Few cases of overdose have been described. A 58-year-old man with acute lymphoblastic leukemia received 10-fold overdose of Ribodoxo HCl (300 mg/m ) in one day. He was treated with charcoal filtration, hemopoietic growth factor (G-CSF), proton pump inhibitor and antimicrobial prophylaxis. The patient suffered sinus tachycardia, grade 4 neutropenia and thrombocytopenia for 11 days, severe mucositis and sepsis. The patient recovered completely 26 days after the overdose. A 17-year-old girl with osteogenic sarcoma received 150 mg of Ribodoxo HCl daily for 2 days (intended dose was 50 mg per day for 3 days). The patient developed severe mucositis on days 4–7 after the overdose and chills and pyrexia on day 7. The patient was treated with antibiotics and platelets and recovered 18 days after overdose.
Few cases of overdose have been described. A 58-year-old man with acute lymphoblastic leukemia received 10-fold overdose of doxorubicin HCl (300 mg/m ) in one day. He was treated with charcoal filtration, hemopoietic growth factor (G-CSF), proton pump inhibitor and antimicrobial prophylaxis. The patient suffered sinus tachycardia, grade 4 neutropenia and thrombocytopenia for 11 days, severe mucositis and sepsis. The patient recovered completely 26 days after the overdose. A 17-year-old girl with osteogenic sarcoma received 150 mg of doxorubicin HCl daily for 2 days (intended dose was 50 mg per day for 3 days). The patient developed severe mucositis on days 4–7 after the overdose and chills and pyrexia on day 7. The patient was treated with antibiotics and platelets and recovered 18 days after overdose.
Ribodoxo HCl is contraindicated in patients with:
Doxorubicin HCl is contraindicated in patients with:
The following adverse reactions are discussed in more detail in other sections of the labeling.
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 clinical practice.
The safety data below were collected from 1492 women who received Ribodoxo HCl at a dose of 60 mg/m and cyclophosphamide at a dose of 600 mg/m (AC) every 3 weeks for 4 cycles for the adjuvant treatment of axillary lymph node positive breast cancer. The median number of cycles received was 4. Selected adverse reactions reported in this study are provided in Table 1. No treatment-related deaths were reported in patients on either arm of the study.
Table 1. Selected Adverse Reactions in Patients with Early Breast Cancer Involving Axillary Lymph Nodes
| AC* | Conventional CMF | |
| N=1492 | N=739 | |
| Adverse reactions, % of patients | ||
| Leukopenia | ||
| Grade 3 (1,000–1,999/mm ) | 3.4 | 9.4 |
| Grade 4 (<1000/mm ) | 0.3 | 0.3 |
| Thrombocytopenia | ||
| Grade 3 (25,000–49,999 /mm ) | 0 | 0.3 |
| Grade 4 (<25,000 /mm ) | 0.1 | 0 |
| Shock, sepsis | 2 | 1 |
| Systemic infection | 2 | 1 |
| Vomiting | ||
| Vomiting ≤12 hours | 34 | 25 |
| Vomiting >12 hours | 37 | 12 |
| Intractable | 5 | 2 |
| Alopecia | 92 | 71 |
| Cardiac dysfunction | ||
| Asymptomatic | 0.2 | 0.1 |
| Transient | 0.1 | 0 |
| Symptomatic | 0.1 | 0 |
| *Includes pooled data from patients who received either AC alone for 4 cycles, or who were treated with AC for 4 cycles followed by 3 cycles of CMF |
The following adverse reactions have been identified during post-approval use of Ribodoxo HCl. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
Cardiac – cardiogenic shock
Cutaneous –Skin and nail hyperpigmentation, oncolysis, rash, itching, photosensitivity, urticaria, acral erythema, palmar plantar erythrodysesthesia
Gastrointestinal – Nausea, mucositis, stomatitis, necrotizing colitis, typhlitis, gastric erosions, gastrointestinal tract bleeding, hematochezia, esophagitis, anorexia, abdominal pain, dehydration, diarrhea, hyperpigmentation of the oral mucosa
Hypersensitivity – Anaphylaxis
Laboratory Abnormalities –Increased alanine aminotransferase, increased aspartate aminotransferase
Neurological – Peripheral sensory and motor neuropathy, seizures, coma
Ocular – Conjunctivitis, keratitis, lacrimation
Vascular – Phlebosclerosis, phlebitis/thrombophlebitis, hot flashes, thromboembolism
Other – Malaise/asthenia, fever, chills, weight gain
The following adverse reactions are discussed in more detail in other sections of the labeling.
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 clinical practice.
The safety data below were collected from 1492 women who received doxorubicin HCl at a dose of 60 mg/m and cyclophosphamide at a dose of 600 mg/m (AC) every 3 weeks for 4 cycles for the adjuvant treatment of axillary lymph node positive breast cancer. The median number of cycles received was 4. Selected adverse reactions reported in this study are provided in Table 1. No treatment-related deaths were reported in patients on either arm of the study.
