Ifosfamide solutions

• Encephalopathy (brain disorders) is a very common, known side effect of ifosfamide and is generally reversible. Two recent studies have suggested that the use of ifosfamide solutions may increase the risk of this side effect compared with use of the powder form. However, an in-depth review of all available data could neither confirm nor rule out this increased risk.
• The package leaflet for these medicines will be updated with the latest information on factors that may increase the risk of encephalopathy and how to recognise signs of this side effect.
• Tell your doctor immediately if you experience confusion, sleepiness, unconsciousness, hallucinations, delusions (false beliefs), blurred vision, perception disorder (difficulty understanding information provided through the senses), problems with movement such as muscle spasms or contractions, restlessness, slow or irregular movement, loss of bladder control and seizures (fits).
• Talk to your doctor before you are given an ifosfamide medicine if you have previously had treatment with another cancer medicine called cisplatin.
• Tell your doctor if you have taken medicines that affect the brain, such as those for treating or preventing vomiting and nausea, sleeping pills, opioid painkillers or allergy medicines.
• If you have any concerns about your treatment, you should discuss them with your doctor.

• Administration of ifosfamide can cause encephalopathy and other neurotoxic effects; these known, very common side effects are generally reversible.
• A review of all available data on ifosfamide-induced encephalopathy concluded that an increased risk of encephalopathy with ifosfamide supplied as a solution could neither be confirmed nor ruled out due to limitations in the data.
• The existing warnings in section 4.4 (Special warnings and precautions for use) of the summary of product characteristics will be revised to include the following information:
  • Ifosfamide-induced CNS toxicity may appear within a few hours to a few days after administration and in most cases resolves within 48 to 72 hours of ifosfamide discontinuation. If CNS toxicity develops, administration of ifosfamide should be discontinued.
  • Patients should be closely monitored for symptoms of encephalopathy, in particular if patients are at increased risk for encephalopathy. Symptoms may include confusion, somnolence, coma, hallucination, blurred vision, psychotic behaviour, extrapyramidal symptoms, urinary incontinence and seizures.
  • CNS toxicity seems to be dose-dependent. Risk factors for the development of ifosfamide-associated encephalopathy include hypoalbuminaemia, impaired renal function, poor performance status, pelvic disease and previous or concomitant nephrotoxic treatments including cisplatin.
  • Due to the potential for additive effects, medicines acting on the CNS (such as antiemetics, sedatives, narcotics or antihistamines) must be used with particular caution or, if necessary, be discontinued in case of ifosfamide-induced encephalopathy.

Ifosfamide is used to treat several cancers, including various solid tumours and lymphomas. It is given into a vein and has been authorised as a ready-made solution, a concentrate for solution and a powder to prepare a solution for infusion in Germany and France. In most other EU Member States it is only available as powder for solution for infusion. 

The review of ifosfamide-containing medicines was initiated at the request of France, under Article 31 of Directive 2001/83/EC.

The review was carried out by the Pharmacovigilance Risk Assessment Committee (PRAC), the Committee responsible for the evaluation of safety issues for human medicines, which made a set of recommendations. The PRAC recommendations were sent to the Co-ordination Group for Mutual Recognition and Decentralised Procedures – Human (CMDh), which adopted its position. The CMDh is a body representing EU Member States as well as Iceland, Liechtenstein and Norway. It is responsible for ensuring harmonised safety standards for medicines authorised via national procedures across the EU.

As the CMDh position was adopted by majority vote, the CMDh position was sent to the European Commission, which issued a final legally binding decision applicable in all EU Member States on 21 June 2021.