Very high doses of idarubicin may be expected to cause acute myocardial toxicity within 24 hours and severe myelosuppression within one to two weeks.
Delayed cardiac failure has been seen with anthracyclines for up to several months after the overdose.
Patients treated with oral idarubicin should be observed for possible gastrointestinal haemorrhage and severe mucosal damage.
Very high doses of Rubide may be expected to cause acute myocardial toxicity within 24 hours and severe myelosuppression within one to two weeks. Delayed cardiac failure has been seen with the anthracyclines up to several months after the overdose.
Patients treated with oral Rubide should be observed for possible gastrointestinal haemorrhage and severe mucosal damage.
- severe hepatic impairment
- severe renal impairment
- uncontrolled infections
- severe cardiomyopathy
- recent myocardial infarction
- severe arrhythmias
- persistent myelosuppression
- previous treatment with maximum cumulative doses of idarubicin and/or other anthracyclines and anthracenediones
- breast-feeding should be stopped during drug therapy
-
- Hypersensitivity to other anthracyclines or anthracenediones
- Severe hepatic impairment
- Severe renal impairment
- Severe cardiomyopathy
- Recent myocardial infarction
- Severe arrhythmias
- Persistent myelosuppression
- Previous treatment with maximum cumulative doses of Rubide and/ or other anthracyclines and anthracenediones
- Breastfeeding should be stopped during drug therapy
Not known.
Prolonged contact with any alkaline pH solution must be avoided, since it can give rise to drug degradation. Rubide hydrochloride must not be mixed with heparin as it may form a precipitate.
The frequencies of undesirable effects are based on the following categories:
Very common (>1/10)
Common (>1/100 to <1/10)
Uncommon (>1/1,000 to <1/100)
Rare (>1/10,000 to <1/1,000)
Very rare (<1/10,000)
Not known (cannot be estimated from the available data)
| Infections and infestations | |
| Very common | Infections |
| Uncommon | Sepsis, septicaemia |
| Neoplasms benign, malignant and unspecified (including cysts and polyps) | |
| Uncommon | Secondary leukaemia (acute myeloid leukaemia and myelodysplastic syndrome) |
| Blood and lymphatic system disorders | |
| Very common | Anaemia, severe leukopenia and neutropenia, thrombocytopenia |
| Not known | Pancytopenia |
| Immune system disorders | |
| Very rare | Anaphylaxis |
| Endocrine disorders | |
| Very common | Anorexia |
| Uncommon | Dehydration |
| Metabolism and nutrition disorders | |
| Uncommon | Hyperuricaemia |
| Not Known | Tumour Lysis Syndrome |
| Nervous system disorders | |
| Rare | Cerebral haemorrhages |
| Cardiac disorders | |
| Common | ) |
| Uncommon | ECG abnormalities (e.g. nonspecific ST segment changes), myocardial infarction |
| Very rare | Pericarditis, myocarditis, atrioventricular and bundle branch block |
| Vascular disorders | |
| Common | Local phlebitis, thrombophlebitis, haemorrhages |
| Uncommon | Shock |
| Very rare | Thromboembolism, flush |
| Gastrointestinal disorders | |
| Very common | Nausea, vomiting, mucositis/stomatitis, diarrhoea, abdominal pain or burning sensation |
| Common | Gastrointestinal tract bleeding, bellyache |
| Uncommon | Oesophagitis, colitis (including severe enterocolitis / neutropenic enterocolitis with perforation) |
| Very rare | Gastric erosions or ulcerations |
| Hepatobiliary disorders | |
| Common | Elevation of the liver enzymes and bilirubin |
| Skin and subcutaneous tissue disorders | |
| Very common | Alopecia |
| Common | Rash, itch, hypersensitivity of irradiated skin ('radiation recall reaction') |
| Uncommon | Skin and nail hyperpigmentation, urticaria, cellulitis (this event can be severe), tissue necrosis |
| Very rare | Acral erythema |
| Renal and urinary disorders | |
| Very common | Red colouration of the urine for 1 - 2 days after the treatment. |
| General disorders and administration site conditions | |
| Very common | Fever, headache, chills |
Description of selected adverse reactions
Haematopoietic system
Pronounced myelosuppression is the most severe adverse effect of idarubicin treatment. However, this is necessary for the eradication of leukemic cells.
Cardiotoxicity
Life-threatening CHF is the most severe form of anthracycline-induced cardiomyopathy and represents the cumulative dose-limiting toxicity of the drug.
Gastrointestinal
Stomatitis and in severe cases ulceration of mucosa, dehydration caused by severe vomiting and diarrhoea; risk of perforation of colon etc.