Table 1. Selected Adverse Reactions in Patients with Early Breast Cancer Involving Axillary Lymph Nodes
| AC* | Conventional CMF | |
| N=1492 | N=739 | |
| Adverse reactions, % of patients | ||
| Leukopenia | ||
| Grade 3 (1,000–1,999/mm ) | 3.4 | 9.4 |
| Grade 4 (<1000/mm ) | 0.3 | 0.3 |
| Thrombocytopenia | ||
| Grade 3 (25,000–49,999 /mm ) | 0 | 0.3 |
| Grade 4 (<25,000 /mm ) | 0.1 | 0 |
| Shock, sepsis | 2 | 1 |
| Systemic infection | 2 | 1 |
| Vomiting | ||
| Vomiting ≤12 hours | 34 | 25 |
| Vomiting >12 hours | 37 | 12 |
| Intractable | 5 | 2 |
| Alopecia | 92 | 71 |
| Cardiac dysfunction | ||
| Asymptomatic | 0.2 | 0.1 |
| Transient | 0.1 | 0 |
| Symptomatic | 0.1 | 0 |
| *Includes pooled data from patients who received either AC alone for 4 cycles, or who were treated with AC for 4 cycles followed by 3 cycles of CMF |
The following adverse reactions have been identified during post-approval use of doxorubicin HCl. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
Cardiac – cardiogenic shock
Cutaneous –Skin and nail hyperpigmentation, oncolysis, rash, itching, photosensitivity, urticaria, acral erythema, palmar plantar erythrodysesthesia
Gastrointestinal – Nausea, mucositis, stomatitis, necrotizing colitis, typhlitis, gastric erosions, gastrointestinal tract bleeding, hematochezia, esophagitis, anorexia, abdominal pain, dehydration, diarrhea, hyperpigmentation of the oral mucosa
Hypersensitivity – Anaphylaxis
Laboratory Abnormalities –Increased alanine aminotransferase, increased aspartate aminotransferase
Neurological – Peripheral sensory and motor neuropathy, seizures, coma
Ocular – Conjunctivitis, keratitis, lacrimation
Vascular – Phlebosclerosis, phlebitis/thrombophlebitis, hot flashes, thromboembolism
Other – Malaise/asthenia, fever, chills, weight gain
Ribodoxo HCl is indicated as a component of multi-agent adjuvant chemotherapy for treatment of women with axillary lymph node involvement following resection of primary breast cancer.
Other CancersRibodoxo HCl is indicated for the treatment of
Doxorubicin HCl is indicated as a component of multi-agent adjuvant chemotherapy for treatment of women with axillary lymph node involvement following resection of primary breast cancer.
Other CancersDoxorubicin HCl is indicated for the treatment of
Pharmacokinetic studies conducted in patients with various types of tumors have shown that Ribodoxo follows multiphasic disposition after intravenous injection. The distribution half-life is approximately 5 minutes, while the terminal half-life is 20 to 48 hours. In four patients, Ribodoxo demonstrated dose-independent pharmacokinetics across a dose range of 30 to 70 mg/m2.
DistributionSteady-state distribution volume ranges from 809 to 1214 L/m2. Binding of Ribodoxo and its major metabolite, Ribodoxool, to plasma proteins is about 75% and is independent of plasma concentration of Ribodoxo up to 1.1 μg/mL.
Ribodoxo was measured in the milk of one lactating patient after therapy with 70 mg/m of Ribodoxo HCl given as a 15-minute intravenous infusion. The peak milk concentration at 24 hours after treatment was 4.4-fold greater than the corresponding plasma concentration. Ribodoxo was detectable in the milk up to 72 hours.
Ribodoxo does not cross the blood brain barrier.
MetabolismEnzymatic reduction at the 7 position and cleavage of the daunosamine sugar yields aglycones which are accompanied by free radical formation, the local production of which may contribute to the cardiotoxic activity of Ribodoxo HCl. Disposition of Ribodoxool in patients is formation rate limited, with the terminal half-life of Ribodoxool being similar to Ribodoxo. The relative exposure of Ribodoxool, i.e., the ratio between the AUC of Ribodoxool and the AUC of Ribodoxo is approximately 0.5.
ExcretionPlasma clearance is in the range 324 to 809 mL/min/m2 and is predominately by metabolism and biliary excretion. Approximately 40% of the dose appears in the bile in 5 days, while only 5 to 12% of the drug and its metabolites appear in the urine during the same time period. In urine, <3% of the dose was recovered as Ribodoxool over 7 days.
Systemic clearance of Ribodoxo is significantly reduced in obese women with ideal body weight greater than 130%. There was a significant reduction in clearance without any change in volume of distribution in obese patients when compared with normal patients with less than 115% ideal body weight.
Pediatric PatientsFollowing administration of doses ranging from 10 to 75 mg/m of Ribodoxo HCl to 60 children and adolescents ranging from 2 months to 20 years of age, Ribodoxo clearance averaged 1443 ± 114 mL/min/m. Further analysis demonstrated that clearance in 52 children greater than 2 years of age (1540 mL/min/m ) was increased compared with adults. However, clearance in infants younger than 2 years of age (813 mL/min/m ) was decreased compared with older children and approached the range of clearance values determined in adults.
