TOPOTECAN HYDROCHLORIDE injection, powder, lyophilized, for solution

Topotecan Hydrochloride by

Drug Labeling and Warnings

Topotecan Hydrochloride by is a Prescription medication manufactured, distributed, or labeled by Fresenius Kabi USA, LLC. Drug facts, warnings, and ingredients follow.

Drug Details [pdf]

  • BOXED WARNING (What is this?)

    BOXED WARNING

    BONE MARROW SUPPRESSION

    Do not give topotecan hydrochloride to patients with baseline neutrophil counts less than 1,500 cells/mm 3.  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 topotecan hydrochloride [see Warnings and Precautions (5.1)].

  • 1 INDICATIONS AND USAGE

    Topotecan hydrochloride is indicated for the treatment of: 

    • 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   Clinical Studies (14)] .

    Topotecan hydrochloride 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 topotecan hydrochloride, patients must have a baseline neutrophil count of >1,500 cells/mm 3 and a platelet count of >100,000 cells/mm 3.

    2.1 Small Cell Lung Cancer

    Recommended Dosage 

    • The recommended dose of topotecan hydrochloride is 1.5 mg/m 2 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 4 small cell lung cancer trials was 5 to 7 weeks.

    Dosage Modification Guidelines

    • In the event of severe neutropenia (defined as <500 cells/ mm 3) during any course, reduce the dose by 0.25 mg/m 2 (to 1.25 mg/m 2) 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/mm 3, reduce doses by 0.25 mg/m 2 (to 1.25 mg/m 2) for subsequent courses.

    2.2 Cervical Cancer

    Recommended Dosage

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

    Dosage Modification Guidelines

    Dosage adjustments for subsequent courses of topotecan hydrochloride 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 <1,000 cells/mm 3 with temperature of 38°C or 100.4°F), reduce the dose of topotecan hydrochloride to 0.6 mg/m 2 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 topotecan hydrochloride).
    • If febrile neutropenia occurs despite the use of G-CSF, reduce the dose of topotecan hydrochloride to 0.45 mg/m 2 for subsequent courses.
    • In the event the platelet count falls below 25,000 cells/mm 3, reduce doses to 0.6 mg/m 2 for subsequent courses.

    2.3 Dosage Adjustment in Specific Populations

    Renal Impairment

    No dosage adjustment of topotecan hydrochloride appears to be required for patients with mild renal impairment (Cl cr 40 to 60 mL/min).  Dosage adjustment of topotecan hydrochloride to 0.75 mg/m 2 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 topotecan hydrochloride [see Use in Specific Populations (8.6) and Clinical Pharmacology (12.3)].

    Topotecan hydrochloride 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 topotecan hydrochloride after cisplatin discontinuation in patients with cervical cancer.

    2.4 Instructions for Handling, Preparation and Intravenous Administration

    Handling

    Topotecan hydrochloride is a cytotoxic anticancer drug.  Prepare topotecan hydrochloride under a vertical laminar flow hood while wearing gloves and protective clothing.  If topotecan hydrochloride solution contacts the skin, wash the skin immediately and thoroughly with soap and water.  If topotecan hydrochloride 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. 1-4


    Preparation and Administration

    Each 4 mg vial of topotecan hydrochloride 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 topotecan hydrochloride are stable until the date indicated on the package when stored between 20° and 25°C (68° and 77°F) [see USP Controlled Room Temperature] and protected from light in the original package.  Because the vials contain no preservative, contents should be used immediately after reconstitution.

    Reconstituted vials of topotecan hydrochloride 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

    Topotecan hydrochloride is contraindicated in patients who have a history of severe hypersensitivity reactions (e.g., anaphylactoid reactions) to topotecan or to any of its ingredients.  Topotecan hydrochloride 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 topotecan hydrochloride.  Neutropenia is not cumulative over time.  In the comparative study, in small cell lung cancer, the treatment-related death rates were 5% for topotecan hydrochloride and 4% for CAV (cyclophosphamide-doxorubicin-vincristine).

    Neutropenia  

    • Small cell lung cancer experience: Grade 4 neutropenia (<500 cells/mm 3) 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

    • Small cell lung cancer experience: Grade 4 thrombocytopenia (<25,000/mm 3) 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

    • 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 topotecan hydrochloride only in patients with adequate bone marrow reserves, including baseline neutrophil count of at least 1,500 cells/mm 3 and platelet count at least 100,000/mm 3.  Monitor peripheral blood counts frequently during treatment with topotecan hydrochloride.  Do not treat patients with subsequent courses of topotecan hydrochloride until neutrophils recover to >1,000 cells/mm 3, platelets recover to >100,000 cells/mm 3, and hemoglobin levels recover to 9 g/dL (with transfusion if necessary).  Severe myelotoxicity has been reported when topotecan hydrochloride is used in combination with cisplatin [see Drug Interactions (7)].

