There is no known antidote for Oxaliplatin-Teva overdose. In addition to thrombocytopenia, the anticipated complications of an Oxaliplatin-Teva overdose include hypersensitivity reaction, myelosuppression, nausea, vomiting, diarrhea and neurotoxicity. Several cases of overdoses have been reported with Oxaliplatin-Teva. Adverse reactions observed were Grade 4 thrombocytopenia ( < 25,000/mm³) without any bleeding, anemia, sensory neuropathy such as paresthesia, dysesthesia, laryngospasm and facial muscle spasms, gastrointestinal disorders such as nausea, vomiting, stomatitis, flatulence, abdomen enlarged and Grade 4 intestinal obstruction, Grade 4 dehydration, dyspnea, wheezing, chest pain, respiratory failure, severe bradycardia and death.
Patients suspected of receiving an overdose should be monitored, and supportive treatment should be administered. The maximum dose of oxaliplatin that has been administered in a single infusion is 825 mg.
Oxaliplatin-Teva should not be administered to patients with a history of known allergy to Oxaliplatin-Teva or other platinum compounds.
The following serious adverse reactions are discussed in greater detail in other sections of the label:
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.
More than 1100 patients with stage II or III colon cancer and more than 4,000 patients with advanced colorectal cancer have been treated in clinical studies with Oxaliplatin-Teva. The most common adverse reactions in patients with stage II or III colon cancer receiving adjuvant therapy were peripheral sensory neuropathy, neutropenia, thrombocytopenia, anemia, nausea, increase in transaminases and alkaline phosphatase, diarrhea, emesis, fatigue and stomatitis. The most common adverse reactions in previously untreated and treated patients were peripheral sensory neuropathies, fatigue, neutropenia, nausea, emesis, and diarrhea.
Combination Adjuvant Therapy with Oxaliplatin-Teva and Infusional 5-fluorouracil/leucovorin in Patients with Colon CancerOne thousand one hundred and eight patients with stage II or III colon cancer, who had undergone complete resection of the primary tumor, have been treated in a clinical study with Oxaliplatin-Teva in combination with infusional 5-fluorouracil/leucovorin. The incidence of grade 3 or 4 adverse reactions was 70% on the Oxaliplatin-Teva combination arm, and 31% on the infusional 5-fluorouracil/leucovorin arm. The adverse reactions in this trial are shown in the tables below. Discontinuation of treatment due to adverse reactions occurred in 15% of the patients receiving Oxaliplatin-Teva and infusional 5-fluorouracil/leucovorin. Both 5fluorouracil/leucovorin and Oxaliplatin-Teva are associated with gastrointestinal or hematologic adverse reactions. When Oxaliplatin-Teva is administered in combination with infusional 5fluorouracil/leucovorin, the incidence of these events is increased.
The incidence of death within 28 days of last treatment, regardless of causality, was 0.5% (n=6) in both the Oxaliplatin-Teva combination and infusional 5-fluorouracil/leucovorin arms, respectively. Deaths within 60 days from initiation of therapy were 0.3% (n=3) in both the Oxaliplatin-Teva combination and infusional 5-fluorouracil/leucovorin arms, respectively. On the Oxaliplatin-Teva combination arm, 3 deaths were due to sepsis/neutropenic sepsis, 2 from intracerebral bleeding and one from eosinophilic pneumonia. On the 5-fluorouracil/leucovorin arm, one death was due to suicide, 2 from Steven-Johnson Syndrome (1 patient also had sepsis), 1 unknown cause, 1 anoxic cerebral infarction and 1 probable abdominal aorta rupture.
The following table provides adverse reactions reported in the adjuvant therapy colon cancer clinical trial by body system and decreasing order of frequency in the Oxaliplatin-Teva and infusional 5-fluorouracil/leucovorin arm for events with overall incidences ≥ 5% and for NCI grade 3/4 events with incidences ≥ 1%.
Table 3: Adverse Reactions Reported in Patients with Colon Cancer receiving Adjuvant Treatment ( ≥ 5% of all patients and with ≥ 1% NCI Grade 3/4 events)
| Adverse reaction (WHO/Pref) | Oxaliplatin-Teva + 5-FU/LV N=1108 | 5-FU/LV N=1111 | ||
| All Grades (%) | Grade 3/4 (%) | All Grades (%) | Grade 3/4 (%) | |
| Any Event | 100 | 70 | 99 | 31 |
| Allergy/Immunology | ||||
| Allergic Reaction | 10 | 3 | 2 | < 1 |
| Constitutional Symptoms/Pain | ||||
| Fatigue | 44 | 4 | 38 | 1 |
| Abdominal Pain | 18 | 1 | 17 | 2 |
| Dermatology/Skin | ||||
| Skin Disorder | 32 | 2 | 36 | 2 |
| Injection Site Reaction1 | 11 | 3 | 10 | 3 |
| Gastrointestinal | ||||
| Nausea | 74 | 5 | 61 | 2 |
| Diarrhea | 56 | 11 | 48 | 7 |
| Vomiting | 47 | 6 | 24 | 1 |
| Stomatitis | 42 | 3 | 40 | 2 |
| Anorexia | 13 | 1 | 8 | < 1 |
| Fever/Infection | ||||
| Fever | 27 | 1 | 12 | 1 |
| Infection | 25 | 4 | 25 | 3 |
| Neurology | ||||
| Overall Peripheral Sensory Neuropathy | 92 | 12 | 16 | < 1 |
| 1Includes thrombosis related to the catheter | ||||
The following table provides adverse reactions reported in the adjuvant therapy colon cancer clinical trial by body system and decreasing order of frequency in the Oxaliplatin-Teva and infusional 5-fluorouracil/leucovorin arm for events with overall incidences ≥ 5% but with incidences < 1% NCI grade 3/4 events.