Patient GenderThere is no recommended dose adjustment based on gender. A published clinical study involving 6 men and 21 women with no prior anthracycline therapy reported a significantly higher median Ribodoxo clearance in men compared to women (1088 mL/min/m versus 433 mL/min/m ). However, the terminal half-life of Ribodoxo was longer in men compared to women (54 versus 35 hours).
Patients With Hepatic ImpairmentThe clearance of Ribodoxo and Ribodoxool was reduced in patients with elevation in serum bilirubin.
Pharmacokinetic studies conducted in patients with various types of tumors have shown that doxorubicin follows multiphasic disposition after intravenous injection. The distribution half-life is approximately 5 minutes, while the terminal half-life is 20 to 48 hours. In four patients, doxorubicin demonstrated dose-independent pharmacokinetics across a dose range of 30 to 70 mg/m2.
DistributionSteady-state distribution volume ranges from 809 to 1214 L/m2. Binding of doxorubicin and its major metabolite, doxorubicinol, to plasma proteins is about 75% and is independent of plasma concentration of doxorubicin up to 1.1 μg/mL.
Doxorubicin was measured in the milk of one lactating patient after therapy with 70 mg/m of doxorubicin HCl given as a 15-minute intravenous infusion. The peak milk concentration at 24 hours after treatment was 4.4-fold greater than the corresponding plasma concentration. Doxorubicin was detectable in the milk up to 72 hours.
Doxorubicin does not cross the blood brain barrier.
MetabolismEnzymatic reduction at the 7 position and cleavage of the daunosamine sugar yields aglycones which are accompanied by free radical formation, the local production of which may contribute to the cardiotoxic activity of doxorubicin HCl. Disposition of doxorubicinol in patients is formation rate limited, with the terminal half-life of doxorubicinol being similar to doxorubicin. The relative exposure of doxorubicinol, i.e., the ratio between the AUC of doxorubicinol and the AUC of doxorubicin is approximately 0.5.
ExcretionPlasma clearance is in the range 324 to 809 mL/min/m2 and is predominately by metabolism and biliary excretion. Approximately 40% of the dose appears in the bile in 5 days, while only 5 to 12% of the drug and its metabolites appear in the urine during the same time period. In urine, <3% of the dose was recovered as doxorubicinol over 7 days.
Systemic clearance of doxorubicin is significantly reduced in obese women with ideal body weight greater than 130%. There was a significant reduction in clearance without any change in volume of distribution in obese patients when compared with normal patients with less than 115% ideal body weight.
Pediatric PatientsFollowing administration of doses ranging from 10 to 75 mg/m of doxorubicin HCl to 60 children and adolescents ranging from 2 months to 20 years of age, doxorubicin clearance averaged 1443 ± 114 mL/min/m. Further analysis demonstrated that clearance in 52 children greater than 2 years of age (1540 mL/min/m ) was increased compared with adults. However, clearance in infants younger than 2 years of age (813 mL/min/m ) was decreased compared with older children and approached the range of clearance values determined in adults.
Patient GenderThere is no recommended dose adjustment based on gender. A published clinical study involving 6 men and 21 women with no prior anthracycline therapy reported a significantly higher median doxorubicin clearance in men compared to women (1088 mL/min/m versus 433 mL/min/m ). However, the terminal half-life of doxorubicin was longer in men compared to women (54 versus 35 hours).
Patients With Hepatic ImpairmentThe clearance of doxorubicin and doxorubicinol was reduced in patients with elevation in serum bilirubin.
Included as part of the "PRECAUTIONS" Section
PRECAUTIONS Cardiomyopathy And Arrhythmias CardiomyopathyRibodoxo HCl can result in myocardial damage, including acute left ventricular failure. The risk of cardiomyopathy is generally proportional to the cumulative exposure. Include prior doses of other anthracyclines or anthracenediones in calculations of total cumulative dosage for Ribodoxo HCl. Cardiomyopathy may develop during treatment or up to several years after completion of treatment and can include decrease in LVEF and signs and symptoms of congestive heart failure (CHF). The probability of developing cardiomyopathy is estimated to be 1 to 2% at a total cumulative dose of 300 mg/m2 of Ribodoxo HCl, 3 to 5% at a dose of 400 mg/m2 , 5 to 8% at a dose of 450 mg/m2 , and 6 to 20% at a dose of 500 mg/m2 , when Ribodoxo HCl is administered every 3 weeks. There is an additive or potentially synergistic increase in the risk of cardiomyopathy in patients who have received radiotherapy to the mediastinum or concomitant therapy with other known cardiotoxic agents such as cyclophosphamide and trastuzumab.
Pericarditis and myocarditis have also been reported during or following Ribodoxo HCl treatment.
Assess left ventricular cardiac function (e.g., MUGA or echocardiogram) prior to initiation of Ribodoxo HCl, during treatment to detect acute changes, and after treatment to detect delayed cardiotoxicity. Increase the frequency of assessments as the cumulative dose exceeds 300 mg/m2. Use the same method of assessment of LVEF at all time points.