Other adverse reactions: hyperuricaemia
Prevention of symptoms by hydration, urine alkalinisation, and prophylaxis with allopurinol may minimise potential complications of tumour lysis syndrome.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product.
Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at www.mhra.gov.uk/yellowcard.
List of adverse reactions
The frequencies of adverse events are ranked according to the following convention:
Very common (> 1/10); common (> 1/100to <1/10); uncommon (> 1/1,000to < 1/100); rare (> 1/10,000to < 1/1,000); very rare (< 1/10,000); not known (cannot be estimated from the available data).
Infections and infestations:
Very common: Infections
Uncommon: Sepsis, septicaemia
Neoplasms benign, malignant and unspecified (including cysts and polyps)
Uncommon: Secondary leukemias (acute myeloid leukemia and myelodysplastic syndrome)
Blood and lymphatic system disorders
Very common: Anaemia, severe leukopenia and neutropenia, thrombocytopenia
Not known: Pancytopenia
Immune system disorders
Very rare: Anaphylaxis
Endocrine disorders
Very common: Anorexia
Uncommon: Dehydration
Metabolism and nutrition disorders
Uncommon: Hyperuricaemia
Not known: Tumor lysis syndrome
Nervous system disorders
Rare: Cerebral haemorrhages
Cardiac disorders
)
Uncommon: ECG abnormalities (e.g., non-specific ST segment changes), myocardial infarction
Very rare: Pericarditis, myocarditis, atrioventricular and bundle branch block
Vascular disorders
Common: Haemorrhages, local phlebitis, thrombophlebitis
Uncommon: Shock
Very rare: Thromboembolism, flush
Gastrointestinal disorders
Very common: Nausea, vomiting, mucositis/stomatitis, diarrhoea, abdominal pain or burning feeling
Common: Gastrointestinal tract bleeding, bellyache
Uncommon: Oesophagitis, colitis (including severe enterocolitis/neutropenic enterocolitis with perforation)
Very rare: Gastric erosions or ulcerations
Hepatobiliary disorders
Common: Elevation of liver enzymes and bilirubin
Skin and subcutaneous tissue disorders
Very common: Alopecia
Common: Rash, itch, hypersensitivity of irradiated skin ('radiation recall reaction')
Uncommon: Skin and nail hyperpigmentation, urticaria, cellulitis (possibly severe), tissue necrosis
Very rare: Acral erythema
Not known: Local reaction
Renal and urinary disorders
Very common: Red colour to the urine for 1-2 days after treatment
General disorders and administration site conditions
Very common: Fever, headaches, chills
Description of selected adverse reactions
Haematopoietic system
Pronounced myelosuppression is the most severe adverse effect of Rubide treatment. However, this is necessary for the eradication of leukemic cells.
Cardiotoxicity
Life-threatening congestive heart failure is the most severe form of anthracycline-induced cardiomyopathy and represents the cumulative dose-limiting toxicity of the drug.
Gastrointestinal
Stomatitis and, in severe cases ulceration of mucosa, dehydration caused by severe diarrhoea and vomiting, risk of perforation of colon, etc.
Administration site
; unintended paravenous infiltrates may cause pain, severe cellulites and tissue necrosis.Other adverse reactions: hyperuricaemia
Prevention of symptoms by hydration, urine alkalinisation, and prophylaxis with allopurinol may minimise potential complications of tumour lysis syndrome.
Paediatric population
Undesirable effects are similar in adults and children except a greater susceptibility to anthracycline-induced cardiac toxicity of children.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via Yellow Card Scheme Website: www.mhra.gov.uk/yellowcard.
No further preclinical safety data are available.
The LD50 (median values) intravenous Rubide was 4.4 mg / kg in mice, 2.9 mg / kg in rats and about 1.0 mg / kg in dogs. The main targets after a single dose were hemolymphopoietic system, especially dogs, the gastrointestinal tract. Toxic effects in rats and dogs after repeated intravenous administration of Rubide were investigated. The main target of intravenous Rubide in the above species were hemolymphopoietic system, gastrointestinal tract, kidney, liver, and male and female reproductive organs.
In relation to the heart, subacute and cardiotoxicity studies indicate that intravenous Rubide was mild to moderately cardiotoxic only lethal doses, whereas doxorubicin and daunorubicin clear even cause myocardial changes to non-lethal doses.
Rubide was genotoxic in most in vitro or in vivo performed. Intravenous Rubide was toxic to the reproductive organs, and embryotoxic and teratogenic in rats. No effects were detected worthy of mention in both mothers and in the progeny of mice which have been administered doses up to 0.2 mg/kg/day during the perinatal and postnatal periods. It is unknown whether the compound is excreted in breast milk. Intravenous Rubide, such as anthracyclines and other cytotoxic drugs, was carcinogenic in rats. A local safety study in dogs showed that the drug causes tissue necrosis from extravasation.
