Depocyt

Overdose

No overdosages with DepoCyt® (cytarabine liposome injection) have been reported. An overdose with DepoCyt may be associated with severe chemical arachnoiditis including encephalopathy. In an early uncontrolled study without dexamethasone prophylaxis, single doses up to 125 mg were administered. There is no antidote for overdose of intrathecal DepoCyt or unencapsulated cytarabine released from DepoCyt. Exchange of CSF with isotonic saline has been carried out in a case of intrathecal overdose of free cytarabine, and such a procedure may be considered in the case of DepoCyt overdose. Management of overdose should be directed at maintaining vital functions.

Contraindications

DepoCyt® (cytarabine liposome injection) is contraindicated in patients who are hypersensitive to cytarabine or any component of the formulation, and in patients with active meningeal infection.

Undesirable effects

The following serious adverse reactions are described in greater detail in other sections of the label:

• Chemical Arachnoiditis
• Neurotoxicity
• Transient elevations in CSF protein and CSF white blood cells

After intrathecal administration of cytarabine the most frequently reported reactions (≥ 10%) are headache NOS, nausea, vomiting NOS, arachnoiditis, weakness, confusion, pyrexia, fatigue, constipation, back pain, gait abnormal NOS, convulsions NOS, dizziness NOS, lethargy, pain in limb, insomnia, urinary tract infection NOS, neck pain, death NOS, pain, memory impairment, dehydration, anemia NOS, diarrhea NOS, appetite decreased NOS, thrombocytopenia, edema peripheral, arthralgia, neck stiffness, vision blurred, muscle weakness, neutropenia, hypoesthesia, agitation, and dyspnea NOS.

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The toxicity database consists of the observations made during Phase 1-4 studies. The most common adverse reactions in all patients and in patients with lymphoma are shown in Table 1. The incidences of symptoms possibly reflecting meningeal irritation are shown in Table 2.

Table 1: Incidence of adverse reactions occurring in > 10% of patients in all Phase 1-4 adult study patients and in patients with lymphomatous meningitis receiving DepoCyt 50 mg or an active comparator

Table 2: Incidence of adverse reactions possibly reflecting meningeal irritation occurring in > 10% of all studied adult patients receiving DepoCyt 50 mg or an active comparator*

During the clinical studies, 2 deaths related to DepoCyt were reported. One patient at the 125 mg dose level died of encephalopathy 36 hours after receiving an intraventricular dose of DepoCyt. This patient, however, was also receiving concomitant whole brain irradiation and had previously received intraventricular methotrexate. The other patient received DepoCyt, 50 mg by the intraventricular route and developed focal seizures progressing to status epilepticus. This patient died approximately 8 weeks after the last dose of study medication. In the controlled lymphoma study, the patient incidence of seizures was higher in the DepoCyt group (4/17, 23.5%) than in the cytarabine group (1/16, 6.3%). The death of 1 additional patient was considered “possibly” related to DepoCyt. He was a 63-year-old with extensive lymphoma involving the  nasopharynx, brain, and meninges with multiple neurologic deficits who died of apparent disease progression 4 days after his second dose of DepoCyt.

Therapeutic indications

DepoCyt® (cytarabine liposome injection) is indicated for the intrathecal treatment of lymphomatous meningitis.

Pharmacokinetic properties

Following intrathecal administration of DepoCyt 50 mg, peak levels of free CSF cytarabine were observed within 1 hour of dosing and ranged from 30 to 50 mcg/mL. The terminal half-life for the free CSF cytarabine ranged from of 5.9 to 82.4 hours. Systemic exposure to cytarabine was negligible following intrathecal administration of DepoCyt 50 mg.

The primary route of elimination of cytarabine is metabolism to the inactive compound ara-U, followed by urinary excretion of ara-U. In contrast to systemically administered cytarabine, which is rapidly metabolized to ara-U, conversion to ara-U in the CSF is negligible after intrathecal administration because of the significantly lower cytidine deaminase activity in the CNS tissues and CSF. The CSF clearance rate of cytarabine is similar to the CSF bulk flow rate of 0.24 mL/min.

Name of the medicinal product

Fertility, pregnancy and lactation

Pregnancy Category D (see WARNINGS).

