DACTINOMYCIN injection, powder, lyophilized, for solution

Dactinomycin by

Drug Labeling and Warnings

Dactinomycin by is a Prescription medication manufactured, distributed, or labeled by Meitheal Pharmaceuticals Inc., Kindos Pharmaceuticals Co., Ltd.. Drug facts, warnings, and ingredients follow.

Drug Details [pdf]

  • 1 INDICATIONS AND USAGE

    1.1 Wilms Tumor

    Dactinomycin for Injection is indicated for the treatment of adult and pediatric patients with Wilms tumor, as part of a multi-phase, combination chemotherapy regimen.

    1.2 Rhabdomyosarcoma

    Dactinomycin for Injection is indicated for the treatment of adult and pediatric patients with rhabdomyosarcoma, as part of a multi-phase, combination chemotherapy regimen.

    1.3 Ewing Sarcoma

    Dactinomycin for Injection is indicated for the treatment of adult and pediatric patients with Ewing sarcoma, as part of a multi-phase, combination chemotherapy regimen.

    1.4 Metastatic Nonseminomatous Testicular Cancer

    Dactinomycin for Injection is indicated for the treatment of adult and pediatric patients with metastatic, nonseminomatous testicular cancer, as part of a multi-phase, combination chemotherapy regimen.

    1.5 Gestational Trophoblastic Neoplasia

    Dactinomycin for Injection is indicated for the treatment of post-menarchal patients with gestational trophoblastic neoplasia, as a single agent or as part of a combination chemotherapy regimen.

    1.6 Regional Perfusion in Locally Recurrent and Locoregional Solid Malignancies

    Dactinomycin for Injection is indicated for the treatment of adult patients with locally recurrent or locoregional solid malignancies, as a component of palliative or adjunctive regional perfusion.

  • 2 DOSAGE AND ADMINISTRATION

    2.1 Recommended Dosage for Wilms Tumor

    The recommended dose of dactinomycin for injection, as part of a multi-agent combination chemotherapy regimen, is 45 mcg/kg intravenously once every 3 to 6 weeks for up to 26 weeks.

    2.2 Recommended Dosage for Rhabdomyosarcoma

    The recommended dose of dactinomycin for injection, as part of a multi-agent combination chemotherapy regimen, is 15 mcg/kg intravenously once daily for 5 days every 3 to 9 weeks for up to 112 weeks.

    2.3 Recommended Dosage for Ewing Sarcoma

    The recommended dose of dactinomycin for injection, as part of a multi-agent combination chemotherapy regimen, is 1,250 mcg/m2 intravenously once every 3 weeks for 51 weeks.

    2.4 Recommended Dosage for Metastatic Nonseminomatous Testicular Cancer

    The recommended dose of dactinomycin for injection, as part of a cisplatin-based, multi-agent combination chemotherapy regimen, is 1,000 mcg/m2 intravenously once every 3 weeks for 12 weeks.

    2.5 Recommended Dosage for Gestational Trophoblastic Neoplasia

    The recommended dose of dactinomycin for injection for nonmetastatic and low-risk metastatic disease is 12 mcg/kg intravenously daily for five days as a single agent.

    The recommended dose of dactinomycin for injection, as part of a multi-agent combination chemotherapy regimen, for high-risk metastatic disease is 500 mcg intravenously on Days 1 and 2 every 2 weeks for up to 8 weeks.

    2.6 Recommended Dosage for Regional Perfusion in Locally Recurrent and Locoregional Solid Malignancies

    The recommended dose of dactinomycin for injection, in combination with melphalan, is 50 mcg/kg once for lower extremity or pelvis.

    The recommended dose of dactinomycin for injection, in combination with melphalan, is 35 mcg/kg once for upper extremity.

    Calculate the dose for obese or edematous patients based on ideal body weight.

    2.7 Preparation and Administration

    • Dactinomycin for injection is a cytotoxic drug. Follow applicable special handling and disposal procedures.1
    • Visually inspect the vials for particulate matter and discoloration, whenever solution and container permit.

    Preparation

    • Reconstitute each vial by adding 1.1 mL of Sterile Water for Injection without preservative using aseptic techniques.
    • The reconstituted product should be a clear, gold-colored solution at a concentration of 500 mcg per mL.
    • Further dilute the reconstituted product with 5% Dextrose Injection or 0.9% Sodium Chloride Injection to yield concentrations greater than 10 mcg/mL.
    • Store at room temperature for no more than 4 hours from reconstitution to completion of injection or infusion. Discard after 4 hours.
    • Dactinomycin for injection does not contain a preservative. Discard any unused portions.

