Temodal

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ANNEX I

SUMMARY OF PRODUCT CHARACTERISTICS

 



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1. NAME OF THE MEDICINAL PRODUCT

Temodal 5 mg hard capsules

2. QUALITATIVE AND QUANTITATIVE COMPOSITION

Each hard capsule contains 5 mg temozolomide.

Excipient with known effect:
Each hard capsule contains 132.8 mg of anhydrous lactose.

For the full list of excipients, see section 6.1.

3. PHARMACEUTICAL FORM

Hard capsule (capsule).

The hard capsules have an opaque white body, an opaque green cap, and are imprinted with black ink. 
The cap is imprinted with “Temodal”. The body is imprinted with "5 mg", the Schering-Plough logo 
and two stripes.

4. CLINICAL PARTICULARS

4.1 Therapeutic indications

Temodal is indicated for the treatment of:
- adult patients with newly-diagnosed glioblastoma multiforme concomitantly with radiotherapy 

(RT) and subsequently as monotherapy treatment.
- children from the age of three years, adolescents and adult patients with malignant glioma, such 

as glioblastoma multiforme or anaplastic astrocytoma, showing recurrence or progression after 
standard therapy.

4.2 Posology and method of administration

Temodal should only be prescribed by physicians experienced in the oncological treatment of brain 
tumours.

Anti-emetic therapy may be administered (see section 4.4).

Posology

Adult patients with newly-diagnosed glioblastoma multiforme

Temodal is administered in combination with focal radiotherapy (concomitant phase) followed by up 
to 6 cycles of temozolomide (TMZ) monotherapy (monotherapy phase).

Concomitant phase 

TMZ is administered orally at a dose of 75 mg/m2 daily for 42 days concomitant with focal 
radiotherapy (60 Gy administered in 30 fractions). No dose reductions are recommended, but delay or 
discontinuation of TMZ administration should be decided weekly according to haematological and 
non-haematological toxicity criteria. TMZ administration can be continued throughout the 42 day 
concomitant period (up to 49 days) if all of the following conditions are met: 

 



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- absolute neutrophil count (ANC) ≥ 1.5 x 109/l
- thrombocyte count ≥ 100 x 109/l
- common toxicity criteria (CTC) non-haematological toxicity ≤ Grade 1 (except for alopecia, 

nausea and vomiting). 
During treatment a complete blood count should be obtained weekly. TMZ administration should be 
temporarily interrupted or permanently discontinued during the concomitant phase according to the 
haematological and non-haematological toxicity criteria as noted in Table 1.

Table 1. TMZ dosing interruption or discontinuation during

concomitant radiotherapy and TMZ

Toxicity TMZ interruptiona TMZ discontinuation

Absolute neutrophil count  0.5 and < 1.5 x 109/l < 0.5 x 10
9/l

Thrombocyte count  10 and < 100 x 109/l < 10 x 10
9/l

CTC non-haematological toxicity
(except for alopecia, nausea, vomiting)

CTC Grade 2 CTC Grade 3 or 4

a: Treatment with concomitant TMZ can be continued when all of the following conditions are met: absolute neutrophil 
count  1.5 x 109/l; thrombocyte count  100 x 109/l; CTC non-haematological toxicity  Grade 1 (except for alopecia, 
nausea, vomiting).

Monotherapy phase

Four weeks after completing the TMZ + RT concomitant phase, TMZ is administered for up to 
6 cycles of monotherapy treatment. Dose in Cycle 1 (monotherapy) is 150 mg/m2 once daily for 
5 days followed by 23 days without treatment. At the start of Cycle 2, the dose is escalated to 
200 mg/m2 if the CTC non-haematological toxicity for Cycle 1 is Grade ≤ 2 (except for alopecia, 
nausea and vomiting), absolute neutrophil count (ANC) is ≥ 1.5 x 109/l, and the thrombocyte count is 
≥ 100 x 109/l. If the dose was not escalated at Cycle 2, escalation should not be done in subsequent 
cycles. Once escalated, the dose remains at 200 mg/m2 per day for the first 5 days of each subsequent 
cycle except if toxicity occurs. Dose reductions and discontinuations during the monotherapy phase 
should be applied according to Tables 2 and 3.

During treatment a complete blood count should be obtained on Day 22 (21 days after the first dose of 
TMZ). The dose should be reduced or administration discontinued according to Table 3.

Table 2. TMZ dose levels for monotherapy treatment

Dose level TMZ dose 
(mg/m2/day)

Remarks

–1 100 Reduction for prior toxicity 

0 150 Dose during Cycle 1

1 200 Dose during Cycles 2-6 in absence of toxicity

Table 3. TMZ dose reduction or discontinuation during monotherapy treatment

Toxicity Reduce TMZ by 1 dose levela Discontinue TMZ

Absolute neutrophil count < 1.0 x 109/l See footnote b

Thrombocyte count < 50 x 109/l See footnote b

CTC non-haematological Toxicity
(except for alopecia, nausea, vomiting) CTC Grade 3 CTC Grade 4

b

a: TMZ dose levels are listed in Table 2.
b: TMZ is to be discontinued if:
 dose level -1 (100 mg/m2) still results in unacceptable toxicity

 the same Grade 3 non-haematological toxicity (except for alopecia, nausea, vomiting) recurs after dose reduction.

 



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Adult and paediatric patients 3 years of age or older with recurrent or progressive malignant glioma:

A treatment cycle comprises 28 days. In patients previously untreated with chemotherapy, TMZ is 
administered orally at a dose of 200 mg/m2 once daily for the first 5 days followed by a 23 day 
treatment interruption (total of 28 days). In patients previously treated with chemotherapy, the initial 
dose is 150 mg/m2 once daily, to be increased in the second cycle to 200 mg/m2 once daily, for 5 days 
if there is no haematological toxicity (see section 4.4) 

Special populations

Paediatric population

In patients 3 years of age or older, TMZ is only to be used in recurrent or progressive malignant 
glioma. Experience in these children is very limited (see sections 4.4 and 5.1). The safety and efficacy 
of TMZ in children under the age of 3 years have not been established. No data are available.

Patients with hepatic or renal impairment

The pharmacokinetics of TMZ were comparable in patients with normal hepatic function and in those 
with mild or moderate hepatic impairment. No data are available on the administration of TMZ in 
patients with severe hepatic impairment (Child’s Class C) or with renal impairment. Based on the 
pharmacokinetic properties of TMZ, it is unlikely that dose reductions are required in patients with 
severe hepatic impairment or any degree of renal impairment. However, caution should be exercised 
when TMZ is administered in these patients. 

Elderly patients

Based on a population pharmacokinetic analysis in patients 19-78 years of age, clearance of TMZ is 
not affected by age. However, elderly patients (> 70 years of age) appear to be at increased risk of 
neutropenia and thrombocytopenia (see section 4.4).

Method of administration

Temodal hard capsules should be administered in the fasting state.

The capsules must be swallowed whole with a glass of water and must not be opened or chewed. 

If vomiting occurs after the dose is administered, a second dose should not be administered that day.

4.3 Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

Hypersensitivity to dacarbazine (DTIC).

Severe myelosuppression (see section 4.4).

4.4 Special warnings and precautions for use

Opportunistic infections and reactivation of infections

Opportunistic infections (such as Pneumocystis jirovecii pneumonia) and reactivation of infections 
(such as HBV, CMV) have been observed during the treatment with TMZ (see section 4.8).

Meningoencephalitis herpetic

 



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In post marketing cases, meningoencephalitis herpetic (including fatal cases) has been observed in 
patients receiving TMZ in combination with radiotherapy, including cases of concomitant steroids 
administration.

Pneumocystis jirovecii pneumonia

Patients who received concomitant TMZ and RT in a pilot trial for the prolonged 42-day schedule 
were shown to be at particular risk for developing Pneumocystis jirovecii pneumonia (PCP). Thus, 
prophylaxis against PCP is required for all patients receiving concomitant TMZ and RT for the 
42-day regimen (with a maximum of 49 days) regardless of lymphocyte count. If lymphopenia occurs, 
they are to continue the prophylaxis until recovery of lymphopenia to grade ≤ 1.

There may be a higher occurrence of PCP when TMZ is administered during a longer dosing regimen. 
However, all patients receiving TMZ, particularly patients receiving steroids, should be observed 
closely for the development of PCP, regardless of the regimen. Cases of fatal respiratory failure have 
been reported in patients using TMZ, in particular in combination with dexamethasone or other 
steroids.

HBV

Hepatitis due to hepatitis B virus (HBV) reactivation, in some cases resulting in death, has been 
reported. Experts in liver disease should be consulted before treatment is initiated in patients with 
positive hepatitis B serology (including those with active disease). During treatment patients should 
be monitored and managed appropriately.

Hepatotoxicity

Hepatic injury, including fatal hepatic failure, has been reported in patients treated with TMZ (see 
section 4.8). Baseline liver function tests should be performed prior to treatment initiation. If 
abnormal, physicians should assess the benefit/risk prior to initiating temozolomide including the 
potential for fatal hepatic failure. For patients on a 42 day treatment cycle liver function tests should 
be repeated midway during this cycle. For all patients, liver function tests should be checked after 
each treatment cycle. For patients with significant liver function abnormalities, physicians should 
assess the benefit/risk of continuing treatment. Liver toxicity may occur several weeks or more after 
the last treatment with temozolomide.

Malignancies

Cases of myelodysplastic syndrome and secondary malignancies, including myeloid leukaemia, have 
also been reported very rarely (see section 4.8).

Anti-emetic therapy

Nausea and vomiting are very commonly associated with TMZ.
Anti-emetic therapy may be administered prior to or following administration of TMZ.

Adult patients with newly-diagnosed glioblastoma multiforme 

Anti-emetic prophylaxis is recommended prior to the initial dose of concomitant phase and it is 
strongly recommended during the monotherapy phase.

Patients with recurrent or progressive malignant glioma

Patients who have experienced severe (Grade 3 or 4) vomiting in previous treatment cycles may 
require anti-emetic therapy.

 



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Laboratory parameters

Patients treated with TMZ may experience myelosuppression, including prolonged pancytopenia, 
which may result in aplastic anaemia, which in some cases has resulted in a fatal outcome. In some 
cases, exposure to concomitant medicinal products associated with aplastic anaemia, including 
carbamazepine, phenytoin, and sulfamethoxazole/trimethoprim, complicates assessment. Prior to 
dosing, the following laboratory parameters must be met: ANC  1.5 x 109/l and platelet count 
 100 x 109/l. A complete blood count should be obtained on Day 22 (21 days after the first dose) or 
within 48 hours of that day, and weekly until ANC > 1.5 x 109/l and platelet count > 100 x 109/l. If 
ANC falls to < 1.0 x 109/l or the platelet count is < 50 x 109/l during any cycle, the next cycle should 
be reduced one dose level (see section 4.2). Dose levels include 100 mg/m2, 150 mg/m2, and 
200 mg/m2. The lowest recommended dose is 100 mg/m2.

Paediatric population 

There is no clinical experience with use of TMZ in children under the age of 3 years. Experience in 
older children and adolescents is very limited (see sections 4.2 and 5.1).

Elderly patients (> 70 years of age)

Elderly patients appear to be at increased risk of neutropenia and thrombocytopenia, compared with 
younger patients. Therefore, special care should be taken when TMZ is administered in elderly 
patients.

Male patients

Men being treated with TMZ should be advised not to father a child up to 6 months after receiving the 
last dose and to seek advice on cryoconservation of sperm prior to treatment (see section 4.6).

Lactose

This medicinal product contains lactose. Patients with rare hereditary problems of galactose
intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this 
medicine.

4.5 Interaction with other medicinal products and other forms of interaction

In a separate phase I study, administration of TMZ with ranitidine did not result in alterations in the 
extent of absorption of temozolomide or the exposure to its active metabolite monomethyl 
triazenoimidazole carboxamide (MTIC). 

Administration of TMZ with food resulted in a 33 % decrease in Cmax and a 9 % decrease in area 
under the curve (AUC). 
As it cannot be excluded that the change in Cmax is clinically significant, Temodal should be 
administered without food.

Based on an analysis of population pharmacokinetics in phase II trials, co-administration of 
dexamethasone, prochlorperazine, phenytoin, carbamazepine, ondansetron, H2 receptor antagonists, or 
phenobarbital did not alter the clearance of TMZ. Co-administration with valproic acid was associated 
with a small but statistically significant decrease in clearance of TMZ.

No studies have been conducted to determine the effect of TMZ on the metabolism or elimination of 
other medicinal products. However, since TMZ does not undergo hepatic metabolism and exhibits 
low protein binding, it is unlikely that it would affect the pharmacokinetics of other medicinal 
products (see section 5.2).

 



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Use of TMZ in combination with other myelosuppressive agents may increase the likelihood of 
myelosuppression. 

Paediatric population

Interaction studies have only been performed in adults.

4.6 Fertility, pregnancy and lactation 

Pregnancy

There are no data in pregnant women. In preclinical studies in rats and rabbits receiving 150 mg/m2 

TMZ, teratogenicity and/or foetal toxicity were demonstrated (see section 5.3). Temodal should not 
be administered to pregnant women. If use during pregnancy must be considered, the patient should 
be apprised of the potential risk to the foetus. 

Breast-feeding

It is not known whether TMZ is excreted in human milk; thus, breast-feeding should be discontinued 
while receiving treatment with TMZ. 

Women of childbearing potential

Women of childbearing potential should be advised to use effective contraception to avoid pregnancy 
while they are receiving TMZ.

Male fertility

TMZ can have genotoxic effects. Therefore, men being treated with it should be advised not to father 
a child up to 6 months after receiving the last dose and to seek advice on cryoconservation of sperm 
prior to treatment, because of the possibility of irreversible infertility due to therapy with TMZ.

4.7 Effects on ability to drive and use machines

TMZ has minor influence on the ability to drive and use machines due to fatigue and somnolence (see 
section 4.8). 

4.8 Undesirable effects 

Summary of the safety profile

Clinical trial experience

In patients treated with TMZ in clinical trials, the most common adverse reactions were nausea, 
vomiting, constipation, anorexia, headache, fatigue, convulsions, and rash. Most haematologic 
adverse reactions were reported commonly; the frequency of Grade 3-4 laboratory findings is 
presented after Table 4.

For patients with recurrent or progressive glioma, nausea (43 %) and vomiting (36 %) were usually 
Grade 1 or 2 (0 – 5 episodes of vomiting in 24 hours) and were either self-limiting or readily 
controlled with standard anti-emetic therapy. The incidence of severe nausea and vomiting was 4 %.

Tabulated list of adverse reactions
Adverse reactions observed in clinical studies and reported from post-marketing use of TMZ are listed
in Table 4. These reactions are classified according to System Organ Class and frequency. Frequency 
groupings are defined according to the following convention: Very common (≥ 1/10); Common 

 



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(≥ 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). Within each frequency 
grouping, undesirable effects are presented in order of decreasing seriousness.

Table 4. Adverse reactions in patients treated with temozolomide

Infections and infestations

Common: Infections, herpes zoster, pharyngitisa, candidiasis oral

Uncommon: Opportunistic infection (including PCP), sepsis†, 
meningoencephalitis herpetic†, CMV infection, CMV 
reactivation, hepatitis B virus†, herpes simplex, infection 
reactivation, wound infection, gastroenteritisb

Neoplasm benign, malignant, and unspecified

Uncommon: Myelodysplastic syndrome (MDS), secondary 
malignancies, including myeloid leukaemia

Blood and lymphatic system disorders

Common: Febrile neutropenia, neutropenia, thrombocytopenia, 
lymphopenia, leukopenia, anaemia

Uncommon: Prolonged pancytopenia, aplastic anaemia†, 
pancytopenia, petechiae

Immune system disorders

Common: Allergic reaction

Uncommon: Anaphylaxis

Endocrine disorders

Common: Cushingoidc

Uncommon: Diabetes insipidus

Metabolism and nutrition disorders

Very common: Anorexia
Common: Hyperglycaemia

Uncommon: Hypokalaemia, alkaline phosphatase increased

Psychiatric disorders

Common: Agitation, amnesia, depression, anxiety, confusion, 
insomnia

Uncommon: Behaviour disorder, emotional lability, hallucination, 
apathy

Nervous system disorders

Very common: Convulsions, hemiparesis, aphasia/dysphasia, headache
Common: Ataxia, balance impaired, cognition impaired, 

concentration impaired, consciousness decreased, 
dizziness, hypoesthesia, memory impaired, neurologic 
disorder, neuropathyd, paraesthesia, somnolence, speech 
disorder, taste perversion, tremor

Uncommon: Status epilepticus, hemiplegia, extrapyramidal disorder, 
parosmia, gait abnormality, hyperaesthesia, sensory 
disturbance, coordination abnormal

Eye disorders

Common: Hemianopia, vision blurred, vision disordere, visual field 
defect, diplopia, eye pain

Uncommon: Visual acuity reduced, eyes dry

 



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Table 4. Adverse reactions in patients treated with temozolomide

Ear and labyrinth disorders

Common: Deafnessf, vertigo, tinnitus, earacheg

Uncommon: Hearing impairment, hyperacusis, otitis media

Cardiac disorders

Uncommon: Palpitation

Vascular disorders

Common: Haemorrhage, embolism pulmonary, deep vein 
thrombosis, hypertension 

Uncommon: Cerebral haemorrhage, flushing, hot flushes

Respiratory, thoracic and mediastinal disorders

Common: Pneumonia, dyspnoea, sinusitis, bronchitis, coughing, 
upper respiratory infection

Uncommon: Respiratory failure†, interstitial 
pneumonitis/pneumonitis, pulmonary fibrosis, nasal 
congestion

Gastrointestinal disorders

Very common: Diarrhoea, constipation, nausea, vomiting
Common: Stomatitis, abdominal painh, dyspepsia, dysphagia 

Uncommon: Abdominal distension, faecal incontinence, 
gastrointestinal disorder, haemorrhoids, mouth dry

Hepatobiliary disorders

Uncommon: Hepatic failure†, hepatic injury, hepatitis, cholestasis, 
hyperbilirubinemia

Skin and subcutaneous tissue disorders

Very Common: Rash, alopecia
Common: Erythema, dry skin, pruritus
Uncommon: Toxic epidermal necrolysis, Stevens-Johnson syndrome, 

angioedema, erythema multiforme, erythroderma, skin 
exfoliation, photosensitivity reaction, urticaria, 
exanthema, dermatitis, sweating increased, pigmentation 
abnormal

Not known: Drug reaction with eosinophilia and systemic symptoms 
(DRESS)

Musculoskeletal and connective tissue disorders

Common: Myopathy, muscle weakness, arthralgia, back pain, 
musculoskeletal pain, myalgia 

Renal and urinary disorders

Common: Micturition frequency, urinary incontinence 

Uncommon: Dysuria

Reproductive system and breast disorders

Uncommon: Vaginal haemorrhage, menorrhagia, amenorrhoea, 
vaginitis, breast pain, impotence

General disorders and administration site conditions

Very common: Fatigue
Common: Fever, influenza-like symptoms, asthenia, malaise, pain, 

oedema, oedema peripherali

 



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Table 4. Adverse reactions in patients treated with temozolomide

Uncommon: Condition aggravated, rigors, face oedema, tongue
discolouration, thirst, tooth disorder

Investigations

Common: Liver enzymes elevationj, weight decreased, weight 
increased

Uncommon: Gamma-glutamyltransferase increased

Injury, poisoning and procedural complications 

Common: Radiation injuryk

a Includes pharyngitis, nasopharyngeal pharyngitis, pharyngitis Streptococcal 
b Includes gastroenteritis, gastroenteritis viral
c Includes cushingoid, Cushing syndrome
d Includes neuropathy, peripheral neuropathy, polyneuropathy, peripheral sensory neuropathy, 
peripheral motor neuropathy
e Includes visual impairment, eye disorder
f Includes deafness, deafness bilateral, deafness neurosensory, deafness unilateral
g Includes earache, ear discomfort
h Includes abdominal pain, abdominal pain lower, abdominal pain upper, abdominal discomfort
i Includes oedema peripheral, peripheral swelling
j Includes liver function test increased, alanine aminotransferase increased, aspartate aminotransferase 
increased, hepatic enzymes increased
k Includes radiation injury, radiation skin injury
† Including cases with fatal outcome

Newly-diagnosed glioblastoma multiforme

Laboratory results

Myelosuppression (neutropenia and thrombocytopenia), which is known dose-limiting toxicity for 
most cytotoxic agents, including TMZ, was observed. When laboratory abnormalities and adverse 
events were combined across concomitant and monotherapy treatment phases, Grade 3 or Grade 4 
neutrophil abnormalities including neutropenic events were observed in 8 % of the patients. Grade 3 
or Grade 4 thrombocyte abnormalities, including thrombocytopenic events were observed in 14 % of 
the patients who received TMZ. 

Recurrent or progressive malignant glioma

Laboratory results

Grade 3 or 4 thrombocytopenia and neutropenia occurred in 19 % and 17 % respectively, of patients 
treated for malignant glioma. This led to hospitalisation and/or discontinuation of TMZ in 8 % and 
4 %, respectively. Myelosuppression was predictable (usually within the first few cycles, with the 
nadir between Day 21 and Day 28), and recovery was rapid, usually within 1-2 weeks. No evidence of 
cumulative myelosuppression was observed. The presence of thrombocytopenia may increase the risk 
of bleeding, and the presence of neutropenia or leukopenia may increase the risk of infection.

Gender

In a population pharmacokinetics analysis of clinical trial experience there were 101 female and 
169 male subjects for whom nadir neutrophil counts were available and 110 female and 174 male 
subjects for whom nadir platelet counts were available. There were higher rates of Grade 4 
neutropenia (ANC < 0.5 x 109/l), 12 % vs 5 %, and thrombocytopenia (< 20 x 109/l), 9 % vs 3 %, in 
women vs men in the first cycle of therapy. In a 400 subject recurrent glioma data set, Grade 4 
neutropenia occurred in 8 % of female vs 4 % of male subjects and Grade 4 thrombocytopenia in 8 % 

 



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of female vs 3 % of male subjects in the first cycle of therapy. In a study of 288 subjects with newly-
diagnosed glioblastoma multiforme, Grade 4 neutropenia occurred in 3 % of female vs 0 % of male 
subjects and Grade 4 thrombocytopenia in 1 % of female vs 0 % of male subjects in the first cycle of 
therapy.

Paediatric population

Oral TMZ has been studied in paediatric patients (age 3-18 years) with recurrent brainstem glioma or 
recurrent high grade astrocytoma, in a regimen administered daily for 5 days every 28 days. Although 
the data is limited, tolerance in children is expected to be the same as in adults. The safety of TMZ in 
children under the age of 3 years has not been established.

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 national reporting system 
listed in Appendix V.

4.9 Overdose

Doses of 500, 750, 1,000, and 1,250 mg/m2 (total dose per cycle over 5 days) have been evaluated 
clinically in patients. Dose-limiting toxicity was haematological and was reported with any dose but is 
expected to be more severe at higher doses. An overdose of 10,000 mg (total dose in a single cycle, 
over 5 days) was taken by one patient and the adverse reactions reported were pancytopenia, pyrexia, 
multi-organ failure and death. There are reports of patients who have taken the recommended dose for 
more than 5 days of treatment (up to 64 days) with adverse events reported including bone marrow 
suppression, with or without infection, in some cases severe and prolonged and resulting in death. In 
the event of an overdose, haematological evaluation is needed. Supportive measures should be 
provided as necessary.

5. PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Antineoplastic agents - Other alkylating agents, ATC code: L01A X03

Mechanism of action

Temozolomide is a triazene, which undergoes rapid chemical conversion at physiologic pH to the 
active monomethyl triazenoimidazole carboxamide (MTIC). The cytotoxicity of MTIC is thought to 
be due primarily to alkylation at the O6 position of guanine with additional alkylation also occurring 
at the N7 position. Cytotoxic lesions that develop subsequently are thought to involve aberrant repair 
of the methyl adduct.

Clinical efficacy and safety

Newly-diagnosed glioblastoma multiforme

A total of 573 patients were randomised to receive either TMZ + RT (n=287) or RT alone (n=286). 
Patients in the TMZ + RT arm received concomitant TMZ (75 mg/m2) once daily, starting the first 
day of RT until the last day of RT, for 42 days (with a maximum of 49 days). This was followed by 
monotherapy TMZ (150 - 200 mg/m2) on Days 1 - 5 of every 28-day cycle for up to 6 cycles, starting 
4 weeks after the end of RT. Patients in the control arm received RT only. Pneumocystis jirovecii
pneumonia (PCP) prophylaxis was required during RT and combined TMZ therapy.

 

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TMZ was administered as salvage therapy in the follow-up phase in 161 patients of the 282 (57 %) in 
the RT alone arm, and 62 patients of the 277 (22 %) in the TMZ + RT arm.

The hazard ratio (HR) for overall survival was 1.59 (95 % CI for HR=1.33 -1.91) with a log-rank 
p < 0.0001 in favour of the TMZ arm. The estimated probability of surviving 2 years or more (26 % 
vs 10 %) is higher for the RT + TMZ arm. The addition of concomitant TMZ to RT, followed by 
TMZ monotherapy in the treatment of patients with newly-diagnosed glioblastoma multiforme 
demonstrated a statistically significant improvement in overall survival (OS) compared with RT alone 
(Figure 1).

H R  (95%  C .I.) =  1 .59  (1 .33 – 1 .91)
log-rank p-value <  .0001

12.1 14.6

RT+TM Z

RT O n ly

26%

10%

Figure 1 Kaplan-Meier curves for overall survival (intent-to-treat population)

The results from the trial were not consistent in the subgroup of patients with a poor performance 
status (WHO PS=2, n=70), where overall survival and time to progression were similar in both arms. 
However, no unacceptable risks appear to be present in this patient group.

Recurrent or progressive malignant glioma

Data on clinical efficacy in patients with glioblastoma multiforme (Karnofsky performance status 
[KPS]  70), progressive or recurrent after surgery and RT, were based on two clinical trials with oral 
TMZ. One was a non-comparative trial in 138 patients (29 % received prior chemotherapy), and the 
other was a randomised active-controlled trial of TMZ vs procarbazine in a total of 225 patients (67 % 
received prior treatment with nitrosourea based chemotherapy). In both trials, the primary endpoint 
was progression-free survival (PFS) defined by MRI scans or neurological worsening. In the non-
comparative trial, the PFS at 6 months was 19 %, the median progression-free survival was 
2.1 months, and the median overall survival 5.4 months. The objective response rate (ORR) based on 
MRI scans was 8 %.

In the randomised active-controlled trial, the PFS at 6 months was significantly greater for TMZ than 
for procarbazine (21 % vs 8 %, respectively – chi-square p = 0.008) with median PFS of 2.89 and 
1.88 months respectively (log rank p = 0.0063). The median survival was 7.34 and 5.66 months for 
TMZ and procarbazine, respectively (log rank p = 0.33). At 6 months, the fraction of surviving 
patients was significantly higher in the TMZ arm (60 %) compared with the procarbazine arm (44 %) 
(chi-square p = 0.019). In patients with prior chemotherapy a benefit was indicated in those with a 
KPS  80.

 



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Data on time to worsening of neurological status favoured TMZ over procarbazine as did data on time 
to worsening of performance status (decrease to a KPS of < 70 or a decrease by at least 30 points). 
The median times to progression in these endpoints ranged from 0.7 to 2.1 months longer for TMZ 
than for procarbazine (log rank p = < 0.01 to 0.03). 

Recurrent anaplastic astrocytoma

In a multicentre, prospective phase II trial evaluating the safety and efficacy of oral TMZ in the 
treatment of patients with anaplastic astrocytoma at first relapse, the 6 month PFS was 46 %. The 
median PFS was 5.4 months. Median overall survival was 14.6 months. Response rate, based on the 
central reviewer assessment, was 35 % (13 CR and 43 PR) for the intent-to-treat population (ITT) 
n=162. In 43 patients stable disease was reported. The 6-month event-free survival for the ITT 
population was 44 % with a median event-free survival of 4.6 months, which was similar to the results
for the progression-free survival. For the eligible histology population, the efficacy results were 
similar. Achieving a radiological objective response or maintaining progression-free status was 
strongly associated with maintained or improved quality of life.

Paediatric population

Oral TMZ has been studied in paediatric patients (age 3-18 years) with recurrent brainstem glioma or 
recurrent high grade astrocytoma, in a regimen administered daily for 5 days every 28 days. Tolerance 
to TMZ is similar to adults.

5.2 Pharmacokinetic properties 

TMZ is spontaneously hydrolyzed at physiologic pH primarily to the active species, 3-methyl-
(triazen-1-yl)imidazole-4-carboxamide (MTIC). MTIC is spontaneously hydrolyzed to 5-amino-
imidazole-4-carboxamide (AIC), a known intermediate in purine and nucleic acid biosynthesis, and to 
methylhydrazine, which is believed to be the active alkylating species. The cytotoxicity of MTIC is 
thought to be primarily due to alkylation of DNA mainly at the O6 and N7 positions of guanine. 
Relative to the AUC of TMZ, the exposure to MTIC and AIC is ~ 2.4 % and 23 %, respectively. In 
vivo, the t1/2 of MTIC was similar to that of TMZ, 1.8 hr.

Absorption

After oral administration to adult patients, TMZ is absorbed rapidly, with peak concentrations reached 
as early as 20 minutes post-administration (mean time between 0.5 and 1.5 hours). After oral 
administration of 14C-labelled TMZ, mean faecal excretion of 14C over 7 days post-dose was 0.8 % 
indicating complete absorption.

Distribution

TMZ demonstrates low protein binding (10 % to 20 %), and thus it is not expected to interact with 
highly protein-bound substances.

PET studies in humans and preclinical data suggest that TMZ crosses the blood-brain barrier rapidly 
and is present in the CSF. CSF penetration was confirmed in one patient; CSF exposure based on 
AUC of TMZ was approximately 30 % of that in plasma, which is consistent with animal data.

Elimination

The half-life (t1/2) in plasma is approximately 1.8 hours. The major route of 
14C elimination is renal. 

Following oral administration, approximately 5 % to 10 % of the dose is recovered unchanged in the 
urine over 24 hours, and the remainder excreted as temozolomide acid, 5-aminoimidazole-4-
carboxamide (AIC) or unidentified polar metabolites.

 



14

Plasma concentrations increase in a dose-related manner. Plasma clearance, volume of distribution 
and half-life are independent of dose. 

Special populations

Analysis of population-based pharmacokinetics of TMZ revealed that plasma TMZ clearance was 
independent of age, renal function or tobacco use. In a separate pharmacokinetic study, plasma 
pharmacokinetic profiles in patients with mild to moderate hepatic impairment were similar to those 
observed in patients with normal hepatic function.

Paediatric patients had a higher AUC than adult patients; however, the maximum tolerated dose 
(MTD) was 1,000 mg/m2 per cycle both in children and in adults.

5.3 Preclinical safety data

Single-cycle (5-day dosing, 23 days non-treatment), 3- and 6-cycle toxicity studies were conducted in 
rats and dogs. The primary targets of toxicity included the bone marrow, lymphoreticular system, 
testes, the gastrointestinal tract and, at higher doses, which were lethal to 60 % to 100 % of rats and 
dogs tested, degeneration of the retina occurred. Most of the toxicity showed evidence of reversibility, 
except for adverse events on the male reproductive system and retinal degeneration. However, 
because the doses implicated in retinal degeneration were in the lethal dose range, and no comparable 
effect has been observed in clinical studies, this finding was not considered to have clinical relevance.

TMZ is an embryotoxic, teratogenic and genotoxic alkylating agent. TMZ is more toxic to the rat and 
dog than to humans, and the clinical dose approximates the minimum lethal dose in rats and dogs. 
Dose-related reductions in leukocytes and platelets appear to be sensitive indicators of toxicity. A 
variety of neoplasms, including mammary carcinomas, keratocanthoma of the skin and basal cell 
adenoma were observed in the 6-cycle rat study while no tumours or pre-neoplastic changes were 
evident in dog studies. Rats appear to be particularly sensitive to oncogenic effects of TMZ, with the 
occurrence of first tumours within 3 months of initiating dosing. This latency period is very short 
even for an alkylating agent.

Results of the Ames/salmonella and Human Peripheral Blood Lymphocyte (HPBL) chromosome 
aberration tests showed a positive mutagenicity response.

6. PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Capsule content:
anhydrous lactose, 
colloidal anhydrous silica, 
sodium starch glycolate type A, 
tartaric acid, 
stearic acid. 

Capsule shell: 
gelatin, 
titanium dioxide (E 171), 
sodium laurilsulfate, 
yellow iron oxide (E 172), 
indigo carmine (E 132), 

Printing ink: 
shellac, 

 



15

propylene glycol, 
purified water, 
ammonium hydroxide, 
potassium hydroxide, 
black iron oxide (E 172).

6.2 Incompatibilities

Not applicable.

6.3 Shelf life

3 years

6.4 Special precautions for storage

Bottle presentation

Do not store above 30 C.
Store in the original bottle in order to protect from moisture.
Keep the bottle tightly closed.

Sachet presentation

Do not store above 30 C.

6.5 Nature and contents of container

Bottle presentation

Type I amber glass bottles with polypropylene child-resistant closures containing 5 or 20 hard 
capsules.
The carton contains one bottle.

Sachet presentation

Sachets are composed of linear low density polyethylene (innermost layer), aluminium and 
polyethylene terephthalate.
Each sachet contains 1 hard capsule and is dispensed in a cardboard carton.
The carton contains 5 or 20 hard capsules, individually sealed in sachets.

Not all pack sizes may be marketed.

6.6 Special precautions for disposal and other handling

Capsules should not be opened. If a capsule becomes damaged, contact of the powder contents with 
skin or mucous membrane must be avoided. If Temodal comes into contact with skin or mucosa, it 
should be washed immediately and thoroughly with soap and water. 

Patients should be advised to keep capsules out of the sight and reach of children, preferably in a 
locked cupboard. Accidental ingestion can be lethal for children.

Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements.

 



16

7. MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

8. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/001
EU/1/98/096/002
EU/1/98/096/024
EU/1/98/096/025

9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

Date of first authorisation: 26 January 1999
Date of latest renewal: 26 January 2009

10. DATE OF REVISION OF THE TEXT

Detailed information on this medicinal product is available on the website of the European Medicines 
Agency http://www.ema.europa.eu.

 

http://www.ema.europa.eu/


17

1. NAME OF THE MEDICINAL PRODUCT

Temodal 20 mg hard capsules

2. QUALITATIVE AND QUANTITATIVE COMPOSITION

Each hard capsule contains 20 mg temozolomide.

Excipient with known effect:
Each hard capsule contains 182.2 mg of anhydrous lactose.

For the full list of excipients, see section 6.1.

3. PHARMACEUTICAL FORM

Hard capsule (capsule).

The hard capsules have an opaque white body, an opaque yellow cap, and are imprinted with black 
ink. The cap is imprinted with “Temodal”. The body is imprinted with "20 mg", the Schering-Plough 
logo and two stripes.

4. CLINICAL PARTICULARS

4.1 Therapeutic indications

Temodal is indicated for the treatment of:
- adult patients with newly-diagnosed glioblastoma multiforme concomitantly with radiotherapy 

(RT) and subsequently as monotherapy treatment.
- children from the age of three years, adolescents and adult patients with malignant glioma, such 

as glioblastoma multiforme or anaplastic astrocytoma, showing recurrence or progression after 
standard therapy.

4.2 Posology and method of administration

Temodal should only be prescribed by physicians experienced in the oncological treatment of brain 
tumours.

Anti-emetic therapy may be administered (see section 4.4).

Posology

Adult patients with newly-diagnosed glioblastoma multiforme

Temodal is administered in combination with focal radiotherapy (concomitant phase) followed by up 
to 6 cycles of temozolomide (TMZ) monotherapy (monotherapy phase).

Concomitant phase 

TMZ is administered orally at a dose of 75 mg/m2 daily for 42 days concomitant with focal 
radiotherapy (60 Gy administered in 30 fractions). No dose reductions are recommended, but delay or 
discontinuation of TMZ administration should be decided weekly according to haematological and 
non-haematological toxicity criteria. TMZ administration can be continued throughout the 42 day 
concomitant period (up to 49 days) if all of the following conditions are met: 

 



18

- absolute neutrophil count (ANC) ≥ 1.5 x 109/l
- thrombocyte count ≥ 100 x 109/l
- common toxicity criteria (CTC) non-haematological toxicity ≤ Grade 1 (except for alopecia, 

nausea and vomiting). 
During treatment a complete blood count should be obtained weekly. TMZ administration should be 
temporarily interrupted or permanently discontinued during the concomitant phase according to the 
haematological and non-haematological toxicity criteria as noted in Table 1.

Table 1. TMZ dosing interruption or discontinuation during

concomitant radiotherapy and TMZ

Toxicity TMZ interruptiona TMZ discontinuation

Absolute neutrophil count  0.5 and < 1.5 x 109/l < 0.5 x 10
9/l

Thrombocyte count  10 and < 100 x 109/l < 10 x 10
9/l

CTC non-haematological toxicity
(except for alopecia, nausea, vomiting)

CTC Grade 2 CTC Grade 3 or 4

a: Treatment with concomitant TMZ can be continued when all of the following conditions are met: absolute neutrophil 
count  1.5 x 109/l; thrombocyte count  100 x 109/l; CTC non-haematological toxicity  Grade 1 (except for alopecia, 
nausea, vomiting).

Monotherapy phase

Four weeks after completing the TMZ + RT concomitant phase, TMZ is administered for up to 
6 cycles of monotherapy treatment. Dose in Cycle 1 (monotherapy) is 150 mg/m2 once daily for 
5 days followed by 23 days without treatment. At the start of Cycle 2, the dose is escalated to 
200 mg/m2 if the CTC non-haematological toxicity for Cycle 1 is Grade ≤ 2 (except for alopecia, 
nausea and vomiting), absolute neutrophil count (ANC) is ≥ 1.5 x 109/l, and the thrombocyte count is 
≥ 100 x 109/l. If the dose was not escalated at Cycle 2, escalation should not be done in subsequent 
cycles. Once escalated, the dose remains at 200 mg/m2 per day for the first 5 days of each subsequent 
cycle except if toxicity occurs. Dose reductions and discontinuations during the monotherapy phase 
should be applied according to Tables 2 and 3.

During treatment a complete blood count should be obtained on Day 22 (21 days after the first dose of 
TMZ). The dose should be reduced or administration discontinued according to Table 3.

Table 2. TMZ dose levels for monotherapy treatment

Dose level TMZ dose 
(mg/m2/day)

Remarks

–1 100 Reduction for prior toxicity 

0 150 Dose during Cycle 1

1 200 Dose during Cycles 2-6 in absence of toxicity

Table 3. TMZ dose reduction or discontinuation during monotherapy treatment

Toxicity Reduce TMZ by 1 dose levela Discontinue TMZ

Absolute neutrophil count < 1.0 x 109/l See footnote b

Thrombocyte count < 50 x 109/l See footnote b

CTC non-haematological Toxicity
(except for alopecia, nausea, vomiting) CTC Grade 3 CTC Grade 4

b

a: TMZ dose levels are listed in Table 2.
b: TMZ is to be discontinued if:
 dose level -1 (100 mg/m2) still results in unacceptable toxicity

 the same Grade 3 non-haematological toxicity (except for alopecia, nausea, vomiting) recurs after dose reduction.

