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Drug: Topotecan - Hycamtin®

Usual Diluents

NS, D5W

Dilution Data

DILUTION SUMMARY

[Amount of drug] [Infusion volume] [Infusion rate]

[Prescribed dose ] [50-100 ml] [ 30 minutes]*
*Usual final concentration: 0.01 - 0.5 mg/ml.

Preparation and Administration:
Each 4-mg vial of HYCAMTIN is reconstituted with 4 mL Sterile Water for Injection. Then the appropriate volume of the reconstituted solution is diluted in either 0.9% Sodium Chloride Intravenous Infusion or 5% Dextrose Intravenous Infusion prior to administration.¹
IV preparation : add reconstituted solution to 50 - 100 ml D5W or NS. Usual final concentration: 0.01 - 0.5 mg/ml.
Administration: Give by intravenous infusion over 30 minutes¹ or by 24 hour continuous infusion ².

Stability: Unopened vials of HYCAMTIN are stable until the date indicated on the package when stored between 20° and 25°C (68° and 77°F) [see USP] and protected from light in the original package. Because the vials contain no preservative, contents should be used immediately after reconstitution.
Reconstituted vials of HYCAMTIN diluted for infusion are stable at approximately 20° to 25°C (68° to 77°F) and ambient lighting conditions for 24 hours ¹. Alt: When further diluted in 50 to 100 mL D5W or NS, the final solution is stable for 24 hours (RT) or up to 7 days (REF)².    Storage: Store the vials protected from light in the original cartons at controlled room temperature between 20° and 25°C (68° and 77°F) [see USP].

Stability / Miscellaneous

WARNINGS	CLINICAL PHARMACOLOGY	INDICATIONS
CONTRAINDICATIONS	DOSAGE AND ADMINISTRATION	RECONSTITUTION / DILUTION
	HOW SUPPLIED
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WARNINGS
BONE MARROW SUPPRESSION
Do not give HYCAMTIN to patients with baseline neutrophil counts less than 1,500 cells/mm3. In order to monitor the occurrence of bone marrow suppression, primarily neutropenia, which may be severe and result in infection and death, monitor peripheral blood counts frequently on all patients receiving HYCAMTIN [see Warnings and Precautions (5.1)].

DESCRIPTION
HYCAMTIN (topotecan hydrochloride) is a semi-synthetic derivative of camptothecin and is an anti-tumor drug with topoisomerase I-inhibitory activity.

HYCAMTIN for Injection is supplied as a sterile lyophilized, buffered, light yellow to greenish powder available in single-dose vials. Each vial contains topotecan hydrochloride equivalent to 4 mg of topotecan as free base. The reconstituted solution ranges in color from yellow to yellow-green and is intended for administration by intravenous infusion.

Inactive ingredients are mannitol, 48 mg, and tartaric acid, 20 mg. Hydrochloric acid and sodium hydroxide may be used to adjust the pH. The solution pH ranges from 2.5 to 3.5.

CLINICAL PHARMACOLOGY

Mechanism of Action
Topoisomerase I relieves torsional strain in DNA by inducing reversible single strand breaks. Topotecan binds to the topoisomerase I-DNA complex and prevents religation of these single strand breaks. The cytotoxicity of topotecan is thought to be due to double strand DNA damage produced during DNA synthesis, when replication enzymes interact with the ternary complex formed by topotecan, topoisomerase I, and DNA. Mammalian cells cannot efficiently repair these double strand breaks.

Pharmacodynamics
The dose-limiting toxicity of topotecan is leukopenia. White blood cell count decreases with increasing topotecan dose or topotecan AUC. When topotecan is administered at a dose of 1.5 mg/m2/day for 5 days, an 80% to 90% decrease in white blood cell count at nadir is typically observed after the first cycle of therapy.

1. INDICATIONS AND USAGE
HYCAMTIN is indicated for the treatment of:

metastatic carcinoma of the ovary after failure of initial or subsequent chemotherapy.
small cell lung cancer sensitive disease after failure of first-line chemotherapy. In clinical studies submitted to support approval, sensitive disease was defined as disease responding to chemotherapy but subsequently progressing at least 60 days (in the Phase 3 study) or at least 90 days (in the Phase 2 studies) after chemotherapy [see PACKAGE INSERT for Clinical Studies(14)].

HYCAMTIN in combination with cisplatin is indicated for the treatment of:

stage IV-B, recurrent, or persistent carcinoma of the cervix which is not amenable to curative treatment with surgery and/or radiation therapy.

2. DOSAGE AND ADMINISTRATION
Prior to administration of the first course of HYCAMTIN, patients must have a baseline neutrophil count of >1,500 cells/mm³ and a platelet count of >100,000 cells/mm³.