    Administration

    • Administer the diluted reconstituted product intravenously over 10 to 15 minutes.
    • Do not use in-line filters with a cellulose ester membrane.

    Management of Extravasation

    • Discontinue dactinomycin for injection for burning or stinging sensation or other evidence indicating perivenous infiltration or extravasation.
    • Manage confirmed or suspected extravasation as follows:
      • Terminate the injection or infusion immediately and restart in another vein.
      • Intermittent application of ice to the site for 15 minutes 4 times daily for 3 days [see Warnings and Precautions (5.3)].
  • 3 DOSAGE FORMS AND STRENGTHS

    For injection: 500 mcg as a sterile, amorphous yellow to orange, lyophilized powder in a single-dose vial.

  • 4 CONTRAINDICATIONS

    None.

  • 5 WARNINGS AND PRECAUTIONS

    5.1 Secondary Malignancy or Leukemia

    The risk of developing secondary malignancies, including leukemia, is increased following treatment with dactinomycin.

    5.2 Veno-occlusive Disease

    Severe and fatal hepatic veno-occlusive disease (VOD) can occur with dactinomycin. Risk factors for the development of VOD include age younger than 4 years or concomitant radiotherapy. After treatment with dactinomycin, monitor frequently for signs and symptoms of VOD; these include elevations in AST, ALT, total bilirubin, hepatomegaly, weight gain, or ascites. If patients develop VOD, considering delaying next dose of dactinomycin. Resume, reduce dose or permanently discontinue based on severity of reaction and disease being treated.

    5.3 Extravasation

    Extravasation of dactinomycin can result in severe local tissue injury manifesting as blistering, ulcerations and persistent pain requiring wide excision surgery followed by split-thickness skin grafting. If any signs or symptoms of extravasation occur, immediately interrupt the injection or infusion. Apply ice to the site intermittently for 15 minutes, 4 times a day for 3 days [see Dosage and Administration (2.7)]. Observe closely and consult plastic surgery if necessary based on severity of reaction.

    5.4 Myelosuppression

    Severe and fatal myelosuppression, which may include neutropenia, thrombocytopenia and anemia, can occur with dactinomycin. The nadir in neutrophil counts generally occurs 14 to 21 days after administration. Obtain complete blood counts prior to each treatment cycle. Delay next dose of dactinomycin if severe myelosuppression has not improved. Consider dose reduction for patients with prolonged myelosuppression based on severity of reaction and disease being treated.

    5.5 Immunizations

    The safety with live viral vaccines following dactinomycin has not been studied and vaccination with live virus vaccines is not recommended before or during treatment.

    5.6 Severe Mucocutaneous Reactions

    Severe mucocutaneous reactions, such as Steven-Johnson syndrome and Toxic Epidermal Necrolysis (TEN), can occur with dactinomycin. Permanently discontinue dactinomycin in patients who experience a severe mucocutaneous reaction.

    5.7 Renal Toxicity

    Abnormalities of renal function can occur with dactinomycin. Monitor creatinine and electrolytes frequently during dactinomycin therapy.

    5.8 Hepatotoxicity

    Hepatotoxicity can occur with dactinomycin. Monitor AST, ALT, alkaline phosphatase, and bilirubin prior to and during dactinomycin therapy.

    5.9 Potentiation of Radiation Toxicity and Radiation Recall

    Dactinomycin can increase radiation-induced gastrointestinal toxicity, myelosuppression, or erythema and vesiculation of the skin or buccal and pharyngeal mucosa. Reduce the dose of dactinomycin by 50% during concomitant radiation.

    Radiation recall, affecting previously treated radiation fields, can occur in patients who receive dactinomycin after prior radiation therapy. Although the risk can occur with distant radiation exposure, the risk appears highest when dactinomycin is administered within two months of prior radiation.

    5.10 Embryo-Fetal Toxicity

    Based on findings from animal studies and its mechanism of action, dactinomycin can cause fetal harm when administered to a pregnant woman. In animal reproduction studies, administration of dactinomycin to pregnant animals during the period of organogenesis was teratogenic, resulting in malformations at doses lower than the recommended human dose.

    Advise pregnant women of the potential risk to the fetus. Advise females of reproductive potential to use effective contraception during treatment with dactinomycin and for at least 6 months after the final dose. Advise males with female partners of reproductive potential to use effective contraception during treatment with dactinomycin and for 3 months after the final dose [see Use in Specific Populations (8.1, 8.3)].

