• Keep this leaflet. You may need to read it again.
• If you have any further questions, ask your doctor.
• If you get any side effects, talk to your doctor. This includes any possible side effects not listed in this leaflet. See section 4.

1. What Cyramza is and what it is used for
2. What you need to know before you are given Cyramza
3. How you are given Cyramza
4. Possible side effects
5. How to store Cyramza
6. Contents of the pack and other information

• if you are allergic to ramucirumab or any of the other ingredients of this medicine (listed in section 6).
• if there is X-ray evidence that the lung cancer has a cavity or hole in it or if the lung cancer is close to major blood vessels.

Talk to your doctor or nurse before you are given Cyramza if you:

• have any condition which increases the risk of bleeding. Also tell your doctor if you are taking any medicines which may increase the risk of bleeding or which affect blood clotting ability. In such cases, your doctor will perform regular blood tests to monitor the risk of bleeding.
• have liver cancer and have had previous bleeding from enlarged veins in your food pipe (oesophagus) or have high blood pressure in the portal vein, which carries the blood from the bowel and spleen to the liver.
• have lung cancer and have had recent bleeding in the lung (coughing up bright red blood) or you are regularly taking non-steroidal anti-inflammatory medicines, or medicines which affect blood clotting ability.
• have high blood pressure. Cyramza can increase the incidence of high blood pressure. Your doctor will make sure that if you already have high blood pressure, it is brought under control before starting Cyramza. Your doctor will monitor your blood pressure and adjust your blood pressure medicine as needed during treatment with Cyramza. Treatment with Cyramza may need to be stopped temporarily until high blood pressure is controlled with medicines, or stopped permanently if it cannot be adequately controlled.
• have or have had an aneurysm (enlargement and weakening of a blood vessel wall) or a tear in a blood vessel wall.
• are going to have planned surgery, if you had recent surgery or if you have poor wound healing after surgery. Cyramza may increase the risk of problems with wound healing. You should not receive Cyramza for at least 4 weeks before you undergo planned surgery and your doctor will decide when to re-start treatment. If you have a wound that heals poorly during treatment, dosing of Cyramza will be stopped until the wound is fully healed.
• have severe liver disease (‘cirrhosis’) and associated conditions, such as excessive accumulation of fluid in your abdomen (‘ascites’). Your doctor will discuss with you if the potential benefits of treatment are judged to outweigh the potential risks for you. If you have liver cancer your doctor will monitor you for signs and symptoms of confusion and/or disorientation associated with chronic liver problems and will stop treatment with Cyramza if you develop these signs and symptoms.
• have severe kidney problems. There are limited data available about the use of Cyramza in patients with severely impaired kidney function.

Talk to your doctor or nurse immediately if any of the following applies to you (or you are not sure) during treatment with Cyramza or anytime thereafter:

• Blocking of the arteries by a blood clot (‘arterial thromboembolic events’):
  Cyramza can cause blood clots in your arteries. Arterial blood clots can lead to serious conditions, including heart attack or stroke. Symptoms of a heart attack may include chest pain or heaviness in the chest. Symptoms of a stroke may include sudden numbness or weakness of the arm, leg and face, feeling confused, difficulty speaking or understanding others, sudden difficulty in walking or loss of balance or coordination or sudden dizziness. Cyramza will be permanently stopped if you develop a blood clot in your arteries.
• A hole in the wall of your gut (‘gastrointestinal perforation’): Cyramza may increase the risk of developing a hole in the wall of your gut. Symptoms include severe abdominal pain, being sick (vomiting), fever or chills. Cyramza will be permanently stopped if you develop a hole in the wall of your gut.
• Severe bleeding: Cyramza may increase the risk of severe bleeding. Symptoms may include: extreme tiredness, weakness, dizziness or changes in the colour of your stools. Cyramza will be permanently stopped if you experience severe bleeding.
• Infusion-related reaction: Infusion-related reactions may happen during treatment because Cyramza is given as an intravenous infusion via a drip (see section 3). Your doctor or nurse will check for side effects during your infusion. Symptoms may include: increased muscle tension, back pain, chest pain and/or tightness, chills, flushing, difficulty in breathing, wheezing, and feeling of tingling or numbness in hands or feet. In severe cases, symptoms may include breathing distress caused by narrowing of the airways, faster heartbeat, and feeling faint. Cyramza will be permanently stopped if you experience a severe infusion-related reaction.
• A rare but serious brain condition called ‘posterior reversible encephalopathy syndrome’ or ‘PRES’: Cyramza may increase the risk of developing this brain condition. Symptoms may include fits (seizures), headache, feeling sick (nausea), being sick (vomiting), blindness or reduced level of consciousness, with or without high blood pressure. Cyramza will be stopped if you experience this brain condition.
• Cardiac Failure: Cyramza, when given in combination with chemotherapy or erlotinib may increase the risk of cardiac failure. Symptoms may include weakness and tiredness, swelling, and fluid build-up in the lungs, which can cause shortness of breath. Your symptoms will be evaluated and suspension of your treatment with Cyramza may be considered.
• Abnormal tube-like connections or passageways inside the body (‘fistula’): Cyramza may increase the risk of abnormal tube-like connections or passageways inside the body between internal organs and skin or other tissues. Cyramza will be permanently stopped if you develop a fistula.
• Abnormal urine test (‘proteinuria’): Cyramza may increase the risk of developing or worsening of abnormal levels of protein in the urine. Treatment with Cyramza may need to be stopped temporarily until the levels of protein in the urine decrease and then treatment resumed at a lower dose, or stopped permanently if the urine protein level does not reduce sufficiently.
• Inflammation of the mouth (‘stomatitis’): Cyramza, when given in combination with chemotherapy may increase the risk of developing inflammation of the mouth. Symptoms may include a burning sensation in the mouth, ulceration, blisters or swelling. Your doctor may prescribe treatment to help with the symptoms.
• Fever or infection: You may develop a temperature of 38 ºC or greater during treatment (since you might have fewer white blood cells than normal which is very common). Symptoms may include sweating or other signs of infection, such as headache, pain in the limbs or decreased appetite. Infection (sepsis) may be severe and could lead to death.
• Elderly people with lung cancer: Your doctor will carefully evaluate the most appropriate treatment for you.