 



19

Adult and paediatric patients 3 years of age or older with recurrent or progressive malignant glioma:

A treatment cycle comprises 28 days. In patients previously untreated with chemotherapy, TMZ is 
administered orally at a dose of 200 mg/m2 once daily for the first 5 days followed by a 23 day 
treatment interruption (total of 28 days). In patients previously treated with chemotherapy, the initial 
dose is 150 mg/m2 once daily, to be increased in the second cycle to 200 mg/m2 once daily, for 5 days 
if there is no haematological toxicity (see section 4.4) 

Special populations

Paediatric population

In patients 3 years of age or older, TMZ is only to be used in recurrent or progressive malignant 
glioma. Experience in these children is very limited (see sections 4.4 and 5.1). The safety and efficacy 
of TMZ in children under the age of 3 years have not been established. No data are available.

Patients with hepatic or renal impairment

The pharmacokinetics of TMZ were comparable in patients with normal hepatic function and in those 
with mild or moderate hepatic impairment. No data are available on the administration of TMZ in 
patients with severe hepatic impairment (Child’s Class C) or with renal impairment. Based on the 
pharmacokinetic properties of TMZ, it is unlikely that dose reductions are required in patients with 
severe hepatic impairment or any degree of renal impairment. However, caution should be exercised 
when TMZ is administered in these patients. 

Elderly patients

Based on a population pharmacokinetic analysis in patients 19-78 years of age, clearance of TMZ is 
not affected by age. However, elderly patients (> 70 years of age) appear to be at increased risk of 
neutropenia and thrombocytopenia (see section 4.4).

Method of administration

Temodal hard capsules should be administered in the fasting state.

The capsules must be swallowed whole with a glass of water and must not be opened or chewed. 

If vomiting occurs after the dose is administered, a second dose should not be administered that day.

4.3 Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

Hypersensitivity to dacarbazine (DTIC).

Severe myelosuppression (see section 4.4).

4.4 Special warnings and precautions for use

Opportunistic infections and reactivation of infections

Opportunistic infections (such as Pneumocystis jirovecii pneumonia) and reactivation of infections 
(such as HBV, CMV) have been observed during the treatment with TMZ (see section 4.8).

Meningoencephalitis herpetic

 



20

In post marketing cases, meningoencephalitis herpetic (including fatal cases) has been observed in 
patients receiving TMZ in combination with radiotherapy, including cases of concomitant steroids 
administration.

Pneumocystis jirovecii pneumonia

Patients who received concomitant TMZ and RT in a pilot trial for the prolonged 42-day schedule 
were shown to be at particular risk for developing Pneumocystis jirovecii pneumonia (PCP). Thus, 
prophylaxis against PCP is required for all patients receiving concomitant TMZ and RT for the 
42-day regimen (with a maximum of 49 days) regardless of lymphocyte count. If lymphopenia occurs, 
they are to continue the prophylaxis until recovery of lymphopenia to grade ≤ 1.

There may be a higher occurrence of PCP when TMZ is administered during a longer dosing regimen. 
However, all patients receiving TMZ, particularly patients receiving steroids, should be observed 
closely for the development of PCP, regardless of the regimen. Cases of fatal respiratory failure have 
been reported in patients using TMZ, in particular in combination with dexamethasone or other 
steroids.

HBV

Hepatitis due to hepatitis B virus (HBV) reactivation, in some cases resulting in death, has been 
reported. Experts in liver disease should be consulted before treatment is initiated in patients with 
positive hepatitis B serology (including those with active disease). During treatment patients should 
be monitored and managed appropriately.

Hepatotoxicity

Hepatic injury, including fatal hepatic failure, has been reported in patients treated with TMZ (see 
section 4.8). Baseline liver function tests should be performed prior to treatment initiation. If 
abnormal, physicians should assess the benefit/risk prior to initiating temozolomide including the 
potential for fatal hepatic failure. For patients on a 42 day treatment cycle liver function tests should 
be repeated midway during this cycle. For all patients, liver function tests should be checked after 
each treatment cycle. For patients with significant liver function abnormalities, physicians should 
assess the benefit/risk of continuing treatment. Liver toxicity may occur several weeks or more after 
the last treatment with temozolomide.

Malignancies

Cases of myelodysplastic syndrome and secondary malignancies, including myeloid leukaemia, have 
also been reported very rarely (see section 4.8).

Anti-emetic therapy

Nausea and vomiting are very commonly associated with TMZ.
Anti-emetic therapy may be administered prior to or following administration of TMZ.

Adult patients with newly-diagnosed glioblastoma multiforme 

Anti-emetic prophylaxis is recommended prior to the initial dose of concomitant phase and it is 
strongly recommended during the monotherapy phase.

Patients with recurrent or progressive malignant glioma

Patients who have experienced severe (Grade 3 or 4) vomiting in previous treatment cycles may 
require anti-emetic therapy.

 



21

Laboratory parameters

Patients treated with TMZ may experience myelosuppression, including prolonged pancytopenia, 
which may result in aplastic anaemia, which in some cases has resulted in a fatal outcome. In some 
cases, exposure to concomitant medicinal products associated with aplastic anaemia, including 
carbamazepine, phenytoin, and sulfamethoxazole/trimethoprim, complicates assessment. Prior to 
dosing, the following laboratory parameters must be met: ANC  1.5 x 109/l and platelet count 
 100 x 109/l. A complete blood count should be obtained on Day 22 (21 days after the first dose) or 
within 48 hours of that day, and weekly until ANC > 1.5 x 109/l and platelet count > 100 x 109/l. If 
ANC falls to < 1.0 x 109/l or the platelet count is < 50 x 109/l during any cycle, the next cycle should 
be reduced one dose level (see section 4.2). Dose levels include 100 mg/m2, 150 mg/m2, and 
200 mg/m2. The lowest recommended dose is 100 mg/m2.

Paediatric population 

There is no clinical experience with use of TMZ in children under the age of 3 years. Experience in 
older children and adolescents is very limited (see sections 4.2 and 5.1).

Elderly patients (> 70 years of age)

Elderly patients appear to be at increased risk of neutropenia and thrombocytopenia, compared with 
younger patients. Therefore, special care should be taken when TMZ is administered in elderly 
patients.

Male patients

Men being treated with TMZ should be advised not to father a child up to 6 months after receiving the 
last dose and to seek advice on cryoconservation of sperm prior to treatment (see section 4.6).

Lactose

This medicinal product contains lactose. Patients with rare hereditary problems of galactose 
intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this 
medicine.

4.5 Interaction with other medicinal products and other forms of interaction

In a separate phase I study, administration of TMZ with ranitidine did not result in alterations in the 
extent of absorption of temozolomide or the exposure to its active metabolite monomethyl 
triazenoimidazole carboxamide (MTIC). 

Administration of TMZ with food resulted in a 33 % decrease in Cmax and a 9 % decrease in area 
under the curve (AUC). 
As it cannot be excluded that the change in Cmax is clinically significant, Temodal should be 
administered without food.

Based on an analysis of population pharmacokinetics in phase II trials, co-administration of 
dexamethasone, prochlorperazine, phenytoin, carbamazepine, ondansetron, H2 receptor antagonists, or 
phenobarbital did not alter the clearance of TMZ. Co-administration with valproic acid was associated 
with a small but statistically significant decrease in clearance of TMZ.

No studies have been conducted to determine the effect of TMZ on the metabolism or elimination of 
other medicinal products. However, since TMZ does not undergo hepatic metabolism and exhibits 
low protein binding, it is unlikely that it would affect the pharmacokinetics of other medicinal 
products (see section 5.2).

 



22

Use of TMZ in combination with other myelosuppressive agents may increase the likelihood of 
myelosuppression. 

Paediatric population

Interaction studies have only been performed in adults.

4.6 Fertility, pregnancy and lactation 

Pregnancy

There are no data in pregnant women. In preclinical studies in rats and rabbits receiving 150 mg/m2 

TMZ, teratogenicity and/or foetal toxicity were demonstrated (see section 5.3). Temodal should not 
be administered to pregnant women. If use during pregnancy must be considered, the patient should 
be apprised of the potential risk to the foetus. 

Breast-feeding

It is not known whether TMZ is excreted in human milk; thus, breast-feeding should be discontinued 
while receiving treatment with TMZ. 

Women of childbearing potential

Women of childbearing potential should be advised to use effective contraception to avoid pregnancy 
while they are receiving TMZ.

Male fertility

TMZ can have genotoxic effects. Therefore, men being treated with it should be advised not to father 
a child up to 6 months after receiving the last dose and to seek advice on cryoconservation of sperm 
prior to treatment, because of the possibility of irreversible infertility due to therapy with TMZ.

4.7 Effects on ability to drive and use machines

TMZ has minor influence on the ability to drive and use machines due to fatigue and somnolence (see 
section 4.8). 

4.8 Undesirable effects 

Summary of the safety profile

Clinical trial experience

In patients treated with TMZ in clinical trials, the most common adverse reactions were nausea, 
vomiting, constipation, anorexia, headache, fatigue, convulsions, and rash. Most haematologic 
adverse reactions were reported commonly; the frequency of Grade 3-4 laboratory findings is 
presented after Table 4.

For patients with recurrent or progressive glioma, nausea (43 %) and vomiting (36 %) were usually 
Grade 1 or 2 (0 – 5 episodes of vomiting in 24 hours) and were either self-limiting or readily 
controlled with standard anti-emetic therapy. The incidence of severe nausea and vomiting was 4 %.

Tabulated list of adverse reactions
Adverse reactions observed in clinical studies and reported from post-marketing use of TMZ are listed
in Table 4. These reactions are classified according to System Organ Class and frequency. Frequency 
groupings are defined according to the following convention: Very common (≥ 1/10); Common 

 



23

(≥ 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). Within each frequency 
grouping, undesirable effects are presented in order of decreasing seriousness.

Table 4. Adverse reactions in patients treated with temozolomide

Infections and infestations

Common: Infections, herpes zoster, pharyngitisa, candidiasis oral

Uncommon: Opportunistic infection (including PCP), sepsis†, 
meningoencephalitis herpetic†, CMV infection, CMV 
reactivation, hepatitis B virus†, herpes simplex, infection 
reactivation, wound infection, gastroenteritisb

Neoplasm benign, malignant, and unspecified

Uncommon: Myelodysplastic syndrome (MDS), secondary 
malignancies, including myeloid leukaemia

Blood and lymphatic system disorders

Common: Febrile neutropenia, neutropenia, thrombocytopenia, 
lymphopenia, leukopenia, anaemia

Uncommon: Prolonged pancytopenia, aplastic anaemia†, 
pancytopenia, petechiae

Immune system disorders

Common: Allergic reaction

Uncommon: Anaphylaxis

Endocrine disorders

Common: Cushingoidc

Uncommon: Diabetes insipidus

Metabolism and nutrition disorders

Very common: Anorexia
Common: Hyperglycaemia

Uncommon: Hypokalaemia, alkaline phosphatase increased

Psychiatric disorders

Common: Agitation, amnesia, depression, anxiety, confusion, 
insomnia

Uncommon: Behaviour disorder, emotional lability, hallucination, 
apathy

Nervous system disorders

Very common: Convulsions, hemiparesis, aphasia/dysphasia, headache
Common: Ataxia, balance impaired, cognition impaired, 

concentration impaired, consciousness decreased, 
dizziness, hypoesthesia, memory impaired, neurologic 
disorder, neuropathyd, paraesthesia, somnolence, speech 
disorder, taste perversion, tremor

Uncommon: Status epilepticus, hemiplegia, extrapyramidal disorder, 
parosmia, gait abnormality, hyperaesthesia, sensory 
disturbance, coordination abnormal

Eye disorders

Common: Hemianopia, vision blurred, vision disordere, visual field 
defect, diplopia, eye pain

Uncommon: Visual acuity reduced, eyes dry

 



24

Table 4. Adverse reactions in patients treated with temozolomide

Ear and labyrinth disorders

Common: Deafnessf, vertigo, tinnitus, earacheg

Uncommon: Hearing impairment, hyperacusis, otitis media

Cardiac disorders

Uncommon: Palpitation

Vascular disorders

Common: Haemorrhage, embolism pulmonary, deep vein 
thrombosis, hypertension 

Uncommon: Cerebral haemorrhage, flushing, hot flushes

Respiratory, thoracic and mediastinal disorders

Common: Pneumonia, dyspnoea, sinusitis, bronchitis, coughing, 
upper respiratory infection

Uncommon: Respiratory failure†, interstitial 
pneumonitis/pneumonitis, pulmonary fibrosis, nasal 
congestion

Gastrointestinal disorders

Very common: Diarrhoea, constipation, nausea, vomiting
Common: Stomatitis, abdominal painh, dyspepsia, dysphagia 

Uncommon: Abdominal distension, faecal incontinence, 
gastrointestinal disorder, haemorrhoids, mouth dry

Hepatobiliary disorders

Uncommon: Hepatic failure†, hepatic injury, hepatitis, cholestasis, 
hyperbilirubinemia

Skin and subcutaneous tissue disorders

Very Common: Rash, alopecia
Common: Erythema, dry skin, pruritus
Uncommon: Toxic epidermal necrolysis, Stevens-Johnson syndrome, 

angioedema, erythema multiforme, erythroderma, skin 
exfoliation, photosensitivity reaction, urticaria, 
exanthema, dermatitis, sweating increased, pigmentation 
abnormal

Not known: Drug reaction with eosinophilia and systemic symptoms 
(DRESS)

Musculoskeletal and connective tissue disorders

Common: Myopathy, muscle weakness, arthralgia, back pain, 
musculoskeletal pain, myalgia 

Renal and urinary disorders

Common: Micturition frequency, urinary incontinence 

Uncommon: Dysuria

Reproductive system and breast disorders

Uncommon: Vaginal haemorrhage, menorrhagia, amenorrhoea,
vaginitis, breast pain, impotence

General disorders and administration site conditions

Very common: Fatigue
Common: Fever, influenza-like symptoms, asthenia, malaise, pain, 

oedema, oedema peripherali

 



25

Table 4. Adverse reactions in patients treated with temozolomide

Uncommon: Condition aggravated, rigors, face oedema, tongue
discolouration, thirst, tooth disorder

Investigations

Common: Liver enzymes elevationj, weight decreased, weight 
increased

Uncommon: Gamma-glutamyltransferase increased

Injury, poisoning and procedural complications 

Common: Radiation injuryk

a Includes pharyngitis, nasopharyngeal pharyngitis, pharyngitis Streptococcal 
b Includes gastroenteritis, gastroenteritis viral
c Includes cushingoid, Cushing syndrome
d Includes neuropathy, peripheral neuropathy, polyneuropathy, peripheral sensory neuropathy, 
peripheral motor neuropathy
e Includes visual impairment, eye disorder
f Includes deafness, deafness bilateral, deafness neurosensory, deafness unilateral
g Includes earache, ear discomfort
h Includes abdominal pain, abdominal pain lower, abdominal pain upper, abdominal discomfort
i Includes oedema peripheral, peripheral swelling
j Includes liver function test increased, alanine aminotransferase increased, aspartate aminotransferase 
increased, hepatic enzymes increased
k Includes radiation injury, radiation skin injury
† Including cases with fatal outcome

Newly-diagnosed glioblastoma multiforme

Laboratory results

Myelosuppression (neutropenia and thrombocytopenia), which is known dose-limiting toxicity for 
most cytotoxic agents, including TMZ, was observed. When laboratory abnormalities and adverse 
events were combined across concomitant and monotherapy treatment phases, Grade 3 or Grade 4 
neutrophil abnormalities including neutropenic events were observed in 8 % of the patients. Grade 3 
or Grade 4 thrombocyte abnormalities, including thrombocytopenic events were observed in 14 % of 
the patients who received TMZ. 

Recurrent or progressive malignant glioma

Laboratory results

Grade 3 or 4 thrombocytopenia and neutropenia occurred in 19 % and 17 % respectively, of patients 
treated for malignant glioma. This led to hospitalisation and/or discontinuation of TMZ in 8 % and 
4 %, respectively. Myelosuppression was predictable (usually within the first few cycles, with the 
nadir between Day 21 and Day 28), and recovery was rapid, usually within 1-2 weeks. No evidence of 
cumulative myelosuppression was observed. The presence of thrombocytopenia may increase the risk 
of bleeding, and the presence of neutropenia or leukopenia may increase the risk of infection.

Gender

In a population pharmacokinetics analysis of clinical trial experience there were 101 female and 
169 male subjects for whom nadir neutrophil counts were available and 110 female and 174 male 
subjects for whom nadir platelet counts were available. There were higher rates of Grade 4 
neutropenia (ANC < 0.5 x 109/l), 12 % vs 5 %, and thrombocytopenia (< 20 x 109/l), 9 % vs 3 %, in 
women vs men in the first cycle of therapy. In a 400 subject recurrent glioma data set, Grade 4 
neutropenia occurred in 8 % of female vs 4 % of male subjects and Grade 4 thrombocytopenia in 8 % 

 



26

of female vs 3 % of male subjects in the first cycle of therapy. In a study of 288 subjects with newly-
diagnosed glioblastoma multiforme, Grade 4 neutropenia occurred in 3 % of female vs 0 % of male 
subjects and Grade 4 thrombocytopenia in 1 % of female vs 0 % of male subjects in the first cycle of 
therapy.

Paediatric population

Oral TMZ has been studied in paediatric patients (age 3-18 years) with recurrent brainstem glioma or 
recurrent high grade astrocytoma, in a regimen administered daily for 5 days every 28 days. Although 
the data is limited, tolerance in children is expected to be the same as in adults. The safety of TMZ in 
children under the age of 3 years has not been established.

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 national reporting system 
listed in Appendix V.

4.9 Overdose

Doses of 500, 750, 1,000, and 1,250 mg/m2 (total dose per cycle over 5 days) have been evaluated 
clinically in patients. Dose-limiting toxicity was haematological and was reported with any dose but is 
expected to be more severe at higher doses. An overdose of 10,000 mg (total dose in a single cycle, 
over 5 days) was taken by one patient and the adverse reactions reported were pancytopenia, pyrexia, 
multi-organ failure and death. There are reports of patients who have taken the recommended dose for 
more than 5 days of treatment (up to 64 days) with adverse events reported including bone marrow 
suppression, with or without infection, in some cases severe and prolonged and resulting in death. In 
the event of an overdose, haematological evaluation is needed. Supportive measures should be 
provided as necessary.

5. PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Antineoplastic agents - Other alkylating agents, ATC code: L01A X03

Mechanism of action

Temozolomide is a triazene, which undergoes rapid chemical conversion at physiologic pH to the 
active monomethyl triazenoimidazole carboxamide (MTIC). The cytotoxicity of MTIC is thought to 
be due primarily to alkylation at the O6 position of guanine with additional alkylation also occurring 
at the N7 position. Cytotoxic lesions that develop subsequently are thought to involve aberrant repair 
of the methyl adduct.

Clinical efficacy and safety

Newly-diagnosed glioblastoma multiforme

A total of 573 patients were randomised to receive either TMZ + RT (n=287) or RT alone (n=286). 
Patients in the TMZ + RT arm received concomitant TMZ (75 mg/m2) once daily, starting the first 
day of RT until the last day of RT, for 42 days (with a maximum of 49 days). This was followed by 
monotherapy TMZ (150 - 200 mg/m2) on Days 1 - 5 of every 28-day cycle for up to 6 cycles, starting 
4 weeks after the end of RT. Patients in the control arm received RT only. Pneumocystis jirovecii
pneumonia (PCP) prophylaxis was required during RT and combined TMZ therapy.

 

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27

TMZ was administered as salvage therapy in the follow-up phase in 161 patients of the 282 (57 %) in 
the RT alone arm, and 62 patients of the 277 (22 %) in the TMZ + RT arm.

The hazard ratio (HR) for overall survival was 1.59 (95 % CI for HR=1.33 -1.91) with a log-rank 
p < 0.0001 in favour of the TMZ arm. The estimated probability of surviving 2 years or more (26 % 
vs 10 %) is higher for the RT + TMZ arm. The addition of concomitant TMZ to RT, followed by 
TMZ monotherapy in the treatment of patients with newly-diagnosed glioblastoma multiforme 
demonstrated a statistically significant improvement in overall survival (OS) compared with RT alone 
(Figure 1).

H R  (95%  C .I.) =  1 .59  (1 .33 – 1 .91)
log-rank p-value <  .0001

12.1 14.6

RT+TM Z

RT O n ly

26%

10%

Figure 1 Kaplan-Meier curves for overall survival (intent-to-treat population)

The results from the trial were not consistent in the subgroup of patients with a poor performance 
status (WHO PS=2, n=70), where overall survival and time to progression were similar in both arms. 
However, no unacceptable risks appear to be present in this patient group.

Recurrent or progressive malignant glioma

Data on clinical efficacy in patients with glioblastoma multiforme (Karnofsky performance status 
[KPS]  70), progressive or recurrent after surgery and RT, were based on two clinical trials with oral 
TMZ. One was a non-comparative trial in 138 patients (29 % received prior chemotherapy), and the 
other was a randomised active-controlled trial of TMZ vs procarbazine in a total of 225 patients (67 % 
received prior treatment with nitrosourea based chemotherapy). In both trials, the primary endpoint 
was progression-free survival (PFS) defined by MRI scans or neurological worsening. In the non-
comparative trial, the PFS at 6 months was 19 %, the median progression-free survival was 
2.1 months, and the median overall survival 5.4 months. The objective response rate (ORR) based on 
MRI scans was 8 %.

In the randomised active-controlled trial, the PFS at 6 months was significantly greater for TMZ than 
for procarbazine (21 % vs 8 %, respectively – chi-square p = 0.008) with median PFS of 2.89 and 
1.88 months respectively (log rank p = 0.0063). The median survival was 7.34 and 5.66 months for 
TMZ and procarbazine, respectively (log rank p = 0.33). At 6 months, the fraction of surviving 
patients was significantly higher in the TMZ arm (60 %) compared with the procarbazine arm (44 %) 
(chi-square p = 0.019). In patients with prior chemotherapy a benefit was indicated in those with a 
KPS  80.

Data on time to worsening of neurological status favoured TMZ over procarbazine as did data on time 
to worsening of performance status (decrease to a KPS of < 70 or a decrease by at least 30 points). 

 



28

The median times to progression in these endpoints ranged from 0.7 to 2.1 months longer for TMZ 
than for procarbazine (log rank p = < 0.01 to 0.03). 

Recurrent anaplastic astrocytoma

In a multicentre, prospective phase II trial evaluating the safety and efficacy of oral TMZ in the 
treatment of patients with anaplastic astrocytoma at first relapse, the 6 month PFS was 46 %. The 
median PFS was 5.4 months. Median overall survival was 14.6 months. Response rate, based on the 
central reviewer assessment, was 35 % (13 CR and 43 PR) for the intent-to-treat population (ITT) 
n=162. In 43 patients stable disease was reported. The 6-month event-free survival for the ITT 
population was 44 % with a median event-free survival of 4.6 months, which was similar to the results
for the progression-free survival. For the eligible histology population, the efficacy results were 
similar. Achieving a radiological objective response or maintaining progression-free status was 
strongly associated with maintained or improved quality of life.

Paediatric population

Oral TMZ has been studied in paediatric patients (age 3-18 years) with recurrent brainstem glioma or 
recurrent high grade astrocytoma, in a regimen administered daily for 5 days every 28 days. Tolerance 
to TMZ is similar to adults.

5.2 Pharmacokinetic properties 

TMZ is spontaneously hydrolyzed at physiologic pH primarily to the active species, 3-methyl-
(triazen-1-yl)imidazole-4-carboxamide (MTIC). MTIC is spontaneously hydrolyzed to 5-amino-
imidazole-4-carboxamide (AIC), a known intermediate in purine and nucleic acid biosynthesis, and to 
methylhydrazine, which is believed to be the active alkylating species. The cytotoxicity of MTIC is 
thought to be primarily due to alkylation of DNA mainly at the O6 and N7 positions of guanine. 
Relative to the AUC of TMZ, the exposure to MTIC and AIC is ~ 2.4 % and 23 %, respectively. In 
vivo, the t1/2 of MTIC was similar to that of TMZ, 1.8 hr.

Absorption

After oral administration to adult patients, TMZ is absorbed rapidly, with peak concentrations reached 
as early as 20 minutes post-administration (mean time between 0.5 and 1.5 hours). After oral 
administration of 14C-labelled TMZ, mean faecal excretion of 14C over 7 days post-dose was 0.8 % 
indicating complete absorption.

Distribution

TMZ demonstrates low protein binding (10 % to 20 %), and thus it is not expected to interact with 
highly protein-bound substances.

PET studies in humans and preclinical data suggest that TMZ crosses the blood-brain barrier rapidly 
and is present in the CSF. CSF penetration was confirmed in one patient; CSF exposure based on 
AUC of TMZ was approximately 30 % of that in plasma, which is consistent with animal data.

Elimination

The half-life (t1/2) in plasma is approximately 1.8 hours. The major route of 
14C elimination is renal. 

Following oral administration, approximately 5 % to 10 % of the dose is recovered unchanged in the 
urine over 24 hours, and the remainder excreted as temozolomide acid, 5-aminoimidazole-4-
carboxamide (AIC) or unidentified polar metabolites.

Plasma concentrations increase in a dose-related manner. Plasma clearance, volume of distribution 
and half-life are independent of dose. 

 



29

Special populations

Analysis of population-based pharmacokinetics of TMZ revealed that plasma TMZ clearance was 
independent of age, renal function or tobacco use. In a separate pharmacokinetic study, plasma 
pharmacokinetic profiles in patients with mild to moderate hepatic impairment were similar to those 
observed in patients with normal hepatic function.

Paediatric patients had a higher AUC than adult patients; however, the maximum tolerated dose 
(MTD) was 1,000 mg/m2 per cycle both in children and in adults.

5.3 Preclinical safety data

Single-cycle (5-day dosing, 23 days non-treatment), 3- and 6-cycle toxicity studies were conducted in 
rats and dogs. The primary targets of toxicity included the bone marrow, lymphoreticular system, 
testes, the gastrointestinal tract and, at higher doses, which were lethal to 60 % to 100 % of rats and 
dogs tested, degeneration of the retina occurred. Most of the toxicity showed evidence of reversibility, 
except for adverse events on the male reproductive system and retinal degeneration. However, 
because the doses implicated in retinal degeneration were in the lethal dose range, and no comparable 
effect has been observed in clinical studies, this finding was not considered to have clinical relevance.

TMZ is an embryotoxic, teratogenic and genotoxic alkylating agent. TMZ is more toxic to the rat and 
dog than to humans, and the clinical dose approximates the minimum lethal dose in rats and dogs. 
Dose-related reductions in leukocytes and platelets appear to be sensitive indicators of toxicity. A 
variety of neoplasms, including mammary carcinomas, keratocanthoma of the skin and basal cell 
adenoma were observed in the 6-cycle rat study while no tumours or pre-neoplastic changes were 
evident in dog studies. Rats appear to be particularly sensitive to oncogenic effects of TMZ, with the 
occurrence of first tumours within 3 months of initiating dosing. This latency period is very short 
even for an alkylating agent.

Results of the Ames/salmonella and Human Peripheral Blood Lymphocyte (HPBL) chromosome 
aberration tests showed a positive mutagenicity response.

6. PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Capsule content:
anhydrous lactose, 
colloidal anhydrous silica,
sodium starch glycolate type A, 
tartaric acid, 
stearic acid. 

Capsule shell: 
gelatin, 
titanium dioxide (E 171),
sodium lauril sulfate, 
yellow iron oxide (E 172)

Printing ink: 
shellac, 
propylene glycol, 
purified water, 
ammonium hydroxide, 

 



30

potassium hydroxide, 
black iron oxide (E 172).

6.2 Incompatibilities

Not applicable.

6.3 Shelf life

3 years

6.4 Special precautions for storage

Bottle presentation

Do not store above 30 C.
Store in the original bottle in order to protect from moisture.
Keep the bottle tightly closed.

Sachet presentation

Do not store above 30 C.

6.5 Nature and contents of container

Bottle presentation

Type I amber glass bottles with polypropylene child-resistant closures containing 5 or 20 hard 
capsules.
The carton contains one bottle.

Sachet presentation

Sachets are composed of linear low density polyethylene (innermost layer), aluminium and 
polyethylene terephthalate.
Each sachet contains 1 hard capsule and is dispensed in a cardboard carton.
The carton contains 5 or 20 hard capsules, individually sealed in sachets.

Not all pack sizes may be marketed.

6.6 Special precautions for disposal and other handling

Capsules should not be opened. If a capsule becomes damaged, contact of the powder contents with 
skin or mucous membrane must be avoided. If Temodal comes into contact with skin or mucosa, it 
should be washed immediately and thoroughly with soap and water. 

Patients should be advised to keep capsules out of the sight and reach of children, preferably in a 
locked cupboard. Accidental ingestion can be lethal for children.

Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements.

 



31

7. MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

8. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/003
EU/1/98/096/004
EU/1/98/096/013
EU/1/98/096/014

9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

Date of first authorisation: 26 January 1999
Date of latest renewal: 26 January 2009

10. DATE OF REVISION OF THE TEXT

Detailed information on this medicinal product is available on the website of the European Medicines 
Agency http://www.ema.europa.eu.

 

http://www.ema.europa.eu/


32

1. NAME OF THE MEDICINAL PRODUCT

Temodal 100 mg hard capsules

2. QUALITATIVE AND QUANTITATIVE COMPOSITION

Each hard capsule contains 100 mg temozolomide.

Excipient with known effect: 
Each hard capsule contains 175.7 mg of anhydrous lactose.

For the full list of excipients, see section 6.1.

3. PHARMACEUTICAL FORM

Hard capsule (capsule).

The hard capsules have an opaque white body, an opaque pink cap, and are imprinted with black ink.
The cap is imprinted with “Temodal”. The body is imprinted with "100 mg", the Schering-Plough 
logo and two stripes.

4. CLINICAL PARTICULARS

4.1 Therapeutic indications

Temodal is indicated for the treatment of:
- adult patients with newly-diagnosed glioblastoma multiforme concomitantly with radiotherapy 

(RT) and subsequently as monotherapy treatment.
- children from the age of three years, adolescents and adult patients with malignant glioma, such 

as glioblastoma multiforme or anaplastic astrocytoma, showing recurrence or progression after 
standard therapy.

4.2 Posology and method of administration

Temodal should only be prescribed by physicians experienced in the oncological treatment of brain 
tumours.

Anti-emetic therapy may be administered (see section 4.4).

Posology

Adult patients with newly-diagnosed glioblastoma multiforme

Temodal is administered in combination with focal radiotherapy (concomitant phase) followed by up 
to 6 cycles of temozolomide (TMZ) monotherapy (monotherapy phase).

Concomitant phase 

TMZ is administered orally at a dose of 75 mg/m2 daily for 42 days concomitant with focal 
radiotherapy (60 Gy administered in 30 fractions). No dose reductions are recommended, but delay or 
discontinuation of TMZ administration should be decided weekly according to haematological and 
non-haematological toxicity criteria. TMZ administration can be continued throughout the 42 day 
concomitant period (up to 49 days) if all of the following conditions are met: 

 



33

- absolute neutrophil count (ANC) ≥ 1.5 x 109/l
- thrombocyte count ≥ 100 x 109/l
- common toxicity criteria (CTC) non-haematological toxicity ≤ Grade 1 (except for alopecia, 

nausea and vomiting). 
During treatment a complete blood count should be obtained weekly. TMZ administration should be 
temporarily interrupted or permanently discontinued during the concomitant phase according to the 
haematological and non-haematological toxicity criteria as noted in Table 1.

Table 1. TMZ dosing interruption or discontinuation during

concomitant radiotherapy and TMZ

Toxicity TMZ interruptiona TMZ discontinuation

Absolute neutrophil count  0.5 and < 1.5 x 109/l < 0.5 x 10
9/l

Thrombocyte count  10 and < 100 x 109/l < 10 x 10
9/l

CTC non-haematological toxicity
(except for alopecia, nausea, vomiting)

CTC Grade 2 CTC Grade 3 or 4

a: Treatment with concomitant TMZ can be continued when all of the following conditions are met: absolute neutrophil 
count  1.5 x 109/l; thrombocyte count  100 x 109/l; CTC non-haematological toxicity  Grade 1 (except for alopecia, 
nausea, vomiting).

Monotherapy phase

Four weeks after completing the TMZ + RT concomitant phase, TMZ is administered for up to 
6 cycles of monotherapy treatment. Dose in Cycle 1 (monotherapy) is 150 mg/m2 once daily for 
5 days followed by 23 days without treatment. At the start of Cycle 2, the dose is escalated to 
200 mg/m2 if the CTC non-haematological toxicity for Cycle 1 is Grade ≤ 2 (except for alopecia, 
nausea and vomiting), absolute neutrophil count (ANC) is ≥ 1.5 x 109/l, and the thrombocyte count is 
≥ 100 x 109/l. If the dose was not escalated at Cycle 2, escalation should not be done in subsequent 
cycles. Once escalated, the dose remains at 200 mg/m2 per day for the first 5 days of each subsequent 
cycle except if toxicity occurs. Dose reductions and discontinuations during the monotherapy phase 
should be applied according to Tables 2 and 3.

During treatment a complete blood count should be obtained on Day 22 (21 days after the first dose of 
TMZ). The dose should be reduced or administration discontinued according to Table 3.

Table 2. TMZ dose levels for monotherapy treatment

Dose level TMZ dose 
(mg/m2/day)

Remarks

–1 100 Reduction for prior toxicity 

0 150 Dose during Cycle 1

1 200 Dose during Cycles 2-6 in absence of toxicity

Table 3. TMZ dose reduction or discontinuation during monotherapy treatment

Toxicity Reduce TMZ by 1 dose levela Discontinue TMZ

Absolute neutrophil count < 1.0 x 109/l See footnote b

Thrombocyte count < 50 x 109/l See footnote b

CTC non-haematological Toxicity
(except for alopecia, nausea, vomiting) CTC Grade 3 CTC Grade 4

b

a: TMZ dose levels are listed in Table 2.
b: TMZ is to be discontinued if:
 dose level -1 (100 mg/m2) still results in unacceptable toxicity

 the same Grade 3 non-haematological toxicity (except for alopecia, nausea, vomiting) recurs after dose reduction.

 



34

Adult and paediatric patients 3 years of age or older with recurrent or progressive malignant glioma:

A treatment cycle comprises 28 days. In patients previously untreated with chemotherapy, TMZ is 
administered orally at a dose of 200 mg/m2 once daily for the first 5 days followed by a 23 day 
treatment interruption (total of 28 days). In patients previously treated with chemotherapy, the initial 
dose is 150 mg/m2 once daily, to be increased in the second cycle to 200 mg/m2 once daily, for 5 days 
if there is no haematological toxicity (see section 4.4) 

Special populations

Paediatric population

In patients 3 years of age or older, TMZ is only to be used in recurrent or progressive malignant 
glioma. Experience in these children is very limited (see sections 4.4 and 5.1). The safety and efficacy 
of TMZ in children under the age of 3 years have not been established. No data are available.

Patients with hepatic or renal impairment

The pharmacokinetics of TMZ were comparable in patients with normal hepatic function and in those 
with mild or moderate hepatic impairment. No data are available on the administration of TMZ in 
patients with severe hepatic impairment (Child’s Class C) or with renal impairment. Based on the 
pharmacokinetic properties of TMZ, it is unlikely that dose reductions are required in patients with 
severe hepatic impairment or any degree of renal impairment. However, caution should be exercised 
when TMZ is administered in these patients. 

Elderly patients

Based on a population pharmacokinetic analysis in patients 19-78 years of age, clearance of TMZ is 
not affected by age. However, elderly patients (> 70 years of age) appear to be at increased risk of 
neutropenia and thrombocytopenia (see section 4.4).

Method of administration

Temodal hard capsules should be administered in the fasting state.

The capsules must be swallowed whole with a glass of water and must not be opened or chewed. 

If vomiting occurs after the dose is administered, a second dose should not be administered that day.

4.3 Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

Hypersensitivity to dacarbazine (DTIC).

Severe myelosuppression (see section 4.4).

4.4 Special warnings and precautions for use

Opportunistic infections and reactivation of infections

Opportunistic infections (such as Pneumocystis jirovecii pneumonia) and reactivation of infections 
(such as HBV, CMV) have been observed during the treatment with TMZ (see section 4.8).

Meningoencephalitis herpetic

 



35

In post marketing cases, meningoencephalitis herpetic (including fatal cases) has been observed in 
patients receiving TMZ in combination with radiotherapy, including cases of concomitant steroids 
administration.

Pneumocystis jirovecii pneumonia

Patients who received concomitant TMZ and RT in a pilot trial for the prolonged 42-day schedule 
were shown to be at particular risk for developing Pneumocystis jirovecii pneumonia (PCP). Thus, 
prophylaxis against PCP is required for all patients receiving concomitant TMZ and RT for the 
42-day regimen (with a maximum of 49 days) regardless of lymphocyte count. If lymphopenia occurs, 
they are to continue the prophylaxis until recovery of lymphopenia to grade ≤ 1.

There may be a higher occurrence of PCP when TMZ is administered during a longer dosing regimen. 
However, all patients receiving TMZ, particularly patients receiving steroids, should be observed 
closely for the development of PCP, regardless of the regimen. Cases of fatal respiratory failure have 
been reported in patients using TMZ, in particular in combination with dexamethasone or other 
steroids.

HBV

Hepatitis due to hepatitis B virus (HBV) reactivation, in some cases resulting in death, has been 
reported. Experts in liver disease should be consulted before treatment is initiated in patients with 
positive hepatitis B serology (including those with active disease). During treatment patients should 
be monitored and managed appropriately.

Hepatotoxicity

Hepatic injury, including fatal hepatic failure, has been reported in patients treated with TMZ (see 
section 4.8). Baseline liver function tests should be performed prior to treatment initiation. If 
abnormal, physicians should assess the benefit/risk prior to initiating temozolomide including the 
potential for fatal hepatic failure. For patients on a 42 day treatment cycle liver function tests should 
be repeated midway during this cycle. For all patients, liver function tests should be checked after 
each treatment cycle. For patients with significant liver function abnormalities, physicians should 
assess the benefit/risk of continuing treatment. Liver toxicity may occur several weeks or more after 
the last treatment with temozolomide.

Malignancies

Cases of myelodysplastic syndrome and secondary malignancies, including myeloid leukaemia, have 
also been reported very rarely (see section 4.8).

Anti-emetic therapy

Nausea and vomiting are very commonly associated with TMZ.
Anti-emetic therapy may be administered prior to or following administration of TMZ.

Adult patients with newly-diagnosed glioblastoma multiforme 

Anti-emetic prophylaxis is recommended prior to the initial dose of concomitant phase and it is 
strongly recommended during the monotherapy phase.

Patients with recurrent or progressive malignant glioma

Patients who have experienced severe (Grade 3 or 4) vomiting in previous treatment cycles may 
require anti-emetic therapy.

 



36

Laboratory parameters

Patients treated with TMZ may experience myelosuppression, including prolonged pancytopenia, 
which may result in aplastic anaemia, which in some cases has resulted in a fatal outcome. In some 
cases, exposure to concomitant medicinal products associated with aplastic anaemia, including 
carbamazepine, phenytoin, and sulfamethoxazole/trimethoprim, complicates assessment. Prior to 
dosing, the following laboratory parameters must be met: ANC  1.5 x 109/l and platelet count 
 100 x 109/l. A complete blood count should be obtained on Day 22 (21 days after the first dose) or 
within 48 hours of that day, and weekly until ANC > 1.5 x 109/l and platelet count > 100 x 109/l. If 
ANC falls to < 1.0 x 109/l or the platelet count is < 50 x 109/l during any cycle, the next cycle should 
be reduced one dose level (see section 4.2). Dose levels include 100 mg/m2, 150 mg/m2, and 
200 mg/m2. The lowest recommended dose is 100 mg/m2.