  • 6 ADVERSE REACTIONS

    The following serious adverse reactions are described elsewhere in the labeling:

    • Secondary Malignancy and Leukemia [see Warnings and Precautions (5.1)]
    • Veno-occlusive Disease [see Warnings and Precautions (5.2)]
    • Extravasation [see Warnings and Precautions (5.3)]
    • Myelosuppression [see Warnings and Precautions (5.4)]
    • Immunizations [see Warning and Precautions (5.5)]
    • Severe Mucocutaneous Reactions [see Warnings and Precautions (5.6)]
    • Renal Toxicity [see Warnings and Precautions (5.7)]
    • Hepatotoxicity [see Warnings and Precautions (5.8)]
    • Potentiation of Radiation Toxicity and Radiation Recall [see Warnings and Precautions (5.9)]

    Common adverse reactions are: infection, alopecia, rash, dysphagia, fatigue, fever, nausea, vomiting, anemia, neutropenia, thrombocytopenia, mucositis, and hepatotoxicity.

    The following adverse reactions have been identified in clinical studies or postmarketing reports. Because some of these reactions were 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.

    Infections: infections including sepsis with fatal outcome

    Hematologic: anemia, leukopenia, thrombocytopenia, pancytopenia, reticulocytopenia, neutropenia, febrile neutropenia, disseminated intravascular coagulation

    Immune system: hypersensitivity

    Metabolism and nutrition: anorexia, hypocalcemia, tumor lysis syndrome

    Nervous system: peripheral neuropathy

    Ocular: optic neuropathy

    Vascular: thrombophlebitis, hemorrhage

    Respiratory, thoracic and mediastinal: pneumonitis, pneumothorax

    Gastrointestinal: nausea, vomiting, abdominal pain, diarrhea, constipation, gastrointestinal ulceration, cheilitis, dysphagia, esophagitis, ulcerative stomatitis, ascites, proctitis, mucositis

    Hepatobiliary: liver function test abnormalities, hepatomegaly, hepatitis, hepatic failure with reports of death, hepatic veno-occlusive disease

    Dermatologic: alopecia, rash, dermatitis, acne, erythema multiforme, Stevens Johnson Syndrome, radiation recall, toxic epidermal necrolysis

    Musculoskeletal and connective tissue: myalgia, growth retardation

    Renal and urinary: renal impairment, renal failure

    General: fatigue, fever, malaise

  • 8 USE IN SPECIFIC POPULATIONS

    8.1 Pregnancy

    Risk Summary

    Based on findings from animal studies and its mechanism of action, dactinomycin can cause fetal harm when administered to a pregnant woman [see Clinical Pharmacology (12.1)]. In animal reproduction studies, administration of dactinomycin to pregnant animals during the period of organogenesis was teratogenic, resulting in malformations at doses lower than the recommended human dose (see Data). Advise pregnant women of the potential risk to a fetus [see Use in Special Populations (8.3)].

    In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.

    Data

    Animal Data

    Dactinomycin was teratogenic in animals. Administration of dactinomycin to pregnant rats, rabbits, and hamsters during the period of organogenesis, increased the incidence of fetal malformations and caused embryotoxicity at doses (based on body surface area) as low as 0.2 times the clinical dose of 1,250 mcg/m2.

    8.2 Lactation

    Risk Summary

    There are no data on the presence of dactinomycin or its metabolites in human milk or their effects on the breastfed infant or on milk production. Because of the potential for serious adverse reactions in breastfed infants from dactinomycin, advise women not to breastfeed during treatment with dactinomycin and, based on limited published data regarding the dactinomycin half-life, for 14 days after the final dose.

    8.3 Females and Males of Reproductive Potential

    Pregnancy Testing

    Verify the pregnancy status of females of reproductive potential prior to initiating dactinomycin [see Use in Specific Population (8.1)].

    Contraception

    Dactinomycin can cause fetal harm when administered to a pregnant woman [see Use in Specific Populations (8.1)].

    Females

    Advise females of reproductive potential to use effective contraception during treatment with dactinomycin and for at least 6 months after the final dose.

    Males

    Because of the potential for genotoxicity, advise males with female partners of reproductive potential to use effective contraception during treatment with dactinomycin and for 3 months after the final dose [see Nonclinical Toxicology (13.1)].

    8.4 Pediatric Use

    The safety and effectiveness of dactinomycin have been established in pediatric patients with Wilms tumor, rhabdomyosarcoma, Ewing sarcoma, and metastatic nonseminomatous testicular cancer.