Cyramza should not be given to patients under the age of 18 years because there is no information about how it works in this age group.

Tell your doctor if you are taking, have recently taken or might take any other medicines. This includes medicines obtained without a prescription and herbal medicines.

Before starting treatment you must tell your doctor if you are pregnant or breast-feeding, think you may be pregnant or you are planning to have a baby. You should avoid getting pregnant while receiving this medicine and for at least 3 months after the last dose of Cyramza. Talk to your doctor about the best contraception for you.

As Cyramza inhibits the development of new blood vessels, it may decrease the likelihood of you becoming pregnant or maintaining a pregnancy. It may also cause damage to your unborn baby. You should not use this medicine during pregnancy. If you become pregnant during treatment with Cyramza, your doctor will discuss with you if the benefit of treatment for you is greater than any possible risk to you or your unborn baby.

It is not known if the medicine passes into breast milk and could affect a breastfed baby. Therefore, you should not breast-feed your baby during treatment with Cyramza and for at least 3 months after you receive the last dose.

Cyramza has no or negligible influence on your ability to drive and use machines. If you experience any symptoms affecting your ability to concentrate and react, do not drive or use machines until the effect goes away.

This medicinal product contains less than 1 mmol sodium (23 mg) in each 10 ml vial, that is to say essentially ‘sodium free’.

This medicinal product contains approximately 85 mg sodium (main component of cooking/table salt) in each 50 ml vial. This is equivalent to approximately 4 % of the recommended maximum daily dietary intake of sodium for an adult.

The correct amount of Cyramza needed to treat your disease will be calculated by your doctor or hospital pharmacist depending on your body weight.

The recommended dose of Cyramza for the treatment of gastric cancer, for the treatment of advanced cancer of the colon or rectum and for the treatment of liver cancer is 8 mg per kilogram of your body weight once every 2 weeks.

The recommended dose of Cyramza for the treatment of lung cancer is 10 mg per kilogram of your body weight once every 2 weeks when given in combination with erlotinib or once every 3 weeks when given in combination with docetaxel.

The number of infusions you will receive depends on how you are responding to treatment. Your doctor will discuss this with you.

You may be given another medicine to reduce the risk of an infusion-related reaction before you receive Cyramza. If you experience an infusion-related reaction during Cyramza therapy, you will be given premedication for all future infusions.

During each infusion, your doctor or nurse will check for side effects.

If you experience an infusion-related reaction during treatment, the time taken to give your infusion will be increased for the rest of that infusion and for all future infusions.

The amount of protein in your urine will be checked regularly during treatment. Depending on the protein level measured, Cyramza may be temporarily discontinued. Once the urine protein level has decreased to a certain level, treatment may be restarted with a lower dose.

Cyramza is a concentrate for solution for infusion (also called “sterile concentrate”). A hospital pharmacist, nurse or doctor will have diluted the contents of the vial with sodium chloride 9 mg/ml (0.9 %) solution before use. This medicine is given by infusion via a drip over a period of approximately 60 minutes.