Consider the use of dexrazoxane to reduce the incidence and severity of cardiomyopathy due to Ribodoxo HCl administration in patients who have received a cumulative Ribodoxo HCl dose of 300 mg/m2 and who will continue to receive Ribodoxo HCl.
ArrhythmiasRibodoxo HCl can result in arrhythmias, including life-threatening arrhythmias, during or within a few hours after Ribodoxo HCl administration and at any time point during treatment. Tachyarrhythmias, including sinus tachycardia, premature ventricular contractions, and ventricular tachycardia, as well as bradycardia may occur. Electrocardiographic changes including non-specific ST-T wave changes, atrioventricular and bundle-branch block can also occur. These electrocardiographic changes may be transient and self-limited and may not require dose-modifications of Ribodoxo HCl.
Secondary MalignanciesThe risk of developing secondary acute myelogenous leukemia (AML) and myelodysplastic syndrome (MDS) is increased following treatment with Ribodoxo HCl. Cumulative incidences ranged from 0.2% at five years to 1.5% at 10 years in two separate trials involving the adjuvant treatment of women with breast cancer. These leukemias generally occur within 1 to 3 years of treatment.
Extravasation And Tissue NecrosisExtravasation of Ribodoxo HCl can result in severe local tissue injury manifesting as blistering, ulceration, and necrosis requiring wide excision of the affected area and skin grafting. When given via a peripheral venous line, infuse Ribodoxo over 10 minutes or less to minimize the risk of thrombosis or perivenous extravasation. If signs or symptoms of extravasation occur, immediately terminate the injection or infusion. Extravasation may be present in patients who do not experience a stinging or burning sensation or when blood return is present on aspiration of the infusion needle. If extravasation is suspected, apply ice to the site intermittently for 15 minutes, 4 times a day for 3 days. If appropriate, administer dexrazoxane at the site of extravasation as soon as possible and within the first 6 hours after extravasation.
Severe MyelosuppressionRibodoxo HCl can cause myelosuppression. In Study 1, the incidence of severe myelosuppression was: grade 4 leukopenia (0.3%), grade 3 leukopenia (3%), and grade 4 thrombocytopenia (0.1%). A dose-dependent, reversible neutropenia is the predominant manifestation of hematologic toxicity from Ribodoxo HCl. When Ribodoxo HCl is administered every 21 days, the neutrophil count reaches its nadir 10 to 14 days after administration with recovery usually occurring by the 21st day.
Obtain baseline assessment of blood counts and carefully monitor patients during treatment for possible clinical complications due to myelosuppression.
Use In Patients With Hepatic ImpairmentThe clearance of Ribodoxo is decreased in patients with elevated serum bilirubin with an increased risk of toxicity. Reduce the dose of Ribodoxo HCl in patients with serum bilirubin levels of 1.2–5.0 mg/dL. Ribodoxo is contraindicated in patients with severe hepatic impairment (defined as Child Pugh Class C or serum bilirubin level greater than 5 mg/dL). Obtain liver tests including SGOT, SGPT, alkaline phosphatase, and bilirubin prior to and during Ribodoxo HCl therapy.
Tumor Lysis SyndromeRibodoxo HCl may induce tumor lysis syndrome in patients with rapidly growing tumors. Evaluate blood uric acid levels, potassium, calcium, phosphate, and creatinine after initial treatment. Hydration, urine alkalinization, and prophylaxis with allopurinol to prevent hyperuricemia may minimize potential complications of tumor lysis syndrome.
Radiation Sensitization And Radiation RecallRibodoxo HCl can increase radiation-induced toxicity to the myocardium, mucosa, skin, and liver. Radiation recall, including but not limited to cutaneous and pulmonary toxicity, can occur in patients who receive Ribodoxo HCl after prior radiation therapy.
Embryofetal ToxicityRibodoxo HCl can cause fetal harm when administered to a pregnant woman. Ribodoxo HCl was teratogenic and embryotoxic in rats and rabbits at doses lower than the recommended human dose.
If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, apprise the patient of the potential hazard to a fetus.
Advise female patients of reproductive potential to use highly effective contraception during treatment with Ribodoxo HCl and for 6 months after treatment. Advise patients to contact their healthcare provider if they become pregnant, or if pregnancy is suspected, while taking Ribodoxo HCl.
Patient Counseling InformationSee FDA-Approved Patient Labeling (PATIENT INFORMATION).
Inform patients of the following:
Ribodoxo HCl treatment results in an increased risk of secondary malignancies based on postmarketing reports. Ribodoxo HCl was mutagenic in the in vitro Ames assay, and clastogenic in multiple in vitro assays (CHO cell, V79 hamster cell, human lymphoblast, and SCE assays) and the in vivo mouse micronucleus assay.
Ribodoxo HCl decreased fertility in female rats at the doses of 0.05 and 0.2 mg/kg/day (approximately 0.005 and 0.02 times the recommended human dose, based on body surface area).