Paediatric population 

There is no clinical experience with use of TMZ in children under the age of 3 years. Experience in 
older children and adolescents is very limited (see sections 4.2 and 5.1).

Elderly patients (> 70 years of age)

Elderly patients appear to be at increased risk of neutropenia and thrombocytopenia, compared with 
younger patients. Therefore, special care should be taken when TMZ is administered in elderly 
patients.

Male patients

Men being treated with TMZ should be advised not to father a child up to 6 months after receiving the 
last dose and to seek advice on cryoconservation of sperm prior to treatment (see section 4.6).

Lactose

This medicinal product contains lactose. Patients with rare hereditary problems of galactose 
intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this 
medicine.

4.5 Interaction with other medicinal products and other forms of interaction

In a separate phase I study, administration of TMZ with ranitidine did not result in alterations in the 
extent of absorption of temozolomide or the exposure to its active metabolite monomethyl 
triazenoimidazole carboxamide (MTIC). 

Administration of TMZ with food resulted in a 33 % decrease in Cmax and a 9 % decrease in area 
under the curve (AUC). 
As it cannot be excluded that the change in Cmax is clinically significant, Temodal should be 
administered without food.

Based on an analysis of population pharmacokinetics in phase II trials, co-administration of 
dexamethasone, prochlorperazine, phenytoin, carbamazepine, ondansetron, H2 receptor antagonists, or 
phenobarbital did not alter the clearance of TMZ. Co-administration with valproic acid was associated 
with a small but statistically significant decrease in clearance of TMZ.

No studies have been conducted to determine the effect of TMZ on the metabolism or elimination of 
other medicinal products. However, since TMZ does not undergo hepatic metabolism and exhibits 
low protein binding, it is unlikely that it would affect the pharmacokinetics of other medicinal 
products (see section 5.2).

 



37

Use of TMZ in combination with other myelosuppressive agents may increase the likelihood of 
myelosuppression. 

Paediatric population

Interaction studies have only been performed in adults.

4.6 Fertility, pregnancy and lactation 

Pregnancy

There are no data in pregnant women. In preclinical studies in rats and rabbits receiving 150 mg/m2 

TMZ, teratogenicity and/or foetal toxicity were demonstrated (see section 5.3). Temodal should not 
be administered to pregnant women. If use during pregnancy must be considered, the patient should 
be apprised of the potential risk to the foetus. 

Breast-feeding

It is not known whether TMZ is excreted in human milk; thus, breast-feeding should be discontinued 
while receiving treatment with TMZ. 

Women of childbearing potential

Women of childbearing potential should be advised to use effective contraception to avoid pregnancy 
while they are receiving TMZ.

Male fertility

TMZ can have genotoxic effects. Therefore, men being treated with it should be advised not to father 
a child up to 6 months after receiving the last dose and to seek advice on cryoconservation of sperm 
prior to treatment, because of the possibility of irreversible infertility due to therapy with TMZ.

4.7 Effects on ability to drive and use machines

TMZ has minor influence on the ability to drive and use machines due to fatigue and somnolence (see 
section 4.8). 

4.8 Undesirable effects 

Summary of the safety profile

Clinical trial experience

In patients treated with TMZ in clinical trials, the most common adverse reactions were nausea, 
vomiting, constipation, anorexia, headache, fatigue, convulsions, and rash. Most haematologic 
adverse reactions were reported commonly; the frequency of Grade 3-4 laboratory findings is 
presented after Table 4.

For patients with recurrent or progressive glioma, nausea (43 %) and vomiting (36 %) were usually 
Grade 1 or 2 (0 – 5 episodes of vomiting in 24 hours) and were either self-limiting or readily 
controlled with standard anti-emetic therapy. The incidence of severe nausea and vomiting was 4 %.

Tabulated list of adverse reactions
Adverse reactions observed in clinical studies and reported from post-marketing use of TMZ are listed
in Table 4. These reactions are classified according to System Organ Class and frequency. Frequency 
groupings are defined according to the following convention: Very common (≥ 1/10); Common 

 



38

(≥ 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). Within each frequency 
grouping, undesirable effects are presented in order of decreasing seriousness.

Table 4. Adverse reactions in patients treated with temozolomide

Infections and infestations

Common: Infections, herpes zoster, pharyngitisa, candidiasis oral

Uncommon: Opportunistic infection (including PCP), sepsis†, 
meningoencephalitis herpetic†, CMV infection, CMV 
reactivation, hepatitis B virus†, herpes simplex, infection 
reactivation, wound infection, gastroenteritisb

Neoplasm benign, malignant, and unspecified

Uncommon: Myelodysplastic syndrome (MDS), secondary 
malignancies, including myeloid leukaemia

Blood and lymphatic system disorders

Common: Febrile neutropenia, neutropenia, thrombocytopenia, 
lymphopenia, leukopenia, anaemia

Uncommon: Prolonged pancytopenia, aplastic anaemia†, 
pancytopenia, petechiae

Immune system disorders

Common: Allergic reaction

Uncommon: Anaphylaxis

Endocrine disorders

Common: Cushingoidc

Uncommon: Diabetes insipidus

Metabolism and nutrition disorders

Very common: Anorexia
Common: Hyperglycaemia

Uncommon: Hypokalaemia, alkaline phosphatase increased

Psychiatric disorders

Common: Agitation, amnesia, depression, anxiety, confusion, 
insomnia

Uncommon: Behaviour disorder, emotional lability, hallucination, 
apathy

Nervous system disorders

Very common: Convulsions, hemiparesis, aphasia/dysphasia, headache
Common: Ataxia, balance impaired, cognition impaired, 

concentration impaired, consciousness decreased, 
dizziness, hypoesthesia, memory impaired, neurologic 
disorder, neuropathyd, paraesthesia, somnolence, speech 
disorder, taste perversion, tremor

Uncommon: Status epilepticus, hemiplegia, extrapyramidal disorder, 
parosmia, gait abnormality, hyperaesthesia, sensory 
disturbance, coordination abnormal

Eye disorders

Common: Hemianopia, vision blurred, vision disordere, visual field 
defect, diplopia, eye pain

Uncommon: Visual acuity reduced, eyes dry

 



39

Table 4. Adverse reactions in patients treated with temozolomide

Ear and labyrinth disorders

Common: Deafnessf, vertigo, tinnitus, earacheg

Uncommon: Hearing impairment, hyperacusis, otitis media

Cardiac disorders

Uncommon: Palpitation

Vascular disorders

Common: Haemorrhage, embolism pulmonary, deep vein 
thrombosis, hypertension 

Uncommon: Cerebral haemorrhage, flushing, hot flushes

Respiratory, thoracic and mediastinal disorders

Common: Pneumonia, dyspnoea, sinusitis, bronchitis, coughing, 
upper respiratory infection

Uncommon: Respiratory failure†, interstitial 
pneumonitis/pneumonitis, pulmonary fibrosis, nasal 
congestion

Gastrointestinal disorders

Very common: Diarrhoea, constipation, nausea, vomiting
Common: Stomatitis, abdominal painh, dyspepsia, dysphagia 

Uncommon: Abdominal distension, faecal incontinence, 
gastrointestinal disorder, haemorrhoids, mouth dry

Hepatobiliary disorders

Uncommon: Hepatic failure†, hepatic injury, hepatitis, cholestasis, 
hyperbilirubinemia

Skin and subcutaneous tissue disorders

Very Common: Rash, alopecia
Common: Erythema, dry skin, pruritus
Uncommon: Toxic epidermal necrolysis, Stevens-Johnson syndrome, 

angioedema, erythema multiforme, erythroderma, skin 
exfoliation, photosensitivity reaction, urticaria, 
exanthema, dermatitis, sweating increased, pigmentation 
abnormal

Not known: Drug reaction with eosinophilia and systemic symptoms 
(DRESS)

Musculoskeletal and connective tissue disorders

Common: Myopathy, muscle weakness, arthralgia, back pain, 
musculoskeletal pain, myalgia 

Renal and urinary disorders

Common: Micturition frequency, urinary incontinence 

Uncommon: Dysuria

Reproductive system and breast disorders

Uncommon: Vaginal haemorrhage, menorrhagia, amenorrhoea, 
vaginitis, breast pain, impotence

General disorders and administration site conditions

Very common: Fatigue
Common: Fever, influenza-like symptoms, asthenia, malaise, pain, 

oedema, oedema peripherali

 



40

Table 4. Adverse reactions in patients treated with temozolomide

Uncommon: Condition aggravated, rigors, face oedema, tongue
discolouration, thirst, tooth disorder

Investigations

Common: Liver enzymes elevationj, weight decreased, weight 
increased

Uncommon: Gamma-glutamyltransferase increased

Injury, poisoning and procedural complications 

Common: Radiation injuryk

a Includes pharyngitis, nasopharyngeal pharyngitis, pharyngitis Streptococcal 
b Includes gastroenteritis, gastroenteritis viral
c Includes cushingoid, Cushing syndrome
d Includes neuropathy, peripheral neuropathy, polyneuropathy, peripheral sensory neuropathy, 
peripheral motor neuropathy
e Includes visual impairment, eye disorder
f Includes deafness, deafness bilateral, deafness neurosensory, deafness unilateral
g Includes earache, ear discomfort
h Includes abdominal pain, abdominal pain lower, abdominal pain upper, abdominal discomfort
i Includes oedema peripheral, peripheral swelling
j Includes liver function test increased, alanine aminotransferase increased, aspartate aminotransferase 
increased, hepatic enzymes increased
k Includes radiation injury, radiation skin injury
† Including cases with fatal outcome

Newly-diagnosed glioblastoma multiforme

Laboratory results

Myelosuppression (neutropenia and thrombocytopenia), which is known dose-limiting toxicity for 
most cytotoxic agents, including TMZ, was observed. When laboratory abnormalities and adverse 
events were combined across concomitant and monotherapy treatment phases, Grade 3 or Grade 4 
neutrophil abnormalities including neutropenic events were observed in 8 % of the patients. Grade 3 
or Grade 4 thrombocyte abnormalities, including thrombocytopenic events were observed in 14 % of 
the patients who received TMZ. 

Recurrent or progressive malignant glioma

Laboratory results

Grade 3 or 4 thrombocytopenia and neutropenia occurred in 19 % and 17 % respectively, of patients 
treated for malignant glioma. This led to hospitalisation and/or discontinuation of TMZ in 8 % and 
4 %, respectively. Myelosuppression was predictable (usually within the first few cycles, with the 
nadir between Day 21 and Day 28), and recovery was rapid, usually within 1-2 weeks. No evidence of 
cumulative myelosuppression was observed. The presence of thrombocytopenia may increase the risk 
of bleeding, and the presence of neutropenia or leukopenia may increase the risk of infection.

Gender

In a population pharmacokinetics analysis of clinical trial experience there were 101 female and 
169 male subjects for whom nadir neutrophil counts were available and 110 female and 174 male 
subjects for whom nadir platelet counts were available. There were higher rates of Grade 4 
neutropenia (ANC < 0.5 x 109/l), 12 % vs 5 %, and thrombocytopenia (< 20 x 109/l), 9 % vs 3 %, in 
women vs men in the first cycle of therapy. In a 400 subject recurrent glioma data set, Grade 4 
neutropenia occurred in 8 % of female vs 4 % of male subjects and Grade 4 thrombocytopenia in 8 % 

 



41

of female vs 3 % of male subjects in the first cycle of therapy. In a study of 288 subjects with newly-
diagnosed glioblastoma multiforme, Grade 4 neutropenia occurred in 3 % of female vs 0 % of male 
subjects and Grade 4 thrombocytopenia in 1 % of female vs 0 % of male subjects in the first cycle of 
therapy.

Paediatric population

Oral TMZ has been studied in paediatric patients (age 3-18 years) with recurrent brainstem glioma or 
recurrent high grade astrocytoma, in a regimen administered daily for 5 days every 28 days. Although 
the data is limited, tolerance in children is expected to be the same as in adults. The safety of TMZ in 
children under the age of 3 years has not been established.

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 national reporting system 
listed in Appendix V.

4.9 Overdose

Doses of 500, 750, 1,000, and 1,250 mg/m2 (total dose per cycle over 5 days) have been evaluated 
clinically in patients. Dose-limiting toxicity was haematological and was reported with any dose but is 
expected to be more severe at higher doses. An overdose of 10,000 mg (total dose in a single cycle, 
over 5 days) was taken by one patient and the adverse reactions reported were pancytopenia, pyrexia, 
multi-organ failure and death. There are reports of patients who have taken the recommended dose for 
more than 5 days of treatment (up to 64 days) with adverse events reported including bone marrow 
suppression, with or without infection, in some cases severe and prolonged and resulting in death. In 
the event of an overdose, haematological evaluation is needed. Supportive measures should be 
provided as necessary.

5. PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Antineoplastic agents - Other alkylating agents, ATC code: L01A X03

Mechanism of action

Temozolomide is a triazene, which undergoes rapid chemical conversion at physiologic pH to the 
active monomethyl triazenoimidazole carboxamide (MTIC). The cytotoxicity of MTIC is thought to 
be due primarily to alkylation at the O6 position of guanine with additional alkylation also occurring 
at the N7 position. Cytotoxic lesions that develop subsequently are thought to involve aberrant repair 
of the methyl adduct.

Clinical efficacy and safety

Newly-diagnosed glioblastoma multiforme

A total of 573 patients were randomised to receive either TMZ + RT (n=287) or RT alone (n=286). 
Patients in the TMZ + RT arm received concomitant TMZ (75 mg/m2) once daily, starting the first 
day of RT until the last day of RT, for 42 days (with a maximum of 49 days). This was followed by 
monotherapy TMZ (150 - 200 mg/m2) on Days 1 - 5 of every 28-day cycle for up to 6 cycles, starting 
4 weeks after the end of RT. Patients in the control arm received RT only. Pneumocystis jirovecii
pneumonia (PCP) prophylaxis was required during RT and combined TMZ therapy.

 

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42

TMZ was administered as salvage therapy in the follow-up phase in 161 patients of the 282 (57 %) in 
the RT alone arm, and 62 patients of the 277 (22 %) in the TMZ + RT arm.

The hazard ratio (HR) for overall survival was 1.59 (95 % CI for HR=1.33 -1.91) with a log-rank 
p < 0.0001 in favour of the TMZ arm. The estimated probability of surviving 2 years or more (26 % 
vs 10 %) is higher for the RT + TMZ arm. The addition of concomitant TMZ to RT, followed by 
TMZ monotherapy in the treatment of patients with newly-diagnosed glioblastoma multiforme 
demonstrated a statistically significant improvement in overall survival (OS) compared with RT alone 
(Figure 1).

Figure 1 Kaplan-Meier curves for overall survival (intent-to-treat population)

The results from the trial were not consistent in the subgroup of patients with a poor performance 
status (WHO PS=2, n=70), where overall survival and time to progression were similar in both arms. 
However, no unacceptable risks appear to be present in this patient group.

Recurrent or progressive malignant glioma

Data on clinical efficacy in patients with glioblastoma multiforme (Karnofsky performance status 
[KPS]  70), progressive or recurrent after surgery and RT, were based on two clinical trials with oral 
TMZ. One was a non-comparative trial in 138 patients (29 % received prior chemotherapy), and the 
other was a randomised active-controlled trial of TMZ vs procarbazine in a total of 225 patients (67 % 
received prior treatment with nitrosourea based chemotherapy). In both trials, the primary endpoint 
was progression-free survival (PFS) defined by MRI scans or neurological worsening. In the non-
comparative trial, the PFS at 6 months was 19 %, the median progression-free survival was 
2.1 months, and the median overall survival 5.4 months. The objective response rate (ORR) based on 
MRI scans was 8 %.

In the randomised active-controlled trial, the PFS at 6 months was significantly greater for TMZ than 
for procarbazine (21 % vs 8 %, respectively – chi-square p = 0.008) with median PFS of 2.89 and 
1.88 months respectively (log rank p = 0.0063). The median survival was 7.34 and 5.66 months for 
TMZ and procarbazine, respectively (log rank p = 0.33). At 6 months, the fraction of surviving 
patients was significantly higher in the TMZ arm (60 %) compared with the procarbazine arm (44 %) 
(chi-square p = 0.019). In patients with prior chemotherapy a benefit was indicated in those with a 
KPS  80.

H R  (95%  C .I.) =  1 .59 (1 .33  – 1 .91)
log-rank p -value  <  .0001

12.1 14.6

RT+TM Z

RT O n ly

26%

10%

 



43

Data on time to worsening of neurological status favoured TMZ over procarbazine as did data on time 
to worsening of performance status (decrease to a KPS of < 70 or a decrease by at least 30 points). 
The median times to progression in these endpoints ranged from 0.7 to 2.1 months longer for TMZ 
than for procarbazine (log rank p = < 0.01 to 0.03). 

Recurrent anaplastic astrocytoma

In a multicentre, prospective phase II trial evaluating the safety and efficacy of oral TMZ in the 
treatment of patients with anaplastic astrocytoma at first relapse, the 6 month PFS was 46 %. The 
median PFS was 5.4 months. Median overall survival was 14.6 months. Response rate, based on the 
central reviewer assessment, was 35 % (13 CR and 43 PR) for the intent-to-treat population (ITT) 
n=162. In 43 patients stable disease was reported. The 6-month event-free survival for the ITT 
population was 44 % with a median event-free survival of 4.6 months, which was similar to the results
for the progression-free survival. For the eligible histology population, the efficacy results were 
similar. Achieving a radiological objective response or maintaining progression-free status was 
strongly associated with maintained or improved quality of life.

Paediatric population

Oral TMZ has been studied in paediatric patients (age 3-18 years) with recurrent brainstem glioma or 
recurrent high grade astrocytoma, in a regimen administered daily for 5 days every 28 days. Tolerance 
to TMZ is similar to adults.

5.2 Pharmacokinetic properties 

TMZ is spontaneously hydrolyzed at physiologic pH primarily to the active species, 3-methyl-
(triazen-1-yl)imidazole-4-carboxamide (MTIC). MTIC is spontaneously hydrolyzed to 5-amino-
imidazole-4-carboxamide (AIC), a known intermediate in purine and nucleic acid biosynthesis, and to 
methylhydrazine, which is believed to be the active alkylating species. The cytotoxicity of MTIC is 
thought to be primarily due to alkylation of DNA mainly at the O6 and N7 positions of guanine. 
Relative to the AUC of TMZ, the exposure to MTIC and AIC is ~ 2.4 % and 23 %, respectively. In 
vivo, the t1/2 of MTIC was similar to that of TMZ, 1.8 hr.

Absorption

After oral administration to adult patients, TMZ is absorbed rapidly, with peak concentrations reached 
as early as 20 minutes post-administration (mean time between 0.5 and 1.5 hours). After oral 
administration of 14C-labelled TMZ, mean faecal excretion of 14C over 7 days post-dose was 0.8 % 
indicating complete absorption.

Distribution

TMZ demonstrates low protein binding (10 % to 20 %), and thus it is not expected to interact with 
highly protein-bound substances.

PET studies in humans and preclinical data suggest that TMZ crosses the blood-brain barrier rapidly 
and is present in the CSF. CSF penetration was confirmed in one patient; CSF exposure based on 
AUC of TMZ was approximately 30 % of that in plasma, which is consistent with animal data.

Elimination

The half-life (t1/2) in plasma is approximately 1.8 hours. The major route of 
14C elimination is renal. 

Following oral administration, approximately 5 % to 10 % of the dose is recovered unchanged in the 
urine over 24 hours, and the remainder excreted as temozolomide acid, 5-aminoimidazole-4-
carboxamide (AIC) or unidentified polar metabolites.

 



44

Plasma concentrations increase in a dose-related manner. Plasma clearance, volume of distribution 
and half-life are independent of dose. 

Special populations

Analysis of population-based pharmacokinetics of TMZ revealed that plasma TMZ clearance was 
independent of age, renal function or tobacco use. In a separate pharmacokinetic study, plasma 
pharmacokinetic profiles in patients with mild to moderate hepatic impairment were similar to those 
observed in patients with normal hepatic function.

Paediatric patients had a higher AUC than adult patients; however, the maximum tolerated dose 
(MTD) was 1,000 mg/m2 per cycle both in children and in adults.

5.3 Preclinical safety data

Single-cycle (5-day dosing, 23 days non-treatment), 3- and 6-cycle toxicity studies were conducted in 
rats and dogs. The primary targets of toxicity included the bone marrow, lymphoreticular system, 
testes, the gastrointestinal tract and, at higher doses, which were lethal to 60 % to 100 % of rats and 
dogs tested, degeneration of the retina occurred. Most of the toxicity showed evidence of reversibility, 
except for adverse events on the male reproductive system and retinal degeneration. However, 
because the doses implicated in retinal degeneration were in the lethal dose range, and no comparable 
effect has been observed in clinical studies, this finding was not considered to have clinical relevance.

TMZ is an embryotoxic, teratogenic and genotoxic alkylating agent. TMZ is more toxic to the rat and 
dog than to humans, and the clinical dose approximates the minimum lethal dose in rats and dogs. 
Dose-related reductions in leukocytes and platelets appear to be sensitive indicators of toxicity. A 
variety of neoplasms, including mammary carcinomas, keratocanthoma of the skin and basal cell 
adenoma were observed in the 6-cycle rat study while no tumours or pre-neoplastic changes were 
evident in dog studies. Rats appear to be particularly sensitive to oncogenic effects of TMZ, with the 
occurrence of first tumours within 3 months of initiating dosing. This latency period is very short 
even for an alkylating agent.

Results of the Ames/salmonella and Human Peripheral Blood Lymphocyte (HPBL) chromosome 
aberration tests showed a positive mutagenicity response.

6. PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Capsule content:
anhydrous lactose, 
colloidal anhydrous silica, 
sodium starch glycolate type A, 
tartaric acid, 
stearic acid. 

Capsule shell: 
gelatin, 
titanium dioxide (E 171), 
sodium lauril sulfate, 
red iron oxide (E172).

Printing ink: 
shellac, 
propylene glycol, 

 



45

purified water, 
ammonium hydroxide, 
potassium hydroxide, 
black iron oxide (E 172).

6.2 Incompatibilities

Not applicable.

6.3 Shelf life

3 years

6.4 Special precautions for storage

Bottle presentation

Do not store above 30 C.
Store in the original bottle in order to protect from moisture.
Keep the bottle tightly closed.

Sachet presentation

Do not store above 30 C.

6.5 Nature and contents of container

Bottle presentation

Type I amber glass bottles with polypropylene child-resistant closures containing 5 or 20 hard 
capsules.
The carton contains one bottle.

Sachet presentation

Sachets are composed of linear low density polyethylene (innermost layer), aluminium and 
polyethylene terephthalate.
Each sachet contains 1 hard capsule and is dispensed in a cardboard carton.
The carton contains 5 or 20 hard capsules, individually sealed in sachets.

Not all pack sizes may be marketed.

6.6 Special precautions for disposal and other handling

Capsules should not be opened. If a capsule becomes damaged, contact of the powder contents with 
skin or mucous membrane must be avoided. If Temodal comes into contact with skin or mucosa, it 
should be washed immediately and thoroughly with soap and water. 

Patients should be advised to keep capsules out of the sight and reach of children, preferably in a 
locked cupboard. Accidental ingestion can be lethal for children.

Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements.

 



46

7. MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

8. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/005
EU/1/98/096/006
EU/1/98/096/015
EU/1/98/096/016

9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

Date of first authorisation: 26 January 1999
Date of latest renewal: 26 January 2009

10. DATE OF REVISION OF THE TEXT

Detailed information on this medicinal product is available on the website of the European Medicines 
Agency http://www.ema.europa.eu.

 

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47

1. NAME OF THE MEDICINAL PRODUCT

Temodal 140 mg hard capsules

2. QUALITATIVE AND QUANTITATIVE COMPOSITION

Each hard capsule contains 140 mg temozolomide.

Excipient with known effect: 
Each hard capsule contains 246 mg of anhydrous lactose. 

For the full list of excipients, see section 6.1.

3. PHARMACEUTICAL FORM

Hard capsule (capsule).

The hard capsules have an opaque white body, a blue cap, and are imprinted with black ink. The cap 
is imprinted with “Temodal”. The body is imprinted with "140 mg", the Schering-Plough logo and 
two stripes.

4. CLINICAL PARTICULARS

4.1 Therapeutic indications

Temodal is indicated for the treatment of:
- adult patients with newly-diagnosed glioblastoma multiforme concomitantly with radiotherapy 

(RT) and subsequently as monotherapy treatment.
- children from the age of three years, adolescents and adult patients with malignant glioma, such 

as glioblastoma multiforme or anaplastic astrocytoma, showing recurrence or progression after 
standard therapy.

4.2 Posology and method of administration

Temodal should only be prescribed by physicians experienced in the oncological treatment of brain 
tumours.

Anti-emetic therapy may be administered (see section 4.4).

Posology

Adult patients with newly-diagnosed glioblastoma multiforme

Temodal is administered in combination with focal radiotherapy (concomitant phase) followed by up
to 6 cycles of temozolomide (TMZ) monotherapy (monotherapy phase).

Concomitant phase 

TMZ is administered orally at a dose of 75 mg/m2 daily for 42 days concomitant with focal 
radiotherapy (60 Gy administered in 30 fractions). No dose reductions are recommended, but delay or 
discontinuation of TMZ administration should be decided weekly according to haematological and 
non-haematological toxicity criteria. TMZ administration can be continued throughout the 42 day 
concomitant period (up to 49 days) if all of the following conditions are met: 

 



48

- absolute neutrophil count (ANC) ≥ 1.5 x 109/l
- thrombocyte count ≥ 100 x 109/l
- common toxicity criteria (CTC) non-haematological toxicity ≤ Grade 1 (except for alopecia, 

nausea and vomiting). 
During treatment a complete blood count should be obtained weekly. TMZ administration should be 
temporarily interrupted or permanently discontinued during the concomitant phase according to the 
haematological and non-haematological toxicity criteria as noted in Table 1.

Table 1. TMZ dosing interruption or discontinuation during

concomitant radiotherapy and TMZ

Toxicity TMZ interruptiona TMZ discontinuation

Absolute neutrophil count  0.5 and < 1.5 x 109/l < 0.5 x 10
9/l

Thrombocyte count  10 and < 100 x 109/l < 10 x 10
9/l

CTC non-haematological toxicity
(except for alopecia, nausea, vomiting)

CTC Grade 2 CTC Grade 3 or 4

a: Treatment with concomitant TMZ can be continued when all of the following conditions are met: absolute neutrophil 
count  1.5 x 109/l; thrombocyte count  100 x 109/l; CTC non-haematological toxicity  Grade 1 (except for alopecia, 
nausea, vomiting).

Monotherapy phase

Four weeks after completing the TMZ + RT concomitant phase, TMZ is administered for up to 
6 cycles of monotherapy treatment. Dose in Cycle 1 (monotherapy) is 150 mg/m2 once daily for 
5 days followed by 23 days without treatment. At the start of Cycle 2, the dose is escalated to 
200 mg/m2 if the CTC non-haematological toxicity for Cycle 1 is Grade ≤ 2 (except for alopecia, 
nausea and vomiting), absolute neutrophil count (ANC) is ≥ 1.5 x 109/l, and the thrombocyte count is 
≥ 100 x 109/l. If the dose was not escalated at Cycle 2, escalation should not be done in subsequent 
cycles. Once escalated, the dose remains at 200 mg/m2 per day for the first 5 days of each subsequent 
cycle except if toxicity occurs. Dose reductions and discontinuations during the monotherapy phase 
should be applied according to Tables 2 and 3.

During treatment a complete blood count should be obtained on Day 22 (21 days after the first dose of 
TMZ). The dose should be reduced or administration discontinued according to Table 3.

Table 2. TMZ dose levels for monotherapy treatment

Dose level TMZ dose 
(mg/m2/day)

Remarks

–1 100 Reduction for prior toxicity 

0 150 Dose during Cycle 1

1 200 Dose during Cycles 2-6 in absence of toxicity

Table 3. TMZ dose reduction or discontinuation during monotherapy treatment

Toxicity Reduce TMZ by 1 dose levela Discontinue TMZ

Absolute neutrophil count < 1.0 x 109/l See footnote b

Thrombocyte count < 50 x 109/l See footnote b

CTC non-haematological Toxicity
(except for alopecia, nausea, vomiting) CTC Grade 3 CTC Grade 4

b

a: TMZ dose levels are listed in Table 2.
b: TMZ is to be discontinued if:
 dose level -1 (100 mg/m2) still results in unacceptable toxicity

 the same Grade 3 non-haematological toxicity (except for alopecia, nausea, vomiting) recurs after dose reduction.

 



49

Adult and paediatric patients 3 years of age or older with recurrent or progressive malignant glioma:

A treatment cycle comprises 28 days. In patients previously untreated with chemotherapy, TMZ is 
administered orally at a dose of 200 mg/m2 once daily for the first 5 days followed by a 23 day 
treatment interruption (total of 28 days). In patients previously treated with chemotherapy, the initial 
dose is 150 mg/m2 once daily, to be increased in the second cycle to 200 mg/m2 once daily, for 5 days 
if there is no haematological toxicity (see section 4.4) 

Special populations

Paediatric population

In patients 3 years of age or older, TMZ is only to be used in recurrent or progressive malignant 
glioma. Experience in these children is very limited (see sections 4.4 and 5.1). The safety and efficacy 
of TMZ in children under the age of 3 years have not been established. No data are available.

Patients with hepatic or renal impairment

The pharmacokinetics of TMZ were comparable in patients with normal hepatic function and in those 
with mild or moderate hepatic impairment. No data are available on the administration of TMZ in 
patients with severe hepatic impairment (Child’s Class C) or with renal impairment. Based on the 
pharmacokinetic properties of TMZ, it is unlikely that dose reductions are required in patients with 
severe hepatic impairment or any degree of renal impairment. However, caution should be exercised 
when TMZ is administered in these patients. 

Elderly patients

Based on a population pharmacokinetic analysis in patients 19-78 years of age, clearance of TMZ is 
not affected by age. However, elderly patients (> 70 years of age) appear to be at increased risk of 
neutropenia and thrombocytopenia (see section 4.4).

Method of administration

Temodal hard capsules should be administered in the fasting state.

The capsules must be swallowed whole with a glass of water and must not be opened or chewed. 

If vomiting occurs after the dose is administered, a second dose should not be administered that day.

4.3 Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

Hypersensitivity to dacarbazine (DTIC).

Severe myelosuppression (see section 4.4).

4.4 Special warnings and precautions for use

Opportunistic infections and reactivation of infections

Opportunistic infections (such as Pneumocystis jirovecii pneumonia) and reactivation of infections 
(such as HBV, CMV) have been observed during the treatment with TMZ (see section 4.8).

Meningoencephalitis herpetic

 



50

In post marketing cases, meningoencephalitis herpetic (including fatal cases) has been observed in 
patients receiving TMZ in combination with radiotherapy, including cases of concomitant steroids 
administration.

Pneumocystis jirovecii pneumonia

Patients who received concomitant TMZ and RT in a pilot trial for the prolonged 42-day schedule 
were shown to be at particular risk for developing Pneumocystis jirovecii pneumonia (PCP). Thus, 
prophylaxis against PCP is required for all patients receiving concomitant TMZ and RT for the 
42-day regimen (with a maximum of 49 days) regardless of lymphocyte count. If lymphopenia occurs, 
they are to continue the prophylaxis until recovery of lymphopenia to grade ≤ 1.

There may be a higher occurrence of PCP when TMZ is administered during a longer dosing regimen. 
However, all patients receiving TMZ, particularly patients receiving steroids, should be observed 
closely for the development of PCP, regardless of the regimen. Cases of fatal respiratory failure have 
been reported in patients using TMZ, in particular in combination with dexamethasone or other 
steroids.

HBV

Hepatitis due to hepatitis B virus (HBV) reactivation, in some cases resulting in death, has been 
reported. Experts in liver disease should be consulted before treatment is initiated in patients with 
positive hepatitis B serology (including those with active disease). During treatment patients should 
be monitored and managed appropriately.

Hepatotoxicity

Hepatic injury, including fatal hepatic failure, has been reported in patients treated with TMZ (see 
section 4.8). Baseline liver function tests should be performed prior to treatment initiation. If 
abnormal, physicians should assess the benefit/risk prior to initiating temozolomide including the 
potential for fatal hepatic failure. For patients on a 42 day treatment cycle liver function tests should 
be repeated midway during this cycle. For all patients, liver function tests should be checked after 
each treatment cycle. For patients with significant liver function abnormalities, physicians should 
assess the benefit/risk of continuing treatment. Liver toxicity may occur several weeks or more after 
the last treatment with temozolomide.

Malignancies

Cases of myelodysplastic syndrome and secondary malignancies, including myeloid leukaemia, have 
also been reported very rarely (see section 4.8).

Anti-emetic therapy

Nausea and vomiting are very commonly associated with TMZ.
Anti-emetic therapy may be administered prior to or following administration of TMZ.

Adult patients with newly-diagnosed glioblastoma multiforme 

Anti-emetic prophylaxis is recommended prior to the initial dose of concomitant phase and it is 
strongly recommended during the monotherapy phase.

Patients with recurrent or progressive malignant glioma

Patients who have experienced severe (Grade 3 or 4) vomiting in previous treatment cycles may 
require anti-emetic therapy.

 



51

Laboratory parameters

Patients treated with TMZ may experience myelosuppression, including prolonged pancytopenia, 
which may result in aplastic anaemia, which in some cases has resulted in a fatal outcome. In some 
cases, exposure to concomitant medicinal products associated with aplastic anaemia, including 
carbamazepine, phenytoin, and sulfamethoxazole/trimethoprim, complicates assessment. Prior to 
dosing, the following laboratory parameters must be met: ANC  1.5 x 109/l and platelet count 
 100 x 109/l. A complete blood count should be obtained on Day 22 (21 days after the first dose) or 
within 48 hours of that day, and weekly until ANC > 1.5 x 109/l and platelet count > 100 x 109/l. If 
ANC falls to < 1.0 x 109/l or the platelet count is < 50 x 109/l during any cycle, the next cycle should 
be reduced one dose level (see section 4.2). Dose levels include 100 mg/m2, 150 mg/m2, and 
200 mg/m2. The lowest recommended dose is 100 mg/m2.

Paediatric population 

There is no clinical experience with use of TMZ in children under the age of 3 years. Experience in 
older children and adolescents is very limited (see sections 4.2 and 5.1).

Elderly patients (> 70 years of age)

Elderly patients appear to be at increased risk of neutropenia and thrombocytopenia, compared with 
younger patients. Therefore, special care should be taken when TMZ is administered in elderly 
patients.

Male patients

Men being treated with TMZ should be advised not to father a child up to 6 months after receiving the 
last dose and to seek advice on cryoconservation of sperm prior to treatment (see section 4.6).

Lactose

This medicinal product contains lactose. Patients with rare hereditary problems of galactose 
intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this 
medicine.

4.5 Interaction with other medicinal products and other forms of interaction

In a separate phase I study, administration of TMZ with ranitidine did not result in alterations in the 
extent of absorption of temozolomide or the exposure to its active metabolite monomethyl 
triazenoimidazole carboxamide (MTIC). 

Administration of TMZ with food resulted in a 33 % decrease in Cmax and a 9 % decrease in area 
under the curve (AUC). 
As it cannot be excluded that the change in Cmax is clinically significant, Temodal should be 
administered without food.

Based on an analysis of population pharmacokinetics in phase II trials, co-administration of 
dexamethasone, prochlorperazine, phenytoin, carbamazepine, ondansetron, H2 receptor antagonists, or 
phenobarbital did not alter the clearance of TMZ. Co-administration with valproic acid was associated 
with a small but statistically significant decrease in clearance of TMZ.

No studies have been conducted to determine the effect of TMZ on the metabolism or elimination of 
other medicinal products. However, since TMZ does not undergo hepatic metabolism and exhibits 
low protein binding, it is unlikely that it would affect the pharmacokinetics of other medicinal 
products (see section 5.2).

 



52

Use of TMZ in combination with other myelosuppressive agents may increase the likelihood of 
myelosuppression. 

Paediatric population

Interaction studies have only been performed in adults.

4.6 Fertility, pregnancy and lactation 

Pregnancy

There are no data in pregnant women. In preclinical studies in rats and rabbits receiving 150 mg/m2 

TMZ, teratogenicity and/or foetal toxicity were demonstrated (see section 5.3). Temodal should not 
be administered to pregnant women. If use during pregnancy must be considered, the patient should 
be apprised of the potential risk to the foetus. 

Breast-feeding

It is not known whether TMZ is excreted in human milk; thus, breast-feeding should be discontinued 
while receiving treatment with TMZ. 

Women of childbearing potential

Women of childbearing potential should be advised to use effective contraception to avoid pregnancy 
while they are receiving TMZ.

Male fertility

TMZ can have genotoxic effects. Therefore, men being treated with it should be advised not to father 
a child up to 6 months after receiving the last dose and to seek advice on cryoconservation of sperm 
prior to treatment, because of the possibility of irreversible infertility due to therapy with TMZ.

4.7 Effects on ability to drive and use machines

TMZ has minor influence on the ability to drive and use machines due to fatigue and somnolence (see 
section 4.8). 

4.8 Undesirable effects 

Summary of the safety profile

Clinical trial experience

In patients treated with TMZ in clinical trials, the most common adverse reactions were nausea, 
vomiting, constipation, anorexia, headache, fatigue, convulsions, and rash. Most haematologic 
adverse reactions were reported commonly; the frequency of Grade 3-4 laboratory findings is 
presented after Table 4.

For patients with recurrent or progressive glioma, nausea (43 %) and vomiting (36 %) were usually 
Grade 1 or 2 (0 – 5 episodes of vomiting in 24 hours) and were either self-limiting or readily 
controlled with standard anti-emetic therapy. The incidence of severe nausea and vomiting was 4 %.

Tabulated list of adverse reactions
Adverse reactions observed in clinical studies and reported from post-marketing use of TMZ are listed
in Table 4. These reactions are classified according to System Organ Class and frequency. Frequency 
groupings are defined according to the following convention: Very common (≥ 1/10); Common 

 



53

(≥ 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). Within each frequency 
grouping, undesirable effects are presented in order of decreasing seriousness.