Acute non-lymphocytic leukaemia (ANLL).
Whenever intravenous idarubicin cannot be employed e.g. for medical, psychological or social reasons, oral idarubicin can be used for remission induction in patients with previously untreated, relapsed or refractory acute non-lymphocytic leukaemia.
Rubide may be used in combination chemotherapy regimens involving other cytotoxic agents.
As a single agent in the treatment of advanced breast cancer after failure of front line chemotherapy not including anthracyclines.
Cytotoxic and antimitotic agent.
Adults
- For the treatment of acute myeloid leukaemia (AML), for remission induction in untreated patients or for remission induction in relapsed or refractory patients.
- For second line treatment of relapsed acute lymphoblastic leukaemia (ALL).
Children
- For first line treatment of acute myeloid leukaemia (AML), in combination with cytarabine, for remission induction.
- For second line treatment of relapsed acute lymphoblastic leukaemia (ALL).
Rubide Accord may be used in combination chemotherapy regimens involving other cytotoxic agents.
Pharmacotherapeutic group: Anthracyclines and related substances, ATC code: L01DB06
Idarubicin is an antimitotic and cytotoxic agent which intercalates with DNA and interacts with topoisomerase II and has an inhibitory effect on nucleic acid synthesis.
The compound has a high lipophilicity which results in an increased rate of cellular uptake compared with doxorubicin and daunorubicin. Idarubicin has been shown to have a higher potency with respect to daunorubicin and to be an effective agent against murine leukaemia and lymphomas both by i.v. and oral routes. Studies in-vitro on human and murine anthracycline-resistant cells have shown a lower degree of cross-resistance for idarubicin compared with doxorubicin and daunorubicin. Cardiotoxicity studies in animals have indicated that idarubicin has a better therapeutic index than daunorubicin and doxorubicin. The main metabolite, idarubicinol, has shown in-vitro and in-vivo antitumoral activity in experimental models. In the rat, idarubicinol, administered at the same doses as the parent drug, is clearly less cardiotoxic than idarubicin.
Pharmacotherapeutic group: Cytotoxic antibiotics; Anthracyclines and related substances
ATC code: L01DB06
Rubide is a DNA-intercalating anthracycline which interacts with the enzyme topoisomerase II and has an inhibitory effect on nucleic acid synthesis. The modification of position 4 of the anthracycline structure gives the compound a high lipophilicity which results in an increased rate of cellular uptake compared with doxorubicin and daunorubicin. Rubide has been shown to have greater potency with respect to daunorubicin and to be an effective agent against murine leukaemia and lymphomas both by i.v. and oral routes. Studies in vitro on human and murine anthracycline-resistant cells have shown a lower degree of cross-resistance for Rubide compared with doxorubicin and daunorubicin. Cardiotoxicity studies in animals have indicated that Rubide has a better therapeutic index than daunorubicin and doxorubicin. The main metabolite, Rubideol, has shown, in vitro and in vivo, antitumoural activity in experimental models. In the rat, Rubideol administered at the same doses as the parent drug, is clearly less cardiotoxic than Rubide.
After oral administration to patients with normal renal and hepatic function, idarubicin is rapidly absorbed, with a peak time of 2-4 hours., is eliminated from systemic circulation with a terminal plasma T½ ranging between 10-35 hours and is extensively metabolized to an active metabolite, idarubicinol, which is more slowly eliminated with a plasma T½ ranging between 33 and 60 hours. The drug is mostly eliminated by biliary excretion, mainly in the form of idarubicinol, urinary excretion accounting for 1-2% of the dose as unchanged drug and for up to 4.6% as idarubicinol.
Average values of absolute bioavailability have been shown to range between 18 and 39% (individual values observed in the studies ranging between 3 and 77%), whereas the average values calculated on the data from the active metabolite, idarubicinol, are somewhat higher (29 - 58%; extremes 12 - 153%).
Studies of cellular (nucleated blood and bone marrow cells) drug concentrations in leukaemic patients have shown that uptake is rapid and almost parallels the appearance of the drug in plasma. Idarubicin and idarubicinol concentrations in nucleated blood and bone marrow cells are more than two hundred times the plasma concentrations. Idarubicin and idarubicinol disappearance rates in plasma and cells were almost comparable.