Qualitative and quantitative composition

Ready-to-use, single dose vial containing 50 mg/5 mL (10 mg/mL) of cytarabine liposome injection.

DepoCyt® (cytarabine liposome injection) is supplied as a sterile, white to off-white suspension in 5 mL glass, single dose vials.

Store refrigerated at 2° to 8°C (36° to 46°F). Protect from freezing and avoid aggressive agitation.

Available in individual carton containing one ready to use vial. NDC 57665-331-01.

Do not use beyond expiration date printed on the label.

DepoCyt is a genotoxic drug. Follow special handling and disposal procedures.

REFERENCES

OSHA Hazardous Drugs. OSHA. [Accessed on November 4, 2014, from http://www.osha.gov/SLTC/hazardousdrugs/index.html].

Manufactured by: Pacira Pharmaceuticals, Inc., San Diego, CA 92121. Distributed by: Sigma-Tau Pharmaceuticals, Inc., Gaithersburg, MD 20878

Special warnings and precautions for use

(see BOXED WARNING)

DepoCyt® (cytarabine liposome injection) should be administered only under the supervision of a qualified physician experienced in the use of cancer chemotherapeutic agents. Appropriate management of complications is possible only when adequate diagnostic and treatment facilities are readily available. Chemical arachnoiditis, a syndrome manifested primarily by nausea, vomiting, headache and fever, has been a common adverse event in all studies. If left untreated, chemical arachnoiditis may be fatal. The incidence and severity of chemical arachnoiditis can be reduced by coadministration of dexamethasone. Patients receiving DepoCyt should be treated concurrently with dexamethasone to mitigate the symptoms of chemical arachnoiditis (see DOSAGE AND ADMINISTRATION). Infectious meningitis may be associated with intrathecal drug administration. Hydrocephalus has also been reported, possibly precipitated by arachnoiditis.

During the clinical studies, 2 deaths related to DepoCyt were reported. One patient died after developing encephalopathy 36 hours after an intraventricular dose of DepoCyt, 125 mg. This patient was receiving concurrent whole-brain irradiation and had previously received systemic chemotherapy with cyclophosphamide, doxorubicin, and fluorouracil, as well as intraventricular methotrexate. The other patient received DepoCyt, 50 mg by the intraventricular route and developed focal seizures progressing to status epilepticus. This patient died approximately 8 weeks after the last dose of study medication. In the controlled lymphoma study, the patient incidence of seizures was higher in the DepoCyt group (4/17, 23.5%) than in the cytarabine group (1/16, 6.3%). The death of 1 additional patient was considered “possibly” related to DepoCyt. He was a 63-year-old with extensive lymphoma involving the nasopharynx, brain, and meninges with multiple neurologic deficits who died of apparent disease progression 4 days after his second dose of DepoCyt.

After intrathecal administration of cytarabine the most frequently reported reactions are nausea, vomiting and fever. Intrathecal administration of cytarabine may cause myelopathy and other neurologic toxicity and can rarely lead to a permanent neurologic deficit. Administration of intrathecal cytarabine in combination with other chemotherapeutic agents or with cranial/spinal irradiation may increase this risk of neurotoxicity.

Blockage to CSF flow may result in increased free cytarabine concentrations in the CSF and an increased risk of neurotoxicity. Therefore, as with any intrathecal cytotoxic therapy, consideration should be given to the need for assessment of CSF flow before treatment is started.

Following intrathecal administration of DepoCyt, central nervous system toxicity, including persistent extreme somnolence, hemiplegia, visual disturbances including blindness which may be total and permanent, deafness and cranial nerve palsies have been reported. Symptoms and signs of peripheral neuropathy, such as pain, numbness, paresthesia, weakness, and impaired bowel and bladder control have also been observed. In some cases, a combination of neurological signs and symptoms have been reported as Cauda Equina Syndrome.