A single intravenous dose of 0.1 mg/kg Ribodoxo HCl (approximately 0.01 times the recommended human dose based on body surface area) was toxic to male reproductive organs in animal studies, producing testicular atrophy, diffuse degeneration of the seminiferous tubules, and oligospermia/hypospermia in rats. Ribodoxo HCl induces DNA damage in rabbit spermatozoa and dominant lethal mutations in mice.
Use In Specific Populations Pregnancy Pregnancy Category DRisk Summary
Ribodoxo HCl can cause fetal harm when administered to a pregnant woman. Ribodoxo HCl was teratogenic and embryotoxic in rats and rabbits at doses approximately 0.07 times (based on body surface area) the recommended human dose of 60 mg/m. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, apprise the patient of the potential hazard to a fetus.
Animal Data
Ribodoxo HCl was teratogenic and embryotoxic at doses of 0.8 mg/kg/day (about 0.07 times the recommended human dose based on body surface area) when administered during the period of organogenesis in rats. Teratogenicity and embryotoxicity were also seen using Includes pooled data from patients who received either AC alone for 4 cycles, or who were treated with AC for 4 cycles followed by 3 cycles of CMF discrete periods of treatment. The most susceptible was the 6- to 9-day gestation period at doses of 1.25 mg/kg/day and greater. Characteristic malformations included esophageal and intestinal atresia, tracheo-esophageal fistula, hypoplasia of the urinary bladder, and cardiovascular anomalies. Ribodoxo HCl was embryotoxic (increase in embryofetal deaths) and abortifacient at 0.4 mg/kg/day (about 0.07 times the recommended human dose based on body surface area) in rabbits when administered during the period of organogenesis.
Nursing MothersRibodoxo has been detected in the milk of at least one lactating patient. Because of the potential for serious adverse reactions in nursing infants from Ribodoxo HCl, 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 UseBased on postmarketing reports, pediatric patients treated with Ribodoxo HCl are at risk for developing late cardiovascular dysfunction. Risk factors include young age at treatment (especially < 5 years), high cumulative doses and receipt of combined modality therapy. Longterm periodic cardiovascular monitoring is recommended for all pediatric patients who have received Ribodoxo HCl. Ribodoxo HCl, as a component of intensive chemotherapy regimens administered to pediatric patients, may contribute to prepubertal growth failure and may also contribute to gonadal impairment, which is usually temporary.
There are no recommended dose adjustments based on age. Ribodoxo clearance was increased in patients aged 2 years to 20 years as compared to adults, while Ribodoxo clearance was similar in children less than 2 years as compared to adults.
Geriatric UseClinical experience in patients who were 65 years of age and older who received Ribodoxo HCl-based chemotherapy regimens for metastatic breast cancer showed no overall differences in safety and effectiveness compared with younger patients.
Females And Males Of Reproductive Potential ContraceptionFemales
Ribodoxo HCl can cause fetal harm when administered during pregnancy. Advise female patients of reproductive potential to use highly effective contraception during treatment with Ribodoxo HCl and for 6 months after treatment. Advise patients to contact their healthcare provider if they become pregnant, or if pregnancy is suspected, while taking Ribodoxo HCl.
Males
Ribodoxo HCl may damage spermatozoa and testicular tissue, resulting in possible genetic fetal abnormalities. Males with female sexual partners of reproductive potential should use effective contraception during and for 6 months after treatment.
InfertilityFemales
In females of reproductive potential, Ribodoxo HCl may cause infertility and result in amenorrhea. Premature menopause can occur. Recovery of menses and ovulation is related to age at treatment.
Males
Ribodoxo HCl may result in oligospermia, azoospermia, and permanent loss of fertility. Sperm counts have been reported to return to normal levels in some men. This may occur several years after the end of therapy.
Hepatic ImpairmentThe clearance of Ribodoxo was reduced in patients with elevated serum bilirubin levels. Reduce the dose of Ribodoxo HCl in patients with serum bilirubin levels greater than 1.2 mg/dL.
Ribodoxo HCl is contraindicated in patients with severe hepatic impairment (defined as Child Pugh Class C or serum bilirubin levels greater than 5 mg/dL).
WARNINGSIncluded as part of the "PRECAUTIONS" Section
PRECAUTIONS Cardiomyopathy And Arrhythmias CardiomyopathyDoxorubicin HCl can result in myocardial damage, including acute left ventricular failure. The risk of cardiomyopathy is generally proportional to the cumulative exposure. Include prior doses of other anthracyclines or anthracenediones in calculations of total cumulative dosage for doxorubicin HCl. Cardiomyopathy may develop during treatment or up to several years after completion of treatment and can include decrease in LVEF and signs and symptoms of congestive heart failure (CHF). The probability of developing cardiomyopathy is estimated to be 1 to 2% at a total cumulative dose of 300 mg/m2 of doxorubicin HCl, 3 to 5% at a dose of 400 mg/m2 , 5 to 8% at a dose of 450 mg/m2 , and 6 to 20% at a dose of 500 mg/m2 , when doxorubicin HCl is administered every 3 weeks. There is an additive or potentially synergistic increase in the risk of cardiomyopathy in patients who have received radiotherapy to the mediastinum or concomitant therapy with other known cardiotoxic agents such as cyclophosphamide and trastuzumab.