Table 4. Adverse reactions in patients treated with temozolomide

Infections and infestations

Common: Infections, herpes zoster, pharyngitisa, candidiasis oral

Uncommon: Opportunistic infection (including PCP), sepsis†, 
meningoencephalitis herpetic†, CMV infection, CMV 
reactivation, hepatitis B virus†, herpes simplex, infection 
reactivation, wound infection, gastroenteritisb

Neoplasm benign, malignant, and unspecified

Uncommon: Myelodysplastic syndrome (MDS), secondary 
malignancies, including myeloid leukaemia

Blood and lymphatic system disorders

Common: Febrile neutropenia, neutropenia, thrombocytopenia, 
lymphopenia, leukopenia, anaemia

Uncommon: Prolonged pancytopenia, aplastic anaemia†, 
pancytopenia, petechiae

Immune system disorders

Common: Allergic reaction

Uncommon: Anaphylaxis

Endocrine disorders

Common: Cushingoidc

Uncommon: Diabetes insipidus

Metabolism and nutrition disorders

Very common: Anorexia
Common: Hyperglycaemia

Uncommon: Hypokalaemia, alkaline phosphatase increased

Psychiatric disorders

Common: Agitation, amnesia, depression, anxiety, confusion, 
insomnia

Uncommon: Behaviour disorder, emotional lability, hallucination, 
apathy

Nervous system disorders

Very common: Convulsions, hemiparesis, aphasia/dysphasia, headache
Common: Ataxia, balance impaired, cognition impaired, 

concentration impaired, consciousness decreased, 
dizziness, hypoesthesia, memory impaired, neurologic 
disorder, neuropathyd, paraesthesia, somnolence, speech 
disorder, taste perversion, tremor

Uncommon: Status epilepticus, hemiplegia, extrapyramidal disorder, 
parosmia, gait abnormality, hyperaesthesia, sensory 
disturbance, coordination abnormal

Eye disorders

Common: Hemianopia, vision blurred, vision disordere, visual field 
defect, diplopia, eye pain

Uncommon: Visual acuity reduced, eyes dry

 



54

Table 4. Adverse reactions in patients treated with temozolomide

Ear and labyrinth disorders

Common: Deafnessf, vertigo, tinnitus, earacheg

Uncommon: Hearing impairment, hyperacusis, otitis media

Cardiac disorders

Uncommon: Palpitation

Vascular disorders

Common: Haemorrhage, embolism pulmonary, deep vein 
thrombosis, hypertension 

Uncommon: Cerebral haemorrhage, flushing, hot flushes

Respiratory, thoracic and mediastinal disorders

Common: Pneumonia, dyspnoea, sinusitis, bronchitis, coughing, 
upper respiratory infection

Uncommon: Respiratory failure†, interstitial 
pneumonitis/pneumonitis, pulmonary fibrosis, nasal 
congestion

Gastrointestinal disorders

Very common: Diarrhoea, constipation, nausea, vomiting
Common: Stomatitis, abdominal painh, dyspepsia, dysphagia 

Uncommon: Abdominal distension, faecal incontinence, 
gastrointestinal disorder, haemorrhoids, mouth dry

Hepatobiliary disorders

Uncommon: Hepatic failure†, hepatic injury, hepatitis, cholestasis, 
hyperbilirubinemia

Skin and subcutaneous tissue disorders

Very Common: Rash, alopecia
Common: Erythema, dry skin, pruritus
Uncommon: Toxic epidermal necrolysis, Stevens-Johnson syndrome, 

angioedema, erythema multiforme, erythroderma, skin 
exfoliation, photosensitivity reaction, urticaria, 
exanthema, dermatitis, sweating increased, pigmentation 
abnormal

Not known: Drug reaction with eosinophilia and systemic symptoms 
(DRESS)

Musculoskeletal and connective tissue disorders

Common: Myopathy, muscle weakness, arthralgia, back pain, 
musculoskeletal pain, myalgia 

Renal and urinary disorders

Common: Micturition frequency, urinary incontinence 

Uncommon: Dysuria

Reproductive system and breast disorders

Uncommon: Vaginal haemorrhage, menorrhagia, amenorrhoea, 
vaginitis, breast pain, impotence

General disorders and administration site conditions

Very common: Fatigue
Common: Fever, influenza-like symptoms, asthenia, malaise, pain, 

oedema, oedema peripherali

 



55

Table 4. Adverse reactions in patients treated with temozolomide

Uncommon: Condition aggravated, rigors, face oedema, tongue
discolouration, thirst, tooth disorder

Investigations

Common: Liver enzymes elevationj, weight decreased, weight 
increased

Uncommon: Gamma-glutamyltransferase increased

Injury, poisoning and procedural complications 

Common: Radiation injuryk

a Includes pharyngitis, nasopharyngeal pharyngitis, pharyngitis Streptococcal 
b Includes gastroenteritis, gastroenteritis viral
c Includes cushingoid, Cushing syndrome
d Includes neuropathy, peripheral neuropathy, polyneuropathy, peripheral sensory neuropathy, 
peripheral motor neuropathy
e Includes visual impairment, eye disorder
f Includes deafness, deafness bilateral, deafness neurosensory, deafness unilateral
g Includes earache, ear discomfort
h Includes abdominal pain, abdominal pain lower, abdominal pain upper, abdominal discomfort
i Includes oedema peripheral, peripheral swelling
j Includes liver function test increased, alanine aminotransferase increased, aspartate aminotransferase 
increased, hepatic enzymes increased
k Includes radiation injury, radiation skin injury
† Including cases with fatal outcome

Newly-diagnosed glioblastoma multiforme

Laboratory results

Myelosuppression (neutropenia and thrombocytopenia), which is known dose-limiting toxicity for 
most cytotoxic agents, including TMZ, was observed. When laboratory abnormalities and adverse 
events were combined across concomitant and monotherapy treatment phases, Grade 3 or Grade 4 
neutrophil abnormalities including neutropenic events were observed in 8 % of the patients. Grade 3 
or Grade 4 thrombocyte abnormalities, including thrombocytopenic events were observed in 14 % of 
the patients who received TMZ. 

Recurrent or progressive malignant glioma

Laboratory results

Grade 3 or 4 thrombocytopenia and neutropenia occurred in 19 % and 17 % respectively, of patients 
treated for malignant glioma. This led to hospitalisation and/or discontinuation of TMZ in 8 % and 
4 %, respectively. Myelosuppression was predictable (usually within the first few cycles, with the 
nadir between Day 21 and Day 28), and recovery was rapid, usually within 1-2 weeks. No evidence of 
cumulative myelosuppression was observed. The presence of thrombocytopenia may increase the risk 
of bleeding, and the presence of neutropenia or leukopenia may increase the risk of infection.

Gender

In a population pharmacokinetics analysis of clinical trial experience there were 101 female and 
169 male subjects for whom nadir neutrophil counts were available and 110 female and 174 male 
subjects for whom nadir platelet counts were available. There were higher rates of Grade 4 
neutropenia (ANC < 0.5 x 109/l), 12 % vs 5 %, and thrombocytopenia (< 20 x 109/l ), 9 % vs 3 %, in 
women vs men in the first cycle of therapy. In a 400 subject recurrent glioma data set, Grade 4 
neutropenia occurred in 8 % of female vs 4 % of male subjects and Grade 4 thrombocytopenia in 8 % 

 



56

of female vs 3 % of male subjects in the first cycle of therapy. In a study of 288 subjects with newly-
diagnosed glioblastoma multiforme, Grade 4 neutropenia occurred in 3 % of female vs 0 % of male 
subjects and Grade 4 thrombocytopenia in 1 % of female vs 0 % of male subjects in the first cycle of 
therapy.

Paediatric population

Oral TMZ has been studied in paediatric patients (age 3-18 years) with recurrent brainstem glioma or 
recurrent high grade astrocytoma, in a regimen administered daily for 5 days every 28 days. Although 
the data is limited, tolerance in children is expected to be the same as in adults. The safety of TMZ in 
children under the age of 3 years has not been established.

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 national reporting system 
listed in Appendix V.

4.9 Overdose

Doses of 500, 750, 1,000, and 1,250 mg/m2 (total dose per cycle over 5 days) have been evaluated 
clinically in patients. Dose-limiting toxicity was haematological and was reported with any dose but is 
expected to be more severe at higher doses. An overdose of 10,000 mg (total dose in a single cycle, 
over 5 days) was taken by one patient and the adverse reactions reported were pancytopenia, pyrexia, 
multi-organ failure and death. There are reports of patients who have taken the recommended dose for 
more than 5 days of treatment (up to 64 days) with adverse events reported including bone marrow 
suppression, with or without infection, in some cases severe and prolonged and resulting in death. In 
the event of an overdose, haematological evaluation is needed. Supportive measures should be 
provided as necessary.

5. PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Antineoplastic agents - Other alkylating agents, ATC code: L01A X03

Mechanism of action

Temozolomide is a triazene, which undergoes rapid chemical conversion at physiologic pH to the 
active monomethyl triazenoimidazole carboxamide (MTIC). The cytotoxicity of MTIC is thought to 
be due primarily to alkylation at the O6 position of guanine with additional alkylation also occurring 
at the N7 position. Cytotoxic lesions that develop subsequently are thought to involve aberrant repair 
of the methyl adduct.

Clinical efficacy and safety

Newly-diagnosed glioblastoma multiforme

A total of 573 patients were randomised to receive either TMZ + RT (n=287) or RT alone (n=286). 
Patients in the TMZ + RT arm received concomitant TMZ (75 mg/m2) once daily, starting the first 
day of RT until the last day of RT, for 42 days (with a maximum of 49 days). This was followed by 
monotherapy TMZ (150 - 200 mg/m2) on Days 1 - 5 of every 28-day cycle for up to 6 cycles, starting 
4 weeks after the end of RT. Patients in the control arm received RT only. Pneumocystis jirovecii
pneumonia (PCP) prophylaxis was required during RT and combined TMZ therapy.

 

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57

TMZ was administered as salvage therapy in the follow-up phase in 161 patients of the 282 (57 %) in 
the RT alone arm, and 62 patients of the 277 (22 %) in the TMZ + RT arm.

The hazard ratio (HR) for overall survival was 1.59 (95 % CI for HR=1.33 -1.91) with a log-rank 
p < 0.0001 in favour of the TMZ arm. The estimated probability of surviving 2 years or more (26 % 
vs 10 %) is higher for the RT + TMZ arm. The addition of concomitant TMZ to RT, followed by 
TMZ monotherapy in the treatment of patients with newly-diagnosed glioblastoma multiforme 
demonstrated a statistically significant improvement in overall survival (OS) compared with RT alone 
(Figure 1).

Figure 1 Kaplan-Meier curves for overall survival (intent-to-treat population)

The results from the trial were not consistent in the subgroup of patients with a poor performance 
status (WHO PS=2, n=70), where overall survival and time to progression were similar in both arms. 
However, no unacceptable risks appear to be present in this patient group.

Recurrent or progressive malignant glioma

Data on clinical efficacy in patients with glioblastoma multiforme (Karnofsky performance status 
[KPS]  70), progressive or recurrent after surgery and RT, were based on two clinical trials with oral 
TMZ. One was a non-comparative trial in 138 patients (29 % received prior chemotherapy), and the 
other was a randomised active-controlled trial of TMZ vs procarbazine in a total of 225 patients (67 % 
received prior treatment with nitrosourea based chemotherapy). In both trials, the primary endpoint 
was progression-free survival (PFS) defined by MRI scans or neurological worsening. In the non-
comparative trial, the PFS at 6 months was 19 %, the median progression-free survival was 
2.1 months, and the median overall survival 5.4 months. The objective response rate (ORR) based on 
MRI scans was 8 %.

In the randomised active-controlled trial, the PFS at 6 months was significantly greater for TMZ than 
for procarbazine (21 % vs 8 %, respectively – chi-square p = 0.008) with median PFS of 2.89 and 
1.88 months respectively (log rank p = 0.0063). The median survival was 7.34 and 5.66 months for 
TMZ and procarbazine, respectively (log rank p = 0.33). At 6 months, the fraction of surviving 
patients was significantly higher in the TMZ arm (60 %) compared with the procarbazine arm (44 %) 
(chi-square p = 0.019). In patients with prior chemotherapy a benefit was indicated in those with a 
KPS  80.

H R  (95%  C .I.) =  1 .59 (1 .33  – 1 .91)
log-rank p -value  <  .0001

12.1 14.6

RT+TM Z

RT O n ly

26%

10%

 



58

Data on time to worsening of neurological status favoured TMZ over procarbazine as did data on time 
to worsening of performance status (decrease to a KPS of < 70 or a decrease by at least 30 points). 
The median times to progression in these endpoints ranged from 0.7 to 2.1 months longer for TMZ 
than for procarbazine (log rank p = < 0.01 to 0.03). 

Recurrent anaplastic astrocytoma

In a multicentre, prospective phase II trial evaluating the safety and efficacy of oral TMZ in the 
treatment of patients with anaplastic astrocytoma at first relapse, the 6 month PFS was 46 %. The 
median PFS was 5.4 months. Median overall survival was 14.6 months. Response rate, based on the 
central reviewer assessment, was 35 % (13 CR and 43 PR) for the intent-to-treat population (ITT) 
n=162. In 43 patients stable disease was reported. The 6-month event-free survival for the ITT 
population was 44 % with a median event-free survival of 4.6 months, which was similar to the results
for the progression-free survival. For the eligible histology population, the efficacy results were 
similar. Achieving a radiological objective response or maintaining progression-free status was 
strongly associated with maintained or improved quality of life.

Paediatric population

Oral TMZ has been studied in paediatric patients (age 3-18 years) with recurrent brainstem glioma or 
recurrent high grade astrocytoma, in a regimen administered daily for 5 days every 28 days. Tolerance 
to TMZ is similar to adults.

5.2 Pharmacokinetic properties 

TMZ is spontaneously hydrolyzed at physiologic pH primarily to the active species, 3-methyl-
(triazen-1-yl)imidazole-4-carboxamide (MTIC). MTIC is spontaneously hydrolyzed to 5-amino-
imidazole-4-carboxamide (AIC), a known intermediate in purine and nucleic acid biosynthesis, and to 
methylhydrazine, which is believed to be the active alkylating species. The cytotoxicity of MTIC is 
thought to be primarily due to alkylation of DNA mainly at the O6 and N7 positions of guanine. 
Relative to the AUC of TMZ, the exposure to MTIC and AIC is ~ 2.4 % and 23 %, respectively. In 
vivo, the t1/2 of MTIC was similar to that of TMZ, 1.8 hr.

Absorption

After oral administration to adult patients, TMZ is absorbed rapidly, with peak concentrations reached 
as early as 20 minutes post-administration (mean time between 0.5 and 1.5 hours). After oral 
administration of 14C-labelled TMZ, mean faecal excretion of 14C over 7 days post-dose was 0.8 % 
indicating complete absorption.

Distribution

TMZ demonstrates low protein binding (10 % to 20 %), and thus it is not expected to interact with 
highly protein-bound substances.

PET studies in humans and preclinical data suggest that TMZ crosses the blood-brain barrier rapidly 
and is present in the CSF. CSF penetration was confirmed in one patient; CSF exposure based on 
AUC of TMZ was approximately 30 % of that in plasma, which is consistent with animal data.

Elimination

The half-life (t1/2) in plasma is approximately 1.8 hours. The major route of 
14C elimination is renal. 

Following oral administration, approximately 5 % to 10 % of the dose is recovered unchanged in the 
urine over 24 hours, and the remainder excreted as temozolomide acid, 5-aminoimidazole-4-
carboxamide (AIC) or unidentified polar metabolites.

 



59

Plasma concentrations increase in a dose-related manner. Plasma clearance, volume of distribution 
and half-life are independent of dose. 

Special populations

Analysis of population-based pharmacokinetics of TMZ revealed that plasma TMZ clearance was 
independent of age, renal function or tobacco use. In a separate pharmacokinetic study, plasma 
pharmacokinetic profiles in patients with mild to moderate hepatic impairment were similar to those 
observed in patients with normal hepatic function.

Paediatric patients had a higher AUC than adult patients; however, the maximum tolerated dose 
(MTD) was 1,000 mg/m2 per cycle both in children and in adults.

5.3 Preclinical safety data

Single-cycle (5-day dosing, 23 days non-treatment), 3- and 6-cycle toxicity studies were conducted in 
rats and dogs. The primary targets of toxicity included the bone marrow, lymphoreticular system, 
testes, the gastrointestinal tract and, at higher doses, which were lethal to 60 % to 100 % of rats and 
dogs tested, degeneration of the retina occurred. Most of the toxicity showed evidence of reversibility, 
except for adverse events on the male reproductive system and retinal degeneration. However, 
because the doses implicated in retinal degeneration were in the lethal dose range, and no comparable 
effect has been observed in clinical studies, this finding was not considered to have clinical relevance.

TMZ is an embryotoxic, teratogenic and genotoxic alkylating agent. TMZ is more toxic to the rat and 
dog than to humans, and the clinical dose approximates the minimum lethal dose in rats and dogs. 
Dose-related reductions in leukocytes and platelets appear to be sensitive indicators of toxicity. A 
variety of neoplasms, including mammary carcinomas, keratocanthoma of the skin and basal cell 
adenoma were observed in the 6-cycle rat study while no tumours or pre-neoplastic changes were 
evident in dog studies. Rats appear to be particularly sensitive to oncogenic effects of TMZ, with the 
occurrence of first tumours within 3 months of initiating dosing. This latency period is very short 
even for an alkylating agent.

Results of the Ames/salmonella and Human Peripheral Blood Lymphocyte (HPBL) chromosome 
aberration tests showed a positive mutagenicity response.

6. PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Capsule content:
anhydrous lactose, 
colloidal anhydrous silica, 
sodium starch glycolate type A,
tartaric acid, 
stearic acid. 

Capsule shell: 
gelatin, 
titanium dioxide (E 171), 
sodium lauril sulfate ,
indigo carmine (E 132), 

Printing ink: 
shellac, 
propylene glycol, 

 



60

purified water, 
ammonium hydroxide, 
potassium hydroxide, 
black iron oxide (E 172).

6.2 Incompatibilities

Not applicable.

6.3 Shelf life

3 years

6.4 Special precautions for storage

Bottle presentation

Do not store above 30 C.
Store in the original bottle in order to protect from moisture.
Keep the bottle tightly closed.

Sachet presentation

Do not store above 30 C.

6.5 Nature and contents of container

Bottle presentation

Type I amber glass bottles with polypropylene child-resistant closures containing 5 or 20 hard 
capsules.
The carton contains one bottle.

Sachet presentation

Sachets are composed of linear low density polyethylene (innermost layer), aluminium and 
polyethylene terephthalate.
Each sachet contains 1 hard capsule and is dispensed in a cardboard carton.
The carton contains 5 or 20 hard capsules, individually sealed in sachets.

Not all pack sizes may be marketed.

6.6 Special precautions for disposal and other handling

Capsules should not be opened. If a capsule becomes damaged, contact of the powder contents with 
skin or mucous membrane must be avoided. If Temodal comes into contact with skin or mucosa, it 
should be washed immediately and thoroughly with soap and water. 

Patients should be advised to keep capsules out of the sight and reach of children, preferably in a 
locked cupboard. Accidental ingestion can be lethal for children.

Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements.

 



61

7. MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

8. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/009
EU/1/98/096/010
EU/1/98/096/017
EU/1/98/096/018

9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

Date of first authorisation: 26 January 1999
Date of latest renewal: 26 January 2009

10. DATE OF REVISION OF THE TEXT

Detailed information on this medicinal product is available on the website of the European Medicines 
Agency http://www.ema.europa.eu.

 

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62

1. NAME OF THE MEDICINAL PRODUCT

Temodal 180 mg hard capsules

2. QUALITATIVE AND QUANTITATIVE COMPOSITION

Each hard capsule contains 180 mg temozolomide.

Excipient with known effect: 
Each hard capsule contains 316.3 mg of anhydrous lactose. 

For the full list of excipients, see section 6.1.

3. PHARMACEUTICAL FORM

Hard capsule (capsule).

The hard capsules have an opaque white body, an opaque orange cap, and are imprinted with black 
ink. The cap is imprinted with “Temodal”. The body is imprinted with "180 mg", the Schering-Plough 
logo and two stripes.

4. CLINICAL PARTICULARS

4.1 Therapeutic indications

Temodal is indicated for the treatment of:
- adult patients with newly-diagnosed glioblastoma multiforme concomitantly with radiotherapy 

(RT) and subsequently as monotherapy treatment.
- children from the age of three years, adolescents and adult patients with malignant glioma, such 

as glioblastoma multiforme or anaplastic astrocytoma, showing recurrence or progression after 
standard therapy.

4.2 Posology and method of administration

Temodal should only be prescribed by physicians experienced in the oncological treatment of brain 
tumours.

Anti-emetic therapy may be administered (see section 4.4).

Posology

Adult patients with newly-diagnosed glioblastoma multiforme

Temodal is administered in combination with focal radiotherapy (concomitant phase) followed by up 
to 6 cycles of temozolomide (TMZ) monotherapy (monotherapy phase).

Concomitant phase 

TMZ is administered orally at a dose of 75 mg/m2 daily for 42 days concomitant with focal 
radiotherapy (60 Gy administered in 30 fractions). No dose reductions are recommended, but delay or 
discontinuation of TMZ administration should be decided weekly according to haematological and 
non-haematological toxicity criteria. TMZ administration can be continued throughout the 42 day 
concomitant period (up to 49 days) if all of the following conditions are met: 

 



63

- absolute neutrophil count (ANC) ≥ 1.5 x 109/l
- thrombocyte count ≥ 100 x 109/l
- common toxicity criteria (CTC) non-haematological toxicity ≤ Grade 1 (except for alopecia, 

nausea and vomiting). 
During treatment a complete blood count should be obtained weekly. TMZ administration should be 
temporarily interrupted or permanently discontinued during the concomitant phase according to the 
haematological and non-haematological toxicity criteria as noted in Table 1.

Table 1. TMZ dosing interruption or discontinuation during

concomitant radiotherapy and TMZ

Toxicity TMZ interruptiona TMZ discontinuation

Absolute neutrophil count  0.5 and < 1.5 x 109/l < 0.5 x 10
9/l

Thrombocyte count  10 and < 100 x 109/l < 10 x 10
9/l

CTC non-haematological toxicity
(except for alopecia, nausea, vomiting)

CTC Grade 2 CTC Grade 3 or 4

a: Treatment with concomitant TMZ can be continued when all of the following conditions are met: absolute neutrophil 
count  1.5 x 109/l; thrombocyte count  100 x 109/l; CTC non-haematological toxicity  Grade 1 (except for alopecia, 
nausea, vomiting).

Monotherapy phase

Four weeks after completing the TMZ + RT concomitant phase, TMZ is administered for up to 
6 cycles of monotherapy treatment. Dose in Cycle 1 (monotherapy) is 150 mg/m2 once daily for 
5 days followed by 23 days without treatment. At the start of Cycle 2, the dose is escalated to 
200 mg/m2 if the CTC non-haematological toxicity for Cycle 1 is Grade ≤ 2 (except for alopecia, 
nausea and vomiting), absolute neutrophil count (ANC) is ≥ 1.5 x 109/l, and the thrombocyte count is 
≥ 100 x 109/l. If the dose was not escalated at Cycle 2, escalation should not be done in subsequent 
cycles. Once escalated, the dose remains at 200 mg/m2 per day for the first 5 days of each subsequent 
cycle except if toxicity occurs. Dose reductions and discontinuations during the monotherapy phase 
should be applied according to Tables 2 and 3.

During treatment a complete blood count should be obtained on Day 22 (21 days after the first dose of 
TMZ). The dose should be reduced or administration discontinued according to Table 3.

Table 2. TMZ dose levels for monotherapy treatment

Dose level TMZ dose 
(mg/m2/day)

Remarks

–1 100 Reduction for prior toxicity 

0 150 Dose during Cycle 1

1 200 Dose during Cycles 2-6 in absence of toxicity

Table 3. TMZ dose reduction or discontinuation during monotherapy treatment

Toxicity Reduce TMZ by 1 dose levela Discontinue TMZ

Absolute neutrophil count < 1.0 x 109/l See footnote b

Thrombocyte count < 50 x 109/l See footnote b

CTC non-haematological Toxicity
(except for alopecia, nausea, vomiting) CTC Grade 3 CTC Grade 4

b

a: TMZ dose levels are listed in Table 2.
b: TMZ is to be discontinued if:
 dose level -1 (100 mg/m2) still results in unacceptable toxicity

 the same Grade 3 non-haematological toxicity (except for alopecia, nausea, vomiting) recurs after dose reduction.

 



64

Adult and paediatric patients 3 years of age or older with recurrent or progressive malignant glioma:

A treatment cycle comprises 28 days. In patients previously untreated with chemotherapy, TMZ is 
administered orally at a dose of 200 mg/m2 once daily for the first 5 days followed by a 23 day 
treatment interruption (total of 28 days). In patients previously treated with chemotherapy, the initial 
dose is 150 mg/m2 once daily, to be increased in the second cycle to 200 mg/m2 once daily, for 5 days 
if there is no haematological toxicity (see section 4.4) 

Special populations

Paediatric population

In patients 3 years of age or older, TMZ is only to be used in recurrent or progressive malignant 
glioma. Experience in these children is very limited (see sections 4.4 and 5.1). The safety and efficacy 
of TMZ in children under the age of 3 years have not been established. No data are available.

Patients with hepatic or renal impairment

The pharmacokinetics of TMZ were comparable in patients with normal hepatic function and in those 
with mild or moderate hepatic impairment. No data are available on the administration of TMZ in 
patients with severe hepatic impairment (Child’s Class C) or with renal impairment. Based on the 
pharmacokinetic properties of TMZ, it is unlikely that dose reductions are required in patients with 
severe hepatic impairment or any degree of renal impairment. However, caution should be exercised 
when TMZ is administered in these patients. 

Elderly patients

Based on a population pharmacokinetic analysis in patients 19-78 years of age, clearance of TMZ is 
not affected by age. However, elderly patients (> 70 years of age) appear to be at increased risk of 
neutropenia and thrombocytopenia (see section 4.4).

Method of administration

Temodal hard capsules should be administered in the fasting state.

The capsules must be swallowed whole with a glass of water and must not be opened or chewed. 

If vomiting occurs after the dose is administered, a second dose should not be administered that day.

4.3 Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

Hypersensitivity to dacarbazine (DTIC).

Severe myelosuppression (see section 4.4).

4.4 Special warnings and precautions for use

Opportunistic infections and reactivation of infections

Opportunistic infections (such as Pneumocystis jirovecii pneumonia) and reactivation of infections 
(such as HBV, CMV) have been observed during the treatment with TMZ (see section 4.8).

Meningoencephalitis herpetic

 



65

In post marketing cases, meningoencephalitis herpetic (including fatal cases) has been observed in 
patients receiving TMZ in combination with radiotherapy, including cases of concomitant steroids 
administration.

Pneumocystis jirovecii pneumonia

Patients who received concomitant TMZ and RT in a pilot trial for the prolonged 42-day schedule 
were shown to be at particular risk for developing Pneumocystis jirovecii pneumonia (PCP). Thus, 
prophylaxis against PCP is required for all patients receiving concomitant TMZ and RT for the 42-
day regimen (with a maximum of 49 days) regardless of lymphocyte count. If lymphopenia occurs, 
they are to continue the prophylaxis until recovery of lymphopenia to grade ≤ 1.

There may be a higher occurrence of PCP when TMZ is administered during a longer dosing regimen. 
However, all patients receiving TMZ, particularly patients receiving steroids, should be observed 
closely for the development of PCP, regardless of the regimen. Cases of fatal respiratory failure have 
been reported in patients using TMZ, in particular in combination with dexamethasone or other 
steroids.

HBV

Hepatitis due to hepatitis B virus (HBV) reactivation, in some cases resulting in death, has been 
reported. Experts in liver disease should be consulted before treatment is initiated in patients with 
positive hepatitis B serology (including those with active disease). During treatment patients should 
be monitored and managed appropriately.

Hepatotoxicity

Hepatic injury, including fatal hepatic failure, has been reported in patients treated with TMZ (see 
section 4.8). Baseline liver function tests should be performed prior to treatment initiation. If 
abnormal, physicians should assess the benefit/risk prior to initiating temozolomide including the 
potential for fatal hepatic failure. For patients on a 42 day treatment cycle liver function tests should 
be repeated midway during this cycle. For all patients, liver function tests should be checked after 
each treatment cycle. For patients with significant liver function abnormalities, physicians should 
assess the benefit/risk of continuing treatment. Liver toxicity may occur several weeks or more after 
the last treatment with temozolomide.

Malignancies

Cases of myelodysplastic syndrome and secondary malignancies, including myeloid leukaemia, have 
also been reported very rarely (see section 4.8).

Anti-emetic therapy

Nausea and vomiting are very commonly associated with TMZ.
Anti-emetic therapy may be administered prior to or following administration of TMZ.

Adult patients with newly-diagnosed glioblastoma multiforme 

Anti-emetic prophylaxis is recommended prior to the initial dose of concomitant phase and it is 
strongly recommended during the monotherapy phase.

Patients with recurrent or progressive malignant glioma

Patients who have experienced severe (Grade 3 or 4) vomiting in previous treatment cycles may 
require anti-emetic therapy.

 



66

Laboratory parameters

Patients treated with TMZ may experience myelosuppression, including prolonged pancytopenia, 
which may result in aplastic anaemia, which in some cases has resulted in a fatal outcome. In some 
cases, exposure to concomitant medicinal products associated with aplastic anaemia, including 
carbamazepine, phenytoin, and sulfamethoxazole/trimethoprim, complicates assessment. Prior to 
dosing, the following laboratory parameters must be met: ANC  1.5 x 109/l and platelet count 
 100 x 109/l. A complete blood count should be obtained on Day 22 (21 days after the first dose) or 
within 48 hours of that day, and weekly until ANC > 1.5 x 109/l and platelet count > 100 x 109/l. If 
ANC falls to < 1.0 x 109/l or the platelet count is < 50 x 109/l during any cycle, the next cycle should 
be reduced one dose level (see section 4.2). Dose levels include 100 mg/m2, 150 mg/m2, and 
200 mg/m2. The lowest recommended dose is 100 mg/m2.

Paediatric population 

There is no clinical experience with use of TMZ in children under the age of 3 years. Experience in 
older children and adolescents is very limited (see sections 4.2 and 5.1).

Elderly patients (> 70 years of age)

Elderly patients appear to be at increased risk of neutropenia and thrombocytopenia, compared with 
younger patients. Therefore, special care should be taken when TMZ is administered in elderly 
patients.

Male patients

Men being treated with TMZ should be advised not to father a child up to 6 months after receiving the 
last dose and to seek advice on cryoconservation of sperm prior to treatment (see section 4.6).

Lactose

This medicinal product contains lactose. Patients with rare hereditary problems of galactose 
intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this 
medicine.

4.5 Interaction with other medicinal products and other forms of interaction

In a separate phase I study, administration of TMZ with ranitidine did not result in alterations in the 
extent of absorption of temozolomide or the exposure to its active metabolite monomethyl 
triazenoimidazole carboxamide (MTIC). 

Administration of TMZ with food resulted in a 33 % decrease in Cmax and a 9 % decrease in area 
under the curve (AUC). 
As it cannot be excluded that the change in Cmax is clinically significant, Temodal should be 
administered without food.

Based on an analysis of population pharmacokinetics in phase II trials, co-administration of 
dexamethasone, prochlorperazine, phenytoin, carbamazepine, ondansetron, H2 receptor antagonists, or 
phenobarbital did not alter the clearance of TMZ. Co-administration with valproic acid was associated 
with a small but statistically significant decrease in clearance of TMZ.

No studies have been conducted to determine the effect of TMZ on the metabolism or elimination of 
other medicinal products. However, since TMZ does not undergo hepatic metabolism and exhibits 
low protein binding, it is unlikely that it would affect the pharmacokinetics of other medicinal 
products (see section 5.2).

 



67

Use of TMZ in combination with other myelosuppressive agents may increase the likelihood of 
myelosuppression. 

Paediatric population

Interaction studies have only been performed in adults.

4.6 Fertility, pregnancy and lactation 

Pregnancy

There are no data in pregnant women. In preclinical studies in rats and rabbits receiving 150 mg/m2 

TMZ, teratogenicity and/or foetal toxicity were demonstrated (see section 5.3). Temodal should not 
be administered to pregnant women. If use during pregnancy must be considered, the patient should 
be apprised of the potential risk to the foetus. 

Breast-feeding

It is not known whether TMZ is excreted in human milk; thus, breast-feeding should be discontinued 
while receiving treatment with TMZ. 

Women of childbearing potential

Women of childbearing potential should be advised to use effective contraception to avoid pregnancy 
while they are receiving TMZ.

Male fertility

TMZ can have genotoxic effects. Therefore, men being treated with it should be advised not to father 
a child up to 6 months after receiving the last dose and to seek advice on cryoconservation of sperm 
prior to treatment, because of the possibility of irreversible infertility due to therapy with TMZ.

4.7 Effects on ability to drive and use machines

TMZ has minor influence on the ability to drive and use machines due to fatigue and somnolence (see 
section 4.8). 

4.8 Undesirable effects 

Summary of the safety profile

Clinical trial experience

In patients treated with TMZ in clinical trials, the most common adverse reactions were nausea, 
vomiting, constipation, anorexia, headache, fatigue, convulsions, and rash. Most haematologic 
adverse reactions were reported commonly; the frequency of Grade 3-4 laboratory findings is 
presented after Table 4.

For patients with recurrent or progressive glioma, nausea (43 %) and vomiting (36 %) were usually 
Grade 1 or 2 (0 – 5 episodes of vomiting in 24 hours) and were either self-limiting or readily 
controlled with standard anti-emetic therapy. The incidence of severe nausea and vomiting was 4 %.

Tabulated list of adverse reactions
Adverse reactions observed in clinical studies and reported from post-marketing use of TMZ are listed
in Table 4. These reactions are classified according to System Organ Class and frequency. Frequency 
groupings are defined according to the following convention: Very common (≥ 1/10); Common 

 



68

(≥ 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). Within each frequency 
grouping, undesirable effects are presented in order of decreasing seriousness.

Table 4. Adverse reactions in patients treated with temozolomide

Infections and infestations

Common: Infections, herpes zoster, pharyngitisa, candidiasis oral

Uncommon: Opportunistic infection (including PCP), sepsis†,
meningoencephalitis herpetic†, CMV infection, CMV 
reactivation, hepatitis B virus†, herpes simplex, infection 
reactivation, wound infection, gastroenteritisb

Neoplasm benign, malignant, and unspecified

Uncommon: Myelodysplastic syndrome (MDS), secondary
malignancies, including myeloid leukaemia

Blood and lymphatic system disorders

Common: Febrile neutropenia, neutropenia, thrombocytopenia, 
lymphopenia, leukopenia, anaemia

Uncommon: Prolonged pancytopenia, aplastic anaemia†, 
pancytopenia, petechiae

Immune system disorders

Common: Allergic reaction

Uncommon: Anaphylaxis

Endocrine disorders

Common: Cushingoidc

Uncommon: Diabetes insipidus

Metabolism and nutrition disorders

Very common: Anorexia
Common: Hyperglycaemia

Uncommon: Hypokalaemia, alkaline phosphatase increased

Psychiatric disorders

Common: Agitation, amnesia, depression, anxiety, confusion, 
insomnia

Uncommon: Behaviour disorder, emotional lability, hallucination, 
apathy

Nervous system disorders

Very common: Convulsions, hemiparesis, aphasia/dysphasia, headache
Common: Ataxia, balance impaired, cognition impaired, 

concentration impaired, consciousness decreased, 
dizziness, hypoesthesia, memory impaired, neurologic 
disorder, neuropathyd, paraesthesia, somnolence, speech 
disorder, taste perversion, tremor

Uncommon: Status epilepticus, hemiplegia, extrapyramidal disorder, 
parosmia, gait abnormality, hyperaesthesia, sensory 
disturbance, coordination abnormal

Eye disorders

Common: Hemianopia, vision blurred, vision disordere, visual field 
defect, diplopia, eye pain

Uncommon: Visual acuity reduced, eyes dry

 



69

Table 4. Adverse reactions in patients treated with temozolomide

Ear and labyrinth disorders

Common: Deafnessf, vertigo, tinnitus, earacheg

Uncommon: Hearing impairment, hyperacusis, otitis media

Cardiac disorders

Uncommon: Palpitation

Vascular disorders

Common: Haemorrhage, embolism pulmonary, deep vein 
thrombosis, hypertension 

Uncommon: Cerebral haemorrhage, flushing, hot flushes

Respiratory, thoracic and mediastinal disorders

Common: Pneumonia, dyspnoea, sinusitis, bronchitis, coughing, 
upper respiratory infection

Uncommon: Respiratory failure†, interstitial 
pneumonitis/pneumonitis, pulmonary fibrosis, nasal 
congestion

Gastrointestinal disorders

Very common: Diarrhoea, constipation, nausea, vomiting
Common: Stomatitis, abdominal painh, dyspepsia, dysphagia 

Uncommon: Abdominal distension, faecal incontinence, 
gastrointestinal disorder, haemorrhoids, mouth dry

Hepatobiliary disorders

Uncommon: Hepatic failure†, hepatic injury, hepatitis, cholestasis, 
hyperbilirubinemia

Skin and subcutaneous tissue disorders

Very Common: Rash, alopecia
Common: Erythema, dry skin, pruritus
Uncommon: Toxic epidermal necrolysis, Stevens-Johnson syndrome, 

angioedema, erythema multiforme, erythroderma, skin 
exfoliation, photosensitivity reaction, urticaria, 
exanthema, dermatitis, sweating increased, pigmentation 
abnormal

Not known: Drug reaction with eosinophilia and systemic symptoms 
(DRESS)

Musculoskeletal and connective tissue disorders

Common: Myopathy, muscle weakness, arthralgia, back pain, 
musculoskeletal pain, myalgia 

Renal and urinary disorders

Common: Micturition frequency, urinary incontinence 

Uncommon: Dysuria

Reproductive system and breast disorders

Uncommon: Vaginal haemorrhage, menorrhagia, amenorrhoea, 
vaginitis, breast pain, impotence

General disorders and administration site conditions

Very common: Fatigue
Common: Fever, influenza-like symptoms, asthenia, malaise, pain, 

oedema, oedema peripherali

 



70

Table 4. Adverse reactions in patients treated with temozolomide

Uncommon: Condition aggravated, rigors, face oedema, tongue
discolouration, thirst, tooth disorder

Investigations

Common: Liver enzymes elevationj, weight decreased, weight 
increased

Uncommon: Gamma-glutamyltransferase increased

Injury, poisoning and procedural complications 

Common: Radiation injuryk

a Includes pharyngitis, nasopharyngeal pharyngitis, pharyngitis Streptococcal 
b Includes gastroenteritis, gastroenteritis viral
c Includes cushingoid, Cushing syndrome
d Includes neuropathy, peripheral neuropathy, polyneuropathy, peripheral sensory neuropathy, 
peripheral motor neuropathy
e Includes visual impairment, eye disorder
f Includes deafness, deafness bilateral, deafness neurosensory, deafness unilateral
g Includes earache, ear discomfort
h Includes abdominal pain, abdominal pain lower, abdominal pain upper, abdominal discomfort
i Includes oedema peripheral, peripheral swelling
j Includes liver function test increased, alanine aminotransferase increased, aspartate aminotransferase 
increased, hepatic enzymes increased
k Includes radiation injury, radiation skin injury
† Including cases with fatal outcome

Newly-diagnosed glioblastoma multiforme

Laboratory results

Myelosuppression (neutropenia and thrombocytopenia), which is known dose-limiting toxicity for 
most cytotoxic agents, including TMZ, was observed. When laboratory abnormalities and adverse 
events were combined across concomitant and monotherapy treatment phases, Grade 3 or Grade 4 
neutrophil abnormalities including neutropenic events were observed in 8 % of the patients. Grade 3 
or Grade 4 thrombocyte abnormalities, including thrombocytopenic events were observed in 14 % of 
the patients who received TMZ. 

Recurrent or progressive malignant glioma

Laboratory results

Grade 3 or 4 thrombocytopenia and neutropenia occurred in 19 % and 17 % respectively, of patients 
treated for malignant glioma. This led to hospitalisation and/or discontinuation of TMZ in 8 % and 
4 %, respectively. Myelosuppression was predictable (usually within the first few cycles, with the 
nadir between Day 21 and Day 28), and recovery was rapid, usually within 1-2 weeks. No evidence of 
cumulative myelosuppression was observed. The presence of thrombocytopenia may increase the risk 
of bleeding, and the presence of neutropenia or leukopenia may increase the risk of infection.