Table 4: Adverse Reactions Reported in Patients with Colon Cancer receiving Adjuvant Treatment ( ≥ 5% of all patients, but with < 1% NCI Grade 3/4 events)
| Adverse reaction (WHO/Pref) | Oxaliplatin-Teva + 5-FU/LV N=1108 | 5-FU/LV N=1111 |
| All Grades (%) | All Grades (%) | |
| Allergy/Immunology | ||
| Rhinitis | 6 | 8 |
| Constitutional Symptoms/Pain/Ocular/Visual | ||
| Epistaxis | 16 | 12 |
| Weight Increase | 10 | 10 |
| Conjunctivitis | 9 | 15 |
| Headache | 7 | 5 |
| Dyspnea | 5 | 3 |
| Pain | 5 | 5 |
| Lacrimation Abnormal | 4 | 12 |
| Dermatology/Skin | ||
| Alopecia | 30 | 28 |
| Gastrointestinal | ||
| Constipation | 22 | 19 |
| Taste Perversion | 12 | 8 |
| Dyspepsia | 8 | 5 |
| Metabolic | ||
| Phosphate Alkaline increased | 42 | 20 |
| Neurology | ||
| Sensory Disturbance | 8 | 1 |
Although specific events can vary, the overall frequency of adverse reactions was similar in men and women and in patients < 65 and ≥ 65 years. However, the following grade 3/4 events were more common in females: diarrhea, fatigue, granulocytopenia, nausea and vomiting. In patients ≥ 65 years old, the incidence of grade 3/4 diarrhea and granulocytopenia was higher than in younger patients. Insufficient subgroup sizes prevented analysis of safety by race. The following additional adverse reactions, were reported in ≥ 2% and < 5% of the patients in the Oxaliplatin-Teva and infusional 5-fluorouracil/leucovorin combination arm (listed in decreasing order of frequency): pain, leukopenia, weight decrease, coughing.
The number of patients who developed secondary malignancies was similar; 62 in the Oxaliplatin-Teva combination arm and 68 in the infusional 5-fluorouracil/leucovorin arm. An exploratory analysis showed that the number of deaths due to secondary malignancies was 1.96% in the Oxaliplatin-Teva combination arm and 0.98% in infusional 5-fluorouracil/leucovorin arm. In addition, the number of cardiovascular deaths was 1.4% in the Oxaliplatin-Teva combination arm as compared to 0.7% in the infusional 5-fluorouracil/leucovorin arm. Clinical significance of these findings is unknown.
Patients Previously Untreated for Advanced Colorectal CancerTwo hundred and fifty-nine patients were treated in the Oxaliplatin-Teva and 5-fluorouracil/leucovorin combination arm of the randomized trial in patients previously untreated for advanced colorectal cancer. The adverse reaction profile in this study was similar to that seen in other studies and the adverse reactions in this trial are shown in the tables below. Both 5-fluorouracil and Oxaliplatin-Teva are associated with gastrointestinal and hematologic adverse reactions. When Oxaliplatin-Teva is administered in combination with 5-fluorouracil, the incidence of these events is increased.
The incidence of death within 30 days of treatment in the previously untreated for advanced colorectal cancer study, regardless of causality, was 3% with the Oxaliplatin-Teva and 5-fluorouracil/leucovorin combination, 5% with irinotecan plus 5-fluorouracil/leucovorin, and 3% with Oxaliplatin-Teva plus irinotecan. Deaths within 60 days from initiation of therapy were 2.3% with the Oxaliplatin-Teva and 5-fluorouracil/leucovorin combination, 5.1% with irinotecan plus 5-fluorouracil/leucovorin, and 3.1% with Oxaliplatin-Teva plus irinotecan. The following table provides adverse reactions reported in the previously untreated for advanced colorectal cancer study by body system and decreasing order of frequency in the Oxaliplatin-Teva and 5-fluorouracil/leucovorin combination arm for events with overall incidences ≥ 5% and for grade 3/4 events with incidences ≥ 1%.
Table 5: Adverse Reactions Reported in Patients Previously Untreated for Advanced Colorectal Cancer Clinical Trial ( ≥ 5% of all patients and with ≥ 1% NCI Grade 3/4 events)
| Adverse reaction (WHO/Pref) | Oxaliplatin-Teva + 5-FU/LV N=259 | irinotecan + 5-FU/LV N=256 | Oxaliplatin-Teva + irinotecan N=258 | |||
| All Grades (%) | Grade 3/4 (%) | All Grades (%) | Grade 3/4 (%) | All Grades (%) | Grade 3/4 (%) | |
| Any Event | 99 | 82 | 98 | 70 | 99 | 76 |
| Allergy/Immunology | ||||||
| Hypersensitivity | 12 | 2 | 5 | 0 | 6 | 1 |
| Cardiovascular | ||||||
| Thrombosis | 6 | 5 | 6 | 6 | 3 | 3 |
| Hypotension | 5 | 3 | 6 | 3 | 4 | 3 |
| Constitutional Symptoms/Pain/Ocular/Visual | ||||||
| Fatigue | 70 | 7 | 58 | 11 | 66 | 16 |
| Abdominal Pain | 29 | 8 | 31 | 7 | 39 | 10 |
| Myalgia | 14 | 2 | 6 | 0 | 9 | 2 |
| Pain | 7 | 1 | 5 | 1 | 6 | 1 |
| Vision abnormal | 5 | 0 | 2 | 1 | 6 | 1 |
| Neuralgia | 5 | 0 | 0 | 0 | 2 | 1 |
| Dermatology/Skin | ||||||
| Skin reaction -hand/foot | 7 | 1 | 2 | 1 | 1 | 0 |
| Injection site reaction | 6 | 0 | 1 | 0 | 4 | 1 |
| Gastrointestinal | ||||||
| Nausea | 71 | 6 | 67 | 15 | 83 | 19 |
| Diarrhea | 56 | 12 | 65 | 29 | 76 | 25 |
| Vomiting | 41 | 4 | 43 | 13 | 64 | 23 |
| Stomatitis | 38 | 0 | 25 | 1 | 19 | 1 |
| Anorexia | 35 | 2 | 25 | 4 | 27 | 5 |
| Constipation | 32 | 4 | 27 | 2 | 21 | 2 |
| Diarrhea-colostomy | 13 | 2 | 16 | 7 | 16 | 3 |
| Gastrointestinal NOS* | 5 | 2 | 4 | 2 | 3 | 2 |
| Hematology/Infection | ||||||
| Infection normal ANC** | 10 | 4 | 5 | 1 | 7 | 2 |
| Infection low ANC** | 8 | 8 | 12 | 11 | 9 | 8 |
| Lymphopenia | 6 | 2 | 4 | 1 | 5 | 2 |
| Febrile neutropenia | 4 | 4 | 15 | 14 | 12 | 11 |
| Hepatic/Metabolic/Laboratory/Itenal | ||||||
| Hyperglycemia | 14 | 2 | 11 | 3 | 12 | 3 |
| Hypokalemia | 11 | 3 | 7 | 4 | 6 | 2 |
| Dehydration | 9 | 5 | 16 | 11 | 14 | 7 |
| Hypoalbuminemia | 8 | 0 | 5 | 2 | 9 | 1 |
| Hyponatremia | 8 | 2 | 7 | 4 | 4 | 1 |
| Urinary frequency | 5 | 1 | 2 | 1 | 3 | 1 |
| Neurology | ||||||
| Overall Neuropathy | 82 | 19 | 18 | 2 | 69 | 7 |
| Paresthesias | 77 | 18 | 16 | 2 | 62 | 6 |
| Pharyngo-laryngeal dysesthesias | 38 | 2 | 1 | 0 | 28 | 1 |
| Neuro-sensory | 12 | 1 | 2 | 0 | 9 | 1 |
| Neuro NOS* | 1 | 0 | 1 | 0 | 1 | 0 |
| Pulmonary | ||||||
| Cough | 35 | 1 | 25 | 2 | 17 | 1 |
| Dyspnea | 18 | 7 | 14 | 3 | 11 | 2 |
| Hiccups | 5 | 1 | 2 | 0 | 3 | 2 |
| * Not otherwise specified ** Absolute neutrophil count | ||||||
The following table provides adverse reactions reported in the previously untreated for advanced colorectal cancer study by body system and decreasing order of frequency in the Oxaliplatin-Teva and 5-fluorouracil/leucovorin combination arm for events with overall incidences ≥ 5% but with incidences < 1% NCI Grade 3/4 events.