In adults, following oral administration of 10 to 60 mg/m2 Rubide, Rubide was rapidly absorbed with the maximum plasma concentrations of 4-12.65 ng/ml achieved in 1 to 4 hours after dosing. The terminal half-life was 12.7±6.0 hours (mean±SD). Following intravenous administration of Rubide in adults, the terminal half-life was 13.9±5.9 hours, similar to that observed after the oral administration.
After i.v. administration, Rubide is extensively metabolised to an active metabolite, Rubideol, which is slowly eliminated with a plasma T½ ranging between 41 - 69 hours. The drug is eliminated by biliary and renal excretion, mostly in the form or Rubideol.
Studies of cellular (nucleated and bone marrow blood cells) drug concentrations in leukaemic patients have shown that peak cellular Rubide concentrations are reached a few minutes after injection.
Rubide and Rubideol concentrations nucleated blood and bone marrow cells are more than a hundred times the plasma concentrations. Rubide disappearance rates in plasma and cells were almost comparable with a terminal half-life of about 15 hours. The terminal half-life of Rubideol in cells was about 72 hours.
Paediatric Population:
Pharmacokinetic measurements in 7 paediatric patients receiving intravenous Rubide in doses ranging from 15 to 40 mg/m2/3 days of treatment, showed a median Rubide half-life of 8.5 hrs (range: 3.6 - 26.4 hrs). The active metabolite, Rubideol, accumulated during the 3 days of treatment, exhibiting a median half-life of 43.7 hrs (range: 27.8 - 131 hrs).
In a separate study, pharmacokinetic measurements in 15 paediatric patients receiving oral Rubide in doses ranging from 30 to 50 mg/m2/ during the 3 days of treatment, the maximum plasma concentration of Rubide was 10.6 ng/mL (range 2.7 - 16.7 ng/mL at the 40 mg/m2 dose). The median terminal half-life of Rubide was 9.2 hrs (range: 6.4 - 25.5 hrs). Significant accumulation of Rubideol was seen over the 3 day treatment period. The observed terminal half-life value of Rubide after IV was comparable to that following oral administration in paediatric patients.
Since Cmax of Rubide is similar in children and adults following oral administrations, absorption kinetics seem not to differ between adults and children.
Following both oral and IV administrations, the elimination half-life values of Rubide in children and adults differ:
Total body clearance values of 30 - 107.9 L/h/m2 for Rubide reported for adults are higher than the values of 18 - 33 L/h/m2 reported for paediatric populations. Although Rubide has a very large volume of distribution in both adults and children, suggesting that much of the drug is bound to tissues, the shorter elimination half-life and lower total body clearance are not entirely explained by a smaller apparent volume of distribution in children compared to adults.
General
Idarubicin should be administered only under the supervision of physicians experienced in the use of cytotoxic chemotherapy.
This ensures that immediate and effective treatment of severe complications of the disease and/or its treatment (e.g. haemorrhage, overwhelming infections) may be carried out.
Patients should recover from acute toxicities of prior cytotoxic treatment (such as stomatitis, neutropenia, thrombocytopenia, and generalized infections) before beginning treatment with idarubicin.
Cardiac Function
Cardiotoxicity is a risk of anthracycline treatment that may be manifested by early (i.e. acute) or late (i.e. delayed) events.
Early (i.e. Acute) Events. Early cardiotoxicity of idarubicin consists mainly of sinus tachycardia and/or electrocardiogram (ECG) abnormalities, such as non-specific ST-T wave changes. Tachyarrhythmias, including premature ventricular contractions and ventricular tachycardia, bradycardia, as well as atrioventricular and bundle-branch block have also been reported. These effects do not usually predict subsequent development of delayed cardiotoxicity, are rarely of clinical importance, and are generally not a reason for the discontinuation of idarubicin treatment.
Late (i.e. Delayed) Events. Delayed cardiotoxicity usually develops late in the course of therapy or within 2 to 3 months after treatment termination, but later events, several months to years after completion of treatment have also been reported. Delayed cardiomyopathy is manifested by reduced left ventricular ejection fraction (LVEF) and/or signs and symptoms of congestive heart failure (CHF) such as dyspnoea, pulmonary oedema, dependent oedema, cardiomegaly, hepatomegaly, oliguria, ascites, pleural effusion, and gallop rhythm. Subacute effects such as pericarditis/myocarditis have also been reported. Life-threatening CHF is the most severe form of anthracycline-induced cardiomyopathy and represents the cumulative dose-limiting toxicity of the drug.
Cumulative dose limits for IV or oral idarubicin have not been defined. However, idarubicin-related cardiomyopathy was reported in 5% of patients who received cumulative IV doses of 150 to 290 mg/m2. Available data on patients treated with oral idarubicin total cumulative doses up to 400 mg/m2 suggest a low probability of cardiotoxicity.
