
There were two deaths that were possibly treatment related. In one dog, pathology findings revealed vascular thrombosis with disseminated intravascular coagulopathy (DIC) and pancreatitis. The other dog died following gastric perforation.
There were two further deaths; however, relation to treatment could not be established.
Two dogs developed epistaxis that was not associated with thrombocytopenia. Another dog developed epistaxis with concurrent disseminated intravascular coagulopathy.
Three dogs had seizure-like activity; however, relation to treatment could not be established.
User warnings
Palladia may impair male and female fertility and embryo/foetal development. Avoid skin contact with the tablets, faeces, urine, and vomit of treated dogs. The tablets must be administered as a whole and should not be broken or ground. If a broken tablet is rejected by the dog after chewing, it should be disposed of. Wash hands thoroughly with soap and water following handling of the product, and disposing of vomit, urine, or faeces of treated dogs.
Pregnant women should not routinely administer Palladia, should avoid contact with faeces, urine and vomit from treated dogs and broken or moistened Palladia tablets.
Ingestion of Palladia may be harmful for children. Children must not come into contact with the product. Keep children away from faeces, urine or vomit of treated dogs.
Gastrointestinal discomfort such as vomiting or diarrhoea may occur if this drug is accidentally ingested. In the case of accidental ingestion, seek medical advice immediately and show Package Leaflet or label to the physician.