Table 6: Adverse Reactions Reported in Patients Previously Untreated for Advanced Colorectal Cancer Clinical Trial ( ≥ 5% of all patients but with < 1% NCI Grade 3/4 events)
| Adverse reaction (WHO/Pref) | Oxaliplatin-Teva + 5-FU/LV N=259 | irinotecan + 5-FU/LV N=256 | Oxaliplatin-Teva + irinotecan N=258 |
| All Grades (%) | All Grades (%) | All Grades (%) | |
| Allergy/Immunology | |||
| Rash | 11 | 4 | 7 |
| Rhinitis allergic | 10 | 6 | 6 |
| Cardiovascular | |||
| Edema | 15 | 13 | 10 |
| Constitutional Symptoms/Pain/Ocular/Visual | |||
| Headache | 13 | 6 | 9 |
| Weight loss | 11 | 9 | 11 |
| Epistaxis | 10 | 2 | 2 |
| Tearing | 9 | 1 | 2 |
| Rigors | 8 | 2 | 7 |
| Dysphasia | 5 | 3 | 3 |
| Sweating | 5 | 6 | 12 |
| Arthralgia | 5 | 5 | 8 |
| Dermatology/Skin | |||
| Alopecia | 38 | 44 | 67 |
| Flushing | 7 | 2 | 5 |
| Pruritis | 6 | 4 | 2 |
| Dry Skin | 6 | 2 | 5 |
| Gastrointestinal | |||
| Taste perversion | 14 | 6 | 8 |
| Dyspepsia | 12 | 7 | 5 |
| Flatulence | 9 | 6 | 5 |
| Mouth Dryness | 5 | 2 | 3 |
| Hematology/Infection | |||
| Fever normal ANC* | 16 | 9 | 9 |
| Hepatic/Metabolic/Laboratory/Renal | |||
| Hypocalcemia | 7 | 5 | 4 |
| Elevated Creatinine | 4 | 4 | 5 |
| Neurology | |||
| Insomnia | 13 | 9 | 11 |
| Depression | 9 | 5 | 7 |
| Dizziness | 8 | 6 | 10 |
| Anxiety | 5 | 2 | 6 |
| * Absolute neutrophil count | |||
Adverse reactions were similar in men and women and in patients < 65 and ≥ 65 years, but older patients may have been more susceptible to diarrhea, dehydration, hypokalemia, leukopenia, fatigue and syncope. The following additional adverse reactions, at least possibly related to treatment and potentially important, were reported in ≥ 2% and < 5% of the patients in the Oxaliplatin-Teva and 5-fluorouracil/leucovorin combination arm (listed in decreasing order of frequency): metabolic, pneumonitis, catheter infection, vertigo, prothrombin time, pulmonary, rectal bleeding, dysuria, nail changes, chest pain, rectal pain, syncope, hypertension, hypoxia, unknown infection, bone pain, pigmentation changes, and urticaria.
Previously Treated Patients with Advanced Colorectal CancerFour hundred and fifty patients (about 150 receiving the combination of Oxaliplatin-Teva and 5-fluorouracil/leucovorin) were studied in a randomized trial in patients with refractory and relapsed colorectal cancer. The adverse reaction profile in this study was similar to that seen in other studies and the adverse reactions in this trial are shown in the tables below.
Thirteen percent of patients in the Oxaliplatin-Teva and 5-fluorouracil/leucovorin combination arm and 18% in the 5-fluorouracil/leucovorin arm of the previously treated study had to discontinue treatment because of adverse effects related to gastrointestinal, or hematologic adverse reactions, or neuropathies. Both 5-fluorouracil and Oxaliplatin-Teva are associated with gastrointestinal and hematologic adverse reactions. When Oxaliplatin-Teva is administered in combination with 5-fluorouracil, the incidence of these events is increased.
The incidence of death within 30 days of treatment in the previously treated study, regardless of causality, was 5% with the Oxaliplatin-Teva and 5-fluorouracil/leucovorin combination, 8% with Oxaliplatin-Teva alone, and 7% with 5-fluorouracil/leucovorin. Of the 7 deaths that occurred on the Oxaliplatin-Teva and 5-fluorouracil/leucovorin combination arm within 30 days of stopping treatment, 3 may have been treatment related, associated with gastrointestinal bleeding or dehydration.
The following table provides adverse reactions reported in the previously treated study by body system and in decreasing order of frequency in the Oxaliplatin-Teva and 5-fluorouracil/leucovorin combination arm for events with overall incidences ≥ 5% and for grade 3/4 events with incidences ≥ 1%. This table does not include hematologic and blood chemistry abnormalities; these are shown separately below.