There are no studies assessing the reproductive toxicity of DepoCyt. Cytarabine, the active component of DepoCyt, can cause fetal harm if a pregnant woman is exposed to the drug systemically. Three anecdotal cases of major limb malformations have been reported in infants after their mothers received intravenous cytarabine, alone or in combination with other agents, during the first trimester. The concern for fetal harm following intrathecal DepoCyt administration is low because systemic exposure to cytarabine is negligible. Cytarabine was teratogenic in mice (cleft palate, phocomelia, deformed appendages, skeletal abnormalities) when doses ≥ 2 mg/kg/day were administered IP during the period of organogenesis (about 0.2 times the recommended human dose on mg/m² basis), and in rats (deformed appendages) when 20 mg/kg was administered as a single IP dose on day 12 of gestation (about 4 times the recommended human dose on mg/m² basis). Single IP doses of 50 mg/kg in rats (about 10 times the recommended human dose on mg/m² basis) on day 14 of gestation also cause reduced prenatal and postnatal brain size and permanent impairment of learning ability. Cytarabine was embryotoxic in mice when administered during the period of organogenesis. Embryotoxicity was characterized by decreased fetal weight at 0.5 mg/kg/day (about 0.05 times the recommended human dose on mg/m²basis), and increased early and late resorptions and decreased live litter sizes at 8 mg/kg/day (approximately equal to the recommended human dose on mg/m basis). There are no adequate and well-controlled studies in pregnant women. If this drug is used during pregnancy or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential harm to the fetus. Despite the low apparent risk for fetal harm, women of childbearing potential should be advised to avoid becoming pregnant.

DepoCyt® (cytarabine liposome injection) has the potential of producing serious toxicity (see BOXED WARNING). All patients receiving DepoCyt should be treated concurrently with dexamethasone to mitigate the symptoms of chemical arachnoiditis (see DOSAGE AND ADMINISTRATION). Toxic effects may be related to a single dose or to cumulative administration. Because toxic effects can occur at any time during therapy (although they are most likely to occur within 5 days of drug administration), patients receiving intrathecal therapy with DepoCyt should be monitored continuously for the development of neurotoxicity. If patients develop neurotoxicity, subsequent doses of DepoCyt should be reduced, and DepoCyt should be discontinued if toxicity persists.

Some patients with neoplastic meningitis receiving treatment with DepoCyt may require concurrent radiation or systemic therapy with other chemotherapeutic agents; this may increase the rate of adverse events.

Anaphylactic reactions following intravenous administration of free cytarabine have been reported.

Although significant systemic exposure to free cytarabine following intrathecal treatment is not expected, some effect on bone marrow function cannot be excluded. Systemic toxicity due to intravenous administration of cytarabine consists primarily of bone marrow suppression with leukopenia, thrombocytopenia, and anemia. Accordingly, careful monitoring of the hematopoietic system is advised.

Transient elevations in CSF protein and white blood cells have been observed in patients following DepoCyt administration and have also been noted after intrathecal treatment with methotrexate or cytarabine.

No carcinogenicity, mutagenicity or impairment of fertility studies have been conducted with DepoCyt. The active ingredient of DepoCyt, cytarabine, was mutagenic in in vitro tests and was clastogenic in vitro (chromosome aberrations and SCE in human leukocytes) and in vivo (chromosome aberrations and SCE assay in rodent bone marrow, mouse micronucleus assay). Cytarabine caused the transformation of hamster embryo cells and rat H43 cells in vitro . Cytarabine was clastogenic to meiotic cells; a dose-dependent increase in sperm-head abnormalities and chromosomal aberrations occurred in mice given IP cytarabine. Impairment of Fertility: No studies assessing the impact of cytarabine on fertility are available in the literature. Because the systemic exposure to free cytarabine following intrathecal treatment with DepoCyt was negligible, the risk of impaired fertility after intrathecal DepoCyt is likely to be low.

Pregnancy Category D (see WARNINGS).

It is not known whether cytarabine is excreted in human milk following intrathecal DepoCyt administration. The systemic exposure to free cytarabine following intrathecal treatment with DepoCyt was negligible. Despite the low apparent risk, because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants, the use of DepoCyt is not recommended in nursing women.

The safety and efficacy of DepoCyt in pediatric patients has not been established.

Dosage (Posology) and method of administration

DepoCyt is a cytotoxic anticancer drug and, as with other potentially toxic compounds, caution should be used in handling DepoCyt. The use of gloves is recommended. If DepoCyt suspension contacts the skin, wash immediately with soap and water. If it contacts mucous membranes, flush thoroughly with water.

