ONDANSETRON- ondansetron hydrochloride injection, solution

ONDANSETRON by

Drug Labeling and Warnings

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

Drug Details [pdf]

  • 1 INDICATIONS AND USAGE

    1.1 Prevention of Nausea and Vomiting Associated with Initial and Repeat Courses of Emetogenic Cancer Chemotherapy

    Ondansetron Injection is indicated for the prevention of nausea and vomiting associated with initial and repeat courses of emetogenic cancer chemotherapy, including high-dose cisplatin [see Clinical Studies ( 14.1)] .

    Ondansetron is approved for patients aged 6 months and older.

    1.2 Prevention of Postoperative Nausea and/or Vomiting

    Ondansetron Injection is indicated for the prevention of postoperative nausea and/or vomiting. As with other antiemetics, routine prophylaxis is not recommended for patients in whom there is little expectation that nausea and/or vomiting will occur postoperatively. In patients in whom nausea and/or vomiting must be avoided postoperatively, Ondansetron Injection is recommended even when the incidence of postoperative nausea and/or vomiting is low. For patients who do not receive prophylactic Ondansetron Injection and experience nausea and/or vomiting postoperatively, Ondansetron Injection may be given to prevent further episodes [see Clinical Studies ( 14.3)] .

    Ondansetron is approved for patients aged 1 month and older.

  • 2 DOSAGE AND ADMINISTRATION

    2.1 Prevention of Nausea and Vomiting Associated with Initial and Repeat Courses of Emetogenic Cancer Chemotherapy

    Ondansetron Injection should be diluted in 50 mL of 5% Dextrose Injection or 0.9% Sodium Chloride Injection before administration.

    Adults: The recommended adult intravenous dosage of Ondansetron is three 0.15-mg/kg doses up to a maximum of 16 mg per dose [see Clinical Pharmacology ( 12.2)] . The first dose is infused over 15 minutes beginning 30 minutes before the start of emetogenic chemotherapy. Subsequent doses (0.15 mg/kg up to a maximum of 16 mg per dose) are administered 4 and 8 hours after the first dose of Ondansetron.

    Pediatrics: For pediatric patients 6 months through 18 years of age, the intravenous dosage of Ondansetron is three 0.15-mg/kg doses up to a maximum of 16 mg per dose [see Clinical Studies ( 14.1), and Clinical Pharmacology ( 12.2, and 12.3)] . The first dose is to be administered 30 minutes before the start of moderately to highly emetogenic chemotherapy. Subsequent doses (0.15 mg/kg up to a maximum of 16 mg per dose) are administered 4 and 8 hours after the first dose of Ondansetron. The drug should be infused intravenously over 15 minutes.

    2.2 Prevention of Postoperative Nausea and Vomiting

    Caution: Do not administer a full prefilled syringe (4 mg dose) to pediatric patients less than 40 kg as this exceeds the recommended dose.

    Adults: The recommended adult intravenous dosage of Ondansetron is 4 mg undiluted administered intravenously in not less than 30 seconds, preferably over 2 to 5 minutes, immediately before induction of anesthesia, or postoperatively if the patient did not receive prophylactic antiemetics and experiences nausea and/or vomiting occurring within 2 hours after surgery. Alternatively, 4 mg undiluted may be administered intramuscularly as a single injection for adults. While recommended as a fixed dose for patients weighing more than 40 kg, few patients above 80 kg have been studied. In patients who do not achieve adequate control of postoperative nausea and vomiting following a single, prophylactic, preinduction, intravenous dose of ondansetron 4 mg, administration of a second intravenous dose of 4 mg ondansetron postoperatively does not provide additional control of nausea and vomiting.

    Pediatrics: For pediatric patients 1 month through 12 years of age, the dosage is a single 0.1-mg/kg dose for patients weighing 40 kg or less, or a single 4-mg dose for patients weighing more than 40 kg. The rate of administration should not be less than 30 seconds, preferably over 2 to 5 minutes immediately prior to or following anesthesia induction, or postoperatively if the patient did not receive prophylactic antiemetics and experiences nausea and/or vomiting occurring shortly after surgery. Prevention of further nausea and vomiting was only studied in patients who had not received prophylactic Ondansetron.

    2.3 Stability and Handling

    After dilution, do not use beyond 24 hours. Although Ondansetron Injection is chemically and physically stable when diluted as recommended, sterile precautions should be observed because diluents generally do not contain preservative.

    Ondansetron Injection is stable at room temperature under normal lighting conditions for 48 hours after dilution with the following intravenous fluids: 0.9% Sodium Chloride Injection, 5% Dextrose Injection, 5% Dextrose and 0.9% Sodium Chloride Injection, 5% Dextrose and 0.45% Sodium Chloride Injection, and 3% Sodium Chloride Injection.

    Note: Parenteral drug products should be inspected visually for particulate matter and discoloration before administration whenever solution and container permit.

    2.4 Dosage Adjustment for Patients with Impaired Hepatic Function

    In patients with severe hepatic impairment (Child-Pugh score of 10 or greater), a single maximal daily dose of 8 mg infused over 15 minutes beginning 30 minutes before the start of the emetogenic chemotherapy is recommended. There is no experience beyond first-day administration of ondansetron in these patients [see Clinical Pharmacology ( 12.3)] .

  • 3 DOSAGE FORMS AND STRENGTHS

    Ondansetron Injection, USP 2 mg/mL is a clear, colorless, nonpyrogenic, sterile solution available as a 2 mL Prefilled disposable single-use syringe.

  • 4 CONTRAINDICATIONS

    Ondansetron Injection is contraindicated for patients known to have hypersensitivity (e.g., anaphylaxis) to this product or any of its components. Anaphylactic reactions have been reported in patients taking ondansetron. [See Adverse Reactions ( 6.2)].

    The concomitant use of apomorphine with ondansetron is contraindicated based on reports of profound hypotension and loss of consciousness when apomorphine was administered with ondansetron.

  • 5 WARNINGS AND PRECAUTIONS

    5.1 Hypersensitivity Reactions

    Hypersensitivity reactions, including anaphylaxis and bronchospasm, have been reported in patients who have exhibited hypersensitivity to other selective 5-HT 3 receptor antagonists.

    5.2 QT Prolongation

    Ondansetron prolongs the QT interval in a dose-dependent manner [see Clinical Pharmacology ( 12.2)] . In addition, post-marketing cases of Torsade de Pointes have been reported in patients using ondansetron. Avoid Ondansetron in patients with congenital long QT syndrome. ECG monitoring is recommended in patients with electrolyte abnormalities (e.g., hypokalemia or hypomagnesemia), congestive heart failure, bradyarrhythmias, or patients taking other medicinal products that lead to QT prolongation.

    5.3 Serotonin Syndrome

    The development of serotonin syndrome has been reported with 5-HT3 receptor antagonists. Most reports have been associated with concomitant use of serotonergic drugs (e.g., selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors, mirtazapine, fentanyl, lithium, tramadol, and intravenous methylene blue). Some of the reported cases were fatal. Serotonin syndrome occurring with overdose of Ondansetron alone has also been reported. The majority of reports of serotonin syndrome related to 5-HT3 receptor antagonist use occurred in a post-anesthesia care unit or an infusion center.