Table 7: Adverse Reactions Reported In Previously Treated Colorectal Cancer Clinical Trial ( ≥ 5% of all patients and with ≥ 1% NCI Grade 3/4 events)
| Adverse reaction (WHO/Pref) | 5-FU/LV (N = 142) | Oxaliplatin-Teva (N = 153) | Oxaliplatin-Teva + 5-FU/LV (N = 150) | |||
| All Grades (%) | Grade 3/4 (%) | All Grades (%) | Grade 3/4 (%) | All Grades (%) | Grade 3/4 (%) | |
| Any Event | 98 | 41 | 100 | 46 | 99 | 73 |
| Cardiovascular | ||||||
| Dyspnea | 11 | 2 | 13 | 7 | 20 | 4 |
| Coughing | 9 | 0 | 11 | 0 | 19 | 1 |
| Edema | 13 | 1 | 10 | 1 | 15 | 1 |
| Thromboembolism | 4 | 2 | 2 | 1 | 9 | 8 |
| Chest Pain | 4 | 1 | 5 | 1 | 8 | 1 |
| Constitutional Symptoms/Pain | ||||||
| Fatigue | 52 | 6 | 61 | 9 | 68 | 7 |
| Back Pain | 16 | 4 | 11 | 0 | 19 | 3 |
| Pain | 9 | 3 | 14 | 3 | 15 | 2 |
| Dermatology/Skin | ||||||
| Injection Site Reaction | 5 | 1 | 9 | 0 | 10 | 3 |
| Gastrointestinal | ||||||
| Diarrhea | 44 | 3 | 46 | 4 | 67 | 11 |
| Nausea | 59 | 4 | 64 | 4 | 65 | 11 |
| Vomiting | 27 | 4 | 37 | 4 | 40 | 9 |
| Stomatitis | 32 | 3 | 14 | 0 | 37 | 3 |
| Abdominal Pain | 31 | 5 | 31 | 7 | 33 | 4 |
| Anorexia | 20 | 1 | 20 | 2 | 29 | 3 |
| Gastroesophageal Reflux | 3 | 0 | 1 | 0 | 5 | 2 |
| Hematology/Infection | ||||||
| Fever | 23 | 1 | 25 | 1 | 29 | 1 |
| Febrile Neutropenia | 1 | 1 | 0 | 0 | 6 | 6 |
| Hepatic/Metabolic/Laboratory/Renal | ||||||
| Hypokalemia | 3 | 1 | 3 | 2 | 9 | 4 |
| Dehydration | 6 | 4 | 5 | 3 | 8 | 3 |
| Neurology | ||||||
| Neuropathy | 17 | 0 | 76 | 7 | 74 | 7 |
| Acute | 10 | 0 | 65 | 5 | 56 | 2 |
| Persistent | 9 | 0 | 43 | 3 | 48 | 6 |
The following table provides adverse reactions reported in the previously treated study by body system and in decreasing order of frequency in the Oxaliplatin-Teva and 5-fluorouracil/leucovorin combination arm for events with overall incidences ≥ 5% but with incidences < 1% NCI Grade 3/4 events.
Table 8: Adverse Reactions Reported In Previously Treated Colorectal Cancer Clinical Trial ( ≥ 5% of all patients but with < 1% NCI Grade 3/4 events)
| Adverse reaction (WHO/Pref) | 5-FU/LV (N = 142) | Oxaliplatin-Teva (N = 153) | Oxaliplatin-Teva + 5-FU/LV (N = 150) |
| All Grades (%) | All Grades (%) | All Grades (%) | |
| Allergy/Immunology | |||
| Rhinitis | 4 | 6 | 15 |
| Allergic Reaction | 1 | 3 | 10 |
| Rash | 5 | 5 | 9 |
| Cardiovascular | |||
| Peripheral Edema | 11 | 5 | 10 |
| Constitutional Symptoms/Pain/Ocular/Visual | |||
| Headache | 8 | 13 | 17 |
| Arthralgia | 10 | 7 | 10 |
| Epistaxis | 1 | 2 | 9 |
| Abnormal Lacrimation | 6 | 1 | 7 |
| Rigors | 6 | 9 | 7 |
| Dermatology/Skin | |||
| Hand-Foot Syndrome | 13 | 1 | 11 |
| Flushing | 2 | 3 | 10 |
| Alopecia | 3 | 3 | 7 |
| Gastrointestinal | |||
| Constipation | 23 | 31 | 32 |
| Dyspepsia | 10 | 7 | 14 |
| Taste Perversion | 1 | 5 | 13 |
| Mucositis | 10 | 2 | 7 |
| Flatulence | 6 | 3 | 5 |
| Hepatic/Metabolic/Laboratory/Renal | |||
| Hematuria | 4 | 0 | 6 |
| Dysuria | 1 | 1 | 6 |
| Neurology | |||
Oxaliplatin-Teva, used in combination with infusional 5-fluorouracil/leucovorin, is indicated for:
The reactive oxaliplatin derivatives are present as a fraction of the unbound platinum in plasma ultrafiltrate. The decline of ultrafilterable platinum levels following oxaliplatin administration is triphasic, characterized by two relatively short distribution phases (t½α; 0.43 hours and t½β; 16.8 hours) and a long terminal elimination phase (t½γ; 391 hours). Pharmacokinetic parameters obtained after a single 2-hour intravenous infusion of Oxaliplatin-Teva at a dose of 85 mg/m² expressed as ultrafilterable platinum were C max of 0.814 mcg /mL and volume of distribution of 440 L.
Interpatient and intrapatient variability in ultrafilterable platinum exposure (AUC0-48hr ) assessed over 3 cycles was moderate to low (23% and 6%, respectively). A pharmacodynamic relationship between platinum ultrafiltrate levels and clinical safety and effectiveness has not been established.
DistributionAt the end of a 2-hour infusion of Oxaliplatin-Teva, approximately 15% of the administered platinum is present in the systemic circulation. The remaining 85% is rapidly distributed into tissues or eliminated in the urine. In patients, plasma protein binding of platinum is irreversible and is greater than 90%. The main binding proteins are albumin and gamma-globulins. Platinum also binds irreversibly and accumulates (approximately 2-fold) in erythrocytes, where it appears to have no relevant activity. No platinum accumulation was observed in plasma ultrafiltrate following 85 mg/m² every two weeks.