Cardiac function should be assessed before patients undergo treatment with idarubicin and must be monitored throughout therapy to minimize the risk of incurring severe cardiac impairment. The risk may be decreased through regular monitoring of LVEF during the course of treatment with prompt discontinuation of idarubicin at the first sign of impaired function. The appropriate quantitative method for repeated assessment of cardiac function (evaluation of LVEF) includes Multiple Gated Acquisition (MUGA) scan or echocardiography (ECHO). A baseline cardiac evaluation with an ECG and either a MUGA scan or an ECHO is recommended, especially in patients with risk factors for increased cardiotoxicity. Repeated MUGA or ECHO determinations of LVEF should be performed, particularly with higher, cumulative anthracycline doses. The technique used for assessment should be consistent throughout follow-up.
Risk factors for cardiac toxicity include active or dormant cardiovascular disease, prior or concomitant radiotherapy to the mediastinal/pericardial area, previous therapy with other anthracyclines or anthracenediones, and concomitant use of drugs with the ability to suppress cardiac contractility or cardiotoxic drugs (e.g. trastuzumab). Anthracyclines including idarubicin should not be administered in combination with other cardiotoxic agents unless the patient's cardiac function is closely monitored. Patients receiving anthracyclines after stopping treatment with other cardiotoxic agents, especially those with long half-lives such as trastuzumab, may also be at an increased risk of developing cardiotoxicity. The reported half-life of trastuzumab is approximately 28-38 days and may persist in the circulation for up to 27 weeks. Therefore, physicians should avoid anthracycline-based therapy for up to 27 weeks after stopping trastuzumab when possible. If anthracyclines are used before this time, careful monitoring of cardiac function is recommended.
Cardiac function monitoring must be particularly strict in patients receiving high cumulative doses and in those with risk factors. However, cardiotoxicity with idarubicin may occur at lower cumulative doses whether or not cardiac risk factors are present.
In infants and children there appears to be a greater susceptibility to anthracycline induced cardiac toxicity, and a long-term periodic evaluation of cardiac function has to be performed. It is probable that the toxicity of idarubicin and other anthracyclines or anthracenediones is additive.
Haematologic Toxicity
Idarubicin is a potent bone marrow suppressant. Severe myelosuppression will occur in all patients given a therapeutic dose of this agent.
Haematologic profiles should be assessed before and during each cycle of therapy with idarubicin, including differential white blood cell (WBC) counts.
A dose-dependent, reversible leukopenia and/or granulocytopenia (neutropenia) is the predominant manifestation of idarubicin hematologic toxicity and is the most common acute doselimiting toxicity of this drug.
Leukopenia and neutropenia are usually severe; thrombocytopenia and anaemia may also occur. Neutrophil and platelet counts usually reach their nadir 10 to 14 days after drug administration; however, cell counts generally return to normal levels during the third week.
During the phase of severe myelosuppression, deaths due to infections and/or haemorrhages have been reported.
Clinical consequences of severe myelosuppression include fever, infections, sepsis/septicaemia, septic shock, haemorrhage, tissue hypoxia, or death. If febrile neutropenia occurs, treatment with an IV antibiotic is recommended.
Secondary Leukaemia
Secondary leukaemia, with or without a preleukemic phase, has been reported in patients treated with anthracyclines, including idarubicin. Secondary leukaemia is more common when such drugs are given in combination with DNA damaging antineoplastic agents, when patients have been heavily pretreated with cytotoxic drugs, or when doses of the anthracyclines have been escalated. These leukaemias can have a 1- to 3-year latency period.
Gastrointestinal
Idarubicin is emetigenic. Mucositis (mainly stomatitis, less often oesophagitis) generally appears early after drug administration and, if severe, may progress over a few days to mucosal ulcerations. Most patients recover from this adverse event by the third week of therapy.
Occasionally, episodes of serious gastrointestinal events (such as perforation or bleeding) have been observed in patients receiving oral idarubicin who had acute leukaemia or a history of other pathologies or had received medications known to lead to gastrointestinal complications. In patients with active gastrointestinal disease with increased risk of bleeding and/or perforation, the physician must balance the benefit of oral idarubicin therapy against the risk.
Hepatic and/or Renal Function
Since hepatic and/or renal function impairment can affect the disposition of idarubicin, liver and kidney function should be evaluated with conventional clinical laboratory tests (using serum bilirubin and serum creatinine as indicators) prior to, and during, treatment. In a number of Phase III clinical trials, treatment was contraindicated if bilirubin and/or creatinine serum levels exceeded 2.0-mg %. With other anthracyclines a 50% dose reduction is generally used if bilirubin levels are in the range 1.2 to 2.0-mg %.