    Symptoms associated with serotonin syndrome may include the following combination of signs and symptoms: mental status changes (e.g., agitation, hallucinations, delirium, and coma), autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination), seizures, with or without gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). Patients should be monitored for the emergence of serotonin syndrome, especially with concomitant use of Ondansetron and other serotonergic drugs. If symptoms of serotonin syndrome occur, discontinue Ondansetron and initiate supportive treatment. Patients should be informed of the increased risk of serotonin syndrome, especially if Ondansetron is used concomitantly with other serotonergic drugs [see Drug Interactions ( 7.5), Overdosage ( 10), Patient Counseling Information ( 17)].

    5.4 Masking of Progressive Ileus and Gastric Distension

    The use of Ondansetron in patients following abdominal surgery or in patients with chemotherapy-induced nausea and vomiting may mask a progressive ileus and gastric distention.

    5.5 Effect on Peristalsis

    Ondansetron is not a drug that stimulates gastric or intestinal peristalsis. It should not be used instead of nasogastric suction.

  • 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 clinical practice.

    The following adverse reactions have been reported in clinical trials of adult patients treated with ondansetron, the active ingredient of intravenous Ondansetron across a range of dosages. A causal relationship to therapy with Ondansetron was unclear in many cases.

    Chemotherapy-Induced Nausea and Vomiting:

    Table 1. Adverse Reactions Reported in > 5% of Adult Patients Who Received Ondansetron at a Dosage of Three 0.15-mg/kg Doses




    Adverse Reaction     		Number of Adult Patients with Reaction
    Ondansetron Injection
    0.15 mg/kg x 3
    n = 419

    Metoclopramide
    n = 156

    Placebo
    n = 34
    Diarrhea 16% 44% 18%
    Headache 17% 7% 15%
    Fever 8% 5% 3%

    Cardiovascular: Rare cases of angina (chest pain), electrocardiographic alterations, hypotension, and tachycardia have been reported.

    Gastrointestinal: Constipation has been reported in 11% of chemotherapy patients receiving multiday ondansetron.

    Hepatic: In comparative trials in cisplatin chemotherapy patients with normal baseline values of aspartate transaminase (AST) and alanine transaminase (ALT), these enzymes have been reported to exceed twice the upper limit of normal in approximately 5% of patients. The increases were transient and did not appear to be related to dose or duration of therapy. On repeat exposure, similar transient elevations in transaminase values occurred in some courses, but symptomatic hepatic disease did not occur.

    Integumentary: Rash has occurred in approximately 1% of patients receiving ondansetron.

    Neurological: There have been rare reports consistent with, but not diagnostic of, extrapyramidal reactions in patients receiving Ondansetron injection, and rare cases of grand mal seizure.

    Other: Rare cases of hypokalemia have been reported.

    Postoperative Nausea and Vomiting: The adverse reactions in Table 2 have been reported in ≥ 2% of adults receiving ondansetron at a dosage of 4 mg intravenous over 2 to 5 minutes in clinical trials.

    Table 2. Adverse Reactions Reported in ≥ 2% (and with Greater Frequency than the Placebo Group) of Adult Patients Receiving Ondansetron at a Dosage of 4 mg Intravenous over 2 to 5 Minutes

    a Adverse Reactions: Rates of these reactions were not significantly different in the ondansetron and placebo groups

    b Patients were receiving multiple concomitant perioperative and postoperative medications



    Adverse Reaction a,b    		Ondansetron Injection
    4 mg Intravenous
    n = 547 patients
    Placebo
    n = 547 patients
    Headache 92 (17%) 77 (14%)
    Drowsiness/sedation 44 (8%) 37 (7%)
    Injection site reaction 21 (4%) 18 (3%)
    Fever 10 (2%) 6 (1%)
    Cold sensation 9 (2%) 8 (1%)
    Pruritus 9 (2%) 3 (< 1%)
    Paresthesia 9 (2%) 2 (< 1%)

    Pediatric Use: Rates of adverse reactions were similar in both the ondansetron and placebo groups in pediatric patients receiving ondansetron (a single 0.1-mg/kg dose for pediatric patients weighing 40 kg or less, or 4 mg for pediatric patients weighing more than 40 kg) administered intravenously over at least 30 seconds. Diarrhea was seen more frequently in patients taking Ondansetron (2%) compared to placebo (<1%) in the 1 month to 24 month age group. These patients were receiving multiple concomitant perioperative and postoperative medications.

    6.2 Postmarketing Experience

    The following adverse reactions have been identified during post-approval use of ondansetron. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. The reactions have been chosen for inclusion due to a combination of their seriousness, frequency of reporting, or potential causal connection to ondansetron.

    Cardiovascular: Arrhythmias (including ventricular and supraventricular tachycardia, premature ventricular contractions, and atrial fibrillation), bradycardia, electrocardiographic alterations (including second-degree heart block, QT/QTc interval prolongation, and ST segment depression), palpitations , and syncope. Rarely and predominantly with intravenous ondansetron, transient ECG changes including QT/QTc interval prolongation have been reported [see Warnings and Precautions ( 5.2)] .

    General: Flushing. Rare cases of hypersensitivity reactions, sometimes severe (e.g., anaphylactic reactions, angioedema, bronchospasm, cardiopulmonary arrest, hypotension, laryngeal edema, laryngospasm, shock, shortness of breath, stridor) have also been reported. A positive lymphocyte transformation test to ondansetron has been reported, which suggests immunologic sensitivity to ondansetron.

    Hepatobiliary: Liver enzyme abnormalities have been reported. Liver failure and death have been reported in patients with cancer receiving concurrent medications including potentially hepatotoxic cytotoxic chemotherapy and antibiotics.

    Local Reactions: Pain, redness, and burning at site of injection.

    Lower Respiratory: Hiccups

    Neurological: Oculogyric crisis, appearing alone, as well as with other dystonic reactions. Transient dizziness during or shortly after intravenous infusion.

    Skin: Urticaria, Stevens-Johnson syndrome, and toxic epidermal necrolysis.

    Eye Disorders: Cases of transient blindness, predominantly during intravenous administration, have been reported. These cases of transient blindness were reported to resolve within a few minutes up to 48 hours. Transient blurred vision, in some cases associated with abnormalities of accommodation, have also been reported.

  • 7 DRUG INTERACTIONS

    7.1 Drugs Affecting Cytochrome P-450 Enzymes

    Ondansetron does not appear to induce or inhibit the cytochrome P-450

    drug-metabolizing enzyme system of the liver. Because ondansetron is metabolized by hepatic cytochrome P-450 drug-metabolizing enzymes (CYP3A4, CYP2D6, CYP1A2), inducers or inhibitors of these enzymes may change the clearance and, hence, the half-life of ondansetron [see Clinical Pharmacology ( 12.3)] . On the basis of limited available data, no dosage adjustment is recommended for patients on these drugs.

    7.2 Apomorphine

    Based on reports of profound hypotension and loss of consciousness when apomorphine was administered with ondansetron, concomitant use of apomorphine with ondansetron is contraindicated [see Contraindications ( 4)].