MetabolismOxaliplatin undergoes rapid and extensive nonenzymatic biotransformation. There is no evidence of cytochrome P450-mediated metabolism in vitro.
Up to 17 platinum-containing derivatives have been observed in plasma ultrafiltrate samples from patients, including several cytotoxic species (monochloro DACH platinum, dichloro DACH platinum, and monoaquo and diaquo DACH platinum) and a number of noncytotoxic, conjugated species.
EliminationThe major route of platinum elimination is renal excretion. At five days after a single 2-hour infusion of Oxaliplatin-Teva, urinary elimination accounted for about 54% of the platinum eliminated, with fecal excretion accounting for only about 2%. Platinum was cleared from plasma at a rate (10 – 17 L/h) that was similar to or exceeded the average human glomerular filtration rate (GFR; 7.5 L/h). There was no significant effect of gender on the clearance of ultrafilterable platinum. The renal clearance of ultrafilterable platinum is significantly correlated with GFR.
Included as part of the PRECAUTIONS section.
PRECAUTIONS Allergic ReactionsSee BOXED WARNING
Grade 3/4 hypersensitivity, including anaphylactic/anaphylactoid reactions, to Oxaliplatin-Teva has been observed in 2-3% of colon cancer patients. These allergic reactions which can be fatal, can occur within minutes of administration and at any cycle, and were similar in nature and severity to those reported with other platinum-containing compounds, such as rash, urticaria, erythema, pruritus, and, rarely, bronchospasm and hypotension. The symptoms associated with hypersensitivity reactions reported in the previously untreated patients were urticaria, pruritus, flushing of the face, diarrhea associated with oxaliplatin infusion, shortness of breath, bronchospasm, diaphoresis, chest pains, hypotension, disorientation and syncope. These reactions are usually managed with standard epinephrine, corticosteroid, antihistamine therapy, and require discontinuation of therapy. Rechallenge is contraindicated in these patients. Drug-related deaths associated with platinum compounds from anaphylaxis have been reported.
Neurologic Toxicity NeuropathyOxaliplatin-Teva is associated with two types of neuropathy:
An acute, reversible, primarily peripheral, sensory neuropathy that is of early onset, occurring within hours or one to two days of dosing, that resolves within 14 days, and that frequently recurs with further dosing. The symptoms may be precipitated or exacerbated by exposure to cold temperature or cold objects and they usually present as transient paresthesia, dysesthesia and hypoesthesia in the hands, feet, perioral area, or throat. Jaw spasm, abnormal tongue sensation, dysarthria, eye pain, and a feeling of chest pressure have also been observed. The acute, reversible pattern of sensory neuropathy was observed in about 56% of study patients who received Oxaliplatin-Teva with 5-fluorouracil/leucovorin. In any individual cycle acute neurotoxicity was observed in approximately 30% of patients. In adjuvant patients the median cycle of onset for grade 3 peripheral sensory neuropathy was 9 in the previously treated patients the median number of cycles administered on the Oxaliplatin-Teva with 5-fluorouracil/leucovorin combination arm was 6.
An acute syndrome of pharyngolaryngeal dysesthesia seen in 1-2% (grade 3/4) of patients previously untreated for advanced colorectal cancer, and the previously treated patients, is characterized by subjective sensations of dysphagia or dyspnea, without any laryngospasm or bronchospasm (no stridor or wheezing). Ice (mucositis prophylaxis) should be avoided during the infusion of Oxaliplatin-Teva because cold temperature can exacerbate acute neurological symptoms.
A persistent ( > 14 days), primarily peripheral, sensory neuropathy that is usually characterized by paresthesias, dysesthesias, hypoesthesias, but may also include deficits in proprioception that can interfere with daily activities (e.g., writing, buttoning, swallowing, and difficulty walking from impaired proprioception). These forms of neuropathy occurred in 48% of the study patients receiving Oxaliplatin-Teva with 5-fluorouracil/leucovorin. Persistent neuropathy can occur without any prior acute neuropathy event. The majority of the patients (80%) who developed grade 3 persistent neuropathy progressed from prior Grade 1 or 2 events. These symptoms may improve in some patients upon discontinuation of Oxaliplatin-Teva.
In the adjuvant colon cancer trial, neuropathy was graded using a prelisted module derived from the Neuro-Sensory section of the National Cancer Institute Common Toxicity Criteria (NCI CTC) scale, Version 1, as follows:
Table 1: NCI CTC Grading for Neuropathy in Adjuvant Patients
| Grade | Definition |
| Grade 0 | No change or none |
| Grade 1 | Mild paresthesias, loss of deep tendon reflexes |
| Grade 2 | Mild or moderate objective sensory loss, moderate paresthesias |
| Grade 3 | Severe objective sensory loss or paresthesias that interfere with function |
| Grade 4 | Not applicable |
Peripheral sensory neuropathy was reported in adjuvant patients treated with the Oxaliplatin-Teva combination with a frequency of 92% (all grades) and 13% (grade 3). At the 28-day follow-up after the last treatment cycle, 60% of all patients had any grade (Grade 1=40%, Grade 2=16%, Grade 3=5%) peripheral sensory neuropathy decreasing to 39% at 6 months follow-up (Grade 1=31%, Grade 2=7%, Grade 3=1%) and 21% at 18 months of follow-up (Grade 1=17%, Grade 2=3%, Grade 3=1%).
In the advanced colorectal cancer studies, neuropathy was graded using a study-specific neurotoxicity scale, which was different from the NCI CTC scale, Version 2.0 (see below).
Table 2: Grading Scale for Paresthesias/Dysesthesias in Advanced Colorectal Cancer Patients
| Grade | Definition |
| Grade 1 | Resolved and did not interfere with functioning |
| Grade 2 | Interfered with function but not daily activities |
| Grade 3 | Pain or functional impairment that interfered with daily activities |
| Grade 4 | Persistent impairment that is disabling or life-threatening |
Overall, neuropathy was reported in patients previously untreated for advanced colorectal cancer in 82% (all grades) and 19% (grade 3/4), and in the previously treated patients in 74% (all grades) and 7% (grade 3/4) events. Information regarding reversibility of neuropathy was not available from the trial for patients who had not been previously treated for colorectal cancer.