Gender

In a population pharmacokinetics analysis of clinical trial experience there were 101 female and 
169 male subjects for whom nadir neutrophil counts were available and 110 female and 174 male 
subjects for whom nadir platelet counts were available. There were higher rates of Grade 4 
neutropenia (ANC < 0.5 x 109/l), 12 % vs 5 %, and thrombocytopenia (< 20 x 109/l), 9 % vs 3 %, in 
women vs men in the first cycle of therapy. In a 400 subject recurrent glioma data set, Grade 4 
neutropenia occurred in 8 % of female vs 4 % of male subjects and Grade 4 thrombocytopenia in 8 % 

 



71

of female vs 3 % of male subjects in the first cycle of therapy. In a study of 288 subjects with newly-
diagnosed glioblastoma multiforme, Grade 4 neutropenia occurred in 3 % of female vs 0 % of male 
subjects and Grade 4 thrombocytopenia in 1 % of female vs 0 % of male subjects in the first cycle of 
therapy.

Paediatric population

Oral TMZ has been studied in paediatric patients (age 3-18 years) with recurrent brainstem glioma or 
recurrent high grade astrocytoma, in a regimen administered daily for 5 days every 28 days. Although 
the data is limited, tolerance in children is expected to be the same as in adults. The safety of TMZ in 
children under the age of 3 years has not been established.

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 national reporting system 
listed in Appendix V.

4.9 Overdose

Doses of 500, 750, 1,000, and 1,250 mg/m2 (total dose per cycle over 5 days) have been evaluated 
clinically in patients. Dose-limiting toxicity was haematological and was reported with any dose but is 
expected to be more severe at higher doses. An overdose of 10,000 mg (total dose in a single cycle, 
over 5 days) was taken by one patient and the adverse reactions reported were pancytopenia, pyrexia, 
multi-organ failure and death. There are reports of patients who have taken the recommended dose for 
more than 5 days of treatment (up to 64 days) with adverse events reported including bone marrow 
suppression, with or without infection, in some cases severe and prolonged and resulting in death. In 
the event of an overdose, haematological evaluation is needed. Supportive measures should be 
provided as necessary.

5. PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Antineoplastic agents - Other alkylating agents, ATC code: L01A X03

Mechanism of action

Temozolomide is a triazene, which undergoes rapid chemical conversion at physiologic pH to the 
active monomethyl triazenoimidazole carboxamide (MTIC). The cytotoxicity of MTIC is thought to 
be due primarily to alkylation at the O6 position of guanine with additional alkylation also occurring 
at the N7 position. Cytotoxic lesions that develop subsequently are thought to involve aberrant repair 
of the methyl adduct.

Clinical efficacy and safety

Newly-diagnosed glioblastoma multiforme

A total of 573 patients were randomised to receive either TMZ + RT (n=287) or RT alone (n=286). 
Patients in the TMZ + RT arm received concomitant TMZ (75 mg/m2) once daily, starting the first 
day of RT until the last day of RT, for 42 days (with a maximum of 49 days). This was followed by 
monotherapy TMZ (150 - 200 mg/m2) on Days 1 - 5 of every 28-day cycle for up to 6 cycles, starting 
4 weeks after the end of RT. Patients in the control arm received RT only. Pneumocystis jirovecii
pneumonia (PCP) prophylaxis was required during RT and combined TMZ therapy.

 

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72

TMZ was administered as salvage therapy in the follow-up phase in 161 patients of the 282 (57 %) in 
the RT alone arm, and 62 patients of the 277 (22 %) in the TMZ + RT arm.

The hazard ratio (HR) for overall survival was 1.59 (95 % CI for HR=1.33 -1.91) with a log-rank 
p < 0.0001 in favour of the TMZ arm. The estimated probability of surviving 2 years or more (26 % 
vs 10 %) is higher for the RT + TMZ arm. The addition of concomitant TMZ to RT, followed by 
TMZ monotherapy in the treatment of patients with newly-diagnosed glioblastoma multiforme 
demonstrated a statistically significant improvement in overall survival (OS) compared with RT alone 
(Figure 1).

H R  (95%  C .I.) =  1 .59  (1 .33 – 1 .91)
log-rank p-value <  .0001

12.1 14.6

RT+TM Z

RT O n ly

26%

10%

Figure 1 Kaplan-Meier curves for overall survival (intent-to-treat population)

The results from the trial were not consistent in the subgroup of patients with a poor performance 
status (WHO PS=2, n=70), where overall survival and time to progression were similar in both arms. 
However, no unacceptable risks appear to be present in this patient group.

Recurrent or progressive malignant glioma

Data on clinical efficacy in patients with glioblastoma multiforme (Karnofsky performance status 
[KPS]  70), progressive or recurrent after surgery and RT, were based on two clinical trials with oral 
TMZ. One was a non-comparative trial in 138 patients (29 % received prior chemotherapy), and the 
other was a randomised active-controlled trial of TMZ vs procarbazine in a total of 225 patients (67 % 
received prior treatment with nitrosourea based chemotherapy). In both trials, the primary endpoint 
was progression-free survival (PFS) defined by MRI scans or neurological worsening. In the non-
comparative trial, the PFS at 6 months was 19 %, the median progression-free survival was 
2.1 months, and the median overall survival 5.4 months. The objective response rate (ORR) based on 
MRI scans was 8 %.

In the randomised active-controlled trial, the PFS at 6 months was significantly greater for TMZ than 
for procarbazine (21 % vs 8 %, respectively – chi-square p = 0.008) with median PFS of 2.89 and 
1.88 months respectively (log rank p = 0.0063). The median survival was 7.34 and 5.66 months for 
TMZ and procarbazine, respectively (log rank p = 0.33). At 6 months, the fraction of surviving 
patients was significantly higher in the TMZ arm (60 %) compared with the procarbazine arm (44 %) 
(chi-square p = 0.019). In patients with prior chemotherapy a benefit was indicated in those with a 
KPS  80.

 



73

Data on time to worsening of neurological status favoured TMZ over procarbazine as did data on time 
to worsening of performance status (decrease to a KPS of < 70 or a decrease by at least 30 points). 
The median times to progression in these endpoints ranged from 0.7 to 2.1 months longer for TMZ 
than for procarbazine (log rank p = < 0.01 to 0.03). 

Recurrent anaplastic astrocytoma

In a multicentre, prospective phase II trial evaluating the safety and efficacy of oral TMZ in the 
treatment of patients with anaplastic astrocytoma at first relapse, the 6 month PFS was 46 %. The 
median PFS was 5.4 months. Median overall survival was 14.6 months. Response rate, based on the 
central reviewer assessment, was 35 % (13 CR and 43 PR) for the intent-to-treat population (ITT) 
n=162. In 43 patients stable disease was reported. The 6-month event-free survival for the ITT 
population was 44 % with a median event-free survival of 4.6 months, which was similar to the results
for the progression-free survival. For the eligible histology population, the efficacy results were 
similar. Achieving a radiological objective response or maintaining progression-free status was 
strongly associated with maintained or improved quality of life.

Paediatric population

Oral TMZ has been studied in paediatric patients (age 3-18 years) with recurrent brainstem glioma or 
recurrent high grade astrocytoma, in a regimen administered daily for 5 days every 28 days. Tolerance 
to TMZ is similar to adults.

5.2 Pharmacokinetic properties 

TMZ is spontaneously hydrolyzed at physiologic pH primarily to the active species, 3-methyl-
(triazen-1-yl)imidazole-4-carboxamide (MTIC). MTIC is spontaneously hydrolyzed to 5-amino-
imidazole-4-carboxamide (AIC), a known intermediate in purine and nucleic acid biosynthesis, and to 
methylhydrazine, which is believed to be the active alkylating species. The cytotoxicity of MTIC is 
thought to be primarily due to alkylation of DNA mainly at the O6 and N7 positions of guanine. 
Relative to the AUC of TMZ, the exposure to MTIC and AIC is ~ 2.4 % and 23 %, respectively. In 
vivo, the t1/2 of MTIC was similar to that of TMZ, 1.8 hr.

Absorption

After oral administration to adult patients, TMZ is absorbed rapidly, with peak concentrations reached 
as early as 20 minutes post-administration (mean time between 0.5 and 1.5 hours). After oral 
administration of 14C-labelled TMZ, mean faecal excretion of 14C over 7 days post-dose was 0.8 % 
indicating complete absorption.

Distribution

TMZ demonstrates low protein binding (10 % to 20 %), and thus it is not expected to interact with 
highly protein-bound substances.

PET studies in humans and preclinical data suggest that TMZ crosses the blood-brain barrier rapidly 
and is present in the CSF. CSF penetration was confirmed in one patient; CSF exposure based on 
AUC of TMZ was approximately 30 % of that in plasma, which is consistent with animal data.

Elimination

The half-life (t1/2) in plasma is approximately 1.8 hours. The major route of 
14C elimination is renal. 

Following oral administration, approximately 5 % to 10 % of the dose is recovered unchanged in the 
urine over 24 hours, and the remainder excreted as temozolomide acid, 5-aminoimidazole-4-
carboxamide (AIC) or unidentified polar metabolites.

 



74

Plasma concentrations increase in a dose-related manner. Plasma clearance, volume of distribution 
and half-life are independent of dose. 

Special populations

Analysis of population-based pharmacokinetics of TMZ revealed that plasma TMZ clearance was 
independent of age, renal function or tobacco use. In a separate pharmacokinetic study, plasma 
pharmacokinetic profiles in patients with mild to moderate hepatic impairment were similar to those 
observed in patients with normal hepatic function.

Paediatric patients had a higher AUC than adult patients; however, the maximum tolerated dose 
(MTD) was 1,000 mg/m2 per cycle both in children and in adults.

5.3 Preclinical safety data

Single-cycle (5-day dosing, 23 days non-treatment), 3- and 6-cycle toxicity studies were conducted in 
rats and dogs. The primary targets of toxicity included the bone marrow, lymphoreticular system, 
testes, the gastrointestinal tract and, at higher doses, which were lethal to 60 % to 100 % of rats and 
dogs tested, degeneration of the retina occurred. Most of the toxicity showed evidence of reversibility, 
except for adverse events on the male reproductive system and retinal degeneration. However, 
because the doses implicated in retinal degeneration were in the lethal dose range, and no comparable 
effect has been observed in clinical studies, this finding was not considered to have clinical relevance.

TMZ is an embryotoxic, teratogenic and genotoxic alkylating agent. TMZ is more toxic to the rat and 
dog than to humans, and the clinical dose approximates the minimum lethal dose in rats and dogs. 
Dose-related reductions in leukocytes and platelets appear to be sensitive indicators of toxicity. A 
variety of neoplasms, including mammary carcinomas, keratocanthoma of the skin and basal cell 
adenoma were observed in the 6-cycle rat study while no tumours or pre-neoplastic changes were 
evident in dog studies. Rats appear to be particularly sensitive to oncogenic effects of TMZ, with the 
occurrence of first tumours within 3 months of initiating dosing. This latency period is very short 
even for an alkylating agent.

Results of the Ames/salmonella and Human Peripheral Blood Lymphocyte (HPBL) chromosome 
aberration tests showed a positive mutagenicity response.

6. PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Capsule content:
anhydrous lactose, 
colloidal anhydrous silica, 
sodium starch glycolate type A, 
tartaric acid,
stearic acid. 

Capsule shell: 
gelatin, 
titanium dioxide (E 171), 
sodium lauril sulfate, 
yellow iron oxide (E 172), 
red iron oxide (E 172) 

Printing ink: 
shellac, 

 



75

propylene glycol, 
purified water, 
ammonium hydroxide, 
potassium hydroxide, 
black iron oxide (E 172).

6.2 Incompatibilities

Not applicable.

6.3 Shelf life

3 years

6.4 Special precautions for storage

Bottle presentation

Do not store above 30 C.
Store in the original bottle in order to protect from moisture.
Keep the bottle tightly closed.

Sachet presentation

Do not store above 30 C.

6.5 Nature and contents of container

Bottle presentation

Type I amber glass bottles with polypropylene child-resistant closures containing 5 or 20 hard 
capsules.
The carton contains one bottle.

Sachet presentation

Sachets are composed of linear low density polyethylene (innermost layer), aluminium and 
polyethylene terephthalate.
Each sachet contains 1 hard capsule and is dispensed in a cardboard carton.
The carton contains 5 or 20 hard capsules, individually sealed in sachets.

Not all pack sizes may be marketed.

6.6 Special precautions for disposal and other handling

Capsules should not be opened. If a capsule becomes damaged, contact of the powder contents with 
skin or mucous membrane must be avoided. If Temodal comes into contact with skin or mucosa, it 
should be washed immediately and thoroughly with soap and water. 

Patients should be advised to keep capsules out of the sight and reach of children, preferably in a 
locked cupboard. Accidental ingestion can be lethal for children.

Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements.

 



76

7. MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

8. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/011
EU/1/98/096/012 
EU/1/98/096/019
EU/1/98/096/020

9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

Date of first authorisation: 26 January 1999
Date of latest renewal: 26 January 2009

10. DATE OF REVISION OF THE TEXT

Detailed information on this medicinal product is available on the website of the European Medicines 
Agency http://www.ema.europa.eu.

 

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77

1. NAME OF THE MEDICINAL PRODUCT

Temodal 250 mg hard capsules

2. QUALITATIVE AND QUANTITATIVE COMPOSITION

Each hard capsule contains 250 mg temozolomide.

Excipient with known effect: 
Each hard capsule contains 154.3 mg of anhydrous lactose.

For the full list of excipients, see section 6.1.

3. PHARMACEUTICAL FORM

Hard capsule (capsule).

The hard capsules have an opaque white body and cap, and are imprinted with black ink. The cap is 
imprinted with “Temodal”. The body is imprinted with "250 mg", the Schering-Plough logo and two 
stripes.

4. CLINICAL PARTICULARS

4.1 Therapeutic indications

Temodal is indicated for the treatment of:
- adult patients with newly-diagnosed glioblastoma multiforme concomitantly with radiotherapy 

(RT) and subsequently as monotherapy treatment.
- children from the age of three years, adolescents and adult patients with malignant glioma, such 

as glioblastoma multiforme or anaplastic astrocytoma, showing recurrence or progression after 
standard therapy.

4.2 Posology and method of administration

Temodal should only be prescribed by physicians experienced in the oncological treatment of brain 
tumours.

Anti-emetic therapy may be administered (see section 4.4).

Posology

Adult patients with newly-diagnosed glioblastoma multiforme

Temodal is administered in combination with focal radiotherapy (concomitant phase) followed by up 
to 6 cycles of temozolomide (TMZ) monotherapy (monotherapy phase).

Concomitant phase 

TMZ is administered orally at a dose of 75 mg/m2 daily for 42 days concomitant with focal 
radiotherapy (60 Gy administered in 30 fractions). No dose reductions are recommended, but delay or 
discontinuation of TMZ administration should be decided weekly according to haematological and 
non-haematological toxicity criteria. TMZ administration can be continued throughout the 42 day 
concomitant period (up to 49 days) if all of the following conditions are met: 

 



78

- absolute neutrophil count (ANC) ≥ 1.5 x 109/l
- thrombocyte count ≥ 100 x 109/l
- common toxicity criteria (CTC) non-haematological toxicity ≤ Grade 1 (except for alopecia, 

nausea and vomiting). 
During treatment a complete blood count should be obtained weekly. TMZ administration should be 
temporarily interrupted or permanently discontinued during the concomitant phase according to the 
haematological and non-haematological toxicity criteria as noted in Table 1.

Table 1. TMZ dosing interruption or discontinuation during

concomitant radiotherapy and TMZ

Toxicity TMZ interruptiona TMZ discontinuation

Absolute neutrophil count  0.5 and < 1.5 x 109/l < 0.5 x 10
9/l

Thrombocyte count  10 and < 100 x 109/l < 10 x 10
9/l

CTC non-haematological toxicity
(except for alopecia, nausea, vomiting)

CTC Grade 2 CTC Grade 3 or 4

a: Treatment with concomitant TMZ can be continued when all of the following conditions are met: absolute neutrophil 
count  1.5 x 109/l; thrombocyte count  100 x 109/l; CTC non-haematological toxicity  Grade 1 (except for alopecia, 
nausea, vomiting).

Monotherapy phase

Four weeks after completing the TMZ + RT concomitant phase, TMZ is administered for up to 
6 cycles of monotherapy treatment. Dose in Cycle 1 (monotherapy) is 150 mg/m2 once daily for 
5 days followed by 23 days without treatment. At the start of Cycle 2, the dose is escalated to 
200 mg/m2 if the CTC non-haematological toxicity for Cycle 1 is Grade ≤ 2 (except for alopecia, 
nausea and vomiting), absolute neutrophil count (ANC) is ≥ 1.5 x 109/l, and the thrombocyte count is 
≥ 100 x 109/l. If the dose was not escalated at Cycle 2, escalation should not be done in subsequent 
cycles. Once escalated, the dose remains at 200 mg/m2 per day for the first 5 days of each subsequent 
cycle except if toxicity occurs. Dose reductions and discontinuations during the monotherapy phase 
should be applied according to Tables 2 and 3.

During treatment a complete blood count should be obtained on Day 22 (21 days after the first dose of 
TMZ). The dose should be reduced or administration discontinued according to Table 3.

Table 2. TMZ dose levels for monotherapy treatment

Dose level TMZ dose 
(mg/m2/day)

Remarks

–1 100 Reduction for prior toxicity 

0 150 Dose during Cycle 1

1 200 Dose during Cycles 2-6 in absence of toxicity

Table 3. TMZ dose reduction or discontinuation during monotherapy treatment

Toxicity Reduce TMZ by 1 dose levela Discontinue TMZ

Absolute neutrophil count < 1.0 x 109/l See footnote b

Thrombocyte count < 50 x 109/l See footnote b

CTC non-haematological Toxicity
(except for alopecia, nausea, vomiting) CTC Grade 3 CTC Grade 4

b

a: TMZ dose levels are listed in Table 2.
b: TMZ is to be discontinued if:
 dose level -1 (100 mg/m2) still results in unacceptable toxicity

 the same Grade 3 non-haematological toxicity (except for alopecia, nausea, vomiting) recurs after dose reduction.

 



79

Adult and paediatric patients 3 years of age or older with recurrent or progressive malignant glioma:

A treatment cycle comprises 28 days. In patients previously untreated with chemotherapy, TMZ is 
administered orally at a dose of 200 mg/m2 once daily for the first 5 days followed by a 23 day 
treatment interruption (total of 28 days). In patients previously treated with chemotherapy, the initial 
dose is 150 mg/m2 once daily, to be increased in the second cycle to 200 mg/m2 once daily, for 5 days 
if there is no haematological toxicity (see section 4.4) 

Special populations

Paediatric population

In patients 3 years of age or older, TMZ is only to be used in recurrent or progressive malignant 
glioma. Experience in these children is very limited (see sections 4.4 and 5.1). The safety and efficacy 
of TMZ in children under the age of 3 years have not been established. No data are available.

Patients with hepatic or renal impairment

The pharmacokinetics of TMZ were comparable in patients with normal hepatic function and in those 
with mild or moderate hepatic impairment. No data are available on the administration of TMZ in 
patients with severe hepatic impairment (Child’s Class C) or with renal impairment. Based on the 
pharmacokinetic properties of TMZ, it is unlikely that dose reductions are required in patients with 
severe hepatic impairment or any degree of renal impairment. However, caution should be exercised 
when TMZ is administered in these patients. 

Elderly patients

Based on a population pharmacokinetic analysis in patients 19-78 years of age, clearance of TMZ is 
not affected by age. However, elderly patients (> 70 years of age) appear to be at increased risk of 
neutropenia and thrombocytopenia (see section 4.4).

Method of administration

Temodal hard capsules should be administered in the fasting state.

The capsules must be swallowed whole with a glass of water and must not be opened or chewed. 

If vomiting occurs after the dose is administered, a second dose should not be administered that day.

4.3 Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

Hypersensitivity to dacarbazine (DTIC).

Severe myelosuppression (see section 4.4).

4.4 Special warnings and precautions for use

Opportunistic infections and reactivation of infections

Opportunistic infections (such as Pneumocystis jirovecii pneumonia) and reactivation of infections 
(such as HBV, CMV) have been observed during the treatment with TMZ (see section 4.8).

Meningoencephalitis herpetic

 



80

In post marketing cases, meningoencephalitis herpetic (including fatal cases) has been observed in 
patients receiving TMZ in combination with radiotherapy, including cases of concomitant steroids 
administration.

Pneumocystis jirovecii pneumonia

Patients who received concomitant TMZ and RT in a pilot trial for the prolonged 42-day schedule 
were shown to be at particular risk for developing Pneumocystis jirovecii pneumonia (PCP). Thus, 
prophylaxis against PCP is required for all patients receiving concomitant TMZ and RT for the 42-
day regimen (with a maximum of 49 days) regardless of lymphocyte count. If lymphopenia occurs, 
they are to continue the prophylaxis until recovery of lymphopenia to grade ≤ 1.

There may be a higher occurrence of PCP when TMZ is administered during a longer dosing regimen. 
However, all patients receiving TMZ, particularly patients receiving steroids, should be observed 
closely for the development of PCP, regardless of the regimen. Cases of fatal respiratory failure have 
been reported in patients using TMZ, in particular in combination with dexamethasone or other 
steroids.

HBV

Hepatitis due to hepatitis B virus (HBV) reactivation, in some cases resulting in death, has been 
reported. Experts in liver disease should be consulted before treatment is initiated in patients with 
positive hepatitis B serology (including those with active disease). During treatment patients should 
be monitored and managed appropriately.

Hepatotoxicity

Hepatic injury, including fatal hepatic failure, has been reported in patients treated with TMZ (see 
section 4.8). Baseline liver function tests should be performed prior to treatment initiation. If 
abnormal, physicians should assess the benefit/risk prior to initiating temozolomide including the 
potential for fatal hepatic failure. For patients on a 42 day treatment cycle liver function tests should 
be repeated midway during this cycle. For all patients, liver function tests should be checked after 
each treatment cycle. For patients with significant liver function abnormalities, physicians should 
assess the benefit/risk of continuing treatment. Liver toxicity may occur several weeks or more after 
the last treatment with temozolomide.

Malignancies

Cases of myelodysplastic syndrome and secondary malignancies, including myeloid leukaemia, have 
also been reported very rarely (see section 4.8).

Anti-emetic therapy

Nausea and vomiting are very commonly associated with TMZ.
Anti-emetic therapy may be administered prior to or following administration of TMZ.

Adult patients with newly-diagnosed glioblastoma multiforme 

Anti-emetic prophylaxis is recommended prior to the initial dose of concomitant phase and it is 
strongly recommended during the monotherapy phase.

Patients with recurrent or progressive malignant glioma

Patients who have experienced severe (Grade 3 or 4) vomiting in previous treatment cycles may 
require anti-emetic therapy.

 



81

Laboratory parameters

Patients treated with TMZ may experience myelosuppression, including prolonged pancytopenia, 
which may result in aplastic anaemia, which in some cases has resulted in a fatal outcome. In some 
cases, exposure to concomitant medicinal products associated with aplastic anaemia, including 
carbamazepine, phenytoin, and sulfamethoxazole/trimethoprim, complicates assessment. Prior to 
dosing, the following laboratory parameters must be met: ANC  1.5 x 109/l and platelet count 
 100 x 109/l. A complete blood count should be obtained on Day 22 (21 days after the first dose) or 
within 48 hours of that day, and weekly until ANC > 1.5 x 109/l and platelet count > 100 x 109/l. If 
ANC falls to < 1.0 x 109/l or the platelet count is < 50 x 109/l during any cycle, the next cycle should 
be reduced one dose level (see section 4.2). Dose levels include 100 mg/m2, 150 mg/m2, and 
200 mg/m2. The lowest recommended dose is 100 mg/m2.

Paediatric population 

There is no clinical experience with use of TMZ in children under the age of 3 years. Experience in 
older children and adolescents is very limited (see sections 4.2 and 5.1).

Elderly patients (> 70 years of age)

Elderly patients appear to be at increased risk of neutropenia and thrombocytopenia, compared with 
younger patients. Therefore, special care should be taken when TMZ is administered in elderly 
patients.

Male patients

Men being treated with TMZ should be advised not to father a child up to 6 months after receiving the 
last dose and to seek advice on cryoconservation of sperm prior to treatment (see section 4.6).

Lactose

This medicinal product contains lactose. Patients with rare hereditary problems of galactose 
intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this 
medicine.

4.5 Interaction with other medicinal products and other forms of interaction

In a separate phase I study, administration of TMZ with ranitidine did not result in alterations in the 
extent of absorption of temozolomide or the exposure to its active metabolite monomethyl 
triazenoimidazole carboxamide (MTIC). 

Administration of TMZ with food resulted in a 33 % decrease in Cmax and a 9 % decrease in area 
under the curve (AUC). 
As it cannot be excluded that the change in Cmax is clinically significant, Temodal should be 
administered without food.

Based on an analysis of population pharmacokinetics in phase II trials, co-administration of 
dexamethasone, prochlorperazine, phenytoin, carbamazepine, ondansetron, H2 receptor antagonists, or 
phenobarbital did not alter the clearance of TMZ. Co-administration with valproic acid was associated 
with a small but statistically significant decrease in clearance of TMZ.

No studies have been conducted to determine the effect of TMZ on the metabolism or elimination of 
other medicinal products. However, since TMZ does not undergo hepatic metabolism and exhibits 
low protein binding, it is unlikely that it would affect the pharmacokinetics of other medicinal 
products (see section 5.2).

 



82

Use of TMZ in combination with other myelosuppressive agents may increase the likelihood of 
myelosuppression. 

Paediatric population

Interaction studies have only been performed in adults.

4.6 Fertility, pregnancy and lactation 

Pregnancy

There are no data in pregnant women. In preclinical studies in rats and rabbits receiving 150 mg/m2 

TMZ, teratogenicity and/or foetal toxicity were demonstrated (see section 5.3). Temodal should not 
be administered to pregnant women. If use during pregnancy must be considered, the patient should 
be apprised of the potential risk to the foetus.

Breast-feeding

It is not known whether TMZ is excreted in human milk; thus, breast-feeding should be discontinued 
while receiving treatment with TMZ. 

Women of childbearing potential

Women of childbearing potential should be advised to use effective contraception to avoid pregnancy 
while they are receiving TMZ.

Male fertility

TMZ can have genotoxic effects. Therefore, men being treated with it should be advised not to father 
a child up to 6 months after receiving the last dose and to seek advice on cryoconservation of sperm 
prior to treatment, because of the possibility of irreversible infertility due to therapy with TMZ.

4.7 Effects on ability to drive and use machines

TMZ has minor influence on the ability to drive and use machines due to fatigue and somnolence (see 
section 4.8). 

4.8 Undesirable effects 

Summary of the safety profile

Clinical trial experience

In patients treated with TMZ in clinical trials, the most common adverse reactions were nausea, 
vomiting, constipation, anorexia, headache, fatigue, convulsions, and rash. Most haematologic 
adverse reactions were reported commonly; the frequency of Grade 3-4 laboratory findings is 
presented after Table 4.

For patients with recurrent or progressive glioma, nausea (43 %) and vomiting (36 %) were usually 
Grade 1 or 2 (0 – 5 episodes of vomiting in 24 hours) and were either self-limiting or readily 
controlled with standard anti-emetic therapy. The incidence of severe nausea and vomiting was 4 %.

Tabulated list of adverse reactions
Adverse reactions observed in clinical studies and reported from post-marketing use of TMZ are listed
in Table 4. These reactions are classified according to System Organ Class and frequency. Frequency 
groupings are defined according to the following convention: Very common (≥ 1/10); Common 

 



83

(≥ 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). Within each frequency 
grouping, undesirable effects are presented in order of decreasing seriousness.

Table 4. Adverse reactions in patients treated with temozolomide

Infections and infestations

Common: Infections, herpes zoster, pharyngitisa, candidiasis oral

Uncommon: Opportunistic infection (including PCP), sepsis†, 
meningoencephalitis herpetic†, CMV infection, CMV 
reactivation, hepatitis B virus†, herpes simplex, infection 
reactivation, wound infection, gastroenteritisb

Neoplasm benign, malignant, and unspecified

Uncommon: Myelodysplastic syndrome (MDS), secondary 
malignancies, including myeloid leukaemia

Blood and lymphatic system disorders

Common: Febrile neutropenia, neutropenia, thrombocytopenia, 
lymphopenia, leukopenia, anaemia

Uncommon: Prolonged pancytopenia, aplastic anaemia†, 
pancytopenia, petechiae

Immune system disorders

Common: Allergic reaction

Uncommon: Anaphylaxis

Endocrine disorders

Common: Cushingoidc

Uncommon: Diabetes insipidus

Metabolism and nutrition disorders

Very common: Anorexia
Common: Hyperglycaemia

Uncommon: Hypokalaemia, alkaline phosphatase increased

Psychiatric disorders

Common: Agitation, amnesia, depression, anxiety, confusion, 
insomnia

Uncommon: Behaviour disorder, emotional lability, hallucination, 
apathy

Nervous system disorders

Very common: Convulsions, hemiparesis, aphasia/dysphasia, headache
Common: Ataxia, balance impaired, cognition impaired, 

concentration impaired, consciousness decreased, 
dizziness, hypoesthesia, memory impaired, neurologic 
disorder, neuropathyd, paraesthesia, somnolence, speech 
disorder, taste perversion, tremor

Uncommon: Status epilepticus, hemiplegia, extrapyramidal disorder, 
parosmia, gait abnormality, hyperaesthesia, sensory 
disturbance, coordination abnormal

Eye disorders

Common: Hemianopia, vision blurred, vision disordere, visual field 
defect, diplopia, eye pain

Uncommon: Visual acuity reduced, eyes dry

 



84

Table 4. Adverse reactions in patients treated with temozolomide

Ear and labyrinth disorders

Common: Deafnessf, vertigo, tinnitus, earacheg

Uncommon: Hearing impairment, hyperacusis, otitis media

Cardiac disorders

Uncommon: Palpitation

Vascular disorders

Common: Haemorrhage, embolism pulmonary, deep vein 
thrombosis, hypertension 

Uncommon: Cerebral haemorrhage, flushing, hot flushes

Respiratory, thoracic and mediastinal disorders

Common: Pneumonia, dyspnoea, sinusitis, bronchitis, coughing, 
upper respiratory infection

Uncommon: Respiratory failure†, interstitial 
pneumonitis/pneumonitis, pulmonary fibrosis, nasal 
congestion

Gastrointestinal disorders

Very common: Diarrhoea, constipation, nausea, vomiting
Common: Stomatitis, abdominal painh, dyspepsia, dysphagia 

Uncommon: Abdominal distension, faecal incontinence, 
gastrointestinal disorder, haemorrhoids, mouth dry

Hepatobiliary disorders

Uncommon: Hepatic failure†, hepatic injury, hepatitis, cholestasis, 
hyperbilirubinemia

Skin and subcutaneous tissue disorders

Very Common: Rash, alopecia
Common: Erythema, dry skin, pruritus
Uncommon: Toxic epidermal necrolysis, Stevens-Johnson syndrome, 

angioedema, erythema multiforme, erythroderma, skin 
exfoliation, photosensitivity reaction, urticaria, 
exanthema, dermatitis, sweating increased, pigmentation 
abnormal

Not known: Drug reaction with eosinophilia and systemic symptoms 
(DRESS)

Musculoskeletal and connective tissue disorders

Common: Myopathy, muscle weakness, arthralgia, back pain,
musculoskeletal pain, myalgia 

Renal and urinary disorders

Common: Micturition frequency, urinary incontinence 

Uncommon: Dysuria

Reproductive system and breast disorders

Uncommon: Vaginal haemorrhage, menorrhagia, amenorrhoea, 
vaginitis, breast pain, impotence

General disorders and administration site conditions

Very common: Fatigue
Common: Fever, influenza-like symptoms, asthenia, malaise, pain, 

oedema, oedema peripherali

 



85

Table 4. Adverse reactions in patients treated with temozolomide

Uncommon: Condition aggravated, rigors, face oedema, tongue
discolouration, thirst, tooth disorder

Investigations

Common: Liver enzymes elevationj, weight decreased, weight 
increased

Uncommon: Gamma-glutamyltransferase increased

Injury, poisoning and procedural complications 

Common: Radiation injuryk

a Includes pharyngitis, nasopharyngeal pharyngitis, pharyngitis Streptococcal 
b Includes gastroenteritis, gastroenteritis viral
c Includes cushingoid, Cushing syndrome
d Includes neuropathy, peripheral neuropathy, polyneuropathy, peripheral sensory neuropathy, 
peripheral motor neuropathy
e Includes visual impairment, eye disorder
f Includes deafness, deafness bilateral, deafness neurosensory, deafness unilateral
g Includes earache, ear discomfort
h Includes abdominal pain, abdominal pain lower, abdominal pain upper, abdominal discomfort
i Includes oedema peripheral, peripheral swelling
j Includes liver function test increased, alanine aminotransferase increased, aspartate aminotransferase 
increased, hepatic enzymes increased
k Includes radiation injury, radiation skin injury
† Including cases with fatal outcome

Newly-diagnosed glioblastoma multiforme

Laboratory results

Myelosuppression (neutropenia and thrombocytopenia), which is known dose-limiting toxicity for 
most cytotoxic agents, including TMZ, was observed. When laboratory abnormalities and adverse 
events were combined across concomitant and monotherapy treatment phases, Grade 3 or Grade 4 
neutrophil abnormalities including neutropenic events were observed in 8 % of the patients. Grade 3 
or Grade 4 thrombocyte abnormalities, including thrombocytopenic events were observed in 14 % of 
the patients who received TMZ. 

Recurrent or progressive malignant glioma

Laboratory results

Grade 3 or 4 thrombocytopenia and neutropenia occurred in 19 % and 17 % respectively, of patients 
treated for malignant glioma. This led to hospitalisation and/or discontinuation of TMZ in 8 % and 
4 %, respectively. Myelosuppression was predictable (usually within the first few cycles, with the 
nadir between Day 21 and Day 28), and recovery was rapid, usually within 1-2 weeks. No evidence of 
cumulative myelosuppression was observed. The presence of thrombocytopenia may increase the risk 
of bleeding, and the presence of neutropenia or leukopenia may increase the risk of infection.

Gender

In a population pharmacokinetics analysis of clinical trial experience there were 101 female and 
169 male subjects for whom nadir neutrophil counts were available and 110 female and 174 male 
subjects for whom nadir platelet counts were available. There were higher rates of Grade 4 
neutropenia (ANC < 0.5 x 109/l), 12 % vs 5 %, and thrombocytopenia (< 20 x 109/l), 9 % vs 3 %, in 
women vs men in the first cycle of therapy. In a 400 subject recurrent glioma data set, Grade 4 
neutropenia occurred in 8 % of female vs 4 % of male subjects and Grade 4 thrombocytopenia in 8 % 

 



86

of female vs 3 % of male subjects in the first cycle of therapy. In a study of 288 subjects with newly-
diagnosed glioblastoma multiforme, Grade 4 neutropenia occurred in 3 % of female vs 0 % of male 
subjects and Grade 4 thrombocytopenia in 1 % of female vs 0 % of male subjects in the first cycle of 
therapy.

Paediatric population

Oral TMZ has been studied in paediatric patients (age 3-18 years) with recurrent brainstem glioma or 
recurrent high grade astrocytoma, in a regimen administered daily for 5 days every 28 days. Although 
the data is limited, tolerance in children is expected to be the same as in adults. The safety of TMZ in 
children under the age of 3 years has not been established.

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 national reporting system 
listed in Appendix V.

4.9 Overdose

Doses of 500, 750, 1,000, and 1,250 mg/m2 (total dose per cycle over 5 days) have been evaluated 
clinically in patients. Dose-limiting toxicity was haematological and was reported with any dose but is 
expected to be more severe at higher doses. An overdose of 10,000 mg (total dose in a single cycle, 
over 5 days) was taken by one patient and the adverse reactions reported were pancytopenia, pyrexia, 
multi-organ failure and death. There are reports of patients who have taken the recommended dose for 
more than 5 days of treatment (up to 64 days) with adverse events reported including bone marrow 
suppression, with or without infection, in some cases severe and prolonged and resulting in death. In 
the event of an overdose, haematological evaluation is needed. Supportive measures should be 
provided as necessary.

5. PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Antineoplastic agents - Other alkylating agents, ATC code: L01A X03

Mechanism of action

Temozolomide is a triazene, which undergoes rapid chemical conversion at physiologic pH to the 
active monomethyl triazenoimidazole carboxamide (MTIC). The cytotoxicity of MTIC is thought to 
be due primarily to alkylation at the O6 position of guanine with additional alkylation also occurring 
at the N7 position. Cytotoxic lesions that develop subsequently are thought to involve aberrant repair 
of the methyl adduct.

Clinical efficacy and safety

Newly-diagnosed glioblastoma multiforme

A total of 573 patients were randomised to receive either TMZ + RT (n=287) or RT alone (n=286). 
Patients in the TMZ + RT arm received concomitant TMZ (75 mg/m2) once daily, starting the first 
day of RT until the last day of RT, for 42 days (with a maximum of 49 days). This was followed by 
monotherapy TMZ (150 - 200 mg/m2) on Days 1 - 5 of every 28-day cycle for up to 6 cycles, starting 
4 weeks after the end of RT. Patients in the control arm received RT only. Pneumocystis jirovecii
pneumonia (PCP) prophylaxis was required during RT and combined TMZ therapy.

 

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TMZ was administered as salvage therapy in the follow-up phase in 161 patients of the 282 (57 %) in 
the RT alone arm, and 62 patients of the 277 (22 %) in the TMZ + RT arm.

The hazard ratio (HR) for overall survival was 1.59 (95 % CI for HR=1.33 -1.91) with a log-rank 
p < 0.0001 in favour of the TMZ arm. The estimated probability of surviving 2 years or more (26 % 
vs 10 %) is higher for the RT + TMZ arm. The addition of concomitant TMZ to RT, followed by 
TMZ monotherapy in the treatment of patients with newly-diagnosed glioblastoma multiforme 
demonstrated a statistically significant improvement in overall survival (OS) compared with RT alone 
(Figure 1).

H R  (95%  C .I.) =  1 .59  (1 .33 – 1 .91)
log-rank p-value <  .0001

12.1 14.6

RT+TM Z

RT O n ly

26%

10%

Figure 1 Kaplan-Meier curves for overall survival (intent-to-treat population)

The results from the trial were not consistent in the subgroup of patients with a poor performance 
status (WHO PS=2, n=70), where overall survival and time to progression were similar in both arms. 
However, no unacceptable risks appear to be present in this patient group.

Recurrent or progressive malignant glioma

Data on clinical efficacy in patients with glioblastoma multiforme (Karnofsky performance status 
[KPS]  70), progressive or recurrent after surgery and RT, were based on two clinical trials with oral 
TMZ. One was a non-comparative trial in 138 patients (29 % received prior chemotherapy), and the 
other was a randomised active-controlled trial of TMZ vs procarbazine in a total of 225 patients (67 % 
received prior treatment with nitrosourea based chemotherapy). In both trials, the primary endpoint 
was progression-free survival (PFS) defined by MRI scans or neurological worsening. In the non-
comparative trial, the PFS at 6 months was 19 %, the median progression-free survival was 
2.1 months, and the median overall survival 5.4 months. The objective response rate (ORR) based on 
MRI scans was 8 %.

In the randomised active-controlled trial, the PFS at 6 months was significantly greater for TMZ than 
for procarbazine (21 % vs 8 %, respectively – chi-square p = 0.008) with median PFS of 2.89 and 
1.88 months respectively (log rank p = 0.0063). The median survival was 7.34 and 5.66 months for 
TMZ and procarbazine, respectively (log rank p = 0.33). At 6 months, the fraction of surviving 
patients was significantly higher in the TMZ arm (60 %) compared with the procarbazine arm (44 %) 
(chi-square p = 0.019). In patients with prior chemotherapy a benefit was indicated in those with a 
KPS  80.