    5.2 Neutropenic Colitis

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

    5.3 Interstitial Lung Disease

    Topotecan hydrochloride has been associated with reports of interstitial lung disease (ILD), some of which have been fatal [see 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 topotecan hydrochloride if a new diagnosis of ILD is confirmed.

    5.4 Pregnancy

    Pregnancy Category D

    Topotecan hydrochloride 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 topotecan hydrochloride in pregnant women.  If this drug is used during pregnancy, or if a patient becomes pregnant while receiving topotecan hydrochloride, the patient should be apprised of the potential hazard to the fetus [see Use in Specific Populations, Pregnancy (8.1)].

    5.5 Inadvertent Extravasation

    Inadvertent extravasation with topotecan hydrochloride has been observed, most reactions have been mild but severe cases have been reported.

  • 6 ADVERSE REACTIONS

    6.1 Clinical Trials Experience

    Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

    Small Cell Lung Cancer

    Data in the following section are based on the combined experiences of the 879 patients studied, including 426 patients with small cell lung cancer treated with topotecan hydrochloride injection.  Table 1 lists the principal hematologic adverse reactions and Table 2 lists non-hematologic adverse reactions occurring in at least 15% of patients.


    Table 1. Hematologic Adverse Reactions Experienced in ≥ 15% of Patients Receiving Topotecan Hydrochloride

    Hematologic

     Adverse Reaction

    Patients

    (n = 879)

    % Incidence

    Neutropenia

      <1,500 cells/mm 3

      <500 cells/mm 3


    97

    78

    Leukopenia

      <3,000 cells/mm 3

      <1,000 cells/mm 3


    97

    32

    Thrombocytopenia

      <75,000/mm 3

      <25,000/mm 3


    69

    27

    Anemia

      <10 g/dL

      <8 g/dL


    89

    37


    Table 2. Non-hematologic Adverse Reactions Experienced by ≥ 15% of Patients Receiving Topotecan Hydrochloride


    Non-hematologic

    Adverse Reaction

    Percentage of Patients with Adverse Reaction (879 Patients)

    All Grades

    Grade 3

    Grade 4

    Infections and infestations

       Sepsis or pyrexia/infection

       with neutropenia a

    43

    NR

    23

    Metabolism and nutrition disorders

       Anorexia


    19


    2


    <1

    Nervous system disorders

       Headache


    18


    1


    <1

    Respiratory, thoracic, and mediastinal disorders

       Dyspnea

       Coughing



    22

    15



    5

    1



    3

    0

    Gastrointestinal disorders

       Nausea

       Vomiting

       Diarrhea

       Constipation

       Abdominal pain

       Stomatitis


    64

    45

    32

    29

    22

    18


    7

    4

    3

    2

    2

    1


    1

    1

    1

    1

    2

    <1

    Skin and subcutaneous tissue disorders

       Alopecia

       Rash b



    49

    16



    NA

    1



    NA

    0

    General disorders and administrative site conditions

       Fatigue

       Pyrexia

       Pain c

       Asthenia



    29

    28

    23

    25



    5

    1

    2

    4



    0

    <1

    1

    2

    NA=Not applicable

    NR=Not reported separately

    a   Does not include Grade 1 sepsis or pyrexia.

    b    Rash also includes pruritus, rash erythematous, urticaria, dermatitis, bullous eruption, and maculopapular rash.

     c  Pain includes body pain, back pain, and skeletal pain.

    Nervous System Disorders

    Paresthesia occurred in 7% of patients but was generally grade 1.

    Hepatobiliary Disorders

    Grade 1 transient elevations in hepatic enzymes occurred in 8% of patients.  Greater elevations, grade 3/4, occurred in 4%.  Grade 3/4 elevated bilirubin occurred in <2% of patients.

    Table 4 shows the grade 3/4 hematologic and major non-hematologic adverse reactions in the topotecan/CAV comparator trial in small cell lung cancer.


    Table 4. Adverse Reactions Experienced by ≥ 5% of Small Cell Lung Cancer Patients Randomized to Receive Topotecan Hydrochloride or CAV




    Adverse Reaction

    Topotecan

    Hydrochloride

    (n=107)

    CAV

    (n=104)

    Hematologic Grade 3/4

    %

    %

    Grade 4 neutropenia

        (<500 cells/mm 3)


    70


    72

    Grade 3/4 anemia

        (Hgb <8g dL)


    42


    20

    Grade 4 thrombocytopenia

        (<25,000 plts/mm 3)


    29


    5

    Pyrexia/Grade 4 neutropenia

    28

    26

    Non-hematologic Grade 3/4

    %

    %

    Infections and infestations

        Documented sepsis a


    5


    5

    Respiratory, thoracic, and mediastinal disorders

        Dyspnea

        Pneumonia



    9

    8



    14

    6

    Gastrointestinal disorders

        Abdominal pain

        Nausea


    6

    8


    4

    6

    General disorders and administrative site conditions

        Fatigue

        Asthenia

        Pain b


    6

    9

    5

    10

    7

    7

    a    Death related to sepsis occurred in 3% of patients receiving topotecan hydrochloride, and 1% of patients receiving CAV.

    b    Pain includes body pain, skeletal pain, and back pain.