Reversible Posterior Leukoencephalopathy SyndromeReversible Posterior Leukoencephalopathy Syndrome (RPLS, also known as PRES, Posterior Reversible Encephalopathy Syndrome) has been observed in clinical trials ( < 0.1%) and postmarketing experience. Signs and symptoms of RPLS could be headache, altered mental functioning, seizures, abnormal vision from blurriness to blindness, associated or not with hypertension. Diagnosis of RPLS is based upon confirmation by brain imaging.
Severe NeutropeniaGrade 3 or 4 neutropenia occurred in 41-44% of patients with colorectal cancer treated with Oxaliplatin-Teva in combination with 5-flurouracil (5-FU) and leucovorin compared to 5% with 5-FU plus leucovorin alone. Sepsis, neutropenic sepsis and septic shock have been reported in patients treated with Oxaliplatin-Teva, including fatal outcomes.
Delay Oxaliplatin-Teva until neutrophils are ≥ 1.5 x 109/L. Withhold Oxaliplatin-Teva for sepsis or septic shock. Dose reduce Oxaliplatin-Teva after recovery from Grade 4 neutropenia or febrile neutropenia.
Pulmonary ToxicityOxaliplatin-Teva has been associated with pulmonary fibrosis ( < 1% of study patients), which may be fatal. The combined incidence of cough and dyspnea was 7.4% (any grade) and < 1% (grade 3) with no grade 4 events in the Oxaliplatin-Teva plus infusional 5-fluorouracil/leucovorin arm compared to 4.5% (any grade) and no grade 3 and 0.1% grade 4 events in the infusional 5fluorouracil/leucovorin alone arm in adjuvant colon cancer patients. In this study, one patient died from eosinophilic pneumonia in the Oxaliplatin-Teva combination arm. The combined incidence of cough, dyspnea and hypoxia was 43% (any grade) and 7% (grade 3 and 4) in the Oxaliplatin-Teva plus 5-fluorouracil/leucovorin arm compared to 32% (any grade) and 5% (grade 3 and 4) in the irinotecan plus 5-fluorouracil/leucovorin arm of unknown duration for patients with previously untreated colorectal cancer. In case of unexplained respiratory symptoms such as non-productive cough, dyspnea, crackles, or radiological pulmonary infiltrates, Oxaliplatin-Teva should be discontinued until further pulmonary investigation excludes interstitial lung disease or pulmonary fibrosis.
HepatotoxicityHepatotoxicity as evidenced in the adjuvant study, by increase in transaminases (57% vs. 34%) and alkaline phosphatase (42% vs. 20%) was observed more commonly in the Oxaliplatin-Teva combination arm than in the control arm. The incidence of increased bilirubin was similar on both arms. Changes noted on liver biopsies include: peliosis, nodular regenerative hyperplasia or sinusoidal alterations, perisinusoidal fibrosis, and veno-occlusive lesions. Hepatic vascular disorders should be considered, and if appropriate, should be investigated in case of abnormal liver function test results or portal hypertension, which cannot be explained by liver metastases.
Cardiovascular ToxicityQT prolongation and ventricular arrhythmias including fatal Torsade de Pointes have been reported in postmarketing experiences following Oxaliplatin-Teva administration. ECG monitoring is recommended if therapy is initiated in patients with congestive heart failure, bradyarrhythmias, drugs known to prolong the QT interval, including Class Ia and III antiarrhythmics, and electrolyte abnormalities. Correct hypokalemia or hypomagnesemia prior to initiating Oxaliplatin-Teva and monitor these electrolytes periodically during therapy. Avoid Oxaliplatin-Teva in patients with congenital long QT syndrome.
RhabdomyolysisRhabdomyolysis, including fatal cases, has been reported in patients treated with Oxaliplatin-Teva. Discontinue Oxaliplatin-Teva if any signs or symptoms of rhabdomyolysis occur..
Use In Pregnancy Pregnancy Category DOxaliplatin-Teva may cause fetal harm when administered to a pregnant woman. There are no adequate and well-controlled studies of Oxaliplatin-Teva in pregnant women. Women of childbearing potential should be advised to avoid becoming pregnant while receiving treatment with Oxaliplatin-Teva..
Recommended Laboratory TestsStandard monitoring of the white blood cell count with differential, hemoglobin, platelet count, and blood chemistries (including ALT, AST, bilirubin and creatinine) is recommended before each Oxaliplatin-Teva cycle.
There have been reports while on study and from post-marketing surveillance of prolonged prothrombin time and INR occasionally associated with hemorrhage in patients who received Oxaliplatin-Teva plus 5-fluorouracil/leucovorin while on anticoagulants. Patients receiving Oxaliplatin-Teva plus 5-fluorouracil/leucovorin and requiring oral anticoagulants may require closer monitoring.
Patient Counseling InformationAdvise patients:
Long-term animal studies have not been performed to evaluate the carcinogenic potential of oxaliplatin. Oxaliplatin was not mutagenic to bacteria (Ames test) but was mutagenic to mammalian cells in vitro (L5178Y mouse lymphoma assay). Oxaliplatin was clastogenic both in vitro (chromosome aberration in human lymphocytes) and in vivo (mouse bone marrow micronucleus assay).
In a fertility study, male rats were given oxaliplatin at 0, 0.5, 1, or 2 mg/kg/day for five days every 21 days for a total of three cycles prior to mating with females that received two cycles of oxaliplatin on the same schedule. A dose of 2 mg/kg/day (less than one-seventh the recommended human dose on a body surface area basis) did not affect pregnancy rate, but caused developmental mortality (increased early resorptions, decreased live fetuses, decreased live births) and delayed growth (decreased fetal weight).
Testicular damage, characterized by degeneration, hypoplasia, and atrophy, was observed in dogs administered oxaliplatin at 0.75 mg/kg/day x 5 days every 28 days for three cycles. A no effect level was not identified. This daily dose is approximately one-sixth of the recommended human dose on a body surface area basis.
Use In Specific Populations Pregnancy Pregnancy Category DBased on direct interaction with DNA, Oxaliplatin-Teva may cause fetal harm when administered to a pregnant woman. There are no adequate and well-controlled studies of Oxaliplatin-Teva in pregnant women. Reproductive toxicity studies in rats demonstrated adverse effects on fertility and embryo-fetal development at maternal doses that were below the recommended human dose based on body surface area. 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 hazard to the fetus. Women of childbearing potential should be advised to avoid becoming pregnant and use effective contraception while receiving treatment with Oxaliplatin-Teva.