    The safety and effectiveness of dactinomycin have been established in post-menarchal pediatric patients with gestational trophoblastic neoplasia.

    The safety and effectiveness of dactinomycin have not been established in pediatric patients undergoing regional perfusion for locally recurrent or locoregional solid malignancies.

    8.5 Geriatric Use

    Clinical studies of dactinomycin did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects.

  • 11 DESCRIPTION

    Dactinomycin is an actinomycin. Dactinomycin is produced by Streptomyces parvullus. The chemical name is 8-amino-N-(2-amino-4,6-dimethyl-3-oxo-phenoxazin-1-yl)carbonyl-N'-[8-amino-4,6-dimethyl-7-oxo-9-[[3,6,10-trimethyl-7,14-bis(1-methylethyl)-2,5,8,12,15-pentaoxo-9-oxa-3,6,13,16-tetrazabicyclo[14.3.0]nonadec-11-yl]carbamoyl]phenoxazin-1-yl]carbonyl-4,6-dimethyl-7-oxo-N,N'-bis[3,6,10-trimethyl-7,14-bis(1-methylethyl)-2,5,8,12,15-pentaoxo-9-oxa-3,6,13,16 tetrazabicyclo[14.3.0]nonadec-11-yl]-1,9-bis[[3,6,10-trimethyl-7,14-bis(1-methylethyl)-2,5,8,12,15-pentaoxo-9-oxa-3,6,13,16-tetrazabicyclo[14.3.0] nonadec-11-yl]carbamoyl]phenoxazine-1,9-dicarboxamide. The molecular formula is C62H86N12O16 and the molecular weight is 1255.42 daltons. The structural formula of dactinomycin is shown below:

    Structural Formula of Dactinomycin

    Dactinomycin for Injection, USP for intravenous use is a sterile, amorphous yellow to orange, lyophilized powder in a single-dose vial. Each vial contains 500 mcg of dactinomycin and 20 mg of mannitol.

  • 12 CLINICAL PHARMACOLOGY

    12.1 Mechanism of Action

    Dactinomycin is a cytotoxic actinomycin that binds DNA and inhibits RNA synthesis. The cytotoxic activity of dactinomycin has been demonstrated in animal models of different human cancers.

    12.2 Pharmacodynamics

    Dactinomycin exposure-response relationships and the time course of pharmacodynamics response are unknown.

    12.3 Pharmacokinetics

    The distribution and excretion of radiolabeled dactinomycin (3H actinomycin D) were assessed in three adult patients with malignant melanoma.

    Distribution

    3H actinomycin D is concentrated in nucleated cells and does not penetrate the blood-brain barrier.

    Elimination

    Excretion

    Following administration of radiolabeled dactinomycin, approximately 30% was recovered in urine and feces in one week.

    Specific Populations

    Pediatric Patients

    Published studies and population analyses in patients ≤ 21 years of age with cancer report a trend of increasing systemic dactinomycin clearance with increasing body weight.

    Drug Interaction Studies

    Published in vitro studies report that dactinomycin may be a substrate of the P-glycoprotein and OATP1B3 transporter systems.

  • 13 NONCLINICAL TOXICOLOGY

    13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

    Dactinomycin is a carcinogen in animals. Local sarcomas were produced in mice and rats after repeated subcutaneous or intraperitoneal injections. Mesenchymal tumors occurred in male rats given intraperitoneal injections of 50 mcg/kg, 2 to 5 times per week, for 18 weeks, at doses (based on body surface area) 0.5 times the clinical dose of 1,250 mcg/m2.

    Dactinomycin was mutagenic in several in vitro and in vivo test systems including human fibroblasts and leukocytes, and HeLa cells. DNA damage and cytogenetic effects have been demonstrated in the mouse and the rat.

  • 15 REFERENCES

    1. “OSHA Hazardous Drugs.” OSHA. http://www.osha.gov/SLTC/hazardousdrugs/index.html

  • 16 HOW SUPPLIED/STORAGE AND HANDLING

    Dactinomycin for Injection, USP for intravenous use is an amorphous yellow to orange powder. Each vial contains 500 mcg (0.5 mg) of dactinomycin and 20 mg of mannitol. It is supplied as follows:

    NDCDactinomycin for Injection, USP (500 mcg per vial)Package Factor
    71288-129-02 500 mcg Single-Dose Vial 1 vial per carton

    Storage Conditions

    Store at 20° to 25°C (68° to 77°F); excursions permitted between 15° to 30°C (59° to 86°F). [See USP Controlled Room Temperature.]