    Cervical Cancer

    In the comparative trial with topotecan hydrochloride plus cisplatin versus cisplatin in patients with cervical cancer, the most common dose-limiting adverse reaction was myelosuppression.  Table 5 shows the hematologic adverse reactions and Table 6 shows the non-hematologic adverse reactions in patients with cervical cancer.


    Table 5. Hematologic Adverse Reactions in Patients with Cervical Cancer Treated with Topotecan Hydrochloride Plus Cisplatin or Cisplatin Monotherapy a

    Hematologic

    Adverse Reaction

    Topotecan Hydrochloride Plus Cisplatin

    (n=140)

    Cisplatin

    (n=144)

    Anemia

       All grades (Hgb <12 g/dL)

       Grade 3 (Hgb <8 to 6.5 g/dL)

       Grade 4 (Hgb <6.5 g/dL)


    131 (94%)

    47 (34%)

    9 (6%)


    130 (90%)

    28 (19%)

    5 (3%)

    Leukopenia

       All grades (<3,800 cells/mm 3)

       Grade 3 (<2,000 to 1,000 cells/mm 3)

       Grade 4 (<1,000 cells/mm 3)


    128 (91%)

    58 (41%)

    35 (25%)


    43 (30%)

    1 (1%)

    0 (0%)

    Neutropenia

       All grades (<2,000 cells/mm 3)

       Grade 3 (<1,000 to 500 cells/mm 3)

       Grade 4 (<500 cells/mm 3)


    125 (89%)

    36 (26%)

    67 (48%)


    28 (19%)

    1 (1%)

    1 (1%)

    Thrombocytopenia

       All grades (<130,000 cells/mm 3)

       Grade 3 (<50,000 to 10,000 cells/mm 3)

       Grade 4 (<10,000 cells/mm 3)


    104 (74%)

    36 (26%)

    10 (7%)


    21 (15%)

    5 (3%)

    0 (0%)

    a Includes patients who were eligible and treated.


    Table 6. Non-hematologic Adverse Reactions Experienced by 5% of Patients with Cervical Cancer Treated with Topotecan Hydrochloride Plus Cisplatin or Cisplatin Monotherapy a



    Adverse Reaction

    Topotecan Hydrochloride Plus Cisplatin

    (n=140)

             Cisplatin

               (n=144)

    All Gradesb

    Grade 3

    Grade 4

    All Gradesb

    Grade 3

    Grade 4

    General disorders and administrative site conditions

    Constitutional c

         Pain d


    96 (69%)

    82 (59%)



    11 (8%)

    28 (20%)



    0

    3 (2%)



    89 (62%)

    72 (50%)



    17 (12%)

    18 (13%)



    0

    5 (3%)

    Gastrointestinal disorders

    Vomiting

         Nausea

         Stomatitis-pharyngitis

         Other

    56 (40%)

    77 (55%)

    8 (6%)

    88 (63%)



    20 (14%)

    18 (13%)

    1 (<1%)

    16 (11%)



    2 (1%)

    2 (1%)

    0

    4 (3%)



    53 (37%)

    79 (55%)

    0

    80 (56%)


    13 (9%)

    13 (9%)

    0

    12 (8%)


    0

    0

    0

    3 (2%)

    Dermatology

    67 (48%)

    1 (<1%)

    0

    29 (20%)

    0

    0

    Metabolic-Laboratory

    55 (39%)

    13 (9%)

    7 (5%)

    44 (31%)

    14 (10%)

    1 (<1%)

    Genitourinary

    51 (36%)

    9 (6%)

    9 (6%)

    49 (34%)

    7 (5%)

    7 (5%)

    Nervous system disorders

    Neuropathy

         Other


    4 (3%)

    49 (35%)


    1 (<1%)

    3 (2%)


    0

    1 (<1%)


    3 (2%)

    43 (30%)


    1 (<1%)

    7 (5%)


    0

    2 (1%)

    Infection-febrile neutropenia

    39 (28%)

    21 (15%)

    5 (4%)

    26 (18%)

    11 (8%)

    0

    Cardiovascular

    35 (25%)

    7 (5%)

    6 (4%)

    22 (15%)

    8 (6%)

    3 (2%)

    Hepatic

    34 (24%)

    5 (4%)

    2 (1%)

    23 (16%)

    2 (1%)

    0

    Pulmonary

    24 (17%)

    4 (3%)

    0

    23 (16%)

    5 (3%)

    3 (2%)

    Vascular disorders

    Hemorrhage

         Coagulation


    21 (15%)

    8 (6%)


    8 (6%)

    4 (3%)


    1 (<1%)

    3 (2%)


    20 (14%)

    10 (7%)


    3 (2%)

    7 (5%)


    1 (<1%)