• develop high blood pressure, until it is controlled with anti-hypertensive medicine
• develop wound healing problems, until the wound is healed
• will undergo planned surgery, four weeks prior to surgery

• develop a blood clot in your arteries
• develop a hole in the wall of your gut
• experience severe bleeding
• experience a severe infusion-related reaction
• develop high blood pressure that cannot be controlled with medicine
• are passing more than a certain amount of protein with your urine or if you develop a severe kidney disease (nephrotic syndrome)
• develop abnormal tube-like connections or passageways inside the body between internal organs and skin or other tissues (fistula)
• develop confusion and/or disorientation associated with chronic liver problems
• decline in kidney function (in the setting of liver failure)

Paclitaxel and docetaxel are also given by a drip into a vein (intravenous infusion) over a period of approximately 60 minutes. If you are receiving Cyramza in combination with either paclitaxel or docetaxel on the same day, Cyramza will be given first.

The amount of paclitaxel or docetaxel needed depends on the surface area of your body. Your doctor or hospital pharmacist will calculate your body surface area by measuring your height and weight and will work out the right dose for you.

The recommended dose of paclitaxel is 80 mg for every square metre (m²) of your body’s surface area once every week for 3 weeks followed by 1 week without treatment.

The recommended dose of docetaxel is 75 mg for every square metre (m²) of your body’s surface area once every 3 weeks. If you are of East Asian origin, you may receive a reduced docetaxel starting dose of 60 mg per every m² of your body’s surface area once every 3 weeks.

Prior to being given any paclitaxel infusion, you will have blood tests to check that your blood counts are high enough and that your liver is functioning well.

Read the paclitaxel or docetaxel package leaflet for further information.

FOLFIRI chemotherapy is given by intravenous infusion, after the Cyramza infusion has finished. Please read the package leaflets for the other medicines that are part of your treatment, to see if they are suitable for you. If you are unsure, ask your doctor, pharmacist or nurse if there are any reasons why you can't use these medicines.

Please read the erlotinib package leaflet for information on erlotinib and whether it is suitable for you. If you are unsure, ask your doctor, pharmacist or nurse if there are any reasons why you can't use erlotinib.

Very common side effects (may affect more than 1 in 10 people):

• feeling tired or weak
• low white blood cell counts (may increase the risk of infection)
• infections
• diarrhoea
• hair loss
• nose bleed
• inflammation of the lining of the mouth
• high blood pressure
• reduction in red blood cells which can make the skin pale
• swelling of hands, feet and legs due to fluid retention
• low platelet count (blood cells that help the blood to clot)
• abdominal pain
• protein in the urine (abnormal urine test)
• headache
• inflammation of mucous membranes, such as digestive and respiratory tracts

Common side effects (may affect up to 1 in 10 people):

• fever accompanied by low white blood cell counts
• low blood levels of a protein called albumin
• infusion-related reactions
• rash
• redness, swelling, numbness/tingling, or pain and/or skin peeling in hands and/or feet (called hand-foot syndrome)
• hoarseness
• bleeding in your lungs
• low blood levels of sodium (hyponatraemia) which can cause tiredness and confusion or muscle twitching
• bleeding gums
• confusion and/or disorientation in patients with chronic liver problems
• intestinal blockage; symptoms may include constipation and abdominal pain
• underactive thyroid gland which can cause tiredness or weight gain (hypothyroidism)
• abnormal growth of blood vessels
• serious infection (sepsis)
• low blood levels of potassium (hypokalaemia) which can cause muscle weakness, twitching or abnormal heart rhythm

Uncommon side effects (may affect up to 1 in 100 people):

• a heart condition when the heart muscle does not pump blood as well as it should, causing shortness of breath and swelling of legs and feet

Rare side effects (may affect up to 1 in 1 000 people):

• abnormal blood clotting in small blood vessels

Not known (frequency cannot be estimated from the available data):

• an enlargement and weakening of a blood vessel wall or a tear in a blood vessel wall (aneurysms and artery dissections).

Cyramza may cause changes in laboratory tests. From the side effects listed above, these are: low white blood cell counts; low platelet count in the blood; low blood levels of albumin, potassium or sodium; presence of protein in the urine.

If you get any side effects, talk to your doctor. This includes any possible side effects not listed in this leaflet. You can also report side effects directly via the Yellow Card Scheme, website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

By reporting side effects you can help provide more information on the safety of this medicine.

• The active substance is ramucirumab. One ml of concentrate for solution for infusion contains 10 mg of ramucirumab.
• Each 10 ml vial contains 100 mg of ramucirumab.
• Each 50 ml vial contains 500 mg of ramucirumab.
• The other ingredients are histidine, histidine monohydrochloride, sodium chloride, glycine (E640), polysorbate 80 (E433) and water for injections (see section 2 “Cyramza contains sodium”).

The concentrate for solution for infusion (or sterile concentrate) is a clear to slightly opalescent and colourless to slightly yellow solution in a glass vial with a rubber stopper.

Cyramza is available in packs of:

• 1 vial of 10 ml
• 2 vials of 10 ml
• 1 vial of 50 ml

Not all pack sizes may be marketed.