    7.3 Phenytoin, Carbamazepine, and Rifampin

    In patients treated with potent inducers of CYP3A4 (i.e., phenytoin, carbamazepine, and rifampin), the clearance of ondansetron was significantly increased and ondansetron blood concentrations were decreased. However, on the basis of available data, no dosage adjustment for ondansetron is recommended for patients on these drugs [see Clinical Pharmacology ( 12.3)] .

    7.4 Tramadol

    Although there are no data on pharmacokinetic drug interactions between ondansetron and tramadol, data from two small studies indicate that concomitant use of ondansetron may result in reduced analgesic activity of tramadol. Patients on concomitant ondansetron self administered tramadol more frequently in these studies, leading to an increased cumulative dose in patient controlled administration (PCA) of tramadol.

    7.5 Serotonergic Drugs

    Serotonin syndrome (including altered mental status, autonomic instability, and neuromuscular symptoms) has been described following the concomitant use of 5-HT3 receptor antagonists and other serotonergic drugs, including selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs) [see Warnings and Precautions ( 5.3)] .

    7.6 Chemotherapy

    In humans, carmustine, etoposide, and cisplatin do not affect the pharmacokinetics of ondansetron.

    In a crossover study in 76 pediatric patients, intravenous ondansetron did not increase blood levels of high-dose methotrexate.

    7.7 Temazepam

    The coadministration of ondansetron had no effect on the pharmacokinetics and pharmacodynamics of temazepam.

    7.8 Alfentanil and Atracurium

    Ondansetron does not alter the respiratory depressant effects produced by alfentanil or the degree of neuromuscular blockade produced by atracurium. Interactions with general or local anesthetics have not been studied.

  • 8 USE IN SPECIFIC POPULATIONS

    8.1 Pregnancy

    Pregnancy Category B. Reproduction studies have been performed in pregnant rats and rabbits at intravenous doses up to 4 mg/kg per day (approximately 1.4 and 2.9 times the recommended human intravenous dose of 0.15 mg/kg given three times a day, respectively, based on body surface area) and have revealed no evidence of impaired fertility or harm to the fetus due to ondansetron. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.

    8.3 Nursing Mothers

    Ondansetron is excreted in the breast milk of rats. It is not known whether

    ondansetron is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when ondansetron is administered to a nursing woman.

    8.4 Pediatric Use

    Little information is available about the use of ondansetron in pediatric surgical

    patients younger than 1 month of age. [See Clinical Studies ( 14.2)]. Little information is available about the use of ondansetron in pediatric cancer patients younger than 6 months of age. [See Clinical Studies ( 14.1), Dosage and Administration ( 2)].

    The clearance of ondansetron in pediatric patients 1 month to 4 months of age is slower and the half-life is ~2.5 fold longer than patients who are > 4 to 24 months of age. As a precaution, it is recommended that patients less than 4 months of age receiving this drug be closely monitored. [See Clinical Pharmacology ( 12.3)] .

    8.5 Geriatric Use

    Of the total number of subjects enrolled in cancer chemotherapy-induced and

    postoperative nausea and vomiting in US- and foreign-controlled clinical trials, 862 were 65 years of age and over. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. Dosage adjustment is not needed in patients over the age of 65 [see Clinical Pharmacology ( 12.3)] .

    8.6 Hepatic Impairment

    In patients with severe hepatic impairment (Child-Pugh score of 10 or greater), clearance is reduced and apparent volume of distribution is increased with a resultant increase in plasma half-life [see Clinical Pharmacology ( 12.3)] . In such patients, a total daily dose of 8 mg should not be exceeded [see Dosage and Administration ( 2.3)] .

    8.7 Renal Impairment

    Although plasma clearance is reduced in patients with severe renal impairment (creatinine clearance < 30 mL/min), no dosage adjustment is recommended [see Clinical Pharmacology ( 12.3)] .

  • 9 DRUG ABUSE AND DEPENDENCE

    Animal studies have shown that ondansetron is not discriminated as a benzodiazepine nor does it substitute for benzodiazepines in direct addiction studies.

  • 10 OVERDOSAGE

    There is no specific antidote for ondansetron overdose. Patients should be managed with appropriate supportive therapy. Individual intravenous doses as large as 150 mg and total daily intravenous doses as large as 252 mg have been inadvertently administered without significant adverse events. These doses are more than 10 times the recommended daily dose.

    In addition to the adverse reactions listed above, the following events have been described in the setting of ondansetron overdose: “Sudden blindness” (amaurosis) of 2 to 3 minutes' duration plus severe constipation occurred in one patient that was administered 72 mg of ondansetron intravenously as a single dose. Hypotension (and faintness) occurred in another patient that took 48 mg of ondansetron hydrochloride tablets. Following infusion of 32 mg over only a 4-minute period, a vasovagal episode with transient second-degree heart block was observed. In all instances, the events resolved completely.

    Pediatric cases consistent with serotonin syndrome have been reported after inadvertent oral overdoses of ondansetron (exceeding estimated ingestion of 5 mg/kg) in young children. Reported symptoms included somnolence, agitation, tachycardia, tachypnea, hypertension, flushing, mydriasis, diaphoresis, myoclonic movements, horizontal nystagmus, hyperreflexia, and seizure. Patients required supportive care, including intubation in some cases, with complete recovery without sequelae within 1 to 2 days.

  • 11 DESCRIPTION

    The active ingredient in Ondansetron Injection, USP is ondansetron hydrochloride, a selective blocking agent of the serotonin 5-HT 3 receptor type. Its chemical name is (±) 1, 2, 3, 9-tetrahydro-9-methyl-3-[(2-methyl-1H-imidazol-1-yl)methyl]-4H-carbazol-4-one, mono-hydrochloride, dihydrate. It has the following structural formula:

    Structural Formula

    The empirical formula is C 18H 19N 3OHCl2H 2O, representing a molecular weight of 365.9.

    Ondansetron HCl is a white to off-white powder that is soluble in water and normal saline.

    Each 1 mL of aqueous solution contains 2 mg of ondansetron as the hydrochloride dihydrate; 9 mg of sodium chloride, USP; and 0.5 mg of citric acid monohydrate, USP and 0.25 mg of sodium citrate dihydrate, USP as buffers in Water for Injection, USP.

    Ondansetron Injection, USP is a clear, colorless, nonpyrogenic, sterile solution for intravenous or intramuscular use. The pH of the injection solution is 3.3 to 4.0.

  • 12 CLINICAL PHARMACOLOGY

    12.1 Mechanism of Action

    Ondansetron is a selective 5-HT 3 receptor antagonist. While ondansetron's mechanism of action has not been fully characterized, it is not a dopamine-receptor antagonist.