2.1 Ovarian Cancer and Small Cell Lung Cancer

Recommended Dosage:

The recommended dose of HYCAMTIN is 1.5 mg/m2 by intravenous infusion over 30 minutes daily for 5 consecutive days, starting on day 1 of a 21-day course.
In the absence of tumor progression, a minimum of 4 courses is recommended because tumor response may be delayed. The median time to response in 3 ovarian clinical trials was 9 to 12 weeks, and median time to response in 4 small cell lung cancer trials was 5 to 7 weeks.

Dosage Modification Guidelines:

In the event of severe neutropenia (defined as <500 cells/mm3) during any course, reduce the dose by 0.25 mg/m2 (to 1.25 mg/m2) for subsequent courses.
Alternatively, in the event of severe neutropenia, administer G-CSF (granulocyte-colony stimulating factor) following the subsequent course (before resorting to dose reduction) starting from day 6 of the course (24 hours after completion of topotecan administration).
In the event the platelet count falls below 25,000 cells/mm3, reduce doses by 0.25 mg/m2 (to 1.25 mg/m2) for subsequent courses.

2.2 Cervical Cancer

Recommended Dosage:
The recommended dose of HYCAMTIN is 0.75 mg/m² by intravenous infusion over 30 minutes daily on days 1, 2, and 3; followed by cisplatin 50 mg/m² by intravenous infusion on day 1 repeated every 21 days (a 21-day course).

Dosage Modification Guidelines:
Dosage adjustments for subsequent courses of HYCAMTIN in combination with cisplatin are specific for each drug. See manufacturer’s prescribing information for cisplatin administration and hydration guidelines and for cisplatin dosage adjustment in the event of hematologic toxicity.

In the event of severe febrile neutropenia (defined as <500 cells/mm3 with temperature of 38.0°C or 100.4°F), reduce the dose of HYCAMTIN to 0.60 mg/m2 for subsequent courses.
Alternatively, in the event of severe febrile neutropenia, administer G-CSF following the subsequent course (before resorting to dose reduction) starting from day 4 of the course (24 hours after completion of administration of HYCAMTIN).
If febrile neutropenia occurs despite the use of G-CSF, reduce the dose of HYCAMTIN to 0.45 mg/m2 for subsequent courses.
In the event the platelet count falls below 25,000 cells/mm3, reduce doses to 0.60 mg/m2 for subsequent courses.

2.3 Dosage Adjustment in Specific Populations

Renal Impairment:
No dosage adjustment of HYCAMTIN appears to be required for patients with mild renal impairment (Clcr 40 to 60 mL/min.). Dosage adjustment of HYCAMTIN to 0.75 mg/m² is recommended for patients with moderate renal impairment (20 to 39 mL/min.). Insufficient data are available in patients with severe renal impairment to provide a dosage recommendation for HYCAMTIN [see PACKAGE INSERT for Use in Specific Populations (8.6) and Clinical Pharmacology (12.3)].

HYCAMTIN in combination with cisplatin for the treatment of cervical cancer should only be initiated in patients with serum creatinine

1.5 mg/dL. In the clinical trial, cisplatin was discontinued for a serum creatinine >1.5 mg/dL. Insufficient data are available regarding continuing monotherapy with HYCAMTIN after cisplatin discontinuation in patients with cervical cancer.

2.4 Instructions for Handling, Preparation and Intravenous Adminstration

Handling:
HYCAMTIN is a cytotoxic anticancer drug. Prepare HYCAMTIN under a vertical laminar flow hood while wearing gloves and protective clothing. If HYCAMTIN solution contacts the skin, wash the skin immediately and thoroughly with soap and water. If HYCAMTIN contacts mucous membranes, flush thoroughly with water.

Use procedures for proper handling and disposal of anticancer drugs. Several guidelines on this subject have been published.

------------------------------------------------
Preparation and Administration:
------------------------------------------------
Each 4-mg vial of HYCAMTIN is reconstituted with 4 mL Sterile Water for Injection. Then the appropriate volume of the reconstituted solution is diluted in either 0.9% Sodium Chloride Intravenous Infusion or 5% Dextrose Intravenous Infusion prior to administration.

Stability:
Unopened vials of HYCAMTIN are stable until the date indicated on the package when stored between 20° and 25°C (68° and 77°F) [see USP] and protected from light in the original package. Because the vials contain no preservative, contents should be used immediately after reconstitution.

Reconstituted vials of HYCAMTIN diluted for infusion are stable at approximately 20° to 25°C (68° to 77°F) and ambient lighting conditions for 24 hours

3. DOSAGE FORMS AND STRENGTHS
4-mg (free base) single-dose vial, light yellow to greenish powder.

4. CONTRAINDICATIONS
HYCAMTIN is contraindicated in patients who have a history of severe hypersensitivity reactions (e.g., anaphylactoid reactions) to topotecan or to any of its ingredients. HYCAMTIN should not be used in patients with severe bone marrow depression.