 



88

Data on time to worsening of neurological status favoured TMZ over procarbazine as did data on time 
to worsening of performance status (decrease to a KPS of < 70 or a decrease by at least 30 points). 
The median times to progression in these endpoints ranged from 0.7 to 2.1 months longer for TMZ 
than for procarbazine (log rank p = < 0.01 to 0.03). 

Recurrent anaplastic astrocytoma

In a multicentre, prospective phase II trial evaluating the safety and efficacy of oral TMZ in the 
treatment of patients with anaplastic astrocytoma at first relapse, the 6 month PFS was 46 %. The 
median PFS was 5.4 months. Median overall survival was 14.6 months. Response rate, based on the 
central reviewer assessment, was 35 % (13 CR and 43 PR) for the intent-to-treat population (ITT) 
n=162. In 43 patients stable disease was reported. The 6-month event-free survival for the ITT 
population was 44 % with a median event-free survival of 4.6 months, which was similar to the results
for the progression-free survival. For the eligible histology population, the efficacy results were 
similar. Achieving a radiological objective response or maintaining progression-free status was 
strongly associated with maintained or improved quality of life.

Paediatric population

Oral TMZ has been studied in paediatric patients (age 3-18 years) with recurrent brainstem glioma or 
recurrent high grade astrocytoma, in a regimen administered daily for 5 days every 28 days. Tolerance 
to TMZ is similar to adults.

5.2 Pharmacokinetic properties 

TMZ is spontaneously hydrolyzed at physiologic pH primarily to the active species, 3-methyl-
(triazen-1-yl)imidazole-4-carboxamide (MTIC). MTIC is spontaneously hydrolyzed to 5-amino-
imidazole-4-carboxamide (AIC), a known intermediate in purine and nucleic acid biosynthesis, and to 
methylhydrazine, which is believed to be the active alkylating species. The cytotoxicity of MTIC is 
thought to be primarily due to alkylation of DNA mainly at the O6 and N7 positions of guanine. 
Relative to the AUC of TMZ, the exposure to MTIC and AIC is ~ 2.4 % and 23 %, respectively. In 
vivo, the t1/2 of MTIC was similar to that of TMZ, 1.8 hr.

Absorption

After oral administration to adult patients, TMZ is absorbed rapidly, with peak concentrations reached 
as early as 20 minutes post-administration (mean time between 0.5 and 1.5 hours). After oral 
administration of 14C-labelled TMZ, mean faecal excretion of 14C over 7 days post-dose was 0.8 % 
indicating complete absorption.

Distribution

TMZ demonstrates low protein binding (10 % to 20 %), and thus it is not expected to interact with 
highly protein-bound substances.

PET studies in humans and preclinical data suggest that TMZ crosses the blood-brain barrier rapidly 
and is present in the CSF. CSF penetration was confirmed in one patient; CSF exposure based on 
AUC of TMZ was approximately 30 % of that in plasma, which is consistent with animal data.

Elimination

The half-life (t1/2) in plasma is approximately 1.8 hours. The major route of 
14C elimination is renal. 

Following oral administration, approximately 5 % to 10 % of the dose is recovered unchanged in the 
urine over 24 hours, and the remainder excreted as temozolomide acid, 5-aminoimidazole-4-
carboxamide (AIC) or unidentified polar metabolites.

 



89

Plasma concentrations increase in a dose-related manner. Plasma clearance, volume of distribution 
and half-life are independent of dose. 

Special populations

Analysis of population-based pharmacokinetics of TMZ revealed that plasma TMZ clearance was 
independent of age, renal function or tobacco use. In a separate pharmacokinetic study, plasma 
pharmacokinetic profiles in patients with mild to moderate hepatic impairment were similar to those 
observed in patients with normal hepatic function.

Paediatric patients had a higher AUC than adult patients; however, the maximum tolerated dose 
(MTD) was 1,000 mg/m2 per cycle both in children and in adults.

5.3 Preclinical safety data

Single-cycle (5-day dosing, 23 days non-treatment), 3- and 6-cycle toxicity studies were conducted in 
rats and dogs. The primary targets of toxicity included the bone marrow, lymphoreticular system, 
testes, the gastrointestinal tract and, at higher doses, which were lethal to 60 % to 100 % of rats and 
dogs tested, degeneration of the retina occurred. Most of the toxicity showed evidence of reversibility, 
except for adverse events on the male reproductive system and retinal degeneration. However, 
because the doses implicated in retinal degeneration were in the lethal dose range, and no comparable 
effect has been observed in clinical studies, this finding was not considered to have clinical relevance.

TMZ is an embryotoxic, teratogenic and genotoxic alkylating agent. TMZ is more toxic to the rat and 
dog than to humans, and the clinical dose approximates the minimum lethal dose in rats and dogs. 
Dose-related reductions in leukocytes and platelets appear to be sensitive indicators of toxicity. A 
variety of neoplasms, including mammary carcinomas, keratocanthoma of the skin and basal cell 
adenoma were observed in the 6-cycle rat study while no tumours or pre-neoplastic changes were 
evident in dog studies. Rats appear to be particularly sensitive to oncogenic effects of TMZ, with the 
occurrence of first tumours within 3 months of initiating dosing. This latency period is very short 
even for an alkylating agent.

Results of the Ames/salmonella and Human Peripheral Blood Lymphocyte (HPBL) chromosome 
aberration tests showed a positive mutagenicity response.

6. PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Capsule content:
anhydrous lactose, 
colloidal anhydrous silica, 
sodium starch glycolate type A, 
tartaric acid, 
stearic acid.

Capsule shell: 
gelatin, 
titanium dioxide (E 171), 
sodium lauril sulfate

Printing ink: 
shellac, 
propylene glycol, 
purified water, 

 



90

ammonium hydroxide,
potassium hydroxide, 
black iron oxide (E 172).

6.2 Incompatibilities

Not applicable.

6.3 Shelf life

3 years

6.4 Special precautions for storage

Bottle presentation

Do not store above 30 C.
Store in the original bottle in order to protect from moisture.
Keep the bottle tightly closed.

Sachet presentation

Do not store above 30 C.

6.5 Nature and contents of container

Bottle presentation

Type I amber glass bottles with polypropylene child-resistant closures containing 5 or 20 hard 
capsules.
The carton contains one bottle.

Sachet presentation

Sachets are composed of linear low density polyethylene (innermost layer), aluminium and 
polyethylene terephthalate.
Each sachet contains 1 hard capsule and is dispensed in a cardboard carton.
The carton contains 5 or 20 hard capsules, individually sealed in sachets.

Not all pack sizes may be marketed.

6.6 Special precautions for disposal and other handling

Capsules should not be opened. If a capsule becomes damaged, contact of the powder contents with 
skin or mucous membrane must be avoided. If Temodal comes into contact with skin or mucosa, it 
should be washed immediately and thoroughly with soap and water. 

Patients should be advised to keep capsules out of the sight and reach of children, preferably in a 
locked cupboard. Accidental ingestion can be lethal for children.

Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements.

 



91

7. MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

8. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/007
EU/1/98/096/008
EU/1/98/096/021
EU/1/98/096/022

9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

Date of first authorisation: 26 January 1999
Date of latest renewal: 26 January 2009

10. DATE OF REVISION OF THE TEXT

Detailed information on this medicinal product is available on the website of the European Medicines 
Agency http://www.ema.europa.eu.

 

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92

1. NAME OF THE MEDICINAL PRODUCT

Temodal 2.5 mg/ml powder for solution for infusion

2. QUALITATIVE AND QUANTITATIVE COMPOSITION

Each vial contains 100 mg of temozolomide. 
After reconstitution, 1 ml solution for infusion contains 2.5 mg temozolomide.

Excipient with known effect:
Each vial contains 2.4 mmol sodium.

For the full list of excipients, see section 6.1.

3. PHARMACEUTICAL FORM

Powder for solution for infusion.

White powder.

4. CLINICAL PARTICULARS

4.1 Therapeutic indications

Temodal is indicated for the treatment of:
- adult patients with newly-diagnosed glioblastoma multiforme concomitantly with radiotherapy 

(RT) and subsequently as monotherapy treatment.
- children from the age of three years, adolescents and adult patients with malignant glioma, such 

as glioblastoma multiforme or anaplastic astrocytoma, showing recurrence or progression after 
standard therapy.

4.2 Posology and method of administration

Temodal should only be prescribed by physicians experienced in the oncological treatment of brain 
tumours.

Anti-emetic therapy may be administered (see section 4.4).

Posology

Adult patients with newly-diagnosed glioblastoma multiforme

Temodal is administered in combination with focal radiotherapy (concomitant phase) followed by up 
to 6 cycles of temozolomide (TMZ) monotherapy (monotherapy phase).

Concomitant phase

TMZ is administered at a dose of 75 mg/m2 daily for 42 days concomitant with focal radiotherapy 
(60 Gy administered in 30 fractions). No dose reductions are recommended, but delay or 
discontinuation of TMZ administration should be decided weekly according to haematological and 
non-haematological toxicity criteria. 
TMZ administration can be continued throughout the 42 day concomitant period (up to 49 days) if all 
of the following conditions are met: 

 



93

- absolute neutrophil count (ANC) ≥ 1.5 x 109/l 
- thrombocyte count ≥ 100 x 109/l
- common toxicity criteria (CTC) non-haematological toxicity ≤ Grade 1 (except for alopecia, 

nausea and vomiting).
During treatment a complete blood count should be obtained weekly. TMZ administration should be 
temporarily interrupted or permanently discontinued during the concomitant phase according to the 
haematological and non-haematological toxicity criteria as noted in Table 1.

Table 1. TMZ dosing interruption or discontinuation during
concomitant radiotherapy and TMZ

Toxicity TMZ interruptiona TMZ discontinuation

Absolute neutrophil count  0.5 and < 1.5 x 109/l < 0.5 x 10
9/l

Thrombocyte count  10 and < 100 x 109/l < 10 x 10
9/l

CTC non-haematological toxicity
(except for alopecia, nausea, vomiting)

CTC Grade 2 CTC Grade 3 or 4

a: Treatment with concomitant TMZ can be continued when all of the following conditions are met: absolute neutrophil 
count  1.5 x 109/l; thrombocyte count  100 x 109/l; CTC non-haematological toxicity  Grade 1 (except for alopecia, 
nausea, vomiting).

Monotherapy phase

Four weeks after completing the TMZ + RT concomitant phase, TMZ is administered for up to 
6 cycles of monotherapy treatment. Dose in Cycle 1 (monotherapy) is 150 mg/m2 once daily for 
5 days followed by 23 days without treatment. At the start of Cycle 2, the dose is escalated to 
200 mg/m2 if the CTC non-haematological toxicity for Cycle 1 is Grade ≤ 2 (except for alopecia, 
nausea and vomiting), absolute neutrophil count (ANC) is ≥ 1.5 x 109/l, and the thrombocyte count is 
≥ 100 x 109/l. If the dose was not escalated at Cycle 2, escalation should not be done in subsequent 
cycles. Once escalated, the dose remains at 200 mg/m2 per day for the first 5 days of each subsequent 
cycle except if toxicity occurs. Dose reductions and discontinuations during the monotherapy phase 
should be applied according to Tables 2 and 3.

During treatment a complete blood count should be obtained on Day 22 (21 days after the first dose of 
TMZ). The dose should be reduced or administration discontinued according to Table 3. 

Table 2. TMZ dose levels for monotherapy treatment

Dose level TMZ dose 
(mg/m2/day)

Remarks

–1 100 Reduction for prior toxicity 

0 150 Dose during Cycle 1

1 200 Dose during Cycles 2-6 in absence of toxicity

Table 3. TMZ dose reduction or discontinuation during monotherapy treatment

Toxicity Reduce TMZ by 1 dose levela Discontinue TMZ

Absolute neutrophil count < 1.0 x 109/l See footnote b

Thrombocyte count < 50 x 109/l See footnote b

CTC non-haematological Toxicity
(except for alopecia, nausea, vomiting)

CTC Grade 3 CTC Grade 4b

a: TMZ dose levels are listed in Table 2.
b: TMZ is to be discontinued if:
 dose level -1 (100 mg/m2) still results in unacceptable toxicity

 the same Grade 3 non-haematological toxicity (except for alopecia, nausea, vomiting) recurs after dose reduction.

 



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Adult and paediatric patients 3 years of age or older with recurrent or progressive malignant glioma:

A treatment cycle comprises 28 days. In patients previously untreated with chemotherapy, TMZ is 
administered at a dose of 200 mg/m2 once daily for the first 5 days followed by a 23 day treatment 
interruption (total of 28 days). In patients previously treated with chemotherapy, the initial dose is 
150 mg/m2 once daily, to be increased in the second cycle to 200 mg/m2 once daily, for 5 days if there 
is no haematological toxicity (see section 4.4) 

Special populations

Paediatric population

In patients 3 years of age or older, TMZ is only to be used in recurrent or progressive malignant
glioma. Experience in these children is very limited (see sections 4.4 and 5.1). The safety and efficacy 
of TMZ in children under the age of 3 years have not been established. No data are available.

Patients with hepatic or renal impairment

The pharmacokinetics of TMZ were comparable in patients with normal hepatic function and in those 
with mild or moderate hepatic impairment. No data are available on the administration of TMZ in 
patients with severe hepatic impairment (Child’s Class C) or with renal impairment. Based on the 
pharmacokinetic properties of TMZ, it is unlikely that dose reductions are required in patients with 
severe hepatic impairment or any degree of renal impairment. However, caution should be exercised 
when TMZ is administered in these patients. 

Elderly patients

Based on a population pharmacokinetic analysis in patients 19-78 years of age, clearance of TMZ is 
not affected by age. However, elderly patients (> 70 years of age) appear to be at increased risk of 
neutropenia and thrombocytopenia (see section 4.4).

Method of administration

Temodal 2.5 mg/ml powder for solution for infusion must be administered only by intravenous 
infusion. It must not be given by other routes of administration, such as the intrathecal, 
intramuscular, or subcutaneous route. Temodal 2.5 mg/ml powder for solution for infusion may be 
administered in the same IV line with 0.9% Sodium Chloride injection. It is incompatible with 
dextrose solutions.

The appropriate dose of TMZ should be infused intravenously using a pump over a period of 
90 minutes. 

As with other similar chemotherapeutic agents, caution is recommended to avoid extravasation. Local 
injection site adverse reactions, which were mostly mild and short-lived were reported in patients 
receiving Temodal 2.5 mg/ml powder for solution for infusion. Preclinical studies did not show 
permanent tissue damage (see sections 4.8 and 5.3).

Temodal is also available as a hard capsule formulation (oral use). Temodal 2.5 mg/ml powder for 
solution for infusion, given as an intravenous infusion over 90 minutes, is bioequivalent to the hard 
capsule formulation (see section 5.2). 

4.3 Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

Hypersensitivity to dacarbazine (DTIC).

 



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Severe myelosuppression (see section 4.4).

4.4 Special warnings and precautions for use

Opportunistic infections and reactivation of infections

Opportunistic infections (such as Pneumocystis jirovecii pneumonia) and reactivation of infections 
(such as HBV, CMV) have been observed during the treatment with TMZ (see section 4.8).

Meningoencephalitis herpetic

In post marketing cases, meningoencephalitis herpetic (including fatal cases) has been observed in 
patients receiving TMZ in combination with radiotherapy, including cases of concomitant steroids 
administration.

Pneumocystis jirovecii pneumonia

Patients who received concomitant TMZ and RT in a pilot trial for the prolonged 42-day schedule 
were shown to be at particular risk for developing Pneumocystis jirovecii pneumonia (PCP). Thus, 
prophylaxis against PCP is required for all patients receiving concomitant TMZ and RT for the 42-
day regimen (with a maximum of 49 days) regardless of lymphocyte count. If lymphopenia occurs, 
they are to continue the prophylaxis until recovery of lymphopenia to grade ≤ 1.

There may be a higher occurrence of PCP when TMZ is administered during a longer dosing regimen. 
However, all patients receiving TMZ, particularly patients receiving steroids, should be observed 
closely for the development of PCP, regardless of the regimen. Cases of fatal respiratory failure have 
been reported in patients using TMZ, in particular in combination with dexamethasone or other 
steroids.

HBV

Hepatitis due to hepatitis B virus (HBV) reactivation, in some cases resulting in death, has been 
reported. Experts in liver disease should be consulted before treatment is initiated in patients with 
positive hepatitis B serology (including those with active disease). During treatment patients should 
be monitored and managed appropriately.

Hepatotoxicity

Hepatic injury, including fatal hepatic failure, has been reported in patients treated with TMZ (see 
section 4.8). Baseline liver function tests should be performed prior to treatment initiation. If 
abnormal, physicians should assess the benefit/risk prior to initiating temozolomide including the 
potential for fatal hepatic failure. For patients on a 42 day treatment cycle liver function tests should 
be repeated midway during this cycle. For all patients, liver function tests should be checked after 
each treatment cycle. For patients with significant liver function abnormalities, physicians should 
assess the benefit/risk of continuing treatment. Liver toxicity may occur several weeks or more after 
the last treatment with temozolomide.

Malignancies

Cases of myelodysplastic syndrome and secondary malignancies, including myeloid leukaemia, have 
also been reported very rarely (see section 4.8).

Anti-emetic therapy

Nausea and vomiting are very commonly associated with TMZ. 

 



96

Anti-emetic therapy may be administered prior to or following administration of TMZ.

Adult patients with newly-diagnosed glioblastoma multiforme

Anti-emetic prophylaxis is recommended prior to the initial dose of concomitant phase and it is 
strongly recommended during the monotherapy phase.

Patients with recurrent or progressive malignant glioma

Patients who have experienced severe (Grade 3 or 4) vomiting in previous treatment cycles may 
require anti-emetic therapy.

Laboratory parameters

Patients treated with TMZ may experience myelosuppression, including prolonged pancytopenia, 
which may result in aplastic anaemia, which in some cases has resulted in a fatal outcome. In some 
cases, exposure to concomitant medicinal products associated with aplastic anaemia, including 
carbamazepine, phenytoin, and sulfamethoxazole/trimethoprim, complicates assessment. Prior to 
dosing, the following laboratory parameters must be met: ANC  1.5 x 109/l and platelet count 
 100 x 109/l. A complete blood count should be obtained on Day 22 (21 days after the first dose) or 
within 48 hours of that day, and weekly until ANC > 1.5 x 109/l and platelet count > 100 x 109/l. If 
ANC falls to < 1.0 x 109/l or the platelet count is < 50 x 109/l during any cycle, the next cycle should 
be reduced one dose level (see section 4.2). Dose levels include 100 mg/m2, 150 mg/m2, and 
200 mg/m2. The lowest recommended dose is 100 mg/m2.

Paediatric population 

There is no clinical experience with use of TMZ in children under the age of 3 years. Experience in 
older children and adolescents is very limited (see sections 4.2 and 5.1).

Elderly patients (> 70 years of age)

Elderly patients appear to be at increased risk of neutropenia and thrombocytopenia, compared with 
younger patients. Therefore, special care should be taken when TMZ is administered in elderly 
patients.

Male patients

Men being treated with TMZ should be advised not to father a child up to 6 months after receiving the 
last dose and to seek advice on cryoconservation of sperm prior to treatment (see section 4.6).

Sodium

This medicinal product contains 2.4 mmol sodium per vial. This should be taken into consideration by 
patients on a controlled sodium diet.

4.5 Interaction with other medicinal products and other forms of interaction

In a separate phase I study, administration of TMZ with ranitidine did not result in alterations in the 
extent of absorption of temozolomide or the exposure to its active metabolite monomethyl 
triazenoimidazole carboxamide (MTIC). 

Based on an analysis of population pharmacokinetics in phase II trials, co-administration of 
dexamethasone, prochlorperazine, phenytoin, carbamazepine, ondansetron, H2 receptor antagonists, or 
phenobarbital did not alter the clearance of TMZ. Co-administration with valproic acid was associated 
with a small but statistically significant decrease in clearance of TMZ.

 



97

No studies have been conducted to determine the effect of TMZ on the metabolism or elimination of 
other medicinal products. However, since TMZ does not undergo hepatic metabolism and exhibits 
low protein binding, it is unlikely that it would affect the pharmacokinetics of other medicinal 
products (see section 5.2).

Use of TMZ in combination with other myelosuppressive agents may increase the likelihood of 
myelosuppression. 

Paediatric population

Interaction studies have only been performed in adults.

4.6 Fertility, pregnancy and lactation 

Pregnancy

There are no data in pregnant women. In preclinical studies in rats and rabbits receiving 150 mg/m2 

TMZ, teratogenicity and/or foetal toxicity were demonstrated (see section 5.3). 
Temodal should not be administered to pregnant women. If use during pregnancy must be considered, 
the patient should be apprised of the potential risk to the foetus. 

Breast-feeding

It is not known whether TMZ is excreted in human milk; thus, breast-feeding should be discontinued 
while receiving treatment with TMZ. 

Women of childbearing potential

Women of childbearing potential should be advised to use effective contraception to avoid pregnancy 
while they are receiving TMZ.

Male fertility

TMZ can have genotoxic effects. Therefore, men being treated with it should be advised not to father 
a child up to 6 months after receiving the last dose and to seek advice on cryoconservation of sperm 
prior to treatment, because of the possibility of irreversible infertility due to therapy with TMZ.

4.7 Effects on ability to drive and use machines

TMZ has minor influence on the ability to drive and use machines due to fatigue and somnolence (see 
section 4.8).

4.8 Undesirable effects 

Summary of the safety profile

Clinical trial experience with hard capsules

In patients treated with TMZ in clinical trials, the most common adverse reactions were nausea, 
vomiting, constipation, anorexia, headache, fatigue, convulsions, and rash. Most haematologic 
adverse reactions were reported commonly; the frequency of Grade 3-4 laboratory findings is 
presented after Table 4.

 



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For patients with recurrent or progressive glioma, nausea (43 %) and vomiting (36 %) were usually 
Grade 1 or 2 (0 – 5 episodes of vomiting in 24 hours) and were either self-limiting or readily 
controlled with standard anti-emetic therapy. The incidence of severe nausea and vomiting was 4 %.

Tabulated list of adverse reactions
Adverse reactions observed in clinical studies and reported from post-marketing use of TMZ are listed
in Table 4. These reactions are classified according to System Organ Class and frequency. Frequency 
groupings are defined according to 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). Within each frequency 
grouping, undesirable effects are presented in order of decreasing seriousness.

Table 4. Adverse reactions in patients treated with temozolomide

Infections and infestations

Common: Infections, herpes zoster, pharyngitisa, candidiasis oral

Uncommon: Opportunistic infection (including PCP), sepsis†, 
meningoencephalitis herpetic†, CMV infection, CMV 
reactivation, hepatitis B virus†, herpes simplex, infection 
reactivation, wound infection, gastroenteritisb

Neoplasm benign, malignant, and unspecified

Uncommon: Myelodysplastic syndrome (MDS), secondary 
malignancies, including myeloid leukaemia

Blood and lymphatic system disorders

Common: Febrile neutropenia, neutropenia, thrombocytopenia, 
lymphopenia, leukopenia, anaemia

Uncommon: Prolonged pancytopenia, aplastic anaemia†, 
pancytopenia, petechiae

Immune system disorders

Common: Allergic reaction

Uncommon: Anaphylaxis

Endocrine disorders

Common: Cushingoidc

Uncommon: Diabetes insipidus

Metabolism and nutrition disorders

Very common: Anorexia
Common: Hyperglycaemia

Uncommon: Hypokalaemia, alkaline phosphatase increased

Psychiatric disorders

Common: Agitation, amnesia, depression, anxiety, confusion, 
insomnia

Uncommon: Behaviour disorder, emotional lability, hallucination, 
apathy

Nervous system disorders

Very common: Convulsions, hemiparesis, aphasia/dysphasia, headache
Common: Ataxia, balance impaired, cognition impaired, 

concentration impaired, consciousness decreased, 
dizziness, hypoesthesia, memory impaired, neurologic 
disorder, neuropathyd, paraesthesia, somnolence, speech 
disorder, taste perversion, tremor

 



99

Table 4. Adverse reactions in patients treated with temozolomide

Uncommon: Status epilepticus, hemiplegia, extrapyramidal disorder, 
parosmia, gait abnormality, hyperaesthesia, sensory 
disturbance, coordination abnormal

Eye disorders

Common: Hemianopia, vision blurred, vision disordere, visual field 
defect, diplopia, eye pain

Uncommon: Visual acuity reduced, eyes dry

Ear and labyrinth disorders

Common: Deafnessf, vertigo, tinnitus, earacheg

Uncommon: Hearing impairment, hyperacusis, otitis media

Cardiac disorders

Uncommon: Palpitation

Vascular disorders

Common: Haemorrhage, embolism pulmonary, deep vein 
thrombosis, hypertension, 

Uncommon: Cerebral haemorrhage, flushing, hot flushes

Respiratory, thoracic and mediastinal disorders

Common: Pneumonia, dyspnoea, sinusitis, bronchitis, coughing, 
upper respiratory infection

Uncommon: Respiratory failure†, interstitial 
pneumonitis/pneumonitis, pulmonary fibrosis, nasal 
congestion

Gastrointestinal disorders

Very common: Diarrhoea, constipation, nausea, vomiting
Common: Stomatitis, abdominal painh, dyspepsia, dysphagia

Uncommon: Abdominal distension, faecal incontinence, 
gastrointestinal disorder, haemorrhoids, mouth dry

Hepatobiliary disorders

Uncommon: Hepatic failure†, hepatic injury, hepatitis, cholestasis, 
hyperbilirubinemia

Skin and subcutaneous tissue disorders

Very Common: Rash, alopecia
Common: Erythema, dry skin, pruritus
Uncommon: Toxic epidermal necrolysis, Stevens-Johnson syndrome, 

angioedema, erythema multiforme, erythroderma, skin 
exfoliation, photosensitivity reaction, urticaria, 
exanthema, dermatitis, sweating increased, pigmentation 
abnormal

Not known: Drug reaction with eosinophilia and systemic symptoms 
(DRESS)

Musculoskeletal and connective tissue disorders

Common: Myopathy, muscle weakness, arthralgia, back pain, 
musculoskeletal pain, myalgia

Renal and urinary disorders

Common: Micturition frequency, urinary incontinence 

Uncommon: Dysuria

 



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Table 4. Adverse reactions in patients treated with temozolomide

Reproductive system and breast disorders

Uncommon: Vaginal haemorrhage, menorrhagia, amenorrhoea, 
vaginitis, breast pain, impotence

General disorders and administration site conditions

Very common: Fatigue
Common: Fever, influenza-like symptoms, asthenia, malaise, pain, 

oedema, oedema peripherali

Uncommon: Condition aggravated, rigors, face oedema, tongue
discolouration, thirst, tooth disorder

Investigations

Common: Liver enzymes elevationj, weight decreased, weight 
increased

Uncommon: Gamma-glutamyltransferase increased

Injury, poisoning and procedural complications 

Common: Radiation injuryk

a Includes pharyngitis, nasopharyngeal pharyngitis, pharyngitis Streptococcal 
b Includes gastroenteritis, gastroenteritis viral
c Includes cushingoid, Cushing syndrome
d Includes neuropathy, peripheral neuropathy, polyneuropathy, peripheral sensory neuropathy, 
peripheral motor neuropathy
e Includes visual impairment, eye disorder
f Includes deafness, deafness bilateral, deafness neurosensory, deafness unilateral
g Includes earache, ear discomfort
h Includes abdominal pain, abdominal pain lower, abdominal pain upper, abdominal discomfort
i Includes oedema peripheral, peripheral swelling
j Includes liver function test increased, alanine aminotransferase increased, aspartate aminotransferase 
increased, hepatic enzymes increased
k Includes radiation injury, radiation skin injury
† Including cases with fatal outcome

Newly-diagnosed glioblastoma multiforme

Laboratory results

Myelosuppression (neutropenia and thrombocytopenia), which is known dose-limiting toxicity for 
most cytotoxic agents, including TMZ, was observed. When laboratory abnormalities and adverse 
events were combined across concomitant and monotherapy treatment phases, Grade 3 or Grade 4 
neutrophil abnormalities including neutropenic events were observed in 8 % of the patients. Grade 3 
or Grade 4 thrombocyte abnormalities, including thrombocytopenic events were observed in 14 % of 
the patients who received TMZ. 

Recurrent or progressive malignant glioma

Laboratory results

Grade 3 or 4 thrombocytopenia and neutropenia occurred in 19 % and 17 % respectively, of patients 
treated for malignant glioma. This led to hospitalisation and/or discontinuation of TMZ in 8 % and 
4 %, respectively. Myelosuppression was predictable (usually within the first few cycles, with the 
nadir between Day 21 and Day 28), and recovery was rapid, usually within 1-2 weeks. No evidence of 
cumulative myelosuppression was observed. The presence of thrombocytopenia may increase the risk 
of bleeding, and the presence of neutropenia or leukopenia may increase the risk of infection.

 



101

Gender

In a population pharmacokinetics analysis of clinical trial experience there were 101 female and 
169 male subjects for whom nadir neutrophil counts were available and 110 female and 174 male 
subjects for whom nadir platelet counts were available. There were higher rates of Grade 4 
neutropenia (ANC < 0.5 x 109/l), 12 % vs 5 %, and thrombocytopenia (< 20 x 109/l), 9 % vs 3 %, in 
women vs men in the first cycle of therapy. In a 400 subject recurrent glioma data set, Grade 4 
neutropenia occurred in 8 % of female vs 4 % of male subjects and Grade 4 thrombocytopenia in 8 % 
of female vs 3 % of male subjects in the first cycle of therapy. In a study of 288 subjects with newly–
diagnosed glioblastoma multiforme, Grade 4 neutropenia occurred in 3 % of female vs 0 % of male 
subjects and Grade 4 thrombocytopenia in 1 % of female vs 0 % of male subjects in the first cycle of 
therapy.

Paediatric population

Oral TMZ has been studied in paediatric patients (age 3-18 years) with recurrent brainstem glioma or 
recurrent high grade astrocytoma, in a regimen administered daily for 5 days every 28 days. Although 
the data is limited, tolerance in children is expected to be the same as in adults. The safety of TMZ in 
children under the age of 3 years has not been established.

Clinical trial experience with IV

Temodal 2.5 mg/ml powder for solution for infusion delivers equivalent TMZ dose and exposure to 
both TMZ and its active metabolite MTIC as the corresponding Temodal hard capsules (see 
section 5.2). Adverse reactions reported during the two studies with the intravenous formulation 
(n=35) but not in studies using hard capsules, were infusion site reactions: pain, irritation, pruritus, 
warmth, swelling, and erythema, as well as haematoma.

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 national reporting system 
listed in Appendix V.

4.9 Overdose

Doses of 500, 750, 1,000, and 1,250 mg/m2 (total dose per cycle over 5 days) have been evaluated 
clinically in patients. Dose-limiting toxicity was haematological and was reported with any dose but is 
expected to be more severe at higher doses. An overdose of 10,000 mg (total dose in a single cycle, 
over 5 days) was taken by one patient and the adverse reactions reported were pancytopenia, pyrexia, 
multi-organ failure and death. There are reports of patients who have taken the recommended dose for 
more than 5 days of treatment (up to 64 days) with adverse events reported including bone marrow 
suppression, with or without infection, in some cases severe and prolonged and resulting in death. In 
the event of an overdose, haematological evaluation is needed. Supportive measures should be 
provided as necessary.

5. PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Antineoplastic agents - Other alkylating agents, ATC code: L01A X03

 

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102

Mechanism of action

Temozolomide is a triazene, which undergoes rapid chemical conversion at physiologic pH to the 
active monomethyl triazenoimidazole carboxamide (MTIC). The cytotoxicity of MTIC is thought to 
be due primarily to alkylation at the O6 position of guanine with additional alkylation also occurring 
at the N7 position. Cytotoxic lesions that develop subsequently are thought to involve aberrant repair 
of the methyl adduct.

Clinical efficacy and safety

Newly-diagnosed glioblastoma multiforme

A total of 573 patients were randomised to receive either TMZ + RT (n=287) or RT alone (n=286). 
Patients in the TMZ + RT arm received concomitant TMZ (75 mg/m2) once daily, starting the first 
day of RT until the last day of RT, for 42 days (with a maximum of 49 days). This was followed by 
monotherapy TMZ (150 - 200 mg/m2) on Days 1 - 5 of every 28-day cycle for up to 6 cycles, starting 
4 weeks after the end of RT. Patients in the control arm received RT only. Pneumocystis jirovecii
pneumonia (PCP) prophylaxis was required during RT and combined TMZ therapy.

TMZ was administered as salvage therapy in the follow-up phase in 161 patients of the 282 (57 %) in 
the RT alone arm, and 62 patients of the 277 (22 %) in the TMZ + RT arm.

The hazard ratio (HR) for overall survival was 1.59 (95 % CI for HR=1.33 -1.91) with a log-rank 
p < 0.0001 in favour of the TMZ arm. The estimated probability of surviving 2 years or more (26 % 
vs 10 %) is higher for the RT + TMZ arm. The addition of concomitant TMZ to RT, followed by 
TMZ monotherapy in the treatment of patients with newly-diagnosed glioblastoma multiforme 
demonstrated a statistically significant improvement in overall survival (OS) compared with RT alone 
(Figure 1).

Figure 1 Kaplan-Meier curves for overall survival (Intent to treat population)

The results from the trial were not consistent in the subgroup of patients with a poor performance 
status (WHO PS=2, n=70), where overall survival and time to progression were similar in both arms. 
However, no unacceptable risks appear to be present in this patient group.

H R  (95%  C .I.) =  1 .59 (1 .33  – 1 .91)
log-rank p -value  <  .0001

12.1 14.6

RT+TM Z

RT O n ly

26%

10%

 



103

Recurrent or progressive malignant glioma

Data on clinical efficacy in patients with glioblastoma multiforme (Karnofsky performance status 
[KPS]  70), progressive or recurrent after surgery and RT, were based on two clinical trials with oral 
TMZ. One was a non-comparative trial in 138 patients (29 % received prior chemotherapy), and the 
other was a randomised active-controlled trial of TMZ vs procarbazine in a total of 225 patients (67 % 
received prior treatment with nitrosourea based chemotherapy). In both trials, the primary endpoint 
was progression-free survival (PFS) defined by MRI scans or neurological worsening. In the 
non-comparative trial, the PFS at 6 months was 19 %, the median progression-free survival was 
2.1 months, and the median overall survival 5.4 months. The objective response rate (ORR) based on 
MRI scans was 8 %.

In the randomised active-controlled trial, the PFS at 6 months was significantly greater for TMZ than 
for procarbazine (21 % vs 8 %, respectively – chi-square p = 0.008) with median PFS of 2.89 and 
1.88 months respectively (log rank p = 0.0063). The median survival was 7.34 and 5.66 months for 
TMZ and procarbazine, respectively (log rank p = 0.33). At 6 months, the fraction of surviving 
patients was significantly higher in the TMZ arm (60 %) compared with the procarbazine arm (44 %) 
(chi-square p = 0.019). In patients with prior chemotherapy a benefit was indicated in those with a 
KPS ≥ 80.

Data on time to worsening of neurological status favoured TMZ over procarbazine as did data on time 
to worsening of performance status (decrease to a KPS of < 70 or a decrease by at least 30 points). 
The median times to progression in these endpoints ranged from 0.7 to 2.1 months longer for TMZ 
than for procarbazine (log rank p = < 0.01 to 0.03). 

Recurrent anaplastic astrocytoma

In a multicentre, prospective phase II trial evaluating the safety and efficacy of oral TMZ in the 
treatment of patients with anaplastic astrocytoma at first relapse, the 6 month PFS was 46 %. The 
median PFS was 5.4 months. Median overall survival was 14.6 months. Response rate, based on the 
central reviewer assessment, was 35 % (13 CR and 43 PR) for the intent-to-treat population (ITT) 
n=162. In 43 patients stable disease was reported. The 6-month event-free survival for the ITT 
population was 44 % with a median event-free survival of 4.6 months, which was similar to the results
for the progression-free survival. For the eligible histology population, the efficacy results were 
similar. Achieving a radiological objective response or maintaining progression-free status was 
strongly associated with maintained or improved quality of life.

Paediatric population

Oral TMZ has been studied in paediatric patients (age 3-18 years) with recurrent brainstem glioma or 
recurrent high grade astrocytoma, in a regimen administered daily for 5 days every 28 days. Tolerance 
to TMZ is similar to adults.

5.2 Pharmacokinetic properties 

TMZ is spontaneously hydrolyzed at physiologic pH primarily to the active species, 
3- methyl(triazen-1-yl)imidazole-4-carboxamide (MTIC). MTIC is spontaneously hydrolyzed to 
5amino-imidazole4carboxamide (AIC), a known intermediate in purine and nucleic acid biosynthesis, 
and to methylhydrazine, which is believed to be the active alkylating species. The cytotoxicity of 
MTIC is thought to be primarily due to alkylation of DNA mainly at the O6 and N7 positions of 
guanine. Relative to the AUC of TMZ, the exposure to MTIC and AIC is ~ 2.4 % and 23 %, 
respectively. In vivo, the t1/2 of MTIC was similar to that of TMZ, 1.8 hr.

In an open-label, two-way crossover bioequivalence study of the pharmacokinetics of oral and 
intravenous TMZ in patients with primary CNS malignancies, Temodal 2.5 mg/ml powder for 
solution for infusion administered over 90 minutes was found to be bioequivalent for Cmax and AUC 

 



104

of TMZ and MTIC as compared to Temodal hard capsules, following administration of 150 mg/m2

dose. Mean Cmax values for TMZ and MTIC were 7.4 µg/ml and 320 ng/ml, respectively, following 
90 minute intravenous infusion. Mean AUC (0 ) values for TMZ and MTIC were 25 µg•h/ml and 
1,004 ng•h/ml, respectively.

Absorption

After oral administration to adult patients, TMZ is absorbed rapidly, with peak concentrations reached 
as early as 20 minutes post-administration (mean time between 0.5 and 1.5 hours). After oral 
administration of 14C-labelled TMZ, mean faecal excretion of 14C over 7 days post-dose was 0.8 % 
indicating complete absorption.

Distribution

TMZ demonstrates low protein binding (10 % to 20 %), and thus it is not expected to interact with 
highly protein-bound substances.

PET studies in humans and preclinical data suggest that TMZ crosses the blood-brain barrier rapidly 
and is present in the CSF. CSF penetration was confirmed in one patient; CSF exposure based on 
AUC of TMZ was approximately 30 % of that in plasma, which is consistent with animal data. 

Elimination

The half-life (t1/2) in plasma is approximately 1.8 hours. The major route of 
14C elimination is renal. 

Following oral administration, approximately 5 % to 10 % of the dose is recovered unchanged in the 
urine over 24 hours, and the remainder excreted as temozolomide acid, 
5-aminoimidazole-4-carboxamide (AIC) or unidentified polar metabolites.

Plasma concentrations increase in a dose-related manner. Plasma clearance, volume of distribution 
and half-life are independent of dose. 

Special populations

Analysis of population-based pharmacokinetics of TMZ revealed that plasma TMZ clearance was 
independent of age, renal function or tobacco use. In a separate pharmacokinetic study, plasma 
pharmacokinetic profiles in patients with mild to moderate hepatic impairment were similar to those 
observed in patients with normal hepatic function.

Paediatric patients had a higher AUC than adult patients; however, the maximum tolerated dose 
(MTD) was 1,000 mg/m2 per cycle both in children and in adults.