    12.2 Pharmacodynamics

    QTc interval prolongation was studied in a double blind, single intravenous dose, placebo- and positive-controlled, crossover study in 58 healthy subjects. The maximum mean (95% upper confidence bound) difference in QTcF from placebo after baseline-correction was 19.5 (21.8) ms and 5.6 (7.4) ms after 15 minute intravenous infusions of 32 mg and 8 mg Ondansetron, respectively. A significant exposure-response relationship was identified between ondansetron concentration and ΔΔQTcF. Using the established exposure-response relationship, 24 mg infused intravenously over 15 min had a mean predicted (95% upper prediction interval) ΔΔQTcF of 14.0 (16.3) ms. In contrast, 16 mg infused intravenously over 15 min using the same model had a mean predicted (95% upper prediction interval) ΔΔQTcF of 9.1 (11.2) ms.

    In normal volunteers, single intravenous doses of 0.15 mg/kg of ondansetron had no effect on esophageal motility, gastric motility, lower esophageal sphincter pressure, or small intestinal transit time. In another study in six normal male volunteers, a 16-mg dose infused over 5 minutes showed no effect of the drug on cardiac output, heart rate, stroke volume, blood pressure, or electrocardiogram (ECG). Multiday administration of ondansetron has been shown to slow colonic transit in normal volunteers. Ondansetron has no effect on plasma prolactin concentrations. In a gender-balanced pharmacodynamic study (n = 56), ondansetron 4 mg administered intravenously or intramuscularly was dynamically similar in the prevention of nausea and vomiting using the ipecacuanha model of emesis.

    12.3 Pharmacokinetics

    In normal adult volunteers, the following mean pharmacokinetic data have been determined following a single 0.15-mg/kg intravenous dose.

    Table 3. Pharmacokinetics in Normal Adult Volunteers

    Age-group
    (years)

    n     		Peak Plasma Concentration (ng/mL) Mean Elimination
    Half-life (h)     		Plasma Clearance
    (L/h/kg)
    19-40 11 102 3.5 0.381
    61-74 12 106 4.7 0.319
    ≥ 75 11 170 5.5 0.262

    Absorption: A study was performed in normal volunteers (n = 56) to evaluate the pharmacokinetics of a single 4-mg dose administered as a 5-minute infusion compared to a single intramuscular injection. Systemic exposure as measured by mean AUC were equivalent, with values of 156 [95% CI 136, 180] and 161 [95% CI 137, 190] ngh/mL for intravenous and intramuscular groups, respectively. Mean peak plasma concentrations were 42.9 [95% CI 33.8, 54.4] ng/mL at 10 minutes after intravenous infusion and 31.9 [95% CI 26.3, 38.6] ng/mL at 41 minutes after intramuscular injection.

    Distribution: Plasma protein binding of ondansetron as measured in vitro was 70% to 76%, over the pharmacologic concentration range of 10 to 500 ng/mL. Circulating drug also distributes into erythrocytes.

    Metabolism: Ondansetron is extensively metabolized in humans, with approximately 5% of a radiolabeled dose recovered as the parent compound from the urine. The primary metabolic pathway is hydroxylation on the indole ring followed by subsequent glucuronide or sulfate conjugation.

    Although some nonconjugated metabolites have pharmacologic activity, these are not found in plasma at concentrations likely to significantly contribute to the biological activity of ondansetron. The metabolites are observed in the urine.

    In vitro metabolism studies have shown that ondansetron is a substrate for multiple human hepatic cytochrome P-450 enzymes, including CYP1A2, CYP2D6, and CYP3A4. In terms of overall ondansetron turnover, CYP3A4 plays a predominant role while formation of the major in vivo metabolites is apparently mediated by CYP1A2. The role of CYP2D6 in ondansetron in vivo metabolism is relatively minor.

    The pharmacokinetics of intravenous ondansetron did not differ between subjects who were poor metabolisers of CYP2D6 and those who were extensive metabolisers of CYP2D6, further supporting the limited role of CYP2D6 in ondansetron disposition in vivo.

    Elimination: In adult cancer patients, the mean ondansetron elimination half-life was 4.0 hours, and there was no difference in the multidose pharmacokinetics over a 4-day period. In a dose proportionality study, systemic exposure to 32 mg of ondansetron was not proportional to dose as measured by comparing dose-normalized AUC values to an 8-mg dose. This is consistent with a small decrease in systemic clearance with increasing plasma concentrations.

    Geriatrics: A reduction in clearance and increase in elimination half-life are seen in patients over 75 years of age. In clinical trials with cancer patients, safety and efficacy were similar in patients over 65 years of age and those under 65 years of age; there was an insufficient number of patients over 75 years of age to permit conclusions in that age-group. No dosage adjustment is recommended in the elderly.

    Pediatrics: Pharmacokinetic samples were collected from 74 cancer patients 6 to 48 months of age, who received a dose of 0.15 mg/kg of intravenous ondansetron every 4 hours for 3 doses during a safety and efficacy trial. These data were combined with sequential pharmacokinetics data from 41 surgery patients 1 month to 24 months of age, who received a single dose of 0.1 mg/kg of intravenous ondansetron prior to surgery with general anesthesia, and a population pharmacokinetic analysis was performed on the combined data set. The results of this analysis are included in Table 4 and are compared to the pharmacokinetic results in cancer patients 4 to 18 years of age.

    Table 4. Pharmacokinetics in Pediatric Cancer Patients 1 Month to 18 Years of Age

    a Population PK (Pharmacokinetic) Patients: 64% cancer patients and 36% surgery patients.


    Subjects and Age Group
    N     		CL
    (L/h/kg)     		Vd ss
    (L/kg)     		T ½
    (h)
    Geometric Mean Mean
    Pediatric Cancer Patients
    4 to 18 years of age
    N = 21
    0.599
    1.9
    2.8
    Population PK Patients a
    1 month to 48 months of age
    N = 115
    0.582
    3.65
    4.9

    Based on the population pharmacokinetic analysis, cancer patients 6 to 48 months of age who receive a dose of 0.15 mg/kg of intravenous ondansetron every 4 hours for 3 doses would be expected to achieve a systemic exposure (AUC) consistent with the exposure achieved in previous pediatric studies in cancer patients (4 to 18 years of age) at similar doses.

    In a study of 21 pediatric patients (3 to 12 years of age) who were undergoing surgery requiring anesthesia for a duration of 45 minutes to 2 hours, a single intravenous dose of ondansetron, 2 mg (3 to 7 years) or 4 mg (8 to 12 years), was administered immediately prior to anesthesia induction. Mean weight-normalized clearance and volume of distribution values in these pediatric surgical patients were similar to those previously reported for young adults. Mean terminal half-life was slightly reduced in pediatric patients (range, 2.5 to 3 hours) in comparison with adults (range, 3 to 3.5 hours).

    In a study of 51 pediatric patients (1 month to 24 months of age) who were undergoing surgery requiring general anesthesia, a single intravenous dose of ondansetron, 0.1 or 0.2 mg/kg, was administered prior to surgery. As shown in Table 5, the 41 patients with pharmacokinetic data were divided into 2 groups, patients 1 month to 4 months of age and patients 5 to 24 months of age, and are compared to pediatric patients 3 to 12 years of age.