    Protect from light and humidity.

    Store the reconstituted Dactinomycin for Injection, USP at room temperature for no more than 4 hours from reconstitution to completion of administration [see Dosage and Administration (2.7)].

    Dactinomycin for Injection, USP is a cytotoxic drug. Follow applicable special handling and disposal procedures.1

    Discard unused portion.

    Lyophilized.

    Sterile, Nonpyrogenic, Preservative-free.
    The container closure is not made with natural rubber latex.

  • 17 PATIENT COUNSELING INFORMATION

    Secondary Malignancy or Leukemia

    Advise patients of the increased risk of secondary malignancies [see Warnings and Precautions (5.1)].

    Veno-occlusive Disease

    Advise patients about the symptoms of VOD and to seek medical attention if they develop new onset jaundice, abdominal distention, or right upper quadrant pain [see Warnings and Precautions (5.2)].

    Myelosuppression

    Advise patients to contact their healthcare provider for any signs or symptoms of myelosuppression or infection [see Warnings and Precautions (5.4)].

    Severe Mucocutaneous Reactions

    Advise patients of the risk of severe mucocutaneous reactions and to contact their health care provided for new skin lesions, mouth sores or oropharyngeal lesions [see Warnings and Precautions (5.5)].

    Renal Toxicity or Hepatotoxicity

    Advise patients of the need for periodic laboratory testing to monitor for renal toxicity and hepatotoxicity [see Warnings and Precautions (5.7, 5.8)].

    Potentiation of Radiation Toxicity and Radiation Recall

    Advise patients of the risk of increased radiation-induced gastrointestinal, myelosuppression and skin toxicity [see Warnings and Precautions (5.9)].

    Embryo-Fetal Toxicity

    Advise females of reproductive potential of the potential risk to a fetus. Advise females to inform their healthcare provider of a known or suspected pregnancy [see Warnings and Precautions (5.10), Use in Specific Populations (8.1)].

    Advise females of reproductive potential to use effective contraception during treatment with dactinomycin and for 6 months after final dose [see Use in Specific Populations (8.3)].

    Advise male patients with female partners of reproductive potential to use effective contraception during treatment with dactinomycin and for 3 months after final dose [see Use in Specific Populations (8.3)].

    Lactation

    Advise females not to breastfeed during treatment with dactinomycin and for 14 days after the final dose [see Use in Specific Populations (8.2)].

    meitheal®
    Mfd. for Meitheal Pharmaceuticals
    Chicago, IL 60631 (USA)
    ©2020 Meitheal Pharmaceuticals Inc.

    August 2020

  • PRINCIPAL DISPLAY PANEL

    Principal Display Panel – Dactinomycin for Injection, USP 500 mcg Vial Label

    NDC 71288-129-02

    Rx Only

    Dactinomycin for Injection, USP

    500 mcg (0.5 mg) per vial

    For Preparation of Intravenous Solutions

    Caution: Cytotoxic Agent

    Single-Dose Vial

    Principal Display Panel – Dactinomycin for Injection, USP 500 mcg Vial Label
  • PRINCIPAL DISPLAY PANEL

    Principal Display Panel – Dactinomycin for Injection, USP 500 mcg Carton

    NDC 71288-129-02

    Rx Only

    1 Single-Dose Vial

    Dactinomycin for Injection, USP

    500 mcg (0.5 mg) per vial

    For Preparation of Intravenous Solutions

    Caution: Cytotoxic Agent

    Principal Display Panel – Dactinomycin for Injection, USP 500 mcg Carton
  • INGREDIENTS AND APPEARANCE
    DACTINOMYCIN 
    dactinomycin injection, powder, lyophilized, for solution
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC: 71288-129
    Route of AdministrationINTRAVENOUS
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    dactinomycin (UNII: 1CC1JFE158) (dactinomycin - UNII:1CC1JFE158) dactinomycin0.5 mg  in 1 mL
    Inactive Ingredients
    Ingredient NameStrength
    mannitol (UNII: 3OWL53L36A)  
    water (UNII: 059QF0KO0R)  
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC: 71288-129-021 in 1 CARTON11/13/2020
    11 mL in 1 VIAL, SINGLE-DOSE; Type 0: Not a Combination Product
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    ANDAANDA21346311/13/2020
    Labeler - Meitheal Pharmaceuticals Inc. (080548348)
    Establishment
    NameAddressID/FEIBusiness Operations
    Kindos Pharmaceuticals Co., Ltd.529111185MANUFACTURE(71288-129)
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