5.3 Preclinical safety data

Single-cycle (5-day dosing, 23 days non-treatment), 3- and 6-cycle toxicity studies were conducted in 
rats and dogs. The primary targets of toxicity included the bone marrow, lymphoreticular system, 
testes, the gastrointestinal tract and, at higher doses, which were lethal to 60 % to 100 % of rats and 
dogs tested, degeneration of the retina occurred. Most of the toxicity showed evidence of reversibility, 
except for adverse events on the male reproductive system and retinal degeneration. However, 
because the doses implicated in retinal degeneration were in the lethal dose range, and no comparable 
effect has been observed in clinical studies, this finding was not considered to have clinical relevance.

TMZ is an embryotoxic, teratogenic and genotoxic alkylating agent. TMZ is more toxic to the rat and 
dog than to humans, and the clinical dose approximates the minimum lethal dose in rats and dogs. 
Dose-related reductions in leukocytes and platelets appear to be sensitive indicators of toxicity. A 
variety of neoplasms, including mammary carcinomas, keratocanthoma of the skin and basal cell 
adenoma were observed in the 6-cycle rat study while no tumours or pre-neoplastic changes were 

 



105

evident in dog studies. Rats appear to be particularly sensitive to oncogenic effects of TMZ, with the 
occurrence of first tumours within 3 months of initiating dosing. This latency period is very short 
even for an alkylating agent.

Results of the Ames/salmonella and Human Peripheral Blood Lymphocyte (HPBL) chromosome 
aberration tests showed a positive mutagenicity response.

The intravenous formulation produced local irritation at the site of injection in both rabbits and rats. 
The irritation was transient and not associated with lasting tissue damage.

6. PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Mannitol (E421)
Threonine
Polysorbate 80
Sodium citrate (for pH adjustment)
Hydrochloric acid concentrated (for pH adjustment)

6.2 Incompatibilities

In the absence of compatibility studies, this medicinal product must not be mixed with other 
medicinal products.

6.3 Shelf life

Unopened vial: 4 years

Reconstituted solution: after reconstitution the chemical and physical in-use stability has been 
demonstrated for 14 hours at 25C, including infusion time.
From a microbiological point of view, the product should be used immediately. If not used 
immediately, in-use storage times and conditions prior to use are the responsibility of the user and 
would normally not be longer than 24 hours at 2 to 8C, unless reconstitution has taken place in 
controlled and validated aseptic conditions.

6.4 Special precautions for storage

Store in a refrigerator (2 C – 8 C).

For storage conditions of the reconstituted medicinal product, see section 6.3.

6.5 Nature and contents of container

Clear type I glass vial sealed with bromobutyl rubber stopper and aluminium overseal with 
peach-coloured flip-off bonnet. Each vial contains 100 mg TMZ.

Temodal 2.5 mg/ml is supplied as a pack of 1 vial.

6.6 Special precautions for disposal and other handling

Caution must be exercised in handling Temodal 2.5 mg/ml powder for solution for infusion. The use 
of gloves and aseptic technique is required. If Temodal 2.5 mg/ml comes into contact with skin or 
mucosa, it should be washed immediately and thoroughly with soap and water. 

 



106

Each vial must be reconstituted with 41 ml sterilised water for injections. The resulting solution 
contains 2.5 mg/ml TMZ. The vials should be gently swirled and not shaken. The solution should be 
inspected and any vial containing visible particulate matter should not be used. A volume up to 40 ml 
reconstituted solution should be withdrawn, according to the total prescribed dose and transferred into 
an empty 250 ml infusion bag (PVC or polyolefin). The pump tubing should be attached to the bag, 
the tubing purged and then capped. Temodal 2.5 mg/ml must be administered by intravenous infusion 
only over a period of 90 minutes. 

Temodal 2.5 mg/ml powder for solution for infusion may be administered in the same IV line with 
0.9% Sodium Chloride injection. It is incompatible with dextrose solutions.
In the absence of additional data, this medicinal product must not be mixed with other medicinal 
products or infused simultaneously through the same intravenous line.

This medicinal product is for single use only. Any unused medicinal product or waste material should 
be disposed of in accordance with local requirements.

7. MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

8. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/023

9. DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

Date of first authorisation: 26 January 1999
Date of latest renewal: 26 January 2009

10. DATE OF REVISION OF THE TEXT

Detailed information on this medicinal product is available on the website of the European Medicines 
Agency http://www.ema.europa.eu.

 

http://www.ema.europa.eu/


107

ANNEX II

A. MANUFACTURER(S) RESPONSIBLE FOR BATCH 
RELEASE

B. CONDITIONS OR RESTRICTIONS REGARDING SUPPLY 
AND USE

C. OTHER CONDITIONS AND REQUIREMENTS OF THE 
MARKETING AUTHORISATION

D. CONDITIONS OR RESTRICTIONS WITH REGARD TO 
THE SAFE AND EFFECTIVE USE OF THE MEDICINAL 
PRODUCT

 



108

A. MANUFACTURER(S) RESPONSIBLE FOR BATCH RELEASE

Name and address of the manufacturer responsible for batch release

SP Labo N.V.
Industriepark 30
2220 Heist op den Berg
Belgium

B. CONDITIONS OR RESTRICTIONS REGARDING SUPPLY AND USE

Medicinal product subject to restricted medical prescription (See Annex I: Summary of Product 
Characteristics, section 4.2).

C. OTHER CONDITIONS AND REQUIREMENTS OF THE MARKETING 
AUTHORISATION

 Periodic safety update reports (PSURs)

The requirements for submission of PSURs for this medicinal product are set out in the list of Union 
reference dates (EURD list) provided for under Article 107c(7) of Directive 2001/83/EC and any 
subsequent updates published on the European medicines web-portal.

D. CONDITIONS OR RESTRICTIONS WITH REGARD TO THE SAFE AND 
EFFECTIVE USE OF THE MEDICINAL PRODUCT

 Risk management plan (RMP)

The marketing authorisation holder (MAH) shall perform the required pharmacovigilance activities 
and interventions detailed in the agreed RMP presented in Module 1.8.2 of the marketing 
authorisation and any agreed subsequent updates of the RMP.

An updated RMP should be submitted:
 At the request of the European Medicines Agency;
 Whenever the risk management system is modified, especially as the result of new information 

being received that may lead to a significant change to the benefit/risk profile or as the result of 
an important (pharmacovigilance or risk minimisation) milestone being reached.

 



109

ANNEX III

LABELLING AND PACKAGE LEAFLET

 



110

A. LABELLING

 



111

PARTICULARS TO APPEAR ON THE OUTER PACKAGING 

CARTON CONTAINING 1 BOTTLE OF 5 OR 20 HARD CAPSULES OF TEMODAL 5 mg

1. NAME OF THE MEDICINAL PRODUCT

Temodal 5 mg hard capsules
temozolomide

2. STATEMENT OF ACTIVE SUBSTANCE(S)

Each hard capsule contains 5 mg temozolomide.

3. LIST OF EXCIPIENTS

Contains lactose. See package leaflet for further information.

4. PHARMACEUTICAL FORM AND CONTENTS

5 hard capsules 
20 hard capsules

5. METHOD AND ROUTE(S) OF ADMINISTRATION

Read the package leaflet before use.
Oral use

6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 
OF THE SIGHT AND REACH OF CHILDREN

Keep out of the sight and reach of children, preferably in a locked cupboard. Accidental ingestion can 
be lethal for children.

7. OTHER SPECIAL WARNING(S), IF NECESSARY

Cytotoxic
Do not open, crush or chew the capsules, swallow whole. If a capsule is damaged, avoid contact with 
your skin, eyes or nose.

8. EXPIRY DATE

EXP 

 



112

9. SPECIAL STORAGE CONDITIONS

Do not store above 30 °C.
Store in the original bottle in order to protect from moisture.
Keep the bottle tightly closed.

10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE

Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements.

11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

12. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/001 (5 hard capsules)
EU/1/98/096/002 (20 hard capsules)

13. BATCH NUMBER

Lot

14. GENERAL CLASSIFICATION FOR SUPPLY

15. INSTRUCTIONS ON USE

16. INFORMATION IN BRAILLE

Temodal 5 mg

17. UNIQUE IDENTIFIER – 2D BARCODE

2D barcode carrying the unique identifier included.

18. UNIQUE IDENTIFIER - HUMAN READABLE DATA

PC
SN 

 



113

NN

 



114

PARTICULARS TO APPEAR ON THE OUTER PACKAGING

CARTON CONTAINING 1 BOTTLE OF 5 OR 20 HARD CAPSULES OF TEMODAL 20 mg

1. NAME OF THE MEDICINAL PRODUCT

Temodal 20 mg hard capsules
temozolomide

2. STATEMENT OF ACTIVE SUBSTANCE(S)

Each hard capsule contains 20 mg temozolomide.

3. LIST OF EXCIPIENTS

Contains lactose. See package leaflet for further information.

4. PHARMACEUTICAL FORM AND CONTENTS

5 hard capsules 
20 hard capsules

5. METHOD AND ROUTE(S) OF ADMINISTRATION

Read the package leaflet before use.
Oral use

6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 
OF THE SIGHT AND REACH OF CHILDREN

Keep out of the sight and reach of children, preferably in a locked cupboard. Accidental ingestion can 
be lethal for children.

7. OTHER SPECIAL WARNING(S), IF NECESSARY

Cytotoxic
Do not open, crush or chew the capsules, swallow whole. If a capsule is damaged, avoid contact with 
your skin, eyes or nose.

8. EXPIRY DATE

EXP 

 



115

9. SPECIAL STORAGE CONDITIONS

Do not store above 30 °C.
Store in the original bottle in order to protect from moisture.
Keep the bottle tightly closed.

10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE

Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements.

11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

12. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/003 (5 hard capsules)
EU/1/98/096/004 (20 hard capsules)

13. BATCH NUMBER

Lot

14. GENERAL CLASSIFICATION FOR SUPPLY

15. INSTRUCTIONS ON USE

16. INFORMATION IN BRAILLE

Temodal 20 mg

17. UNIQUE IDENTIFIER – 2D BARCODE

2D barcode carrying the unique identifier included.

 



116

18. UNIQUE IDENTIFIER - HUMAN READABLE DATA

PC
SN 
NN

 



117

PARTICULARS TO APPEAR ON THE OUTER PACKAGING

CARTON CONTAINING 1 BOTTLE OF 5 OR 20 HARD CAPSULES OF TEMODAL 100 mg

1. NAME OF THE MEDICINAL PRODUCT

Temodal 100 mg hard capsules
temozolomide

2. STATEMENT OF ACTIVE SUBSTANCE(S)

Each hard capsule contains 100 mg temozolomide.

3. LIST OF EXCIPIENTS

Contains lactose. See package leaflet for further information.

4. PHARMACEUTICAL FORM AND CONTENTS

5 hard capsules 
20 hard capsules

5. METHOD AND ROUTE(S) OF ADMINISTRATION

Read the package leaflet before use.
Oral use

6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 
OF THE SIGHT AND REACH OF CHILDREN

Keep out of the sight and reach of children, preferably in a locked cupboard. Accidental ingestion can 
be lethal for children.

7. OTHER SPECIAL WARNING(S), IF NECESSARY

Cytotoxic
Do not open, crush or chew the capsules, swallow whole. If a capsule is damaged, avoid contact with 
your skin, eyes or nose.

8. EXPIRY DATE

EXP 

 



118

9. SPECIAL STORAGE CONDITIONS

Do not store above 30 °C.
Store in the original bottle in order to protect from moisture.
Keep the bottle tightly closed.

10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE

Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements.

11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

12. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/005 (5 hard capsules)
EU/1/98/096/006 (20 hard capsules)

13. BATCH NUMBER

Lot

14. GENERAL CLASSIFICATION FOR SUPPLY

15. INSTRUCTIONS ON USE

16. INFORMATION IN BRAILLE

Temodal 100 mg

17. UNIQUE IDENTIFIER – 2D BARCODE

2D barcode carrying the unique identifier included.

 



119

18. UNIQUE IDENTIFIER - HUMAN READABLE DATA

PC
SN 
NN

 



120

PARTICULARS TO APPEAR ON THE OUTER PACKAGING

CARTON CONTAINING 1 BOTTLE OF 5 OR 20 HARD CAPSULES OF TEMODAL 140 mg

1. NAME OF THE MEDICINAL PRODUCT

Temodal 140 mg hard capsules
temozolomide

2. STATEMENT OF ACTIVE SUBSTANCE(S)

Each hard capsule contains 140 mg temozolomide.

3. LIST OF EXCIPIENTS

Contains lactose. See package leaflet for further information.

4. PHARMACEUTICAL FORM AND CONTENTS

5 hard capsules 
20 hard capsules

5. METHOD AND ROUTE(S) OF ADMINISTRATION

Read the enclosed package leaflet before use.
Oral use

6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 
OF THE SIGHT AND REACH OF CHILDREN

Keep out of the sight and reach of children, preferably in a locked cupboard. Accidental -ingestion 
can be lethal for children.

7. OTHER SPECIAL WARNING(S), IF NECESSARY

Cytotoxic
Do not open, crush or chew the capsules, swallow whole. If a capsule is damaged, avoid contact with 
your skin, eyes or nose.

8. EXPIRY DATE

EXP 

 



121

9. SPECIAL STORAGE CONDITIONS

Do not store above 30 °C.
Store in the original bottle in order to protect from moisture.
Keep the bottle tightly closed.

10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE

Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements.

11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

12. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/009 (5 hard capsules)
EU/1/98/096/010 (20 hard capsules)

13. BATCH NUMBER

Lot

14. GENERAL CLASSIFICATION FOR SUPPLY

15. INSTRUCTIONS ON USE

16. INFORMATION IN BRAILLE

Temodal 140 mg

17. UNIQUE IDENTIFIER – 2D BARCODE

2D barcode carrying the unique identifier included.

 



122

18. UNIQUE IDENTIFIER - HUMAN READABLE DATA

PC
SN 
NN

 



123

PARTICULARS TO APPEAR ON THE OUTER PACKAGING

CARTON CONTAINING 1 BOTTLE OF 5 OR 20 HARD CAPSULES OF TEMODAL 180 mg

1. NAME OF THE MEDICINAL PRODUCT

Temodal 180 mg hard capsules
temozolomide

2. STATEMENT OF ACTIVE SUBSTANCE(S)

Each hard capsule contains 180 mg temozolomide.

3. LIST OF EXCIPIENTS

Contains lactose. See package leaflet for further information.

4. PHARMACEUTICAL FORM AND CONTENTS

5 hard capsules 
20 hard capsules

5. METHOD AND ROUTE(S) OF ADMINISTRATION

Read the enclosed package leaflet before use.
Oral use

6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 
OF THE SIGHT AND REACH OF CHILDREN

Keep out of the sight and reach of children, preferably in a locked cupboard. Accidental -ingestion 
can be lethal for children.

7. OTHER SPECIAL WARNING(S), IF NECESSARY

Cytotoxic
Do not open, crush or chew the capsules, swallow whole. If a capsule is damaged, avoid contact with 
your skin, eyes or nose.

8. EXPIRY DATE

EXP 

 



124

9. SPECIAL STORAGE CONDITIONS

Do not store above 30 °C.
Store in the original bottle in order to protect from moisture.
Keep the bottle tightly closed.

10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE

Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements.

11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

12. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/011 (5 hard capsules)
EU/1/98/096/012 (20 hard capsules)

13. BATCH NUMBER

Lot

14. GENERAL CLASSIFICATION FOR SUPPLY

15. INSTRUCTIONS ON USE

16. INFORMATION IN BRAILLE

Temodal 180 mg

17. UNIQUE IDENTIFIER – 2D BARCODE

2D barcode carrying the unique identifier included.

 



125

18. UNIQUE IDENTIFIER - HUMAN READABLE DATA

PC
SN 
NN

 



126

PARTICULARS TO APPEAR ON THE OUTER PACKAGING

CARTON CONTAINING 1 BOTTLE OF 5 OR 20 HARD CAPSULES OF TEMODAL 250 mg

1. NAME OF THE MEDICINAL PRODUCT

Temodal 250 mg hard capsules
temozolomide

2. STATEMENT OF ACTIVE SUBSTANCE(S)

Each hard capsule contains 250 mg temozolomide.

3. LIST OF EXCIPIENTS

Contains lactose. See package leaflet for further information.

4. PHARMACEUTICAL FORM AND CONTENTS

5 hard capsules 
20 hard capsules

5. METHOD AND ROUTE(S) OF ADMINISTRATION

Read the package leaflet before use.
Oral use

6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 
OF THE SIGHT AND REACH OF CHILDREN

Keep out of the sight and reach of children, preferably in a locked cupboard. Accidental ingestion can 
be lethal for children.

7. OTHER SPECIAL WARNING(S), IF NECESSARY

Cytotoxic
Do not open, crush or chew the capsules, swallow whole. If a capsule is damaged, avoid contact with 
your skin, eyes or nose.

8. EXPIRY DATE

EXP 

 



127

9. SPECIAL STORAGE CONDITIONS

Do not store above 30 °C.
Store in the original bottle in order to protect from moisture.
Keep the bottle tightly closed.

10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE

Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements.

11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

12. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/007 (5 hard capsules)
EU/1/98/096/008 (20 hard capsules)

13. BATCH NUMBER

Lot

14. GENERAL CLASSIFICATION FOR SUPPLY

15. INSTRUCTIONS ON USE

16. INFORMATION IN BRAILLE

Temodal 250 mg

17. UNIQUE IDENTIFIER – 2D BARCODE

2D barcode carrying the unique identifier included.

 



128

18. UNIQUE IDENTIFIER - HUMAN READABLE DATA

PC
SN 
NN

 



129

MINIMUM PARTICULARS TO APPEAR ON SMALL IMMEDIATE PACKAGING UNITS

LABEL FOR BOTTLES CONTAINING 5 OR 20 HARD CAPSULES OF TEMODAL 5 mg

1. NAME OF THE MEDICINAL PRODUCT AND ROUTE(S) OF ADMINISTRATION

Temodal 5 mg hard capsules
temozolomide
Oral use

2. METHOD OF ADMINISTRATION

Read the package leaflet before use.

3. EXPIRY DATE

EXP

4. BATCH NUMBER

Lot

5. CONTENTS BY WEIGHT, BY VOLUME OR BY UNIT

5 hard capsules 
20 hard capsules

6. OTHER

 



130

MINIMUM PARTICULARS TO APPEAR ON SMALL IMMEDIATE PACKAGING UNITS

LABEL FOR BOTTLES CONTAINING 5 OR 20 HARD CAPSULES OF TEMODAL 20 mg

1. NAME OF THE MEDICINAL PRODUCT AND ROUTE(S) OF ADMINISTRATION

Temodal 20 mg hard capsules
temozolomide
Oral use

2. METHOD OF ADMINISTRATION

Read the package leaflet before use.

3. EXPIRY DATE

EXP

4. BATCH NUMBER

Lot

5. CONTENTS BY WEIGHT, BY VOLUME OR BY UNIT

5 hard capsules 
20 hard capsules

6. OTHER

 



131

MINIMUM PARTICULARS TO APPEAR ON SMALL IMMEDIATE PACKAGING UNITS

LABEL FOR BOTTLES CONTAINING 5 OR 20 HARD CAPSULES OF TEMODAL 100 mg

1. NAME OF THE MEDICINAL PRODUCT AND ROUTE(S) OF ADMINISTRATION

Temodal 100 mg hard capsules
temozolomide
Oral use

2. METHOD OF ADMINISTRATION

Read the package leaflet before use.

3. EXPIRY DATE

EXP

4. BATCH NUMBER

Lot

5. CONTENTS BY WEIGHT, BY VOLUME OR BY UNIT

5 hard capsules 
20 hard capsules

6. OTHER

 



132

MINIMUM PARTICULARS TO APPEAR ON SMALL IMMEDIATE PACKAGING UNITS

LABEL FOR BOTTLES CONTAINING 5 OR 20 HARD CAPSULES OF TEMODAL 140 mg

1. NAME OF THE MEDICINAL PRODUCT AND ROUTE(S) OF ADMINISTRATION

Temodal 140 mg hard capsules
temozolomide
Oral use

2. METHOD OF ADMINISTRATION

Read the package leaflet before use.

3. EXPIRY DATE

EXP

4. BATCH NUMBER

Lot

5. CONTENTS BY WEIGHT, BY VOLUME OR BY UNIT

5 hard capsules 
20 hard capsules

6. OTHER

 



133

MINIMUM PARTICULARS TO APPEAR ON SMALL IMMEDIATE PACKAGING UNITS

LABEL FOR BOTTLES CONTAINING 5 OR 20 HARD CAPSULES OF TEMODAL 180 mg

1. NAME OF THE MEDICINAL PRODUCT AND ROUTE(S) OF ADMINISTRATION

Temodal 180 mg hard capsules
temozolomide
Oral use

2. METHOD OF ADMINISTRATION

Read the package leaflet before use.

3. EXPIRY DATE

EXP

4. BATCH NUMBER

Lot

5. CONTENTS BY WEIGHT, BY VOLUME OR BY UNIT

5 hard capsules 
20 hard capsules

6. OTHER

 



134

MINIMUM PARTICULARS TO APPEAR ON SMALL IMMEDIATE PACKAGING UNITS

LABEL FOR BOTTLES CONTAINING 5 OR 20 HARD CAPSULES OF TEMODAL 250 mg

1. NAME OF THE MEDICINAL PRODUCT AND ROUTE(S) OF ADMINISTRATION

Temodal 250 mg hard capsules
temozolomide
Oral use

2. METHOD OF ADMINISTRATION

Read the package leaflet before use.

3. EXPIRY DATE

EXP

4. BATCH NUMBER

Lot

5. CONTENTS BY WEIGHT, BY VOLUME OR BY UNIT

5 hard capsules 
20 hard capsules

6. OTHER

 



135

PARTICULARS TO APPEAR ON THE OUTER PACKAGING 

CARTON CONTAINING 5 OR 20 HARD CAPSULES OF TEMODAL 5 mg INDIVIDUALLY 
SEALED IN SACHETS

1. NAME OF THE MEDICINAL PRODUCT

Temodal 5 mg hard capsules
temozolomide

2. STATEMENT OF ACTIVE SUBSTANCE(S)

Each hard capsule contains 5 mg temozolomide.

3. LIST OF EXCIPIENTS

Contains lactose. See package leaflet for further information.

4. PHARMACEUTICAL FORM AND CONTENTS

5 hard capsules in sachets
20 hard capsules in sachets

5. METHOD AND ROUTE(S) OF ADMINISTRATION

Read the package leaflet before use.
Oral use

6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 
OF THE SIGHT AND REACH OF CHILDREN

Keep out of the sight and reach of children, preferably in a locked cupboard. Accidental ingestion can 
be lethal for children.

7. OTHER SPECIAL WARNING(S), IF NECESSARY

Cytotoxic
Do not open, crush or chew the capsules, swallow whole. If a capsule is damaged, avoid contact with 
your skin, eyes or nose.

8. EXPIRY DATE

EXP 

 



136

9. SPECIAL STORAGE CONDITIONS

Do not store above 30 °C.

10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE

Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements.

11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

12. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/024 (5 hard capsules)
EU/1/98/096/025 (20 hard capsules)

13. BATCH NUMBER

Lot

14. GENERAL CLASSIFICATION FOR SUPPLY

15. INSTRUCTIONS ON USE

16. INFORMATION IN BRAILLE

Temodal 5 mg

17. UNIQUE IDENTIFIER – 2D BARCODE

2D barcode carrying the unique identifier included.

18. UNIQUE IDENTIFIER - HUMAN READABLE DATA

PC
SN 
NN

 



137

PARTICULARS TO APPEAR ON THE OUTER PACKAGING

CARTON CONTAINING 5 OR 20 HARD CAPSULES OF TEMODAL 20 mg 
INDIVIDUALLY SEALED IN SACHETS

1. NAME OF THE MEDICINAL PRODUCT

Temodal 20 mg hard capsules
temozolomide

2. STATEMENT OF ACTIVE SUBSTANCE(S)

Each hard capsule contains 20 mg temozolomide.

3. LIST OF EXCIPIENTS

Contains lactose. See package leaflet for further information.

4. PHARMACEUTICAL FORM AND CONTENTS

5 hard capsules in sachets
20 hard capsules in sachets

5. METHOD AND ROUTE(S) OF ADMINISTRATION

Read the package leaflet before use.
Oral use

6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 
OF THE SIGHT AND REACH OF CHILDREN

Keep out of the sight and reach of children, preferably in a locked cupboard. Accidental ingestion can 
be lethal for children.

7. OTHER SPECIAL WARNING(S), IF NECESSARY

Cytotoxic
Do not open, crush or chew the capsules, swallow whole. If a capsule is damaged, avoid contact with 
your skin, eyes or nose.

8. EXPIRY DATE

EXP 

 



138

9. SPECIAL STORAGE CONDITIONS

Do not store above 30 °C.

10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE

Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements.

11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

12. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/013 (5 hard capsules) 
EU/1/98/096/014 (20 hard capsules)

13. BATCH NUMBER

Lot

14. GENERAL CLASSIFICATION FOR SUPPLY

15. INSTRUCTIONS ON USE

16. INFORMATION IN BRAILLE

Temodal 20 mg

17. UNIQUE IDENTIFIER – 2D BARCODE

2D barcode carrying the unique identifier included.

18. UNIQUE IDENTIFIER - HUMAN READABLE DATA

PC
SN 
NN

 



139

PARTICULARS TO APPEAR ON THE OUTER PACKAGING

CARTON CONTAINING 5 OR 20 HARD CAPSULES OF TEMODAL 100 mg 
INDIVIDUALLY SEALED IN SACHETS

1. NAME OF THE MEDICINAL PRODUCT

Temodal 100 mg hard capsules
temozolomide

2. STATEMENT OF ACTIVE SUBSTANCE(S)

Each hard capsule contains 100 mg temozolomide.

3. LIST OF EXCIPIENTS

Contains lactose. See package leaflet for further information.

4. PHARMACEUTICAL FORM AND CONTENTS

5 hard capsules in sachets
20 hard capsules in sachets

5. METHOD AND ROUTE(S) OF ADMINISTRATION

Read the package leaflet before use.
Oral use

6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 
OF THE SIGHT AND REACH OF CHILDREN

Keep out of the sight and reach of children, preferably in a locked cupboard. Accidental ingestion can 
be lethal for children.

7. OTHER SPECIAL WARNING(S), IF NECESSARY

Cytotoxic
Do not open, crush or chew the capsules, swallow whole. If a capsule is damaged, avoid contact with 
your skin, eyes or nose.

8. EXPIRY DATE

EXP 

 



140

9. SPECIAL STORAGE CONDITIONS

Do not store above 30 °C.

10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE

Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements.

11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

12. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/015 (5 hard capsules)
EU/1/98/096/016 (20 hard capsules

13. BATCH NUMBER

Lot

14. GENERAL CLASSIFICATION FOR SUPPLY

15. INSTRUCTIONS ON USE

16. INFORMATION IN BRAILLE

Temodal 100 mg

17. UNIQUE IDENTIFIER – 2D BARCODE

2D barcode carrying the unique identifier included.

18. UNIQUE IDENTIFIER - HUMAN READABLE DATA

PC
SN 
NN

 



141

PARTICULARS TO APPEAR ON THE OUTER PACKAGING

CARTON CONTAINING 5 OR 20 HARD CAPSULES OF TEMODAL 140 mg 
INDIVIDUALLY SEALED IN SACHETS

1. NAME OF THE MEDICINAL PRODUCT

Temodal 140 mg hard capsules
temozolomide

2. STATEMENT OF ACTIVE SUBSTANCE(S)

Each hard capsule contains 140 mg temozolomide.

3. LIST OF EXCIPIENTS

Contains lactose. See package leaflet for further information.

4. PHARMACEUTICAL FORM AND CONTENTS

5 hard capsules in sachets
20 hard capsules in sachets

5. METHOD AND ROUTE(S) OF ADMINISTRATION

Read the enclosed package leaflet before use.
Oral use

6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 
OF THE SIGHT AND REACH OF CHILDREN

Keep out of the sight and reach of children, preferably in a locked cupboard. Accidental ingestion can 
be lethal for children.

7. OTHER SPECIAL WARNING(S), IF NECESSARY

Cytotoxic
Do not open, crush or chew the capsules, swallow whole. If a capsule is damaged, avoid contact with 
your skin, eyes or nose.

8. EXPIRY DATE

EXP 

 



142

9. SPECIAL STORAGE CONDITIONS

Do not store above 30 °C.

10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE

Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements.

11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

12. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/017 (5 hard capsules)
EU/1/98/096/018 (20 hard capsules)

13. BATCH NUMBER

Lot

14. GENERAL CLASSIFICATION FOR SUPPLY

15. INSTRUCTIONS ON USE

16. INFORMATION IN BRAILLE

Temodal 140 mg

17. UNIQUE IDENTIFIER – 2D BARCODE

2D barcode carrying the unique identifier included.

18. UNIQUE IDENTIFIER - HUMAN READABLE DATA

PC
SN 
NN

 



143

PARTICULARS TO APPEAR ON THE OUTER PACKAGING

CARTON CONTAINING 5 OR 20 HARD CAPSULES OF TEMODAL 180 mg 
INDIVIDUALLY SEALED IN SACHETS

1. NAME OF THE MEDICINAL PRODUCT

Temodal 180 mg hard capsules
temozolomide

2. STATEMENT OF ACTIVE SUBSTANCE(S)

Each hard capsule contains 180 mg temozolomide.

3. LIST OF EXCIPIENTS

Contains lactose. See package leaflet for further information.

4. PHARMACEUTICAL FORM AND CONTENTS

5 hard capsules in sachets
20 hard capsules in sachets

5. METHOD AND ROUTE(S) OF ADMINISTRATION

Read the enclosed package leaflet before use.
Oral use

6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 
OF THE SIGHT AND REACH OF CHILDREN

Keep out of the sight and reach of children, preferably in a locked cupboard. Accidental ingestion can 
be lethal for children.

7. OTHER SPECIAL WARNING(S), IF NECESSARY

Cytotoxic
Do not open, crush or chew the capsules, swallow whole. If a capsule is damaged, avoid contact with 
your skin, eyes or nose.

8. EXPIRY DATE

EXP 

 



144

9. SPECIAL STORAGE CONDITIONS

Do not store above 30 °C.

10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE

Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements.

11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

12. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/019 (5 hard capsules)
EU/1/98/096/020 (20 hard capsules)

13. BATCH NUMBER

Lot

14. GENERAL CLASSIFICATION FOR SUPPLY

15. INSTRUCTIONS ON USE

16. INFORMATION IN BRAILLE

Temodal 180 mg

17. UNIQUE IDENTIFIER – 2D BARCODE

2D barcode carrying the unique identifier included.

18. UNIQUE IDENTIFIER - HUMAN READABLE DATA

PC
SN 
NN

 



145

PARTICULARS TO APPEAR ON THE OUTER PACKAGING

CARTON CONTAINING 5 OR 20 HARD CAPSULES OF TEMODAL 250 mg 
INDIVIDUALLY SEALED IN SACHETS

1. NAME OF THE MEDICINAL PRODUCT

Temodal 250 mg hard capsules
temozolomide

2. STATEMENT OF ACTIVE SUBSTANCE(S)

Each hard capsule contains 250 mg temozolomide.

3. LIST OF EXCIPIENTS

Contains lactose. See package leaflet for further information.

4. PHARMACEUTICAL FORM AND CONTENTS

5 hard capsules in sachets
20 hard capsules in sachets

5. METHOD AND ROUTE(S) OF ADMINISTRATION

Read the enclosed package leaflet before use.
Oral use

6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 
OF THE SIGHT AND REACH OF CHILDREN

Keep out of the sight and reach of children, preferably in a locked cupboard. Accidental ingestion can 
be lethal for children.

7. OTHER SPECIAL WARNING(S), IF NECESSARY

Cytotoxic
Do not open, crush or chew the capsules, swallow whole. If a capsule is damaged, avoid contact with 
your skin, eyes or nose.

8. EXPIRY DATE

EXP 

 



146

9. SPECIAL STORAGE CONDITIONS

Do not store above 30 °C.

10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE

Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements.

11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

12. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/021 (5 hard capsules)
EU/1/98/096/022 (20 hard capsules)

13. BATCH NUMBER

Lot

14. GENERAL CLASSIFICATION FOR SUPPLY

15. INSTRUCTIONS ON USE

16. INFORMATION IN BRAILLE

Temodal 250 mg

17. UNIQUE IDENTIFIER – 2D BARCODE

2D barcode carrying the unique identifier included.

18. UNIQUE IDENTIFIER - HUMAN READABLE DATA

PC
SN 
NN

 



147

MINIMUM PARTICULARS TO APPEAR ON SMALL IMMEDIATE PACKAGING UNITS

SACHET CONTAINING 1 HARD CAPSULE OF TEMODAL 5 mg

1. NAME OF THE MEDICINAL PRODUCT AND ROUTE(S) OF ADMINISTRATION

Temodal 5 mg capsules
temozolomide
Oral use

2. METHOD OF ADMINISTRATION

3. EXPIRY DATE

EXP

4. BATCH NUMBER

Lot

5. CONTENTS BY WEIGHT, BY VOLUME OR BY UNIT

1 capsule

6. OTHER

 



148

MINIMUM PARTICULARS TO APPEAR ON SMALL IMMEDIATE PACKAGING UNITS

SACHET CONTAINING 1 HARD CAPSULE OF TEMODAL 20 mg

1. NAME OF THE MEDICINAL PRODUCT AND ROUTE(S) OF ADMINISTRATION

Temodal 20 mg capsules
temozolomide
Oral use

2. METHOD OF ADMINISTRATION

3. EXPIRY DATE

EXP

4. BATCH NUMBER

Lot

5. CONTENTS BY WEIGHT, BY VOLUME OR BY UNIT

1 capsule

6. OTHER

 



149

MINIMUM PARTICULARS TO APPEAR ON SMALL IMMEDIATE PACKAGING UNITS

SACHET CONTAINING 1 HARD CAPSULE OF TEMODAL 100 mg

1. NAME OF THE MEDICINAL PRODUCT AND ROUTE(S) OF ADMINISTRATION

Temodal 100 mg capsules
temozolomide
Oral use

2. METHOD OF ADMINISTRATION

3. EXPIRY DATE

EXP

4. BATCH NUMBER

Lot

5. CONTENTS BY WEIGHT, BY VOLUME OR BY UNIT

1 capsule

6. OTHER

 



150

MINIMUM PARTICULARS TO APPEAR ON SMALL IMMEDIATE PACKAGING UNITS

SACHET CONTAINING 1 HARD CAPSULE OF TEMODAL 140 mg

1. NAME OF THE MEDICINAL PRODUCT AND ROUTE(S) OF ADMINISTRATION

Temodal 140 mg capsules
temozolomide
Oral use

2. METHOD OF ADMINISTRATION

3. EXPIRY DATE

EXP

4. BATCH NUMBER

Lot

5. CONTENTS BY WEIGHT, BY VOLUME OR BY UNIT

1 capsule

6. OTHER

 



151

MINIMUM PARTICULARS TO APPEAR ON SMALL IMMEDIATE PACKAGING UNITS

SACHET CONTAINING 1 HARD CAPSULE OF TEMODAL 180 mg

1. NAME OF THE MEDICINAL PRODUCT AND ROUTE(S) OF ADMINISTRATION

Temodal 180 mg capsules
temozolomide
Oral use

2. METHOD OF ADMINISTRATION

3. EXPIRY DATE

EXP

4. BATCH NUMBER

Lot

5. CONTENTS BY WEIGHT, BY VOLUME OR BY UNIT

1 capsule

6. OTHER

 



152

MINIMUM PARTICULARS TO APPEAR ON SMALL IMMEDIATE PACKAGING UNITS

SACHET CONTAINING 1 HARD CAPSULE OF TEMODAL 250 mg

1. NAME OF THE MEDICINAL PRODUCT AND ROUTE(S) OF ADMINISTRATION

Temodal 250 mg capsules
temozolomide
Oral use

2. METHOD OF ADMINISTRATION

3. EXPIRY DATE

EXP

4. BATCH NUMBER

Lot

5. CONTENTS BY WEIGHT, BY VOLUME OR BY UNIT

1 capsule

6. OTHER

 



153

PARTICULARS TO APPEAR ON THE OUTER PACKAGING 

CARTON

1. NAME OF THE MEDICINAL PRODUCT

Temodal 2.5 mg/ml powder for solution for infusion
temozolomide

2. STATEMENT OF ACTIVE SUBSTANCE(S)

Each vial contains 100 mg temozolomide. 
After reconstitution, 1 ml of solution for infusion contains 2.5 mg temozolomide.

3. LIST OF EXCIPIENTS

Excipients: mannitol (E421), threonine, polysorbate 80, sodium citrate and hydrochloric acid 
concentrated for pH adjustment.
For sodium, see leaflet for further information.

4. PHARMACEUTICAL FORM AND CONTENTS

Powder for solution for infusion
1 vial 100 mg

5. METHOD AND ROUTE(S) OF ADMINISTRATION

Intravenous use only.
For single use only.
Read the package leaflet before use.

6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 
OF THE SIGHT AND REACH OF CHILDREN

Keep out of the sight and reach of children.

7. OTHER SPECIAL WARNING(S), IF NECESSARY

Cytotoxic
Avoid contact with skin, eyes or nose.

8. EXPIRY DATE

EXP 

 



154

9. SPECIAL STORAGE CONDITIONS

Store in a refrigerator. 
After reconstitution, use the solution within 14 hours at 25 C, including infusion time.

10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE

Any unused medicinal product or waste material should be disposed of in accordance with local 
requirements.

11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

12. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/023

13. BATCH NUMBER

Lot

14. GENERAL CLASSIFICATION FOR SUPPLY

15. INSTRUCTIONS ON USE

16. INFORMATION IN BRAILLE

Justification for not including Braille accepted.

17. UNIQUE IDENTIFIER – 2D BARCODE

2D barcode carrying the unique identifier included.

18. UNIQUE IDENTIFIER - HUMAN READABLE DATA

PC
SN 
NN

 



155

PARTICULARS TO APPEAR ON THE IMMEDIATE PACKAGING 

VIAL LABEL

1. NAME OF THE MEDICINAL PRODUCT

Temodal 2.5 mg/ml powder for solution for infusion
temozolomide

2. STATEMENT OF ACTIVE SUBSTANCE(S)

Each vial contains 100 mg temozolomide. 
After reconstitution, 1 ml of solution for infusion contains 2.5 mg.

3. LIST OF EXCIPIENTS

Mannitol (E421), threonine, polysorbate 80, sodium citrate and hydrochloric acid.
For sodium, see leaflet for further information.

4. PHARMACEUTICAL FORM AND CONTENTS

Powder for solution for infusion
100 mg

5. METHOD AND ROUTE(S) OF ADMINISTRATION

Intravenous use, single use only.
Read the package leaflet before use.

6. SPECIAL WARNING THAT THE MEDICINAL PRODUCT MUST BE STORED OUT 
OF THE SIGHT AND REACH OF CHILDREN

Keep out of the sight and reach of children.

7. OTHER SPECIAL WARNING(S), IF NECESSARY

Cytotoxic
Avoid contact with skin, eyes, nose.

8. EXPIRY DATE

EXP 

 



156

9. SPECIAL STORAGE CONDITIONS

Store in a refrigerator. 
After reconstitution: 14 hours at 25 C, including infusion time.