Tumour Lysis Syndrome
Idarubicin may induce hyperuricaemia as a consequence of the extensive purine catabolism that accompanies rapid drug-induced lysis of neoplastic cells ('tumour lysis syndrome'). Blood uric acid levels, potassium, calcium phosphate, and creatinine should be evaluated after initial treatment. Hydration, urine alkalinization, and prophylaxis with allopurinol to prevent hyperuricaemia may minimize potential complications of tumour lysis syndrome.
Immunosuppressant Effects/Increased Susceptibility to Infections
Administration of live or live-attenuated vaccines (like yellow fever) in patients immunocompromised by chemotherapeutic agents including idarubicin, may result in serious or fatal infections. Vaccination with a live vaccine should be avoided in patients receiving idarubicin. Killed or inactivated vaccines may be administered; however, the response to such vaccines may be diminished.
Reproductive system
Men treated with idarubicin hydrochloride are advised to adopt contraceptive measures during therapy and, if appropriate and available, to seek advice on sperm preservation due to the possibility of irreversible infertility caused by the therapy.
Other
As with other cytotoxic agents, thrombophlebitis and thromboembolic phenomena, including pulmonary embolism have been coincidentally reported with the use of idarubicin.
The product may cause a red colouration of the urine for 1 - 2 days after administration and patients should be advised of this fact.
General
Rubide should be administered only under the supervision of physicians experienced in the use of cytotoxic chemotherapy.
This ensures that immediate and effective treatment of severe complications of the disease and/or its treatment (e.g. hemorrhage, overhelming infections) may be carried out.
Patients should recover from acute toxicities due to prior cytotoxic treatment (such as stomatitis, neutropenia, thrombocytopenia, and generalized infections) before beginning treatment with Rubide.
Cardic function
Cardiotoxicity is a known risk of treatment with anthracyclines that may manifest itself as early (i.e. acute) or late (i.e. delayed) events.
Early (acute) events: Early cardiotoxicity of Rubide consists mainly of sinus tachycardia and/or electrocardiogram (ECG) abnormalities, such as non-specific ST-T wave changes. Tachyarrhythmia, including premature ventricular beats and ventricular tachycardia, bradycardia, and atrioventricular and bundle branch block have also been reported. These effects are not usually predictors of subsequent development of delayed cardiotoxicity, are rarely of clinical significance, and in general do not constitute grounds for discontinuation of treatment with Rubide.
Late (delayed) events: Delayed cardiotoxicity usually develops at a late stage during therapy or within 2 to 3 months of ending treatment, but later events, several months to years after completion of treatment, have also been reported. Delayed cardiomyopathy manifests as a reduction in left ventricular ejection fraction (LVEF) and/or signs and symptoms of congestive heart failure, such as dyspnoea, pulmonary oedema, dependent oedema, cardiomegaly, hepatomegaly, oliguria, ascites, pleural effusion and gallop rhythm. Subacute effects such as pericarditis/myocarditis have also been reported. Life-threatening congestive heart failure is the most severe form of anthracycline-induced cardiomyopathy and constitutes the cumulative dose-limiting toxicity of the drug.
The cumulative dose limits for IV or oral Rubide have not been defined. However, Rubide-related cardiomyopathy was reported in 5% of patients who received cumulative IV doses of 150 to 290 mg/m2. The available data on patients treated with total cumulative doses of up to 400 mg/m2 Rubide p.o. suggest a low incidence of cardiotoxicity.
Cardiac function should be assessed before initiation of treatment with Rubide and must be monitored throughout therapy to minimise the risk of severe cardiac insufficiency. The risk may be reduced by regular monitoring of LVEF throughout the treatment, with prompt discontinuation of Rubide at the first sign of impaired function. Appropriate quantitative methods for repeated assessment of cardiac function (evaluation of LVEF) include cardiac scintigraphy or echocardiography. A baseline cardiac evaluation consisting of an electrocardiogram accompanied by cardiac or myocardial scintigraphy, or an echocardiogram, is recommended, especially in patients with elevated cardiotoxicity risk factors.
Repeated measurements of LVEF must be performed by means of cardiac scintigraphy or echocardiogram, particularly with higher cumulative doses of anthracyclines. The technique used for assessment should be consistent throughout follow-up.