    Table 5. Pharmacokinetics in Pediatric Surgery Patients 1 Month to 12 Years of Age

    Subjects and Age Group
    N     		CL
    (L/h/kg)     		Vd ss
    (L/kg)     		T ½
    (h)
    Geometric Mean Mean
    Pediatric Surgery Patients
    3 to 12 years of age
    N = 21
    0.439
    1.65
    2.9
    Pediatric Surgery Patients
    5 to 24 months of age
    N = 22
    0.581
    2.3
    2.9
    Pediatric Surgery Patients
    1 month to 4 months of age
    N = 19
    0.401
    3.5
    6.7

    In general, surgical and cancer pediatric patients younger than 18 years tend to have a higher ondansetron clearance compared to adults leading to a shorter half-life in most pediatric patients. In patients 1 month to 4 months of age, a longer half-life was observed due to the higher volume of distribution in this age group.

    In a study of 21 pediatric cancer patients (4 to 18 years of age) who received three intravenous doses of 0.15 mg/kg of ondansetron at 4-hour intervals, patients older than 15 years of age exhibited ondansetron pharmacokinetic parameters similar to those of adults.

    Renal Impairment: Due to the very small contribution (5%) of renal clearance to the overall clearance, renal impairment was not expected to significantly influence the total clearance of ondansetron. However, ondansetron mean plasma clearance was reduced by about 41% in patients with severe renal impairment (creatinine clearance < 30 mL/min). This reduction in clearance is variable and was not consistent with an increase in half-life. No reduction in dose or dosing frequency in these patients is warranted.

    Hepatic Impairment: In patients with mild-to-moderate hepatic impairment, clearance is reduced 2-fold and mean half-life is increased to 11.6 hours compared to 5.7 hours in those without hepatic impairment. In patients with severe hepatic impairment (Child-Pugh score of 10 or greater), clearance is reduced 2-fold to 3-fold and apparent volume of distribution is increased with a resultant increase in half-life to 20 hours. In patients with severe hepatic impairment, a total daily dose of 8 mg should not be exceeded.

  • 13 NONCLINICAL TOXICOLOGY

    13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

    Carcinogenic effects were not seen in 2-year studies in rats and mice with oral ondansetron doses up to 10 and 30 mg/kg per day, respectively (approximately 3.6 and 5.4 times the recommended human intravenous dose of 0.15 mg/kg given three times a day, based on body surface area). Ondansetron was not mutagenic in standard tests for mutagenicity.

    Oral administration of ondansetron up to 15 mg/kg per day (approximately 3.8 times the recommended human intravenous dose, based on body surface area) did not affect fertility or general reproductive performance of male and female rats.

  • 14 CLINICAL STUDIES

    The clinical efficacy of ondansetron hydrochloride, the active ingredient of Ondansetron Injection, was assessed in clinical trials as described below.

    14.1 Chemotherapy-Induced Nausea and Vomiting

    Adults: In a double-blind study of three different dosing regimens of Ondansetron Injection, 0.015 mg/kg, 0.15 mg/kg, and 0.30 mg/kg, each given three times during the course of cancer chemotherapy, the 0.15-mg/kg dosing regimen was more effective than the 0.015-mg/kg dosing regimen. The 0.30-mg/kg dosing regimen was not shown to be more effective than the 0.15-mg/kg dosing regimen.

    Cisplatin-Based Chemotherapy: In a double-blind study in 28 patients, Ondansetron Injection (three 0.15-mg/kg doses) was significantly more effective than placebo in preventing nausea and vomiting induced by cisplatin-based chemotherapy. Therapeutic response was as shown in Table 6.

    Table 6. Therapeutic Response in Prevention of Chemotherapy-Induced Nausea and Vomiting in Single-Day Cisplatin Therapy a in Adults

    a Chemotherapy was high dose (100 and 120 mg/m 2; Ondansetron Injection n = 6, placebo n = 5) or moderate dose (50 and 80 mg/m 2; Ondansetron Injection n = 8, placebo n = 9). Other

    chemotherapeutic agents included fluorouracil, doxorubicin, and cyclophosphamide. There was no

    difference between treatments in the types of chemotherapy that would account for differences in

    response.

    b Efficacy based on "all patients treated" analysis.

    c Median undefined since at least 50% of the patients were rescued or had more than five emetic

    episodes.

    d Visual analog scale assessment of nausea: 0 = no nausea, 100 = nausea as bad as it can be.

    e Visual analog scale assessment of satisfaction: 0 = not at all satisfied, 100 = totally satisfied.

    Ondansetron Injection
    (0.15 mg/kg x 3)
    Placebo
    P Value b
    Number of patients 14 14
    Treatment response



       0 Emetic episodes
    		2 (14%)
    		0 (0%)

       1-2 Emetic episodes
    		8 (57%)
    		0 (0%)

       3-5 Emetic episodes
    		2 (14%)
    		1 (7%)
       More than 5 emetic
       episodes/rescued     		2 (14%) 13 (93%) 0.001
    Median number of emetic episodes 1.5 Undefined c
    Median time to first emetic episode (h) 11.6 2.8 0.001
    Median nausea scores (0-100) d3 59 0.034
    Global satisfaction with control of nausea and vomiting (0-100) e96 10.5 0.009

    Ondansetron injection (0.15-mg/kg x 3 doses) was compared with metoclopramide (2 mg/kg x 6 doses) in a single-blind trial in 307 patients receiving cisplatin ≥ 100 mg/m 2 with or without other chemotherapeutic agents. Patients received the first dose of ondansetron or metoclopramide 30 minutes before cisplatin. Two additional ondansetron doses were administered 4 and 8 hours later, or five additional metoclopramide doses were administered 2, 4, 7, 10, and 13 hours later. Cisplatin was administered over a period of 3 hours or less. Episodes of vomiting and retching were tabulated over the period of 24 hours after cisplatin. The results of this study are summarized in Table 7.

    Table 7. Therapeutic Response in Prevention of Vomiting Induced by Cisplatin (≥ 100 mg/m 2) Single-Day Therapy a in Adults

    a In addition to cisplatin, 68% of patients received other chemotherapeutic agents, including cyclophosphamide, etoposide, and fluorouracil. There was no difference between treatments in the types of chemotherapy that would account for differences in response.

    b Visual analog scale assessment: 0 = not at all satisfied, 100 = totally satisfied.

    Ondansetron Injection Metoclopramide P Value
    Dose 0.15 mg/kg x 3 2 mg/kg x 6
    Number of patients in efficacy population
    136
    138
    Treatment response


         0 Emetic episodes
    		54 (40%)
    		41 (30%)
         1-2 Emetic episodes
    		34 (25%)
    		30 (22%)
         3-5 Emetic episodes
    		19 (14%)
    		18 (13%)
         More than 5 emetic episodes/rescued 29 (21%) 49 (36%)
    Comparison of treatments with respect to



         0 Emetic episodes
    		54/136
    		41/138
    		0.083
         More than 5 emetic episodes/rescued 29/136 49/138 0.009
    Median number of emetic episodes 1 2 0.005
    Median time to first emetic episode (h) 20.5 4.3 < 0.001
    Global satisfaction with control of nausea and vomiting (0-100) b
    85
    63
    0.001
    Acute dystonic reactions 0 8 0.005
    Akathisia 0 10 0.002

    Cyclophosphamide-Based Chemotherapy: In a double-blind, placebo-controlled study of Ondansetron Injection (three 0.15-mg/kg doses) in 20 patients receiving cyclophosphamide (500 to 600 mg/m 2) chemotherapy, Ondansetron Injection was significantly more effective than placebo in preventing nausea and vomiting. The results are summarized in Table 8.