    0

    Musculoskeletal

    19 (14%)

    3 (2%)

    0

    7 (5%)

    1 (<1%)

    1 (<1%)

    Allergy-Immunology

    8 (6%)

    2 (1%)

    1 (<1%)

    4 (3%)

    0

    1 (<1%)

    Endocrine

    8 (6%)

    0

    0

    4 (3%)

    2 (1%)

    0

    Sexual reproduction function

    7 (5%)

    0

    0

    10 (7%)

    1 (<1%)

    0

    Ocular-visual

    7 (5%)

    0

    0

    7 (5%)

    1 (<1%)

    0

    Data were collected using NCI Common Toxicity Criteria, v. 2.0.

      a  Includes patients who were eligible and treated.

     b  Grades 1 through 4 only.  There were 3 patients who experienced grade 5 deaths with investigator-designated attribution.  One was a grade 5 hemorrhage in which the drug-related thrombocytopenia aggravated the event.  A second patient experienced bowel obstruction, cardiac arrest, pleural effusion and respiratory failure which were not treatment-related but probably aggravated by treatment.  A third patient experienced a pulmonary embolism and adult respiratory distress syndrome, the latter was indirectly treatment-related.

    Constitutional includes fatigue (lethargy, malaise, asthenia), fever (in the absence of neutropenia), rigors, chills, sweating, and weight gain or loss.

    Pain includes abdominal pain or cramping, arthralgia, bone pain, chest pain (non-cardiac and non-pleuritic), dysmenorrhea, dyspareunia, earache, headache, hepatic pain, myalgia, neuropathic pain, pain due to radiation, pelvic pain, pleuritic pain, rectal or perirectal pain, and tumor pain.

    6.2 Postmarketing Experience

    In addition to adverse reactions reported from clinical trials or listed in other sections of the prescribing information, the following reactions have been identified during post-marketing use of topotecan hydrochloride.  Because they are reported voluntarily from a population of unknown size, estimates of frequency cannot be made.  These reactions have been chosen for inclusion due to a combination of their seriousness, frequency of reporting, or potential causal connection to topotecan hydrochloride.

    Blood and Lymphatic System Disorders: Severe bleeding (in association with thrombocytopenia) [see Warnings and Precautions (5.1)] .

    Immune System Disorders: Allergic manifestations; Anaphylactoid reactions.

    Gastrointestinal Disorders: Abdominal pain potentially associated with neutropenic colitis [see Warnings and Precautions (5.2)].

    Pulmonary Disorders: Interstitial lung disease [see Warnings and Precautions (5.3)].

    Skin and Subcutaneous Tissue Disorders: Angioedema, severe dermatitis, severe pruritus.

    General Disorders and Administration Site Conditions: Inadvertent extravasation [see Warnings and Precautions (5.5)].

  • 7 DRUG INTERACTIONS

    G-CSF

    Concomitant administration of G-CSF can prolong the duration of neutropenia, so if G-CSF is to be used, do not initiate it until day 6 of the course of therapy, 24 hours after completion of treatment with topotecan hydrochloride.

    Platinum and Other Cytotoxic Agents

    Myelosuppression was more severe when topotecan hydrochloride, at a dose of 1.25 mg/m 2/day for 5 days, was given in combination with cisplatin at a dose of 50 mg/m 2 in Phase 1 studies.  In one study, 1 of 3 patients had severe neutropenia for 12 days and a second patient died with neutropenic sepsis.

    Greater myelosuppression is also likely to be seen when topotecan hydrochloride is used in combination with other cytotoxic agents, thereby necessitating a dose reduction.  However, when combining topotecan hydrochloride with platinum agents (e.g., cisplatin or carboplatin), a distinct sequence-dependent interaction on myelosuppression has been reported.  Co-administration of a platinum agent on day 1 of dosing with topotecan hydrochloride required lower doses of each agent compared to co-administration on day 5 of the dosing schedule for topotecan hydrochloride.

    For information on the pharmacokinetics, efficacy, safety, and dosing of topotecan hydrochloride at a dose of 0.75 mg/m 2/day on days 1, 2, and 3 in combination with cisplatin 50 mg/m 2 on day 1 for cervical cancer [see Dosage and Administration (2), Adverse Reactions (6), Clinical Pharmacology (12.3), and Clinical Studies (14)] .

  • 8 USE IN SPECIFIC POPULATIONS

    8.1 Pregnancy

    Pregnancy Category D [see Warnings and Precautions (5.4)].