Pericarditis and myocarditis have also been reported during or following doxorubicin HCl treatment.
Assess left ventricular cardiac function (e.g., MUGA or echocardiogram) prior to initiation of doxorubicin HCl, during treatment to detect acute changes, and after treatment to detect delayed cardiotoxicity. Increase the frequency of assessments as the cumulative dose exceeds 300 mg/m2. Use the same method of assessment of LVEF at all time points.
Consider the use of dexrazoxane to reduce the incidence and severity of cardiomyopathy due to doxorubicin HCl administration in patients who have received a cumulative doxorubicin HCl dose of 300 mg/m2 and who will continue to receive doxorubicin HCl.
ArrhythmiasDoxorubicin HCl can result in arrhythmias, including life-threatening arrhythmias, during or within a few hours after doxorubicin HCl administration and at any time point during treatment. Tachyarrhythmias, including sinus tachycardia, premature ventricular contractions, and ventricular tachycardia, as well as bradycardia may occur. Electrocardiographic changes including non-specific ST-T wave changes, atrioventricular and bundle-branch block can also occur. These electrocardiographic changes may be transient and self-limited and may not require dose-modifications of doxorubicin HCl.
Secondary MalignanciesThe risk of developing secondary acute myelogenous leukemia (AML) and myelodysplastic syndrome (MDS) is increased following treatment with doxorubicin HCl. Cumulative incidences ranged from 0.2% at five years to 1.5% at 10 years in two separate trials involving the adjuvant treatment of women with breast cancer. These leukemias generally occur within 1 to 3 years of treatment.
Extravasation And Tissue NecrosisExtravasation of doxorubicin HCl can result in severe local tissue injury manifesting as blistering, ulceration, and necrosis requiring wide excision of the affected area and skin grafting. When given via a peripheral venous line, infuse doxorubicin over 10 minutes or less to minimize the risk of thrombosis or perivenous extravasation. If signs or symptoms of extravasation occur, immediately terminate the injection or infusion. Extravasation may be present in patients who do not experience a stinging or burning sensation or when blood return is present on aspiration of the infusion needle. If extravasation is suspected, apply ice to the site intermittently for 15 minutes, 4 times a day for 3 days. If appropriate, administer dexrazoxane at the site of extravasation as soon as possible and within the first 6 hours after extravasation.
Severe MyelosuppressionDoxorubicin HCl can cause myelosuppression. In Study 1, the incidence of severe myelosuppression was: grade 4 leukopenia (0.3%), grade 3 leukopenia (3%), and grade 4 thrombocytopenia (0.1%). A dose-dependent, reversible neutropenia is the predominant manifestation of hematologic toxicity from doxorubicin HCl. When doxorubicin HCl is administered every 21 days, the neutrophil count reaches its nadir 10 to 14 days after administration with recovery usually occurring by the 21st day.
Obtain baseline assessment of blood counts and carefully monitor patients during treatment for possible clinical complications due to myelosuppression.
Use In Patients With Hepatic ImpairmentThe clearance of doxorubicin is decreased in patients with elevated serum bilirubin with an increased risk of toxicity. Reduce the dose of doxorubicin HCl in patients with serum bilirubin levels of 1.2–5.0 mg/dL. Doxorubicin is contraindicated in patients with severe hepatic impairment (defined as Child Pugh Class C or serum bilirubin level greater than 5 mg/dL). Obtain liver tests including SGOT, SGPT, alkaline phosphatase, and bilirubin prior to and during doxorubicin HCl therapy.
Tumor Lysis SyndromeDoxorubicin HCl may induce tumor lysis syndrome in patients with rapidly growing tumors. Evaluate blood uric acid levels, potassium, calcium, phosphate, and creatinine after initial treatment. Hydration, urine alkalinization, and prophylaxis with allopurinol to prevent hyperuricemia may minimize potential complications of tumor lysis syndrome.
Radiation Sensitization And Radiation RecallDoxorubicin HCl can increase radiation-induced toxicity to the myocardium, mucosa, skin, and liver. Radiation recall, including but not limited to cutaneous and pulmonary toxicity, can occur in patients who receive doxorubicin HCl after prior radiation therapy.
Embryofetal ToxicityDoxorubicin HCl can cause fetal harm when administered to a pregnant woman. Doxorubicin HCl was teratogenic and embryotoxic in rats and rabbits at doses lower than the recommended human dose.
If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, apprise the patient of the potential hazard to a fetus.
Advise female patients of reproductive potential to use highly effective contraception during treatment with doxorubicin HCl and for 6 months after treatment. Advise patients to contact their healthcare provider if they become pregnant, or if pregnancy is suspected, while taking doxorubicin HCl.
Patient Counseling InformationSee FDA-Approved Patient Labeling (PATIENT INFORMATION).