    Table 8. Therapeutic Response in Prevention of Chemotherapy-Induced Nausea and Vomiting in Single-Day Cyclophosphamide Therapy a in Adults

    a Chemotherapy consisted of cyclophosphamide in all patients, plus other agents, including

    fluorouracil, doxorubicin, methotrexate, and vincristine. There was no difference between

    treatments in the type of chemotherapy that would account for differences in response.

    b Efficacy based on "all patients treated" analysis.

    c Median undefined since at least 50% of patients did not have any emetic episodes.

    d Visual analog scale assessment of nausea: 0 = no nausea, 100 = nausea as bad as it can be.

    e Visual analog scale assessment of satisfaction: 0 = not at all satisfied, 100 = totally satisfied.

    Ondansetron Injection
    (0.15 mg/kg x 3)

    Placebo

    P Value b
    Number of patients 10 10
    Treatment response


         0 Emetic episodes
    		7 (70%)
    		0 (0%)
    		0.001
         1-2 Emetic episodes
    		0 (0%)
    		2 (20%)
         3-5 Emetic episodes
    		2 (20%)
    		4 (40%)
         More than 5 emetic episodes/rescued 1 (10%) 4 (40%) 0.131
    Median number of emetic episodes 0 4 0.008
    Median time to first emetic episode (h) Undefined c8.79
    Median nausea scores (0-100) d0 60 0.001
    Global satisfaction with control of nausea and vomiting (0-100) e100 52 0.008

    Re-treatment: In uncontrolled trials, 127 patients receiving cisplatin (median dose, 100 mg/m 2) and ondansetron who had two or fewer emetic episodes were re-treated with ondansetron and chemotherapy, mainly cisplatin, for a total of 269 re-treatment courses (median, 2; range, 1 to 10). No emetic episodes occurred in 160 (59%), and two or fewer emetic episodes occurred in 217 (81%) re-treatment courses.

    Pediatrics: Four open-label, noncomparative (one US, three foreign) trials have been performed with 209 pediatric cancer patients 4 to 18 years of age given a variety of cisplatin or noncisplatin regimens. In the three foreign trials, the initial Ondansetron injection dose ranged from 0.04 to 0.87 mg/kg for a total dose of 2.16 to 12 mg. This was followed by the oral administration of ondansetron ranging from 4 to 24 mg daily for 3 days. In the US trial, Ondansetron injection was administered intravenously (only) in three doses of 0.15 mg/kg each for a total daily dose of 7.2 to 39 mg. In these studies, 58% of the 196 evaluable patients had a complete response (no emetic episodes) on day 1. Thus, prevention of vomiting in these pediatric patients was essentially the same as for patients older than 18 years of age.

    An open-label, multicenter, noncomparative trial has been performed in 75 pediatric cancer patients 6 to 48 months of age receiving at least one moderately or highly emetogenic chemotherapeutic agent. Fifty-seven percent (57%) were females; 67% were white, 18% were American Hispanic, and 15% were black patients. Ondansetron Injection was administered intravenously over 15 minutes in three doses of 0.15 mg/kg. The first dose was administered 30 minutes before the start of chemotherapy, the second and third doses were administered 4 and 8 hours after the first dose, respectively. Eighteen patients (25%) received routine prophylactic dexamethasone (i.e., not given as rescue). Of the 75 evaluable patients, 56% had a complete response (no emetic episodes) on day 1. Thus, prevention of vomiting in these pediatric patients was comparable to the prevention of vomiting in patients 4 years of age and older.

    14.2 Prevention of Postoperative Nausea and/or Vomiting

    Adults: Adult surgical patients who received ondansetron immediately before the induction of general balanced anesthesia (barbiturate: thiopental, methohexital, or thiamylal; opioid: alfentanil or fentanyl; nitrous oxide; neuromuscular blockade: succinylcholine/curare and/or vecuronium or atracurium; and supplemental isoflurane) were evaluated in two double-blind US studies involving 554 patients. Ondansetron Injection (4 mg) intravenous given over 2 to 5 minutes was significantly more effective than placebo. The results of these studies are summarized in Table 9.

    Table 9. Therapeutic Response in Prevention of Postoperative Nausea and Vomiting in Adult Patients
    Ondansetron 4 mg Intravenous Placebo P Value
    Study 1
    Emetic episodes:

    Number of patients
    		136 139
    Treatment response over 24-h
    postoperative period
         0 Emetic episodes
    		103 (76%)
    		64 (46%)
    		< 0.001
         1 Emetic episode
    		13 (10%)
    		17 (12%)
         More than 1 emetic episode/rescued 20 (15%) 58 (42%)
    Nausea assessments:
    Number of patients
    No nausea over 24-h postoperative
    period
    134
    56 (42%)
    136
    39 (29%)
    Study 2
    Emetic episodes:
    Number of patients
    		136 143
    Treatment response over 24-h
    postoperative period
         0 Emetic episodes
    		85 (63%)
    		63 (44%)
    		0.002
         1 Emetic episode
    		16 (12%)
    		29 (20%)
         More than 1 emetic episode/rescued 35 (26%) 51 (36%)
    Nausea assessments:
    Number of patients
    No nausea over 24-h postoperative
    period     		125
    48 (38%)     		133
    42 (32%)

    The study populations in Table 9 consisted mainly of females undergoing laparoscopic procedures.

    In a placebo-controlled study conducted in 468 males undergoing outpatient procedures, a single 4-mg intravenous ondansetron dose prevented postoperative vomiting over a 24-hour study period in 79% of males receiving drug compared to 63% of males receiving placebo ( P < 0.001 ).

    Two other placebo-controlled studies were conducted in 2,792 patients undergoing major abdominal or gynecological surgeries to evaluate a single 4-mg or 8-mg intravenous ondansetron dose for prevention of postoperative nausea and vomiting over a 24-hour study period. At the 4-mg dosage, 59% of patients receiving ondansetron versus 45% receiving placebo in the first study ( P < 0.001) and 41% of patients receiving ondansetron versus 30% receiving placebo in the second study ( P = 0.001) experienced no emetic episodes. No additional benefit was observed in patients who received intravenous ondansetron 8 mg compared to patients who received intravenous ondansetron 4 mg.

    Pediatrics: Three double-blind, placebo-controlled studies have been performed (one US, two foreign) in 1,049 male and female patients (2 to 12 years of age) undergoing general anesthesia with nitrous oxide. The surgical procedures included tonsillectomy with or without adenoidectomy, strabismus surgery, herniorrhaphy, and orchidopexy. Patients were randomized to either single intravenous doses of ondansetron (0.1 mg/kg for pediatric patients weighing 40 kg or less, 4 mg for pediatric patients weighing more than 40 kg) or placebo. Study drug was administered over at least 30 seconds, immediately prior to or following anesthesia induction. Ondansetron was significantly more effective than placebo in preventing nausea and vomiting. The results of these studies are summarized in Table 10.