    Topotecan hydrochloride can cause fetal harm when administered to a pregnant woman.  In rabbits, a dose of 0.1 mg/kg/day (about equal to the clinical dose on a mg/m 2 basis) given on days 6 through 20 of gestation caused maternal toxicity, embryolethality, and reduced fetal body weight.  In the rat, a dose of 0.23 mg/kg/day (about equal to the clinical dose on a mg/m 2 basis) given for 14 days before mating through gestation day 6 caused fetal resorption, microphthalmia, pre-implant loss, and mild maternal toxicity.  A dose of 0.1 mg/kg/day (about half the clinical dose on a mg/m 2 basis) given to rats on days 6 through 17 of gestation caused an increase in post-implantation mortality.  This dose also caused an increase in total fetal malformations.  The most frequent malformations were of the eye (microphthalmia, anophthalmia, rosette formation of the retina, coloboma of the retina, ectopic orbit), brain (dilated lateral and third ventricles), skull, and vertebrae.

    There are no adequate and well controlled studies of topotecan hydrochloride in pregnant women.  If this drug is used during pregnancy, or if a patient becomes pregnant while receiving topotecan hydrochloride, the patient should be apprised of the potential hazard to the fetus [see Warnings and Precautions (5.4)].

    8.3 Nursing Mothers

    Rats excrete high concentrations of topotecan into milk.  Lactating female rats given 4.72 mg/m 2 IV (about twice the clinical dose on a mg/m 2 basis) excreted topotecan into milk at concentrations up to 48-fold higher than those in plasma.  It is not known whether the drug is excreted in human milk.  Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from topotecan hydrochloride, discontinue breastfeeding when women are receiving topotecan hydrochloride.

    8.4 Pediatric Use

    Safety and effectiveness in pediatric patients have not been established.

    8.5 Geriatric Use

    Of the 879 patients with cancer in clinical studies of topotecan hydrochloride, 32% (n = 281) were 65 years of age and older, while 3.8% (n = 33) were 75 years of age and older.  Of the 140 patients with stage IV-B, relapsed, or refractory cervical cancer in clinical studies of topotecan hydrochloride who received topotecan hydrochloride plus cisplatin in the randomized clinical trial, 6% (n = 9) were 65 years of age and older, while 3% (n = 4) were 75 years of age and older.  No overall differences in effectiveness or safety were observed between these patients and younger adult patients, and other reported clinical experience has not identified differences in responses between the elderly and younger adult patients, but greater sensitivity of some older individuals cannot be ruled out.

    There were no apparent differences in the pharmacokinetics of topotecan in elderly patients, once the age-related decrease in renal function was considered [see Clinical Pharmacology (12.3)].

    This drug is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function.  Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function [see Dosage and Administration (2.3)].

    8.6 Renal Impairment

    No dosage adjustment of topotecan hydrochloride appears to be required for patients with mild renal impairment (Cl cr 40 to 60 mL/min).  Dosage reduction is recommended for patients with moderate renal impairment (Cl cr 20 to 39 mL/min).  Insufficient data are available in patients with severe renal impairment to provide a dosage recommendation for topotecan hydrochloride [see Dosage and Administration (2.3) and Clinical Pharmacology (12.3)].

  • 10 OVERDOSAGE

    There is no known antidote for overdosage with topotecan hydrochloride.  The primary anticipated complication of overdosage would consist of bone marrow suppression.

    One patient on a single-dose regimen of 17.5 mg/m 2 given on day 1 of a 21-day cycle had received a single dose of 35 mg/m 2.  This patient experienced severe neutropenia (nadir of 320/mm 3) 14 days later but recovered without incident.

    Observe patients closely for bone marrow suppression, and consider supportive measures (such as the prophylactic use of G-CSF and/or antibiotic therapy).

  • 11 DESCRIPTION

    Topotecan Hydrochloride for Injection is a semi-synthetic derivative of camptothecin and is an anti-tumor drug with topoisomerase I-inhibitory activity.

    Topotecan Hydrochloride 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.

    The chemical name for topotecan hydrochloride is ( S)-10-[(dimethylamino)methyl]-4-ethyl-4,9-dihydroxy-1 H-pyrano[3’,4’:6,7] indolizino [1,2- b]quinoline-3,14-(4 H,12 H)-dione 1.25 hydrochloride.

    Topotecan hydrochloride has the following structural formula:

    topotecan-structure 


    C 23H 23N 3O 5 1.25HCl               M.W. 467.02

    It is soluble in water and melts with decomposition at 213° to 218°C.

  • 12 CLINICAL PHARMACOLOGY

    12.1 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.

    12.2 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/m 2/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.

    12.3 Pharmacokinetics

    The pharmacokinetics of topotecan have been evaluated in cancer patients following doses of 0.5 to 1.5 mg/m 2 administered as a 30-minute infusion.  Topotecan exhibits multiexponential pharmacokinetics with a terminal half-life of 2 to 3 hours.  Total exposure (AUC) is approximately dose-proportional.

    Distribution

    Binding of topotecan to plasma proteins is about 35%.

    Metabolism

    Topotecan undergoes a reversible pH dependent hydrolysis of its lactone moiety; it is the lactone form that is pharmacologically active.  At pH ≤4, the lactone is exclusively present, whereas the ring-opened hydroxy-acid form predominates at physiologic pH.  In vitro studies in human liver microsomes indicate topotecan is metabolized to an N-demethylated metabolite.  The mean metabolite: parent AUC ratio was about 3% for total topotecan and topotecan lactone following IV administration.