Risk factors for cardiac toxicity include active or dormant cardiovascular disease, prior or concomitant radiotherapy to the mediastinal/pericardial area, previous therapy with other anthracyclines or anthracenedione agents, and concomitant use of drugs capable of suppressing cardiac contractility or cardiotoxic drugs (for example trastuzumab). Anthracyclines, including Rubide, should not be administered in combination with other cardiotoxic agents unless the patient's cardiac function is closely monitored. Patients receiving anthracyclines after stopping treatment with other cardiotoxic agents, especially those with long half-lives, such as trastuzumab, may also be at an increased risk of developing cardiotoxicity. Trastuzumab has a half-life of approximately 28-38 days and it can persist in the circulation for up to 27 weeks. Therefore, physicians should wherever possible avoid anthracycline-based therapy for up to 27 weeks after discontinuation of trastuzumab. If anthracyclines are used within this period, careful monitoring of cardiac function is recommended.
Cardiac function monitoring must be particularly rigorous in patients treated with high cumulative doses and in those with risk factors. However, cardiotoxicity can occur with lower cumulative doses of idaribicin, irrespective of the presence of cardiac risk factors.
A long-term assessment of cardiac function in infants and children must be carried out periodically, since they appear to be highly susceptible to anthracycline-induced cardiac toxicity.
The toxicity caused by Rubide and other anthracyclines or anthracenedione agents is likely to be additive.
Haematological toxicity
Rubide is a potent bone marrow suppressant. Severe myelosuppression will occur in all patients given a therapeutic dose of this drug.
Haematological profiles should be assessed before and during each cycle of therapy with Rubide, including a differential white blood cell (WBC) counts.
A dose-dependent reversible leukopenia and/or granulocytopenia (neutropenia) is the predominant manifestation of Rubide haematologic toxicity and is the most common acute dose-limiting toxicity of this drug.
Leukopenia and neutropenia are usually severe; thrombocytopenia and anaemia may also occur. Neutrophil and platelet counts usually reach their nadir 10 to 14 days after drug administration; however, cell counts generally return to normal levels during the third week.
During the phase of severe myelosuppression, deaths due to infections and/or haemorrhages have been reported.
Clinical consequences of severe myelosuppression include fever, infections, sepsis/septicaemia, septic shock, haemorrhage, tissue hypoxia or death. If febrile neutropenia occurs, treatment with an IV antibiotic is recommended.
Secondary leukaemia
Secondary leukaemia, with or without a preleukaemic phase, has been reported in patients treated with anthracyclines, including Rubide. Secondary leukaemia is more common when such drugs are given in combination with DNA-damaging antineoplastic agents, when patients have been heavily pretreated with cytotoxic drugs, or when doses of anthracyclines have been escalated. These leukaemias can have a 1- to 3-years latency period.
Gastrointestinal
Rubide is emetigenic. Mucositis (mainly stomatitis, less often oesophagitis) generally appears early after drug administration and, if severe, may progress over a few days to mucosal ulcerations. Most patients recover from this adverse event by the third week of therapy.
Occasionally, episodes of serious gastrointestinal events (such as perforation or bleeding) have been observed in patients receiving oral Rubide who had acute leukaemia or a history of other pathologies or had received medications known to lead to gastrointestinal complications. In patients with active gastrointestinal disease with increased risk of bleeding and/or perforation, the physician must balance the benefit of oral Rubide therapy against the risk.
Hepatic and renal function
Since hepatic and/or renal function impairment can affect the disposition of Rubide, liver and kidney function should be evaluated with conventional clinical laboratory tests (using serum bilirubin and serum creatinine as indicators) prior to, and during, treatment. In a number of Phase III clinical trials, treatment was contraindicated if bilirubin and/or creatinine serum levels exceeded 2,0-mg/dl. With other anthracyclines a 50% dose reduction is generally used if bilirubin levels are in the range 1.2 - 2.0-mg/dl.
Effects at the injection site
Phlebosclerosis may result from an injection into a small vessel or from previous injections into the same vein. Following the recommended administration procedures may minimize the risk of phlebitis/thrombophlebitis at the injection site.
Extravasation
Extravasation of Rubide during intravenous injection may cause local pain, severe tissue lesions (vesication, severe cellulitis), and necrosis. Should signs or symptoms of extravasation occur during intravenous administration of Rubide, the drug infusion should be immediately stopped.
In cases of extravasation dexrazoxane can be used to prevent or reduce tissue injury.
Tumour lysis syndrome
Rubide may induce hyperuricemia as a consequence of the extensive purine catabolism that accompanies rapid drug-induced lysis of the neoplastic cells ('tumour lysis syndrome'). Blood uric acid levels, potassium, calcium, phosphate, and creatinine should be evaluated after initial treatment. Hydration, urine alkalinisation, and prophylaxis with allopurinol to prevent hyperuricemia may minimise potential complications of tumour lysis syndrome.