No further reconstitution or dilution is required. DepoCyt particles have a tendency to settle with time. Vials of DepoCyt should be allowed to warm to room temperature and gently agitated or inverted to re-suspend the particles immediately prior to withdrawal from the vial. Avoid aggressive agitation.

DepoCyt should be withdrawn from the vial immediately before administration. DepoCyt is a single dose vial and does not contain any preservative. DepoCyt should be used within 4 hours of withdrawal from the vial. Unused portions of each vial should be discarded properly. Do not save any unused portions for later administration. Do not mix DepoCyt with any other medications.

In-line filters must not be used when administering DepoCyt. DepoCyt is administered directly into the cerebrospinal fluid (CSF) via an intraventricular reservoir or by direct injection into the lumbar sac. DepoCyt should be injected slowly over a period of 1-5 minutes. Following drug administration by lumbar puncture, the patient should be instructed to lie flat for 1 hour. Patients should be observed by the physician for immediate toxic reactions.

For the treatment of lymphomatous meningitis, DepoCyt 50 mg (one vial of DepoCyt) is recommended to be given according to the following schedule:

Patients should be started on dexamethasone 4 mg twice a day either by mouth or intravenously for 5 days beginning on the day of DepoCyt injection.

If drug related neurotoxicity develops, the dose should be reduced to 25 mg. If it persists, treatment with DepoCyt should be discontinued.

Interaction with other medicinal products and other forms of interaction

The following serious adverse reactions are described in greater detail in other sections of the label:

• Chemical Arachnoiditis
• Neurotoxicity
• Transient elevations in CSF protein and CSF white blood cells

After intrathecal administration of cytarabine the most frequently reported reactions (≥ 10%) are headache NOS, nausea, vomiting NOS, arachnoiditis, weakness, confusion, pyrexia, fatigue, constipation, back pain, gait abnormal NOS, convulsions NOS, dizziness NOS, lethargy, pain in limb, insomnia, urinary tract infection NOS, neck pain, death NOS, pain, memory impairment, dehydration, anemia NOS, diarrhea NOS, appetite decreased NOS, thrombocytopenia, edema peripheral, arthralgia, neck stiffness, vision blurred, muscle weakness, neutropenia, hypoesthesia, agitation, and dyspnea NOS.

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The toxicity database consists of the observations made during Phase 1-4 studies. The most common adverse reactions in all patients and in patients with lymphoma are shown in Table 1. The incidences of symptoms possibly reflecting meningeal irritation are shown in Table 2.

Table 1: Incidence of adverse reactions occurring in > 10% of patients in all Phase 1-4 adult study patients and in patients with lymphomatous meningitis receiving DepoCyt 50 mg or an active comparator

Table 2: Incidence of adverse reactions possibly reflecting meningeal irritation occurring in > 10% of all studied adult patients receiving DepoCyt 50 mg or an active comparator*

During the clinical studies, 2 deaths related to DepoCyt were reported. One patient at the 125 mg dose level died of encephalopathy 36 hours after receiving an intraventricular dose of DepoCyt. This patient, however, was also receiving concomitant whole brain irradiation and had previously received intraventricular methotrexate. The other patient received DepoCyt, 50 mg by the intraventricular route and developed focal seizures progressing to status epilepticus. This patient died approximately 8 weeks after the last dose of study medication. In the controlled lymphoma study, the patient incidence of seizures was higher in the DepoCyt group (4/17, 23.5%) than in the cytarabine group (1/16, 6.3%). The death of 1 additional patient was considered “possibly” related to DepoCyt. He was a 63-year-old with extensive lymphoma involving the  nasopharynx, brain, and meninges with multiple neurologic deficits who died of apparent disease progression 4 days after his second dose of DepoCyt.

No formal assessments of pharmacokinetic drug-drug interactions between DepoCyt and other agents have been conducted. Concomitant administration of DepoCyt with other antineoplastic agents administered by the intrathecal route has not been studied. With intrathecal cytarabine and other cytotoxic agents administered intrathecally, enhanced neurotoxicity has been associated with coadministration of drugs.