10. SPECIAL PRECAUTIONS FOR DISPOSAL OF UNUSED MEDICINAL PRODUCTS 
OR WASTE MATERIALS DERIVED FROM SUCH MEDICINAL PRODUCTS, IF 
APPROPRIATE

Dispose of in accordance with local requirements.

11. NAME AND ADDRESS OF THE MARKETING AUTHORISATION HOLDER

Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

12. MARKETING AUTHORISATION NUMBER(S)

EU/1/98/096/023

13. BATCH NUMBER

Lot

14. GENERAL CLASSIFICATION FOR SUPPLY

15. INSTRUCTIONS ON USE

 



157

B. PACKAGE LEAFLET

 



158

Package Leaflet: Information for the user

Temodal 5 mg hard capsules
Temodal 20 mg hard capsules

Temodal 100 mg hard capsules
Temodal 140 mg hard capsules
Temodal 180 mg hard capsules
Temodal 250 mg hard capsules

temozolomide

Read all of this leaflet carefully before you start taking this medicine because it contains 
important information for you.
- Keep this leaflet. You may need to read it again.
- If you have any further questions, ask your doctor, pharmacist or nurse.
- This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, 

even if their signs of illness are the same as yours.
- If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any possible 

side effects not listed in this leaflet. See section 4.

What is in this leaflet
1. What Temodal is and what it is used for
2. What you need to know before you take Temodal
3. How to take Temodal
4. Possible side effects
5. How to store Temodal
6. Contents of the pack and other information

1. What Temodal is and what it is used for

Temodal contains a medicine called temozolomide. This medicine is an antitumour agent.

Temodal is used for the treatment of specific forms of brain tumours:
- in adults with newly-diagnosed glioblastoma multiforme. Temodal is first used together with 

radiotherapy (concomitant phase of treatment) and after that alone (monotherapy phase of 
treatment).

- in children 3 years and older and adult patients with malignant glioma, such as glioblastoma 
multiforme or anaplastic astrocytoma. Temodal is used in these tumours if they return or get 
worse after standard treatment.

2. What you need to know before you take Temodal

Do not take Temodal
- if you are allergic to temozolomide or any of the other ingredients of this medicine (listed in 

section 6).
- if you have had an allergic reaction to dacarbazine (an anticancer medicine sometimes called 

DTIC). Signs of allergic reaction include feeling itchy, breathlessness or wheezing, swelling of 
the face, lips, tongue or throat.

- if certain kinds of blood cells are severely reduced (myelosuppression), such as your white 
blood cell count and platelet count. These blood cells are important for fighting infection and 
for proper blood clotting. Your doctor will check your blood to make sure you have enough of 
these cells before you begin treatment.

 



159

Warnings and precautions
Talk to your doctor, pharmacist or nurse before taking Temodal,
- as you should be observed closely for the development of a serious form of chest infection 

called Pneumocystis jirovecii pneumonia (PCP). If you are a newly-diagnosed patient 
(glioblastoma multiforme) you may be receiving Temodal for 42 days in combination with 
radiotherapy. In this case, your doctor will also prescribe medicine to help you prevent this type 
of pneumonia (PCP).

- if you have ever had or might now have a hepatitis B infection. This is because Temodal could 
cause hepatitis B to become active again, which can be fatal in some cases. Patients will be 
carefully checked by their doctor for signs of this infection before treatment is started.

- if you have low counts of red blood cells (anaemia), white blood cells and platelets, or blood 
clotting problems before starting the treatment, or if you develop them during treatment. Your 
doctor may decide to reduce the dose, interrupt, stop or change your treatment. You may also 
need other treatments. In some cases, it may be necessary to stop treatment with Temodal. Your 
blood will be tested frequently during treatment to monitor the side effects of Temodal on your 
blood cells.

- as you may have a small risk of other changes in blood cells, including leukaemia.
- if you have nausea (feeling sick in your stomach) and/or vomiting which are very common side 

effects of Temodal (see section 4), your doctor may prescribe you a medicine (an anti-emetic) 
to help prevent vomiting. 
If you vomit frequently before or during treatment, ask your doctor about the best time to take 
Temodal until the vomiting is under control. If you vomit after taking your dose, do not take a 
second dose on the same day. 

- if you develop fever or symptoms of an infection, contact your doctor immediately.
- if you are older than 70 years of age, you might be more prone to infections, bruising or 

bleeding.
- if you have liver or kidney problems, your dose of Temodal may need to be adjusted.

Children and adolescents
Do not give this medicine to children under the age of 3 years because it has not been studied. There 
is limited information in patients over 3 years of age who have taken Temodal. 

Other medicines and Temodal
Tell your doctor or pharmacist if you are taking, have recently taken or might take any other 
medicines.

Pregnancy, breast-feeding and fertility
If you are pregnant, think you may be pregnant or are planning to have a baby, ask your doctor or 
pharmacist for advice before taking this medicine. This is because you must not be treated with 
Temodal during pregnancy unless clearly indicated by your doctor.

Effective contraceptive precautions must be taken by both male and female patients who are taking 
Temodal (see also “Male fertility” below).

You should stop breast-feeding while receiving treatment with Temodal.

Male fertility
Temodal may cause permanent infertility. Male patients should use effective contraception and not 
father a child for up to 6 months after stopping treatment. It is recommended to seek advice on 
conservation of sperm prior to treatment.

Driving and using machines
Temodal may make you feel tired or sleepy. In this case, do not drive or use any tools or machines or 
cycle until you see how this medicine affects you (see section 4).

 



160

Temodal contains lactose
Temodal contains lactose (a kind of sugar). If you have been told by your doctor that you have an 
intolerance to some sugars, contact your doctor before taking this medicine.

3. How to take Temodal

Always take this medicine exactly as your doctor or pharmacist has told you. Check with your doctor 
or pharmacist if you are not sure.

Dosage and duration of treatment

Your doctor will work out your dose of Temodal. This is based on your size (height and weight) and 
if you have a recurrent tumour and have had chemotherapy treatment in the past. 
You may be given other medicines (anti-emetics) to take before and/or after taking Temodal to 
prevent or control nausea and vomiting.

Patients with newly-diagnosed glioblastoma multiforme:
If you are a newly-diagnosed patient, treatment will occur in two phases: 
- treatment together with radiotherapy (concomitant phase) first
- followed by treatment with only Temodal (monotherapy phase).

During the concomitant phase, your doctor will start Temodal at a dose of 75 mg/m2 (usual dose). 
You will take this dose every day for 42 days (up to 49 days) in combination with radiotherapy. The 
Temodal dose may be delayed or stopped, depending on your blood counts and how you tolerate your 
medicine during the concomitant phase.
Once the radiotherapy is completed, you will interrupt treatment for 4 weeks. This will give your 
body a chance to recover.
Then, you will start the monotherapy phase.

During the monotherapy phase, the dose and way you take Temodal will be different. Your doctor 
will work out your exact dose. There may be up to 6 treatment periods (cycles). Each one lasts 
28 days. You will take your new dose of Temodal alone once daily for the first 5 days (“dosing days”) 
of each cycle. The first dose will be 150 mg/m2. Then you will have 23 days without Temodal. This 
adds up to a 28-day treatment cycle. 
After Day 28, the next cycle will begin. You will again take Temodal once daily for 5 days followed 
by 23 days without Temodal. The Temodal dose may be adjusted, delayed or stopped depending on 
your blood counts and how you tolerate your medicine during each treatment cycle.

Patients with tumours that have returned or worsened (malignant glioma, such as glioblastoma 
multiforme or anaplastic astrocytoma) taking Temodal only:

A treatment cycle with Temodal lasts 28 days. 
You will take Temodal alone once daily for the first 5 days. This daily dose depends on whether or 
not you have received chemotherapy before.

If you have not been previously treated with chemotherapy, your first dose of Temodal will be 
200 mg/m2 once daily for the first 5 days. If you have been previously treated with chemotherapy, 
your first dose of Temodal will be 150 mg/m2 once daily for the first 5 days.
Then, you will have 23 days without Temodal. This adds up to a 28-day treatment cycle.

After Day 28, the next cycle will begin. You will again receive Temodal once daily for 5 days, 
followed by 23 days without Temodal.

Before each new treatment cycle, your blood will be tested to see if the Temodal dose needs to be 
adjusted. Depending on your blood test results, your doctor may adjust your dose for the next cycle.

 



161

How to take Temodal

Take your prescribed dose of Temodal once a day, preferably at the same time each day.

Take the capsules on an empty stomach; for example, at least one hour before you plan to eat 
breakfast. Swallow the capsule(s) whole with a glass of water. Do not open, crush or chew the 
capsules. If a capsule is damaged, avoid contact of the powder with your skin, eyes or nose. If you 
accidentally get some in your eyes or nose, flush the area with water. 
Depending on the prescribed dose, you may have to take more than one capsule together, eventually 
with different strengths (content of active substance, in mg). The colour of the capsule cap is different 
for each strength (see in the table below). 

Strength Colour of the cap

Temodal     5 mg hard capsules green

Temodal   20 mg hard capsules yellow

Temodal 100 mg hard capsules pink

Temodal 140 mg hard capsules blue

Temodal 180 mg hard capsules orange

Temodal 250 mg hard capsules white

You should make sure you fully understand and remember the following:
 how many capsules you need to take every dosing day. Ask your doctor or pharmacist to write 

it down (including the colour). 
 which days are your dosing days.
Review the dose with your doctor each time you start a new cycle, since it may be different from the 
last cycle.

Always take Temodal exactly as your doctor has told you. It is very important to check with your 
doctor or pharmacist if you are not sure. Errors in how you take this medicine may have serious health 
consequences. 

If you take more Temodal than you should
If you accidentally take more Temodal capsules than you were told to, contact your doctor, 
pharmacist or nurse immediately.

If you forget to take Temodal
Take the missed dose as soon as possible during the same day. If a full day has gone by, check with 
your doctor. Do not take a double dose to make up for a forgotten dose, unless your doctor tells you to 
do so.

If you have any further questions on the use of this medicine, ask your doctor, pharmacist or nurse.

4. Possible side effects

Like all medicines, this medicine can cause side effects, although not everybody gets them.

Contact your doctor immediately if you have any of the following:
- a severe allergic (hypersensitive) reaction (hives, wheezing or other breathing difficulty),
- uncontrolled bleeding, 

 



162

- seizures (convulsions),
- fever, 
- chills,
- severe headache that does not go away.

Temodal treatment can cause a reduction in certain kinds of blood cells. This may cause you to have 
increased bruising or bleeding, anaemia (a shortage of red blood cells), fever, and reduced resistance 
to infections. The reduction in blood cell counts is usually short-lived. In some cases, it may be 
prolonged and may lead to a very severe form of anaemia (aplastic anaemia). Your doctor will 
monitor your blood regularly for any changes, and will decide if any specific treatment is needed. In 
some cases, your Temodal dose will be reduced or treatment stopped.

Other side effects that have been reported are listed below:

Very Common side effects (may affect more than 1 in 10 people) are:
- loss of appetite, difficulty speaking, headache

- vomiting, nausea, diarrhoea, constipation

- rash, hair loss

- tiredness

Common side effects (may affect up to 1 in 10 people) are:
- infections, oral infections, wound infections

- reduced number of blood cells (neutropenia, lymphopenia, thrombocytopenia)

- allergic reaction

- increased blood sugar

- memory impairment, depression, anxiety, confusion, inability to fall asleep or stay asleep

- impaired coordination and balance

- difficulty concentrating, change in mental status or alertness, forgetfulness

- dizziness, impaired sensations, tingling sensations, shaking, abnormal taste

- partial loss of vision, abnormal vision, double vision, dry or painful eyes

- deafness, ringing in the ears, earache

- blood clot in lung or legs, high blood pressure

- pneumonia, shortness of breath, bronchitis, cough, inflammation of your sinuses

- stomach or abdominal pain, upset stomach/heartburn, difficulty swallowing

- dry skin, itching

- muscle damage, muscle weakness, muscle aches and pain

- painful joint, back pain

- frequent urination, difficulty withholding your urine

- fever, flu-like symptoms, pain, feeling unwell, a cold or the flu

- fluid retention, swollen legs

- liver enzyme elevations

- loss of weight, weight gain

- radiation injury

Uncommon side effects (may affect up to 1 in 100 people) are:
- brain infections (meningoencephalitis herpetic) including fatal cases

- new or reactivated cytomegalovirus infections

- reactivated hepatitis B virus infections

- secondary cancers including leukaemia

- reduced blood cell counts (pancytopenia, anaemia, leukopenia)

- red spots under the skin

 



163

- diabetes insipidus (symptoms include increased urination and feeling thirsty), low potassium 

level in the blood

- mood swings, hallucination

- partial paralysis, change in your sense of smell

- hearing impairment, infection of the middle ear

- palpitations (when you can feel your heart beat), hot flushes

- swollen stomach, difficulty controlling your bowel movements, haemorrhoids, dry mouth

- hepatitis and injury to the liver (including fatal liver failure), cholestasis, increased bilirubin

- blisters on body or in mouth, skin peeling, skin eruption, painful reddening of the skin, severe 

rash with skin swelling (including palms and soles)

- increased sensitivity to sunlight, urticaria (hives), increased sweating, change in skin colour

- difficulty in urinating

- vaginal bleeding, vaginal irritation, absent or heavy menstrual periods, breast pain, sexual 

impotence

- shivering, face swelling, discolouration of the tongue, thirst, tooth disorder

Reporting of side effects
If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any possible side 
effects not listed in this leaflet. You can also report side effects directly via the national reporting 
system listed in Appendix V. By reporting side effects you can help provide more information on the 
safety of this medicine.

5. How to store Temodal

Keep this medicine out of the sight and reach of children, preferably in a locked cupboard. Accidental 
ingestion can be lethal for children.

Do not use this medicine after the expiry date which is stated on the label and carton. The expiry date 
refers to the last day of that month.

Bottle presentation
Do not store above 30 C.
Store in the original bottle in order to protect from moisture.
Keep the bottle tightly closed.

Sachet presentation
Do not store above 30 C

Tell your pharmacist if you notice any change in the appearance of the capsules.

Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to 
throw away medicines you no longer use. These measures will help protect the environment. 

6. Contents of the pack and other information

What Temodal contains
The active substance is temozolomide. 

Temodal 5 mg hard capsules: Each capsule contains 5 mg temozolomide.
Temodal 20 mg hard capsules: Each capsule contains 20 mg temozolomide.
Temodal 100 mg hard capsules: Each capsule contains 100 mg temozolomide.
Temodal 140 mg hard capsules: Each capsule contains 140 mg temozolomide.

 

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164

Temodal 180 mg hard capsules: Each capsule contains 180 mg temozolomide.
Temodal 250 mg hard capsules: Each capsule contains 250 mg temozolomide.

The other ingredients are:
capsule content:
anhydrous lactose, colloidal anhydrous silica, sodium starch glycolate type A, tartaric acid, stearic 
acid (see section 2 "Temodal contains lactose"). 
capsule shell: 
Temodal 5 mg hard capsules: gelatin, titanium dioxide (E 171), sodium laurilsulfate, yellow iron 
oxide (E 172), indigo carmine (E 132).
Temodal 20 mg hard capsules: gelatin, titanium dioxide (E 171), sodium lauril sulfate, yellow iron 
oxide (E 172),
Temodal 100 mg hard capsules: gelatin, titanium dioxide (E 171), sodium lauril sulfate, red iron 
oxide (E 172),
Temodal 140 mg hard capsules: gelatin, titanium dioxide (E 171), sodium lauril sulfate, indigo 
carmine (E 132),
Temodal 180 mg hard capsules: gelatin, titanium dioxide (E 171), sodium lauril sulfate, yellow iron 
oxide (E 172), and red iron oxide (E 172),
Temodal 250 mg hard capsules: gelatin, titanium dioxide (E 171), sodium lauril sulfate.
printing ink:
shellac, propylene glycol, purified water, ammonium hydroxide, potassium hydroxide, and black iron 
oxide (E 172).

What Temodal looks like and contents of the pack

Temodal 5 mg hard capsules have an opaque white body, an opaque green cap, and are imprinted with 
black ink. 
Temodal 20 mg hard capsules have an opaque white body, an opaque yellow cap, and are imprinted 
with black ink. 
Temodal 100 mg hard capsules have an opaque white body, an opaque pink cap, and are imprinted 
with black ink. 
Temodal 140 mg hard capsules have an opaque white body, a blue cap, and are imprinted with black 
ink. 
Temodal 180 mg hard capsules have an opaque white body, an opaque orange cap, and are imprinted 
with black ink. 
Temodal 250 mg hard capsules have an opaque white body and cap, and are imprinted with black ink.

Bottle presentation
The hard capsules for oral use are dispensed in amber glass bottles containing 5 or 20 capsules.
The carton contains 1 bottle.

Sachet presentation
The hard capsules (capsules) for oral use are individually sealed in sachets and dispensed in cartons 
containing 5 or 20 hard capsules.

Not all pack sizes may be marketed.

Marketing Authorisation Holder and Manufacturer

Marketing Authorisation Holder: 
Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

Manufacturer: SP Labo N.V., Industriepark 30, B-2220 Heist-op-den-Berg, Belgium

 



165

For any information about this medicine, please contact the local representative of the Marketing 
Authorisation Holder:

Belgique/België/Belgien 
MSD Belgium BVBA/SPRL
Tél/Tel: +32(0)27766211
dpoc_belux@merck.com

Lietuva
UAB Merck Sharp & Dohme
Tel.: +370 5 278 02 47
msd_lietuva@merck.com

България
Мерк Шарп и Доум България ЕООД
Тел.: +359 2 819 3737
info-msdbg@merck.com

Luxembourg/Luxemburg
MSD Belgium BVBA/SPRL
Tél/Tel: 0800 38 693 (+32(0)27766211)
dpoc_belux@merck.com

Česká republika
Merck Sharp & Dohme s.r.o.
Tel.: +420 233 010 111
dpoc_czechslovak@merck.com

Magyarország
MSD Pharma Hungary Kft.
Tel.: +36 1 888 53 00
hungary_msd@merck.com

Danmark
MSD Danmark ApS
Tlf: +45 4482 4000
dkmail@merck.com

Malta
Merck Sharp & Dohme Cyprus Limited
Tel: 8007 4433 (+356 99917558)
malta_info@merck.com 

Deutschland
MSD SHARP & DOHME GMBH
Tel: 0800 673 673 673 (+49 (0) 89 4561 2612)
e-mail@msd.de

Nederland 
Merck Sharp & Dohme B.V.
Tel: 0800 9999000 (+31 23 5153153)
medicalinfo.nl@merck.com

Eesti
Merck Sharp & Dohme OÜ
Tel.: +372 6144 200
msdeesti@merck.com

Norge
MSD (Norge) AS
Tlf: +47 32 20 73 00
msdnorge@msd.no

Eλλάδα
MSD Α.Φ.Β.Ε.Ε.
Τηλ: +30 210 98 97 300
dpoc_greece@merck.com

Österreich
Merck Sharp & Dohme Ges.m.b.H.
Tel: +43 (0) 1 26 044
msd-medizin@merck.com

España
Merck Sharp & Dohme de España, S.A.
Tel: +34 91 321 06 00
msd_info@merck.com

Polska
MSD Polska Sp. z o.o.
Tel: +48 22 549 51 00
msdpolska@merck.com

France
MSD France
Tél: +33 (0) 1 80 46 40 40

Portugal
Merck Sharp & Dohme, Lda.
Tel: +351 21 446 57 00
inform_pt@merck.com

Hrvatska
Merck Sharp & Dohme d.o.o.
Tel: + 385 1 6611 333
croatia_info@merck.com

România
Merck Sharp & Dohme Romania S.R.L.
Tel: + 4021 529 29 00
msdromania@merck.com

 



166

Ireland
Merck Sharp & Dohme Ireland (Human Health) 
Limited
Tel: +353 (0)1 2998700
medinfo_ireland@merck.com

Slovenija
Merck Sharp & Dohme, inovativna zdravila 
d.o.o. 
Tel: +386 1 5204 201
msd_slovenia@merck.com

Ísland
Vistor hf.
Simi: +354 535 7000

Slovenská republika
Merck Sharp & Dohme, s. r. o.
Tel.: +421 2 58282010
dpoc_czechslovak@merck.com

Ιtalia
MSD Italia S.r.l.
Tel: +39 06 361911
medicalinformation.it@merck.com

Suomi/Finland
MSD Finland Oy
Puh/Tel: +358 (0)9 804650
info@msd.fi

Κύπρος
Merck Sharp & Dohme Cyprus Limited
Τηλ: 800 00 673 (+357 22866700)
cyprus_info@merck.com

Sverige
Merck Sharp & Dohme (Sweden) AB
Tel: +46 (0) 77 5700488
medicinskinfo@merck.com

Latvija
SIA Merck Sharp & Dohme Latvija
Tel: +371 67364224
msd_lv@merck.com

United Kingdom
Merck Sharp & Dohme Limited
Tel: +44 (0) 1992 467272
medicalinformationuk@merck.com

This leaflet was last revised in 

Other sources of information
Detailed information on this medicine is available on the European Medicines Agency web site: 
http://www.ema.europa.eu.

 

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167

Package Leaflet: Information for the user

Temodal 2.5 mg/ml powder for solution for infusion
temozolomide

Read all of this leaflet carefully before you start using this medicine because it contains 
important information for you.
- Keep this leaflet. You may need to read it again.
- If you have any further questions, ask your doctor, pharmacist or nurse.
- If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any possible 

side effects not listed in this leaflet. See section 4.

What is in this leaflet
1. What Temodal is and what it is used for
2. What you need to know before you use Temodal
3. How to use Temodal
4. Possible side effects
5. How to store Temodal
6. Contents of the pack and other information

1. What Temodal is and what it is used for

Temodal contains a medicine called temozolomide. This medicine is an antitumour agent.

Temodal is used for the treatment of specific forms of brain tumours:
- in adults with newly-diagnosed glioblastoma multiforme. Temodal is first used together with 

radiotherapy (concomitant phase of treatment) and after that alone (monotherapy phase of 
treatment).

- in children 3 years and older and adult patients with malignant glioma, such as glioblastoma 
multiforme or anaplastic astrocytoma. Temodal is used in these tumours if they return or get 
worse after standard treatment.

2. What you need to know before you use Temodal

Do not use Temodal
- if you are allergic to temozolomide or any of the other ingredients of this medicine (listed in 

section 6).
- if you have had an allergic reaction to dacarbazine (an anticancer medicine sometimes called 

DTIC). Signs of allergic reaction include feeling itchy, breathlessness or wheezing, swelling of 
the face, lips, tongue or throat.

- if certain kinds of blood cells are severely reduced (myelosuppression), such as your white 
blood cell count and platelet count. These blood cells are important for fighting infection and 
for proper blood clotting. Your doctor will check your blood to make sure you have enough of 
these cells before you begin treatment.

Warnings and precautions
Talk to your doctor, pharmacist or nurse before using Temodal,
- as you should be observed closely for the development of a serious form of chest infection 

called Pneumocystis jirovecii pneumonia (PCP). If you are a newly-diagnosed patient 
(glioblastoma multiforme) you may be receiving Temodal for 42 days in combination with 
radiotherapy. In this case, your doctor will also prescribe medicine to help you prevent this type 
of pneumonia (PCP).

 



168

- if you have ever had or might now have a hepatitis B infection. This is because Temodal could 
cause hepatitis B to become active again, which can be fatal in some cases. Patients will be 
carefully checked by their doctor for signs of this infection before treatment is started.

- if you have low counts of red blood cells (anaemia), white blood cells and platelets, or blood 
clotting problems before starting the treatment, or if you develop them during treatment. Your 
doctor may decide to reduce the dose, interrupt, stop or change your treatment. You may also 
need other treatments. In some cases, it may be necessary to stop treatment with Temodal. Your 
blood will be tested frequently during treatment to monitor the side effects of Temodal on your 
blood cells.

- as you may have a small risk of other changes in blood cells, including leukaemia.
- if you have nausea (feeling sick in your stomach) and/or vomiting which are very common side 

effects of Temodal (see section 4), your doctor may prescribe you a medicine (an anti-emetic) 
to help prevent vomiting. 

- if you develop fever or symptoms of an infection, contact your doctor immediately.
- if you are older than 70 years of age, you might be more prone to infections, bruising or 

bleeding.
- if you have liver or kidney problems, your dose of Temodal may need to be adjusted.

Children and adolescents
Do not give this medicine to children under the age of 3 years because it has not been studied. There 
is limited information in patients over 3 years of age who have used Temodal.

Other medicines and Temodal
Tell your doctor or pharmacist if you are taking, have recently taken or might take any other 
medicines.

Pregnancy, breast-feeding and fertility
If you are pregnant, think you may be pregnant or are planning to have a baby, ask your doctor or 
pharmacist for advice before using this medicine. This is because you must not be treated with 
Temodal during pregnancy unless clearly indicated by your doctor.

Effective contraceptive precautions must be taken by both male and female patients who are using 
Temodal (see also “Male fertility” below).

You should stop breast-feeding while receiving treatment with Temodal.

Male fertility
Temodal may cause permanent infertility. Male patients should use effective contraception and not 
father a child for up to 6 months after stopping treatment. It is recommended to seek advice on 
conservation of sperm prior to treatment.

Driving and using machines
Temodal may make you feel tired or sleepy. In this case, do not drive or use any tools or machines or 
cycle until you see how this medicine affects you (see section 4).

Temodal contains sodium
This medicine contains 2.4 mmol sodium per vial. This should be taken into consideration by patients 
on a controlled sodium diet.

3. How to use Temodal

Always use this medicine exactly as your doctor or pharmacist has told you. Check with your doctor 
or pharmacist if you are not sure.

 



169

Your doctor will work out your dose of Temodal. This is based on your size (height and weight) and 
if you have a recurrent tumour and have had chemotherapy treatment in the past. 
You may be given other medicines (anti-emetics) to take before and/or after receiving Temodal to 
prevent or control nausea and vomiting.

Patients with newly-diagnosed glioblastoma multiforme:
If you are a newly-diagnosed patient, treatment will occur in two phases: 
- treatment together with radiotherapy (concomitant phase) first
- followed by treatment with only Temodal (monotherapy phase).

During the concomitant phase, your doctor will start Temodal at a dose of 75 mg/m2 (usual dose). 
You will receive this dose every day for 42 days (up to 49 days) in combination with radiotherapy. 
The Temodal dose may be delayed or stopped, depending on your blood counts and how you tolerate 
your medicine during the concomitant phase.
Once the radiotherapy is completed, you will interrupt treatment for 4 weeks. This will give your 
body a chance to recover.
Then, you will start the monotherapy phase.

During the monotherapy phase, the dose and way you receive Temodal in this phase will be different. 
Your doctor will work out your exact dose.
There may be up to 6 treatment periods (cycles). Each one lasts 28 days.
You will receive your new dose of Temodal alone once daily for the first 5 days of each cycle. The 
first dose will be 150 mg/m2. Then you will have 23 days without Temodal. This adds up to a 28-day 
treatment cycle. 
After Day 28, the next cycle will begin. You will again receive Temodal once daily for 5 days 
followed by 23 days without Temodal. 
The Temodal dose may be adjusted, delayed or stopped depending on your blood counts and how you 
tolerate your medicine during each treatment cycle.

Patients with tumours that have returned or worsened (malignant glioma, such as glioblastoma 
multiforme or anaplastic astrocytoma) receiving Temodal only:

A treatment cycle with Temodal lasts 28 days. 

You will receive Temodal alone once daily for the first 5 days. This daily dose depends on whether or 
not you have received chemotherapy before.
If you have not been previously treated with chemotherapy, your first dose of Temodal will be 
200 mg/m2 once daily for the first 5 days. If you have been previously treated with chemotherapy, 
your first dose of Temodal will be 150 mg/m2 once daily for the first 5 days.

Then, you will have 23 days without Temodal. This adds up to a 28 day treatment cycle.

After Day 28, the next cycle will begin. You will again receive Temodal once daily for 5 days, 
followed by 23 days without Temodal.

Before each new treatment cycle, your blood will be tested to see if the Temodal dose needs to be 
adjusted. Depending on your blood test results, your doctor may adjust your dose for the next cycle.

How Temodal is given
Temodal will be given to you by your doctor in a drip into a vein (intravenous infusion), only over 
approximately 90 minutes. No infusion site other than a vein is acceptable.

If you use more Temodal than you should
Your medicine is given to you by health care professionals. It is therefore unlikely that you will 
receive more Temodal than you should. However, if you do, the doctor or nurse will treat you
accordingly.

 



170

If you have any further questions on the use of this medicine, ask your doctor, pharmacist or nurse.

4. Possible side effects

Like all medicines, this medicine can cause side effects, although not everybody gets them.

Contact your doctor immediately if you have any of the following:
- a severe allergic (hypersensitive) reaction (hives, wheezing or other breathing difficulty), 
- uncontrolled bleeding, 
- seizures (convulsions), 
- fever, 
- chills,
- severe headache that does not go away.

Temodal treatment can cause a reduction in certain kinds of blood cells. This may cause you to have 
increased bruising or bleeding, anaemia (a shortage of red blood cells), fever, and reduced resistance 
to infections. The reduction in blood cell counts is usually short-lived. In some cases, it may be 
prolonged and may lead to a very severe form of anaemia (aplastic anaemia). Your doctor will 
monitor your blood regularly for any changes, and will decide if any specific treatment is needed. In 
some cases, your Temodal dose will be reduced or treatment stopped.

Other side effects that have been reported are listed below:

Very Common side effects (may affect more than 1 in 10 people) are:
- loss of appetite, difficulty speaking, headache

- vomiting, nausea, diarrhoea, constipation

- rash, hair loss

- tiredness

Common side effects (may affect up to 1 in 10 people) are:
- infections, oral infections, wound infections

- reduced number of blood cells (neutropenia, lymphopenia, thrombocytopenia)

- allergic reaction

- increased blood sugar

- memory impairment, depression, anxiety, confusion, inability to fall asleep or stay asleep

- impaired coordination and balance

- difficulty concentrating, change in mental status or alertness, forgetfulness

- dizziness, impaired sensations, tingling sensations, shaking, abnormal taste

- partial loss of vision, abnormal vision, double vision, dry or painful eyes

- deafness, ringing in the ears, earache

- blood clot in lung or legs, high blood pressure

- pneumonia, shortness of breath, bronchitis, cough, inflammation of your sinuses

- stomach or abdominal pain, upset stomach/heartburn, difficulty swallowing

- dry skin, itching

- muscle damage, muscle weakness, muscle aches and pain

- painful joint, back pain

- frequent urination, difficulty withholding your urine

- fever, flu-like symptoms, pain, feeling unwell, a cold or the flu

- fluid retention, swollen legs

- liver enzyme elevations

 



171

- loss of weight, weight gain

- radiation injury

Uncommon side effects (may affect up to 1 in 100 people) are:
- brain infections (meningoencephalitis herpetic) including fatal cases

- new or reactivated cytomegalovirus infections

- reactivated hepatitis B virus infections

- secondary cancers including leukaemia

- reduced blood cell counts (pancytopenia, anaemia, leukopenia)

- red spots under the skin

- diabetes insipidus (symptoms include increased urination and feeling thirsty), low potassium 

level in the blood

- mood swings, hallucination

- partial paralysis, change in your sense of smell

- hearing impairment, infection of the middle ear

- palpitations (when you can feel your heart beat), hot flushes

- swollen stomach, difficulty controlling your bowel movements, haemorrhoids, dry mouth

- hepatitis and injury to the liver (including fatal liver failure), cholestasis, increased bilirubin

- blisters on body or in mouth, skin peeling, skin eruption, painful reddening of the skin, severe 

rash with skin swelling (including palms and soles)

- increased sensitivity to sunlight, urticaria (hives), increased sweating, change in skin colour

- difficulty in urinating

- vaginal bleeding, vaginal irritation, absent or heavy menstrual periods, breast pain, sexual 

impotence

- shivering, face swelling, discolouration of the tongue, thirst, tooth disorder

Temodal powder for solution for infusion
In addition to the side effects listed above, the following may also occur with the use of Temodal 
powder for solution for infusion: pain, irritation, itching, warmth, swelling or redness at the injection 
site; also bruising (haematoma).

Reporting of side effects
If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any possible side 
effects not listed in this leaflet. You can also report side effects directly via the national reporting 
system listed in Appendix V. By reporting side effects you can help provide more information on the 
safety of this medicine.

5. How to store Temodal

Keep this medicine out of the sight and reach of children.

Do not use this medicine after the expiry date which is stated on the label and carton. The expiry date 
refers to the last day of that month.

Store in a refrigerator (2°C – 8°C). 

Once your medicine is prepared for infusion (reconstituted), the solution may be stored at room 
temperature (25°C) for up to 14 hours, including infusion time. 
The reconstituted solution should not be used if discolouration or particulate matter is observed.

Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to 
throw away medicines you no longer use. These measures will help protect the environment. 

 

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172

6. Contents of the pack and other information

What Temodal contains

The active substance is temozolomide. Each vial contains 100 mg temozolomide. After reconstitution, 
each ml solution for infusion contains 2.5 mg of temozolomide.

The other ingredients are mannitol (E421), threonine, polysorbate 80, sodium citrate (for 
pH-adjustment) and hydrochloric acid concentrated (for pH-adjustment) (see section 2).

What Temodal looks like and contents of the pack

The powder for solution for infusion is a white powder. Temodal is available in a glass vial, with a 
butyl rubber stopper and aluminium seal with a flip-off bonnet. 
Each pack contains 1 vial of 100 mg temozolomide.

Marketing Authorisation Holder and Manufacturer

Marketing Authorisation Holder: 
Merck Sharp & Dohme B.V.
Waarderweg 39
2031 BN Haarlem
The Netherlands

Manufacturer: SP Labo N.V., Industriepark 30, B-2220 Heist-op-den-Berg, Belgium

For any information about this medicine, please contact the local representative of the Marketing 
Authorisation Holder:

Belgique/België/Belgien 
MSD Belgium BVBA/SPRL
Tél/Tel: +32(0)27766211
dpoc_belux@merck.com

Lietuva
UAB Merck Sharp & Dohme
Tel.: +370 5 278 02 47
msd_lietuva@merck.com

България
Мерк Шарп и Доум България ЕООД
Тел.: +359 2 819 3737
info-msdbg@merck.com

Luxembourg/Luxemburg
MSD Belgium BVBA/SPRL
Tél/Tel: 0800 38 693 (+32(0)27766211)
dpoc_belux@merck.com

Česká republika
Merck Sharp & Dohme s.r.o.
Tel.: +420 233 010 111
dpoc_czechslovak@merck.com

Magyarország
MSD Pharma Hungary Kft.
Tel.: +36 1 888 53 00
hungary_msd@merck.com

Danmark
MSD Danmark ApS
Tlf: +45 4482 4000
dkmail@merck.com

Malta
Merck Sharp & Dohme Cyprus Limited
Tel: 8007 4433 (+356 99917558)
malta_info@merck.com 

Deutschland
MSD SHARP & DOHME GMBH
Tel: 0800 673 673 673 (+49 (0) 89 4561 2612)
e-mail@msd.de

Nederland 
Merck Sharp & Dohme B.V.
Tel: 0800 9999000 (+31 23 5153153)
medicalinfo.nl@merck.com

 



173

Eesti
Merck Sharp & Dohme OÜ
Tel.: +372 6144 200
msdeesti@merck.com

Norge
MSD (Norge) AS
Tlf: +47 32 20 73 00
msdnorge@msd.no

Eλλάδα
MSD Α.Φ.Β.Ε.Ε.
Τηλ: +30 210 98 97 300
dpoc_greece@merck.com

Österreich
Merck Sharp & Dohme Ges.m.b.H.
Tel: +43 (0) 1 26 044
msd-medizin@merck.com

España
Merck Sharp & Dohme de España, S.A.
Tel: +34 91 321 06 00
msd_info@merck.com

Polska
MSD Polska Sp. z o.o.
Tel: +48 22 549 51 00
msdpolska@merck.com

France
MSD France
Tél: +33 (0) 1 80 46 40 40

Portugal
Merck Sharp & Dohme, Lda.
Tel: +351 21 446 57 00
inform_pt@merck.com

Hrvatska
Merck Sharp & Dohme d.o.o.
Tel: + 385 1 6611 333
croatia_info@merck.com

România
Merck Sharp & Dohme Romania S.R.L.
Tel: + 4021 529 29 00
msdromania@merck.com

Ireland
Merck Sharp & Dohme Ireland (Human Health) 
Limited
Tel: +353 (0)1 2998700
medinfo_ireland@merck.com

Slovenija
Merck Sharp & Dohme, inovativna zdravila 
d.o.o. 
Tel: +386 1 5204 201
msd_slovenia@merck.com

Ísland
Vistor hf.
Simi: +354 535 7000

Slovenská republika
Merck Sharp & Dohme, s. r. o.
Tel.: +421 2 58282010
dpoc_czechslovak@merck.com

Ιtalia
MSD Italia S.r.l.
Tel: +39 06 361911
medicalinformation.it@merck.com

Suomi/Finland
MSD Finland Oy
Puh/Tel: +358 (0)9 804650
info@msd.fi

Κύπρος
Merck Sharp & Dohme Cyprus Limited
Τηλ: 800 00 673 (+357 22866700)
cyprus_info@merck.com

Sverige
Merck Sharp & Dohme (Sweden) AB
Tel: +46 (0) 77 5700488
medicinskinfo@merck.com

Latvija
SIA Merck Sharp & Dohme Latvija
Tel: +371 67364224
msd_lv@merck.com

United Kingdom
Merck Sharp & Dohme Limited
Tel: +44 (0) 1992 467272
medicalinformationuk@merck.com

 



174

This leaflet was last revised in 

Other sources of information
Detailed information on this medicine is available on the European Medicines Agency web site: 
http://www.ema.europa.eu.

The following information is intended for medical or health care professional use only:

Caution must be exercised in handling Temodal 2.5 mg/ml powder for solution for infusion. The use 
of gloves and aseptic technique is required. If Temodal 2.5 mg/ml comes into contact with skin or 
mucosa, it should be washed immediately and thoroughly with soap and water. 

Each vial must be reconstituted with 41 ml sterilised water for injections. The resulting solution 
contains 2.5 mg/ml TMZ. The vials should be gently swirled and not shaken. The solution should be 
inspected and any vial containing visible particulate matter should not be used. Reconstituted product 
must be used within 14 hours, including infusion time.

A volume up to 40 ml reconstituted solution should be withdrawn, according to the total prescribed 
dose and transferred into an empty 250 ml infusion bag (PVC or polyolefin). The pump tubing should 
be attached to the bag, the tubing purged and then capped. Temodal 2.5 mg/ml must be administered 
by intravenous infusion only over a period of 90 minutes. 

Temodal 2.5 mg/ml powder for solution for infusion may be administered in the same IV line with 
0.9% Sodium Chloride injection. It is incompatible with dextrose solutions.
In absence of additional data this medicinal product must not be mixed with other medicinal products 
or infused simultaneously through the same intravenous line.

This medicinal product is for single use only. Any unused product or waste material should be 
disposed of in accordance with local requirements.

 

http://www.ema.europa.eu/

	SUMMARY OF PRODUCT CHARACTERISTICS
	A. MANUFACTURER(S) RESPONSIBLE FOR BATCH RELEASE
	B. CONDITIONS OR RESTRICTIONS REGARDING SUPPLY AND USE
	C. OTHER CONDITIONS AND REQUIREMENTS OF THE MARKETING AUTHORISATION
	D. CONDITIONS OR RESTRICTIONS WITH REGARD TO THE SAFE AND EFFECTIVE USE OF THE MEDICINAL PRODUCT
	A. LABELLING
	B. PACKAGE LEAFLET