Immunosuppressive effects/Increased susceptibility to infections
Administration of live or live-attenuated vaccines (like yellow fever) in patients with immunocompromised by chemotherapeutic agents including Rubide, may result in serious or fatal infections. Vaccination with a live vaccine should be avoided in patients receiving Rubide. Killed or inactivated vaccines can be administered; however, the response to such vaccines may be diminished.
Reproductive system
Male treated with Rubide hydrochloride are advised to adopt contraceptive measures during therapy and, if appropriate and available, to seek advice on sperm preservation due to the possibility of irreversible infertility caused by the therapy.
Other
As with other cytotoxic agents, thrombophlebitis and thromboembolic phenomena, including pulmonary embolism have been coincidentally reported with the use of Rubide.
This product may cause a red colouration of the urine for 1 - 2 days after administration and patients should be advised of this fact.
The effect of idarubicin on the ability to drive or use machinery has not been systematically evaluated.
The effect of Rubide on the ability to drive and use machinery has not been systematically evaluated.
Route of Administration: Oral
Dosage is usually calculated on the basis of body surface area.
In adult acute non-lymphocytic leukaemia (ANLL) also referred to as acute myelogenous leukaemia (AML), the recommended dose schedule suggested is 30 mg/m2 orally given daily for 3 days as a single agent, or between 15 and 30 mg/m2 orally daily for 3 days in combination with other anti-leukemic agents.
In advanced breast cancer the recommended dose schedule as single agent is 45 mg/m2 orally given either on a single day or divided over 3 consecutive days, to be repeated every 3 or 4 weeks based on the haematological recovery.
A maximum cumulative dose of 400 mg/m2 is recommended.
These dosage schedules should, however, take into account the haematological status of the patient and the dosages of other cytotoxic drugs when used in combination.
In patients with hepatic impairment a dose reduction of Rubide should be considered..
The capsules should be swallowed whole with some water and should not be sucked, bitten or chewed. Rubide Capsules may also be taken with a light meal.
Posology
Dosage is usually calculated on the basis of body surface area (mg/m2). For intravenous use.
Acute non-lymphocytic leukaemia (AML)
Adults: In acute non-lymphocytic leukaemia the recommended dose is 12 mg/m2 IV daily for 3 days in combination with cytarabine. Other dose schedule which could be used in acute non-lymphocytic leukaemia, as a single agent or in combination, is 8 mg/m2 IV daily for 5 days.
Children: the recommended dose range is 10-12 mg/m2 i.v. daily for 3 days in combination with cytarabine.
Acute lymphocytic leukaemia (ALL)
Adults: As single agent the suggested dose is 12 mg/m2 i.v. daily for 3 days.
Children: As single agent the suggested dose is 10 mg/m2 i.v. daily for 3 days
Note: These are only general guidelines. Refer to individual protocols for exact dosage.
All of the dosage schedules should take into account the haematological status of the patient, and the dosages of other cytotoxic drugs when used in combination.
Method of administration
Intravenous administration of Rubide should be performed carefully. It's recommended that Rubide is given via the tubing of a freely running intravenous infusion of 0.9% sodium chloride injection taking 5 to 10 minutes over the injection. This technique minimises the risk of thrombosis or perivenous extravasation which can lead to severe cellulitis, vesication and tissue necrosis. Direct injection is not recommended, due to the risk of extravasation, which may occur even with the adequate blood return by aspiration through the needle.
None stated.
Rubide Accord solution must only be administered intravenously via an infusion line with a freely running intravenous infusion of 0.9% sodium chloride over a period of 5 to 10 minutes.
This method minimises the risks of thrombosis and perivascular extravasation which can lead to severe cellulitis and necrosis. Phlebosclerosis can result from injection into small veins or repeated injections into the same vein.
The following recommendations for protection are given, due to the toxic nature of this substance:
- Personnel must be trained in the correct handling method
- Pregnant women must be excluded from working with this drug
- Personnel handling the drug must wear protective clothing: eyewear, overalls, disposable gloves and masks
- A work area should be set up with a surface protected with absorbent paper, plasticised on one side
- All instruments used for administration or cleaning, including gloves, must be disposed of in high-risk containers for incineration at high temperatures
Spills or leaks must be treated with dilute sodium hypochlorite solution (1% chlorine) and then with water.
All cleaning materials must then be disposed of as described above.
Accidental contact with skin or eyes must be treated immediately by washing thoroughly with water, soap and water, or sodium bicarbonate solution; medical attention may be necessary. Discard any unused solution.
Any remaining medicine, as well as all the materials that were used for its reconstitution, dilution and administration, must be destroyed in accordance with the hospital procedure applicable for cytotoxic agents and in compliance with current legislation relating to the elimination of hazardous waste.