Inform patients of the following:
Doxorubicin HCl treatment results in an increased risk of secondary malignancies based on postmarketing reports. Doxorubicin HCl was mutagenic in the in vitro Ames assay, and clastogenic in multiple in vitro assays (CHO cell, V79 hamster cell, human lymphoblast, and SCE assays) and the in vivo mouse micronucleus assay.
Doxorubicin HCl decreased fertility in female rats at the doses of 0.05 and 0.2 mg/kg/day (approximately 0.005 and 0.02 times the recommended human dose, based on body surface area).
A single intravenous dose of 0.1 mg/kg doxorubicin HCl (approximately 0.01 times the recommended human dose based on body surface area) was toxic to male reproductive organs in animal studies, producing testicular atrophy, diffuse degeneration of the seminiferous tubules, and oligospermia/hypospermia in rats. Doxorubicin HCl induces DNA damage in rabbit spermatozoa and dominant lethal mutations in mice.
Use In Specific Populations Pregnancy Pregnancy Category DRisk Summary
Doxorubicin HCl can cause fetal harm when administered to a pregnant woman. Doxorubicin HCl was teratogenic and embryotoxic in rats and rabbits at doses approximately 0.07 times (based on body surface area) the recommended human dose of 60 mg/m. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, apprise the patient of the potential hazard to a fetus.
Animal Data
Doxorubicin HCl was teratogenic and embryotoxic at doses of 0.8 mg/kg/day (about 0.07 times the recommended human dose based on body surface area) when administered during the period of organogenesis in rats. Teratogenicity and embryotoxicity were also seen using Includes pooled data from patients who received either AC alone for 4 cycles, or who were treated with AC for 4 cycles followed by 3 cycles of CMF discrete periods of treatment. The most susceptible was the 6- to 9-day gestation period at doses of 1.25 mg/kg/day and greater. Characteristic malformations included esophageal and intestinal atresia, tracheo-esophageal fistula, hypoplasia of the urinary bladder, and cardiovascular anomalies. Doxorubicin HCl was embryotoxic (increase in embryofetal deaths) and abortifacient at 0.4 mg/kg/day (about 0.07 times the recommended human dose based on body surface area) in rabbits when administered during the period of organogenesis.
Nursing MothersDoxorubicin has been detected in the milk of at least one lactating patient. Because of the potential for serious adverse reactions in nursing infants from doxorubicin HCl, 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 UseBased on postmarketing reports, pediatric patients treated with doxorubicin HCl are at risk for developing late cardiovascular dysfunction. Risk factors include young age at treatment (especially < 5 years), high cumulative doses and receipt of combined modality therapy. Longterm periodic cardiovascular monitoring is recommended for all pediatric patients who have received doxorubicin HCl. Doxorubicin HCl, as a component of intensive chemotherapy regimens administered to pediatric patients, may contribute to prepubertal growth failure and may also contribute to gonadal impairment, which is usually temporary.
There are no recommended dose adjustments based on age. Doxorubicin clearance was increased in patients aged 2 years to 20 years as compared to adults, while doxorubicin clearance was similar in children less than 2 years as compared to adults.
Geriatric UseClinical experience in patients who were 65 years of age and older who received doxorubicin HCl-based chemotherapy regimens for metastatic breast cancer showed no overall differences in safety and effectiveness compared with younger patients.
Females And Males Of Reproductive Potential ContraceptionFemales
Doxorubicin HCl can cause fetal harm when administered during pregnancy. Advise female patients of reproductive potential to use highly effective contraception during treatment with doxorubicin HCl and for 6 months after treatment. Advise patients to contact their healthcare provider if they become pregnant, or if pregnancy is suspected, while taking doxorubicin HCl.
Males
Doxorubicin HCl may damage spermatozoa and testicular tissue, resulting in possible genetic fetal abnormalities. Males with female sexual partners of reproductive potential should use effective contraception during and for 6 months after treatment.
InfertilityFemales
In females of reproductive potential, doxorubicin HCl may cause infertility and result in amenorrhea. Premature menopause can occur. Recovery of menses and ovulation is related to age at treatment.
Males
Doxorubicin HCl may result in oligospermia, azoospermia, and permanent loss of fertility. Sperm counts have been reported to return to normal levels in some men. This may occur several years after the end of therapy.
Hepatic ImpairmentThe clearance of doxorubicin was reduced in patients with elevated serum bilirubin levels. Reduce the dose of doxorubicin HCl in patients with serum bilirubin levels greater than 1.2 mg/dL.
Doxorubicin HCl is contraindicated in patients with severe hepatic impairment (defined as Child Pugh Class C or serum bilirubin levels greater than 5 mg/dL).
The recommended dose of Ribodoxo HCl is 60 mg/m administered as an intravenous bolus on day 1 of each 21-day treatment cycle, in combination with cyclophosphamide, for a total of four cycles.
Metastatic Disease, Leukemia, Or LymphomaDiscontinue Ribodoxo in patients who develop signs or symptoms of cardiomyopathy.