    Table 10. Therapeutic Response in Prevention of Postoperative Nausea and Vomiting in Pediatric Patients 2 to 12 Years of Age

    a Failure was one or more emetic episodes, rescued, or withdrawn.

    b Nausea measured as none, mild, or severe.

    Treatment Response Over 24 Hours Ondansetron
    n (%)     		Placebo
    n (%)
    P Value
    Study 1
    Number of patients
    0 Emetic episodes
    Failure a
    205
    140 (68%)
    65 (32%)
    210
    82 (39%)
    128 (61%)

    ≤ 0.001
    Study 2
    Number of patients
    0 Emetic episodes
    Failure a
    112
    68 (61%)
    44 (39%)
    110
    38 (35%)
    72 (65%)

    ≤ 0.001
    Study 3
    Number of patients
    0 Emetic episodes
    Failure a

    Nausea assessments b:
    Number of patients
    None
    206
    123 (60%)
    83 (40%)


    185
    119 (64%)
    206
    96 (47%)
    110 (53%)


    191
    99 (52%)

    ≤ 0.01



    ≤ 0.01

    A double-blind, multicenter, placebo-controlled study was conducted in 670 pediatric patients 1 month to 24 months of age who were undergoing routine surgery under general anesthesia. Seventy-five percent (75%) were males; 64% were white, 15% were black, 13% were American Hispanic, 2% were Asian, and 6% were “other race” patients. A single 0.1-mg/kg intravenous dose of ondansetron administered within 5 minutes following induction of anesthesia was statistically significantly more effective than placebo in preventing vomiting. In the placebo group, 28% of patients experienced vomiting compared to 11% of subjects who received ondansetron ( P ≤ 0.01). Overall, 32 (10%) of placebo patients and 18 (5%) of patients who received ondansetron received antiemetic rescue medication(s) or prematurely withdrew from the study.

    14.3 Prevention of Further Postoperative Nausea and Vomiting

    Adults: Adult surgical patients receiving general balanced anesthesia (barbiturate: thiopental, methohexital, or thiamylal; opioid: alfentanil or fentanyl; nitrous oxide; neuromuscular blockade: succinylcholine/curare and/or vecuronium or atracurium; and supplemental isoflurane) who received no prophylactic antiemetics and who experienced nausea and/or vomiting within 2 hours postoperatively were evaluated in two double-blind US studies involving 441 patients. Patients who experienced an episode of postoperative nausea and/or vomiting were given Ondansetron Injection (4 mg) intravenous over 2 to 5 minutes, and this was significantly more effective than placebo. The results of these studies are summarized in Table 11.

    Table 11. Therapeutic Response in Prevention of Further Postoperative Nausea and Vomiting in Adult Patients

    a After administration of study drug.

    b Nausea measured on a scale of 0-10 with 0 = no nausea, 10 = nausea as bad as it can be.

    Ondansetron 4 mg Intravenous Placebo P Value
    Study 1
    Emetic episodes:
    Number of patients
    		104 117
    Treatment response 24 h after study drug
         0 Emetic episodes
    		49 (47%)
    		19 (16%)
    		< 0.001
         1 Emetic episode
    		12 (12%)
    		9 (8%)
         More than 1 emetic episode/rescued
    		43 (41%)
    		89 (76%)
    Median time to first emetic episode (min) a55.0 43.0
    Nausea assessments:


    Number of patients
    		98
    		102
    Mean nausea score over 24-h postoperative
    period b    		1.7 3.1
    Study 2
    Emetic episodes:


    Number of patients
    		112 108
    Treatment response 24 h after study drug
         0 Emetic episodes
    		49 (44%)
    		28 (26%)
    		0.006
         1 Emetic episode
    		14 (13%)
    		3 (3%)
         More than 1 emetic episode/rescued
    		49 (44%)
    		77 (71%)
    Median time to first emetic episode (min) a60.5 34.0
    Nausea assessments:
    Number of patients
    Mean nausea score over 24-h postoperative
    period b
    105
    1.9
    85
    2.9

    The study populations in Table 11 consisted mainly of women undergoing laparoscopic procedures.

    Repeat Dosing in Adults: In patients who do not achieve adequate control of postoperative nausea and vomiting following a single, prophylactic, preinduction, intravenous dose of ondansetron 4 mg, administration of a second intravenous dose of ondansetron 4 mg postoperatively does not provide additional control of nausea and vomiting.

    Pediatrics: One double-blind, placebo-controlled, US study was performed in 351 male and female outpatients (2 to 12 years of age) who received general anesthesia with nitrous oxide and no prophylactic antiemetics. Surgical procedures were unrestricted. Patients who experienced two or more emetic episodes within 2 hours following discontinuation of nitrous oxide were randomized to either single intravenous doses of ondansetron (0.1 mg/kg for pediatric patients weighing 40 kg or less, 4 mg for pediatric patients weighing more than 40 kg) or placebo administered over at least 30 seconds. Ondansetron was significantly more effective than placebo in preventing further episodes of nausea and vomiting. The results of the study are summarized in Table 12.

    Table 12. Therapeutic Response in Prevention of Further Postoperative Nausea and Vomiting in Pediatric Patients 2 to 12 Years of Age

    a Failure was one or more emetic episodes, rescued, or withdrawn.

    Treatment Response Over 24 Hours Ondansetron
    n (%)     		Placebo
    n (%)     		P Value
    Number of patients
    0 Emetic episodes
    Failure a    		180
    96 (53%)
    84 (47%)     		171
    29 (17%)
    142 (83%)
    ≤ 0.001
  • 16 HOW SUPPLIED/STORAGE AND HANDLING

    Ondansetron Injection, USP 2 mg/mL is available as:

    4 mg/2 mL in a 2 mL pre-filled disposable single-use syringe, NDC: 76045-103-20

    Available in a carton of twenty-four (24) syringes.

    Store at 20° to 25°C (68° to 77°F) [See USP Controlled Room Temperature.]

    Product may also be stored in a refrigerator 2° to 8°C (36° to 46°F).

    Protect from light. Retain in carton until time of use.

    Do not place syringe on a sterile field

  • INSTRUCTIONS FOR USE

    Instructions For Use:

    CAUTION: Certain glass syringes may malfunction, break or clog when connected to some Needleless Luer Access Devices (NLADs) and needles. This syringe has a larger internal syringe tip and an external collar (luer collar). The external collar must remain attached to the syringe. Data show that the syringe achieves acceptable connections with the BD Eclipse™ Needle and the Terumo SurGuard2™ Safety Needle and with the following non-center post NLADs: Alaris SMARTSITE™, B-Braun ULTRASITE™, BD-Q SYTE™, Maximum MAX PLUS™, and B-Braun SAFSITE™. The data also show acceptable connections are achieved to the center post ICU Medical CLAVE™. However, spontaneous disconnection of this glass syringe from needles and NLADs with leakage of drug product may occur. Assure that the needle or NLAD is securely attached before beginning the injection. Visually inspect the glass syringe-needle or glass syringe –NLAD connection before and during drug administration. Do not remove the clear plastic wrap around the external collar. (See Figure 1)

    Figure 1

    Figure 1
    1. Inspect the outer packaging (blister pack) by verifying:
      • blister integrity
      • drug name
      • drug strength
      • dose volume
      • route of administration
      • expiration date to be sure that the drug has not expired
      • sterile field applicability

      Do not use if package has been damaged.