    Excretion

    Renal clearance is an important determinant of topotecan elimination.

    In a mass balance/excretion study in 4 patients with solid tumors, the overall recovery of total topotecan and its N-desmethyl metabolite in urine and feces over 9 days averaged 73.4 ± 2.3% of the administered IV dose.  Mean values of 50.8 ± 2.9% as total topotecan and 3.1 ± 1% as N-desmethyl topotecan were excreted in the urine following IV administration.  Fecal elimination of total topotecan accounted for 17.9 ± 3.6% while fecal elimination of N-desmethyl topotecan was 1.7 ± 0.6%.  An O-glucuronidation metabolite of topotecan and N-desmethyl topotecan has been identified in the urine.  These metabolites, topotecan-O-glucuronide and N-desmethyl topotecan-O-glucuronide, were less than 2% of the administered dose.

    Effect of Gender

    The overall mean topotecan plasma clearance in male patients was approximately 24% higher than that in female patients, largely reflecting difference in body size.

    Effect of Age

    Topotecan pharmacokinetics have not been specifically studied in an elderly population, but population pharmacokinetic analysis in female patients did not identify age as a significant factor.  Decreased renal clearance, which is common in the elderly, is a more important determinant of topotecan clearance [see Dosage and Administration (2.3) and Use in Specific Populations (8.5)].

    Effect of Race

    The effect of race on topotecan pharmacokinetics has not been studied.

    Effect of Renal Impairment

    In patients with mild renal impairment (creatinine clearance of 40 to 60 mL/min), topotecan plasma clearance was decreased to about 67% of the value in patients with normal renal function.  In patients with moderate renal impairment (Cl cr of 20 to 39 mL/min), topotecan plasma clearance was reduced to about 34% of the value in control patients, with an increase in half-life.  Mean half-life, estimated in 3 renally impaired patients, was about 5 hours.  Dosage adjustment is recommended for these patients [see Dosage and Administration (2.3)].

    Effect of Hepatic Impairment

    Plasma clearance in patients with hepatic impairment (serum bilirubin levels between 1.7 and 15 mg/dL) was decreased to about 67% of the value in patients without hepatic impairment.  Topotecan half-life increased slightly, from 2 hours to 2.5 hours, but these hepatically impaired patients tolerated the usual recommended topotecan dosage regimen.

    Drug Interactions

    Pharmacokinetic studies of the interaction of topotecan with concomitantly administered medications have not been formally investigated. 

    In vitro inhibition studies using marker substrates known to be metabolized by human P450 CYP1A2, CYP2A6, CYP2C8/9, CYP2C19, CYP2D6, CYP2E, CYP3A, or CYP4A or dihydropyrimidine dehydrogenase indicate that the activities of these enzymes were not altered by topotecan.  Enzyme inhibition by topotecan has not been evaluated in vivo.

    Cisplatin

    No pharmacokinetic data are available following topotecan (0.75 mg/m 2/day for 3 consecutive days) and cisplatin (50 mg/m 2/day on day 1) in patients with cervical cancer.

    Myelosuppression was more severe when topotecan hydrochloride was given in combination with cisplatin [seeDrug Interactions (7)].

  • 13 NONCLINICAL TOXICOLOGY

    13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

    Carcinogenicity testing of topotecan has not been performed.  Topotecan is known to be genotoxic to mammalian cells and is a probable carcinogen.  Topotecan was mutagenic to L5178Y mouse lymphoma cells and clastogenic to cultured human lymphocytes with and without metabolic activation.  It was also clastogenic to mouse bone marrow.  Topotecan did not cause mutations in bacterial cells.

    Topotecan given to female rats prior to mating at a dose of 1.4 mg/m 2 IV (about equal to the clinical dose on a mg/m 2 basis) caused superovulation possibly related to inhibition of follicular atresia.  This dose given to pregnant female rats also caused increased pre-implantation loss.  Studies in dogs given 0.4 mg/m 2 IV (about 1/4th the clinical dose on a mg/m 2 basis) of topotecan daily for a month suggest that treatment may cause an increase in the incidence of multinucleated spermatogonial giant cells in the testes.  Topotecan may impair fertility in women and men.

  • 14 CLINICAL STUDIES

    14.2 Small Cell Lung Cancer

    Topotecan hydrochloride was studied in 426 patients with recurrent or progressive small cell lung cancer in 1 randomized, comparative study and in 3 single-arm studies.

    Randomized Comparative Study

    In a randomized, comparative, Phase 3 trial, 107 patients were treated with topotecan hydrochloride (1.5 mg/m 2/day x 5 days starting on day 1 of a 21-day course) and 104 patients were treated with CAV (1,000 mg/m 2 cyclophosphamide, 45 mg/m 2 doxorubicin, 2 mg vincristine administered sequentially on day 1 of a 21-day course).  All patients were considered sensitive to first-line chemotherapy (responders who then subsequently progressed ≥60 days after completion of first-line therapy).  A total of 77% of patients treated with topotecan hydrochloride and 79% of patients treated with CAV received platinum/etoposide with or without other agents as first-line chemotherapy.