5. WARNINGS AND PRECAUTIONS

5.1 Bone Marrow Suppression
Bone marrow suppression (primarily neutropenia) is the dose-limiting toxicity of HYCAMTIN. Neutropenia is not cumulative over time. In ovarian cancer, the overall treatment-related death rate was 1%. In the comparative study in small cell lung cancer, however, the treatment-related death rates were 5% for HYCAMTIN and 4% for CAV (cyclophosphamide-doxorubicin-vincristine).

Neutropenia:

Ovarian and small cell lung cancer experience: Grade 4 neutropenia (<500 cells/mm3) was most common during course 1 of treatment (60% of patients) and occurred in 39% of all courses, with a median duration of 7 days. The nadir neutrophil count occurred at a median of 12 days. Therapy-related sepsis or febrile neutropenia occurred in 23% of patients, and sepsis was fatal in 1%. Pancytopenia has been reported.
Cervical cancer experience: Grade 3 and grade 4 neutropenia affected 26% and 48% of patients, respectively.

Thrombocytopenia:

Ovarian and small cell lung cancer experience: Grade 4 thrombocytopenia (<25,000/mm3) occurred in 27% of patients and in 9% of courses, with a median duration of 5 days and platelet nadir at a median of 15 days. Platelet transfusions were given to 15% of patients in 4% of courses.
Cervical cancer experience: Grade 3 and grade 4 thrombocytopenia affected 26% and 7% of patients, respectively.

Anemia:

Ovarian and small cell lung cancer experience: Grade 3/4 anemia (<8 g/dL) occurred in 37% of patients and in 14% of courses. Median nadir was at day 15. Transfusions were needed in 52% of patients in 22% of courses.
Cervical cancer experience: Grade 3 and grade 4 anemia affected 34% and 6% of patients, respectively

Monitoring of Bone Marrow Function:
Administer HYCAMTIN only in patients with adequate bone marrow reserves, including baseline neutrophil count of at least 1,500 cells/mm³ and platelet count at least 100,000/mm³. Monitor peripheral blood counts frequently during treatment with HYCAMTIN. Do not treat patients with subsequent courses of HYCAMTIN until neutrophils recover to >1,000 cells/mm³, platelets recover to >100,000 cells/mm³, and hemoglobin levels recover to 9.0 g/dL (with transfusion if necessary). Severe myelotoxicity has been reported when HYCAMTIN is used in combination with cisplatin [see PACKAGE INSERT for Drug Interactions (7.1)].

5.2 Neutropenic Colitis
Topotecan-induced neutropenia can lead to neutropenic colitis. Fatalities due to neutropenic colitis have been reported in clinical trials with HYCAMTIN. In patients presenting with fever, neutropenia, and a compatible pattern of abdominal pain, consider the possibility of neutropenic colitis.

5.3 Interstitial Lung Disease
HYCAMTIN has been associated with reports of interstitial lung disease (ILD), some of which have been fatal [see PACKAGE INSERT for Adverse Reactions (6.2)]. Underlying risk factors include history of ILD, pulmonary fibrosis, lung cancer, thoracic exposure to radiation, and use of pneumotoxic drugs and/or colony stimulating factors. Monitor patients for pulmonary symptoms indicative of interstitial lung disease (e.g., cough, fever, dyspnea, and/or hypoxia), and discontinue HYCAMTIN if a new diagnosis of ILD is confirmed.

5.4 Pregnancy
Pregnancy Category D

HYCAMTIN can cause fetal harm when administered to a pregnant woman.

Topotecan caused embryolethality, fetotoxicity, and teratogenicity in rats and rabbits when administered during organogenesis. There are no adequate and well controlled studies of HYCAMTIN in pregnant women. If this drug is used during pregnancy, or if a patient becomes pregnant while receiving HYCAMTIN, the patient should be apprised of the potential hazard to the fetus. [see PACKAGE INSERT for Use in Specific Populations, Pregnancy (8.1)].

5.5 Inadvertent Extravasation
Inadvertent extravasation with HYCAMTIN has been observed, most reactions have been mild but severe cases have been reported

HOW SUPPLIED/STORAGE AND HANDLING
HYCAMTIN for Injection is supplied in 4-mg (free base) single-dose vials.

NDC 0007-4201-01 (package of 1)

NDC 0007-4201-05 (package of 5)

Storage: Store the vials protected from light in the original cartons at controlled room temperature between 20° and 25°C (68° and 77°F) [see USP].

HYCAMTIN is a registered trademark of GlaxoSmithKline. ©2010, GlaxoSmithKline. All rights reserved.

Reference(s)

1) [PACKAGE INSERT DATA] : HYCAMTIN (topotecan hydrochloride) injection, powder, lyophilized, for solution. [GlaxoSmithKline LLC]. Research Triangle Park, NC 27709. April 2010.

2) Solimando, Dominic A. Drug Information Handbook for Oncology: A Complete Guide to Combination Chemotherapy Regimens, 8th ed. Hudson, OH: Lexi-Comp, Inc.; 2010.