Pregnant rats were administered oxaliplatin at less than one-tenth the recommended human dose based on body surface area during gestation days 1-5 (pre-implantation), 6-10, or 11-16 (during organogenesis). Oxaliplatin caused developmental mortality (increased early resorptions) when administered on days 6-10 and 11-16 and adversely affected fetal growth (decreased fetal weight, delayed ossification) when administered on days 6-10. Administration of oxaliplatin to male and female rats prior to mating resulted in 97% post-implantation loss in animals that received approximately one-seventh the recommended human dose based on the body surface area.
Nursing MothersIt is not known whether Oxaliplatin-Teva or its derivatives are excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from Oxaliplatin-Teva, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother.
Pediatric UseThe effectiveness of oxaliplatin in children has not been established. Oxaliplatin has been tested in 2 Phase 1 and 2 Phase 2 trials in 235 patients ages 7 months to 22 years with solid tumors (see below) and no significant activity observed.
In a Phase 1/2 study, oxaliplatin was administered as a 2-hour intravenous infusion on Days 1, 8 and 15 every 4 weeks (1 cycle), for a maximum of 6 cycles, to 43 patients with refractory or relapsed malignant solid tumors, mainly neuroblastoma and osteosarcoma. Twenty eight pediatric patients in the Phase 1 study received oxaliplatin at 6 dose levels starting at 40 mg/m² with escalation to 110 mg/m². The dose limiting toxicity (DLT) was sensory neuropathy at the 110 mg/m² dose. Fifteen patients received oxaliplatin at a dose of 90 mg/m² intravenous in the Phase 2 portion of the study. At this dose, paresthesia (60%, G3/4: 7%), fever (40%, G3/4: 7%) and thrombocytopenia (40%, G3/4: 27%) were the main adverse reactions. No responses were observed.
In a second Phase 1 study, oxaliplatin was administered to 26 pediatric patients as a 2-hour intravenous infusion on day 1 every 3 weeks (1 cycle) at 5 dose levels starting at 100 mg/m² with escalation to 160 mg/m², for a maximum of 6 cycles. In a separate cohort, oxaliplatin 85 mg/m² was administered on day 1 every 2 weeks, for a maximum of 9 doses. Patients had metastatic or unresectable solid tumors mainly neuroblastoma and ganglioneuroblastoma. No responses were observed. The DLT was sensory neuropathy at the 160 mg/m² dose. Based on these studies, oxaliplatin 130 mg/m² as a 2-hour intravenous infusion on day 1 every 3 weeks (1 cycle) was used in subsequent Phase II studies. A dose of 85 mg/m² on day 1 every 2 weeks was also found to be tolerable.
In one Phase 2 study, 43 pediatric patients with recurrent or refractory embryonal CNS tumors received oxaliplatin 130 mg/m² every 3 weeks for a maximum of 12 months in absence of progressive disease or unacceptable toxicity. In patients < 10 kg the oxaliplatin dose used was 4.3 mg/kg. The most common adverse reactions reported were leukopenia (67%, G3/4: 12%), anemia (65%, G3/4: 5%), thrombocytopenia (65%, G3/4: 26%), vomiting (65%, G3/4: 7%), neutropenia (58%, G3/4: 16%) and sensory neuropathy (40%, G3/4: 5%). One partial response was observed.
In a second Phase 2 study, 123 pediatric patients with recurrent solid tumors, including neuroblastoma, osteosarcoma, Ewing sarcoma or peripheral PNET, ependymoma, rhabdomyosarcoma, hepatoblastoma, high grade astrocytoma, Brain stem glioma, low grade astrocytoma, malignant germ cell tumor and other tumors of interest received oxaliplatin 130 mg/m² every 3 weeks for a maximum of 12 months or 17 cycles. In patients < 12 months old the oxaliplatin dose used was 4.3 mg/kg. The most common adverse reactions reported were sensory neuropathy (52%, G3/4: 12%), thrombocytopenia (37%, G3/4: 17%), anemia (37%, G3/4: 9%), vomiting (26%, G3/4: 4%), ALT increased (24%, G3/4: 6%), AST increased (24%, G3/4: 2%), and nausea (23%, G3/4: 3%). Two partial responses were observed.
The pharmacokinetic parameters of ultrafiltrable platinum have been evaluated in 105 pediatric patients during the first cycle. The mean clearance in pediatric patients estimated by the population pharmacokinetic analysis was 4.7 L/h. The inter-patient variability of platinum clearance in pediatric cancer patients was 41%. Mean platinum pharmacokinetic parameters in ultrafiltrate were Cmax of 0.75 ± 0.24 mcg/mL, AUC0-48 of 7.52 ± 5.07 mcg•h/mL and AUCinf of 8.83 ± 1.57 mcg•h/mL at 85 mg/m² of oxaliplatin and Cmax of 1.10 ± 0.43 mcg/mL, AUC 0-48 of 9.74 ± 2.52 mcg•h/mL and AUCinf of 17.3 ± 5.34 mcg•h/mL at 130 mg/m² of oxaliplatin.
Geriatric UseNo significant effect of age on the clearance of ultrafilterable platinum has been observed.
In the adjuvant therapy colon cancer randomized clinical trial, 723 patients treated with Oxaliplatin-Teva and infusional 5-fluorouracil/leucovorin were < 65 years and 400 patients were ≥ 65 years.
A descriptive subgroup analysis demonstrated that the improvement in DFS for the Oxaliplatin-Teva combination arm compared to the infusional 5-fluorouracil/leucovorin alone arm appeared to be maintained across genders. The effect of Oxaliplatin-Teva in patients ≥ 65 years of age was not conclusive. Insufficient subgroup sizes prevented analysis by race. Patients ≥ 65 years of age receiving the Oxaliplatin-Teva combination therapy experienced more grade 3-4 granulocytopenia than patients < 65 years of age (45% versus 39%).