    Response rates, response duration, time to progression, and survival are shown in Table 8.

    Table 8. Efficacy of Topotecan Hydrochloride Versus CAV (cyclophosphamide-doxorubicin-vincristine) in Small Cell Lung Cancer Patients Sensitive to First-Line Chemotherapy

    Parameter

    Topotecan Hydrochloride

    (n=107)

    CAV

    (n=104)

    Complete response rate

    0%

    1%

    Partial response rate

    24%

    17%

    Overall response rate

    24%

    18%

    Difference in overall response rates

    6%

    95% Confidence interval of the difference

    (-6 to 18%)

    Response duration a (weeks)

    n = 26

    n = 19

    Median

    14.4

    15.3

    95% Confidence interval

    13.1 to 18

    13.1 to 23.1

    Hazard-ratio

       (topotecan hydrochloride:

       CAV) (95% Cl)


    1.42 (0.73 to 2.76)

          ( P-value)

    (0.3)

    Time to progression (weeks)


    Median

    13.3

    12.3

    95% Confidence interval

    11.4 to 16.4

    11 to 14.1

    Hazard-ratio 

      (topotecan hydrochloride:

      CAV) (95% Cl)


    0.92 (0.69 to 1.22)

        ( P-value)

    (0.55)

    Survival (weeks)


    Median

    25

    24.7

    95% Confidence interval

    20.6 to 29.6

    21.7 to 30.3

    Hazard-ratio 

      (topotecan hydrochloride:

      CAV) (95% Cl)


    1.04 (0.78 to 1.39)

         ( P-value)

    (0.8)



    a The calculation for duration of response was based on the interval between first response and time to progression.

    The time to response was similar in both arms: topotecan hydrochloride median of 6 weeks (range 2.4 to 15.7) versus CAV median 6 weeks (range 5.1 to 18.1).

    Changes on a disease-related symptom scale in patients who received topotecan hydrochloride or who received CAV are presented in Table 9.  It should be noted that not all patients had all symptoms, nor did all patients respond to all questions.  Each symptom was rated on a 4-category scale with an improvement defined as a change in 1 category from baseline sustained over 2 courses.  Limitations in interpretation of the rating scale and responses preclude formal statistical analysis.

    Table 9. Percentage of Patients with Symptom Improvementa: Topotecan Hydrochloride Versus CAV in Patients with Small Cell Lung Cancer

    Symptoms
     
    Topotecan

    Hydrochloride

    (n=107)

    CAV

    (n=104)


      n b 
      (%)
      n b
      (%)

    Shortness of breath

    68

    (28)

    61

    (7)

    Interference with daily activity

    67

    (27)

    63

    (11)

    Fatigue

    70

    (23)

    65

    (9)

    Hoarseness

    40

    (33)

    38

    (13)

    Cough

    69

    (25)

    61

    (15)

    Insomnia

    57

    (33)

    53

    (19)

    Anorexia

    56

    (32)

    57

    (16)

    Chest pain

    44

    (25)

    41

    (17)

    Hemoptysis

    15

    (27)

    12

    (33)

    a Defined as improvement sustained over at least 2 courses compared to baseline.

    b Number of patients with baseline and at least 1 post-baseline assessment.

    Single-Arm Studies

    Topotecan hydrochloride was also studied in 3 open-label, non-comparative trials in a total of 319 patients with recurrent or progressive small cell lung cancer after treatment with first-line chemotherapy.  In all 3 studies, patients were stratified as either sensitive (responders who then subsequently progressed ≥90 days after completion of first-line therapy) or refractory (no response to first-line chemotherapy or who responded to first-line therapy and then progressed within 90 days of completing first-line therapy).  Response rates ranged from 11% to 31% for sensitive patients and 2% to 7% for refractory patients.  Median time to progression and median survival were similar in all 3 studies and the comparative study.

    14.3 Cervical Cancer

    In a comparative trial, 147 eligible women were randomized to topotecan hydrochloride (0.75 mg/m 2/day IV over 30 minutes x 3 consecutive days starting on day 1 of a 21-day course) plus cisplatin (50 mg/m 2 on day 1) and 146 eligible women were randomized to cisplatin (50 mg/m 2 IV on day 1 of a 21-day course).  All patients had histologically confirmed Stage IV-B, recurrent, or persistent carcinoma of the cervix considered not amenable to curative treatment with surgery and/or radiation.  Fifty-six percent (56%) of patients treated with topotecan hydrochloride plus cisplatin and 56% of patients treated with cisplatin had received prior cisplatin with or without other agents as first-line chemotherapy.