    2. Peel open the paper (top web) of the outer packaging that displays the product information to access the syringe. Do not pop syringe through.
    3. Bend the plastic part of the outer packaging (thermoform) so as to present the plunger rod for syringe removal. (See Figure 2)

      Figure 2

      Figure 2
    4. Perform visual inspection on the syringe by verifying:
      • absence of syringe damage
      • absence of external particles
      • absence of internal particles
      • proper drug color
      • expiration date to be sure that the drug has not expired
      • drug name
      • drug strength
      • dose volume
      • route of administration
      • sterile field applicability
      • integrity of the plastic wrap around the external collar
    5. Do not remove plastic wrap around the external collar. Push plunger rod slightly to break the stopper loose while tip cap is still on.
    6. Do not remove plastic wrap around the external collar. Remove tip cap by twisting it off. (See Figure 3)

      Figure 3

      Figure 3
    7. Discard the tip cap.
    8. Expel air bubble.
    9. Adjust dose into sterile material (if applicable).
    10. Connect the syringe to appropriate injection connection depending on route of administration. Before injection, ensure that the syringe is securely attached to the needle or needleless luer access device (NLAD).
    11. Depress plunger rod to deliver medication. Ensure that pressure is maintained on the plunger rod during the entire administration.
    12. Remove syringe from NLAD (if applicable) and discard into appropriate receptacle. If delivering medication via intramuscular (IM) route, do not recap needle. To prevent needle-stick injuries, needles should not be recapped.

    NOTES:

    • All steps must be done sequentially.
    • Do not autoclave syringe.
    • Do not use this product on a sterile field.
    • Do not introduce any other fluid into the syringe at any time.
    • This product is for single dose only.

    For more information concerning this drug, please call Fresenius Kabi USA, LLC at 1-800-551-7176.

    To report SUSPECTED ADVERSE REACTIONS, contact Fresenius Kabi USA, LLC at 1-800-551-7176 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

  • 17 PATIENT COUNSELING INFORMATION

    • Patients should be informed that Ondansetron Injection may cause serious cardiac arrhythmias such as QT prolongation. Patients should be instructed to tell their healthcare provider right away if they perceive a change in their heart rate, if they feel lightheaded, or if they have a syncopal episode.
    • Patients should be informed that the chances of developing severe cardiac arrhythmias such as QT prolongation and Torsade de Pointes are higher in the following people:
      • Patients with a personal or family history of abnormal heart rhythms, such as congenital long QT syndrome;
      • Patients who take medications, such as diuretics, which may cause electrolyte abnormalities
      • Patients with hypokalemia or hypomagnesemia

      Ondansetron Injection should be avoided in these patients, since they may be more at risk for cardiac arrhythmias such as QT prolongation and Torsade de Pointes.

    • Advise patients of the possibility of serotonin syndrome with concomitant use of Ondansetron and another serotonergic agent such as medications to treat depression and migraines. Advise patients to seek immediate medical attention if the following symptoms occur: changes in mental status, autonomic instability, neuromuscular symptoms with or without gastrointestinal symptoms.
    • Inform patients that Ondansetron Injection may cause hypersensitivity reactions, some as severe as anaphylaxis and bronchospasm. The patient should report any signs and symptoms of hypersensitivity reactions, including fever, chills, rash, or breathing problems.
    • The patient should report the use of all medications, especially apomorphine, to their healthcare provider. Concomitant use of apomorphine and Ondansetron Injection may cause a significant drop in blood pressure and loss of consciousness.
    • Inform patients that Ondansetron may cause headache, drowsiness/sedation, constipation, fever and diarrhea.

    The brand names mentioned in this document are the trademarks of their respective owners.

    FRESENIUS
    KABI
    Lake Zurich, IL 60047

    www.fresenius-kabi.us

    D1025P01

    Rev. 03/2016

  • PRINCIPAL DISPLAY PANEL

    PACKAGE LABEL - PRINCIPAL DISPLAY – Ondansetron 2 mL Carton Panel
    Rx only NDC: 76045-103-20
    Ondansetron Injection, USP
    4 mg/2 mL (2 mg/mL)
    For Intravenous or Intramuscular use.

    Do NOT place syringe on a Sterile Field.
    24 X 2     mL Prefilled single-use syringes
    Discard unused portion

    PACKAGE LABEL - PRINCIPAL DISPLAY – Ondansetron 2 mL Carton Panel
  • PRINCIPAL DISPLAY PANEL

    PACKAGE LABEL - PRINCIPAL DISPLAY - Ondansetron 2 mL Blister Pack Label
    Rx only NDC: 76045-103-20
    Ondansetron Injection, USP
    4 mg/2 mL (2 mg/mL)
    For IV or IM use.

    2 mL Prefilled single use syringe

    PACKAGE LABEL - PRINCIPAL DISPLAY - Ondansetron 2 mL Blister Pack Label
  • PRINCIPAL DISPLAY PANEL

    PACKAGE LABEL - PRINCIPAL DISPLAY - Ondansetron 2 mL Syringe Label
    For IV or IM use. 2 mL Single use.
    Ondansetron Injection, USP

    Rx only
    4 mg/2 mL (2 mg/mL)

    DILUTION REQUIRED FOR CHEMOTHERAPY INDUCED NAUSEA AND VOMITING.

    PACKAGE LABEL - PRINCIPAL DISPLAY - Ondansetron 2 mL Syringe Label
  • INGREDIENTS AND APPEARANCE
    ONDANSETRON 
    ondansetron hydrochloride injection, solution
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC: 76045-103
    Route of AdministrationINTRAVENOUS, INTRAMUSCULAR
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    ONDANSETRON HYDROCHLORIDE (UNII: NMH84OZK2B) (ONDANSETRON - UNII:4AF302ESOS) ONDANSETRON4 mg  in 2 mL
    Inactive Ingredients
    Ingredient NameStrength
    SODIUM CHLORIDE (UNII: 451W47IQ8X)  
    CITRIC ACID MONOHYDRATE (UNII: 2968PHW8QP)  
    TRISODIUM CITRATE DIHYDRATE (UNII: B22547B95K)  
    WATER (UNII: 059QF0KO0R)  
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC: 76045-103-2024 in 1 CARTON12/10/2015
    11 in 1 BLISTER PACK
    12 mL in 1 SYRINGE, GLASS; Type 2: Prefilled Drug Delivery Device/System (syringe, patch, etc.)
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    ANDAANDA20225312/10/2015
    Labeler - Fresenius Kabi USA, LLC (608775388)
    Establishment
    NameAddressID/FEIBusiness Operations
    Fresenius Kabi, USA LLC080381675manufacture(76045-103) , label(76045-103) , pack(76045-103)
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