In the previously untreated for advanced colorectal cancer randomized clinical trial of Oxaliplatin-Teva, 160 patients treated with Oxaliplatin-Teva and 5-fluorouracil/leucovorin were < 65 years and 99 patients were ≥ 65 years. The same efficacy improvements in response rate, time to tumor progression, and overall survival were observed in the ≥ 65 year old patients as in the overall study population. In the previously treated for advanced colorectal cancer randomized clinical trial of Oxaliplatin-Teva, 95 patients treated with Oxaliplatin-Teva and 5-fluorouracil/leucovorin were < 65 years and 55 patients were ≥ 65 years. The rates of overall adverse reactions, including grade 3 and 4 events, were similar across and within arms in the different age groups in all studies. The incidence of diarrhea, dehydration, hypokalemia, leukopenia, fatigue and syncope were higher in patients ≥ 65 years old. No adjustment to starting dose was required in patients ≥ 65 years old.
Patients With Renal ImpairmentThe exposure (AUC) of unbound platinum in plasma ultrafiltrate tends to increase in renally impaired patients. Caution and close monitoring should be exercised when Oxaliplatin-Teva is administered to patients with renal impairment. The starting Oxaliplatin-Teva dose does not need to be reduced in patients with mild (creatinine clearance=50-80 mL/min) or moderate (creatinine clearance=30-49 mL/min) renal impairment. However, the starting dose of Oxaliplatin-Teva should be reduced in patients with severe renal impairment (creatinine clearance < 30 mL/min).
Oxaliplatin-Teva (oxaliplatin injection) should be administered under the supervision of a qualified physician experienced in the use of cancer chemotherapeutic agents. Appropriate management of therapy and complications is possible only when adequate diagnostic and treatment facilities are readily available.
DosageAdminister Oxaliplatin-Teva in combination with 5-fluorouracil/leucovorin every 2 weeks. For advanced disease, treatment is recommended until disease progression or unacceptable toxicity. For adjuvant use, treatment is recommended for a total of 6 months (12 cycles):
Day 1: Oxaliplatin-Teva 85 mg/m² intravenous infusion in 250-500 mL 5% Dextrose injection, USP and leucovorin 200 mg/m² intravenous infusion in 5% Dextrose Injection, USP both given over 120 minutes at the same time in separate bags using a Y-line, followed by 5-fluorouracil 400 mg/m² intravenous bolus given over 2-4 minutes, followed by 5-fluorouracil 600 mg/m² intravenous infusion in 500 mL 5% Dextrose Injection, USP (recommended) as a 22-hour continuous infusion.
Day 2: Leucovorin 200 mg/m² intravenous infusion over 120 minutes, followed by 5-fluorouracil 400 mg/m² intravenous bolus given over 2-4 minutes, followed by 5-fluorouracil 600 mg/m² intravenous infusion in 500 mL 5% Dextrose Injection, USP (recommended) as a 22-hour continuous infusion.
Figure 1
The administration of Oxaliplatin-Teva does not require prehydration. Premedication with antiemetics, including 5-HT3 blockers with or without dexamethasone, is recommended.
For information on 5-fluorouracil and leucovorin, see the respective package inserts.
Dose Modification RecommendationsPrior to subsequent therapy cycles, patients should be evaluated for clinical toxicities and recommended laboratory tests. Prolongation of infusion time for Oxaliplatin-Teva from 2 hours to 6 hours may mitigate acute toxicities. The infusion times for 5-fluorouracil and leucovorin do not need to be changed.
Adjuvant Therapy in Patients with Stage III Colon CancerNeuropathy and other toxicities were graded using the NCI CTC scale version 1.
For patients who experience persistent Grade 2 neurosensory events that do not resolve, a dose reduction of Oxaliplatin-Teva to 75 mg/m² should be considered. For patients with persistent Grade 3 neurosensory events, discontinuing therapy should be considered. The infusional 5-fluorouracil/leucovorin regimen need not be altered.
A dose reduction of Oxaliplatin-Teva to 75 mg/m² and infusional 5-fluorouracil to 300 mg/m² bolus and 500 mg/m² 22 hour infusion is recommended for patients after recovery from grade 3/4 gastrointestinal (despite prophylactic treatment), or grade 4 neutropenia, or febrile neutropenia, or grade 3/4 thrombocytopenia. The next dose should be delayed until: neutrophils ≥ 1.5 x 109/L and platelets ≥ 75 x 109/L.
Dose Modifications in Therapy in Previously Untreated and Previously Treated Patients with Advanced Colorectal CancerNeuropathy was graded using a study-specific neurotoxicity scale. Other toxicities were graded by the NCI CTC, Version 2.0.
For patients who experience persistent Grade 2 neurosensory events that do not resolve, a dose reduction of Oxaliplatin-Teva to 65 mg/m² should be considered. For patients with persistent Grade 3 neurosensory events, discontinuing therapy should be considered. The 5-fluorouracil/leucovorin regimen need not be altered.
A dose reduction of Oxaliplatin-Teva to 65 mg/m² and 5-fluorouracil by 20% (300 mg/m² bolus and 500 mg/m² 22-hour infusion) is recommended for patients after recovery from grade 3/4 gastrointestinal (despite prophylactic treatment), or grade 4 neutropenia, or febrile neutropenia, or grade 3/4 thrombocytopenia. The next dose should be delayed until: neutrophils ≥ 1.5 x 109/L and platelets ≥ 75 x 109/L.
Dose Modifications in Therapy for Patients with Renal ImpairmentIn patients with normal renal function or mild to moderate renal impairment, the recommended dose of Oxaliplatin-Teva is 85 mg/m². In patients with severe renal impairment, the initial recommended Oxaliplatin-Teva dose should be reduced to 65 mg/m².
Preparation Of Infusion SolutionDo not freeze and protect from light the concentrated solution.
A final dilution must never be performed with a sodium chloride solution or other chloride-containing solutions.
The solution must be further diluted in an infusion solution of 250-500 mL of 5% Dextrose Injection, USP.
After dilution with 250-500 mL of 5% Dextrose Injection, USP, the shelf life is 6 hours at room temperature [20-25°C (68-77°F)] or up to 24 hours under refrigeration [2-8°C (36-46°F)]. After final dilution, protection from light is not required.
Oxaliplatin-Teva is incompatible in solution with alkaline medications or media (such as basic solutions of 5-fluorouracil) and must not be mixed with these or administered simultaneously through the same infusion line. The infusion line should be flushed with 5% Dextrose Injection, USP prior to administration of any concomitant medication.
Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration and discarded if present.
Needles or intravenous administration sets containing aluminum parts that may come in contact with Oxaliplatin-Teva should not be used for the preparation or mixing of the drug. Aluminum has been reported to cause degradation of platinum compounds.