    Median survival of eligible patients receiving topotecan hydrochloride plus cisplatin was 9.4 months (95% CI: 7.9 to 11.9) compared to 6.5 months (95% CI: 5.8 to 8.8) among patients randomized to cisplatin alone with a log rank P-value of 0.033 (significance level was 0.044 after adjusting for the interim analysis).  The unadjusted hazard ratio for overall survival was 0.76 (95% CI: 0.59 to 0.98).

    Figure 1. Overall Survival Curves Comparing Topotecan Hydrochloride

    Plus Cisplatin Versus Cisplatin Monotherapy in Cervical Cancer Patients

    figure-1

  • 15 REFERENCES

    1. Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care Settings.  NIOSH Alert 2004-165.
    2. OSHA Technical Manual, TED 1-0.15A, Section VI: Chapter 2. Controlling Occupational Exposure to Hazardous Drugs.  OSHA, 1999. http://www.osha.gov/dts/osta/otm/otm_vi/otm_vi_2.html
    3. American Society of Health-System Pharmacists. ASHP Guidelines on Handling Hazardous Drugs.  Am J Health-Syst Pharm. 2006;63:1172-1193.
    4. Polovich M, White JM, Kelleher LO (eds.) 2005. Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. (2 nd ed) Pittsburgh, PA: Oncology Nursing Society.
  • 16 HOW SUPPLIED/STORAGE AND HANDLING

    Topotecan Hydrochloride for Injection is supplied as follows:

    Product

    No.

    NDC

    No.

    Strength


    PRX760210  

    63323-762-94  

    4 mg/vial   

    Single-dose vial, packaged individually.

    This container closure is not made with natural rubber latex.

    Storage

    Store the vials protected from light in the original cartons between 20° and 25°C (68° and 77°F) [see USP Controlled Room Temperature].

  • 17 PATIENT COUNSELING INFORMATION

    17.1 Bone Marrow Suppression

    Inform patients that topotecan hydrochloride decreases blood cell counts such as white blood cells, platelets, and red blood cells.  Patients who develop fever, other signs of infection (e.g., chills, cough, or burning pain on urination), or bleeding while on therapy should notify their physician promptly.  Inform patients that frequent blood tests will be performed while taking topotecan hydrochloride to monitor for the occurrence of bone marrow suppression.

    17.2 Pregnancy and Breastfeeding

    Advise patients to use effective contraceptive measures to prevent pregnancy and to avoid breastfeeding during treatment with topotecan hydrochloride.

    17.3 Asthenia and Fatigue

    Inform patients that topotecan hydrochloride may cause asthenia or fatigue.  If these symptoms occur, caution should be observed when driving or operating machinery.

  • PRINCIPAL DISPLAY PANEL

    PREMIERPro™Rx is a trademark of Premier, Inc., under license.

     

    Manufactured for:

    Fresenius Kabi USA, LLC

    Lake Zurich, IL 60047

     

    451322

    Issued: March 2013

     

    logo 


  • PRINCIPAL DISPLAY PANEL

    PACKAGE LABEL - PRINCIPAL DISPLAY - Topotecan 4 mg Single-Dose Vial Label

    NDC 63323-762-94

    PRX760210

    Topotecan Hydrochloride for Injeciton

    4 mg (base)

    Must be diluted

    For Intravenous Use

    Rx only

    Single-Dose Vial

     

    prx760210-vial
     

     

    PACKAGE LABEL - PRINCIPAL DISPLAY - Topotecan 4 mg Single-Dose Vial Carton Label

    NDC 63323-762-94

    PRX760210

    Topotecan Hydrochloride for Injection

    4 mg (base)

    Must be diluted

    For Intravenous Use

    Caution: Cytotoxic Agent

    Rx only

    One Single-Dose Vial

     

    prx760210-carton 

  • INGREDIENTS AND APPEARANCE
    TOPOTECAN HYDROCHLORIDE 
    topotecan hydrochloride injection, powder, lyophilized, for solution
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC: 63323-762
    Route of AdministrationINTRAVENOUS
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    TOPOTECAN HYDROCHLORIDE (UNII: 956S425ZCY) (TOPOTECAN - UNII:7M7YKX2N15) TOPOTECAN4 mg  in 4 mL
    Inactive Ingredients
    Ingredient NameStrength
    MANNITOL (UNII: 3OWL53L36A) 48 mg  in 4 mL
    TARTARIC ACID (UNII: W4888I119H) 20 mg  in 4 mL
    HYDROCHLORIC ACID (UNII: QTT17582CB)  
    SODIUM HYDROXIDE (UNII: 55X04QC32I)  
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC: 63323-762-941 in 1 BOX11/30/2010
    14 mL in 1 VIAL; Type 0: Not a Combination Product
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    ANDAANDA09108911/30/2010
    Labeler - Fresenius Kabi USA, LLC (608775388)
    Establishment
    NameAddressID/FEIBusiness Operations
    Fresenius Kabi USA, LLC840771732manufacture(63323-762)

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