Hepatic ImpairmentRibodoxo HCl is contraindicated in patients with severe hepatic impairment (Child-Pugh Class C or serum bilirubin >5.0 mg/dL).
Decrease the dose of Ribodoxo HCl in patients with elevated serum total bilirubin concentrations as follows:
| Serum bilirubin concentration | Ribodoxo HCl Dose reduction |
| 1.2 – 3.0 mg/dL | 50 % |
| 3.1 – 5.0 mg/dL | 75 % |
| greater than 5.0 mg/dL | Do not initiate Ribodoxo HCl Discontinue Ribodoxo HCl |
Reconstitute Ribodoxo hydrochloride for injection with 0.9% Sodium Chloride Injection, USP to obtain a final concentration of 2 mg per mL as follows:
Gently shake vial until the contents have dissolved.
Protect reconstituted solution from light.
Preparation For Continuous Intravenous InfusionDilute Ribodoxo HCl solution or reconstituted solution in 0.9% Sodium Chloride Injection, USP or 5% Dextrose Injection, USP. Protect from light following preparation until completion of infusion.
AdministrationVisually inspect parenteral drug products for particulate matter and discoloration prior to administration, whenever solution and container permit. Discard if the solution is discolored, cloudy, or contains particulate matter.
Storage of vials of Ribodoxo HCl Injection or Ribodoxo HCl for Injection following reconstitution under refrigerated conditions can result in the formation of a gelled product. Place gelled product at room temperature [15º to 30ºC (59º to 86ºF)] for 2 to 4 hours to return the product to a slightly viscous, mobile solution.
Administration By Intravenous Injection:Discontinue Ribodoxo HCl for burning or stinging sensation or other evidence indicating peri-venous infiltration or extravasation. Manage confirmed or suspected extravasation as follows:
Do not admix Ribodoxo HCl with other drugs. If Ribodoxo HCl is mixed with heparin or fluorouracil a precipitate may form. Avoid contact with alkaline solutions which can lead to hydrolysis of Ribodoxo HCl.
Procedures For Proper Handling And DisposalHandle and dispose of Ribodoxo HCl consistent with recommendations for the handling and disposal of hazardous drugs.1 Treat accidental contact with the skin or eyes immediately by copious lavage with water, or soap and water, or sodium bicarbonate solution.
Do not abrade the skin by using a scrub brush. Seek medical attention.
Recommended Dose Adjuvant Breast CancerThe recommended dose of doxorubicin HCl is 60 mg/m administered as an intravenous bolus on day 1 of each 21-day treatment cycle, in combination with cyclophosphamide, for a total of four cycles.
Metastatic Disease, Leukemia, Or LymphomaDiscontinue doxorubicin in patients who develop signs or symptoms of cardiomyopathy.
Hepatic ImpairmentDoxorubicin HCl is contraindicated in patients with severe hepatic impairment (Child-Pugh Class C or serum bilirubin >5.0 mg/dL).
Decrease the dose of doxorubicin HCl in patients with elevated serum total bilirubin concentrations as follows:
| Serum bilirubin concentration | Doxorubicin HCl Dose reduction |
| 1.2 – 3.0 mg/dL | 50 % |
| 3.1 – 5.0 mg/dL | 75 % |
| greater than 5.0 mg/dL | Do not initiate doxorubicin HCl Discontinue doxorubicin HCl |
Reconstitute Ribodoxo for injection with 0.9% Sodium Chloride Injection, USP to obtain a final concentration of 2 mg per mL as follows:
Gently shake vial until the contents have dissolved.
Protect reconstituted solution from light.
Preparation For Continuous Intravenous InfusionDilute doxorubicin HCl solution or reconstituted solution in 0.9% Sodium Chloride Injection, USP or 5% Dextrose Injection, USP. Protect from light following preparation until completion of infusion.
AdministrationVisually inspect parenteral drug products for particulate matter and discoloration prior to administration, whenever solution and container permit. Discard if the solution is discolored, cloudy, or contains particulate matter.
Storage of vials of Doxorubicin HCl Injection or Doxorubicin HCl for Injection following reconstitution under refrigerated conditions can result in the formation of a gelled product. Place gelled product at room temperature [15º to 30ºC (59º to 86ºF)] for 2 to 4 hours to return the product to a slightly viscous, mobile solution.
Administration By Intravenous Injection:Discontinue doxorubicin HCl for burning or stinging sensation or other evidence indicating peri-venous infiltration or extravasation. Manage confirmed or suspected extravasation as follows:
Do not admix doxorubicin HCl with other drugs. If doxorubicin HCl is mixed with heparin or fluorouracil a precipitate may form. Avoid contact with alkaline solutions which can lead to hydrolysis of doxorubicin HCl.
Procedures For Proper Handling And DisposalHandle and dispose of doxorubicin HCl consistent with recommendations for the handling and disposal of hazardous drugs.1 Treat accidental contact with the skin or eyes immediately by copious lavage with water, or soap and water, or sodium bicarbonate solution.
Do not abrade the skin by using a scrub brush. Seek medical attention.
