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warnings and cautions
5 WARNINGS AND PRECAUTIONS KYTRIL does not stimulate gastric or intestinal peristalsis and should not be used instead of nasogastric suction. ( 5.1 ) QT prolongation has been reported with KYTRIL. Use with caution in patients with pre-existing arrhythmias or cardiac conduction disorders. ( 5.2 ) Hypersensitivity reactions, such as anaphylaxis, shortness of breath, hypotension, and urticaria, may occur in patients with known hypersensitivity to other selective 5-HT3 receptor antagonists. ( 5.3 ) Contains benzyl alcohol. ( 5.4 ) 5.1 Gastric or Intestinal Peristalsis KYTRIL is not a drug that stimulates gastric or intestinal peristalsis. It should not be used instead of nasogastric suction. The use of KYTRIL in patients following abdominal surgery or in patients with chemotherapy-induced nausea and vomiting may mask a progressive ileus and/or gastric distention. 5.2 Cardiovascular Events An adequate QT assessment has not been conducted, but QT prolongation has been reported with KYTRIL. Therefore, KYTRIL should be used with caution in patients with pre-existing arrhythmias or cardiac conduction disorders, as this might lead to clinical consequences. Patients with cardiac disease, on cardio-toxic chemotherapy, with concomitant electrolyte abnormalities and/or on concomitant medications that prolong the QT interval are particularly at risk. 5.3 Hypersensitivity Reactions Hypersensitivity reactions (eg. anaphylaxis, shortness of breath, hypotension, urticaria) may occur in patients who have exhibited hypersensitivity to other selective 5-HT 3 receptor antagonists 5.4 Benzyl Alcohol KYTRIL 1 mg/mL contains benzyl alcohol. Benzyl alcohol, a component of KYTRIL 1 mg/mL, has been associated with serious adverse reactions and death, particularly in neonates. The "gasping syndrome," characterized by central nervous system depression, metabolic acidosis, gasping respirations, and high levels of benzyl alcohol and metabolites in blood and urine, has been associated with benzyl alcohol dosages >99 mg/kg/day in neonates and low birth-weight neonates. Additional symptoms may include gradual neurological deterioration, seizures, intracranial hemorrhage, hematologic abnormalities, skin breakdown, hepatic and renal failure, hypotension, bradycardia, and cardiovascular collapse. Although normal therapeutic doses of this product deliver amounts of benzyl alcohol that are substantially lower than those reported in association with the "gasping syndrome," the minimum amount of benzyl alcohol at which toxicity may occur is not known. Premature and low birth-weight infants, as well as patients receiving high dosages, may be more likely to develop toxicity. Practitioners administering this and other medications containing benzyl alcohol should consider the combined daily metabolic load of benzyl alcohol from all sources.
6 ADVERSE REACTIONS QT prolongation has been reported with KYTRIL [see Warnings and Precautions (5.2) and Drug Interactions (7) ] . Most common adverse reactions: Chemotherapy-induced nausea and vomiting (≥3%): Headache, and constipation ( 6.1 ) Postoperative nausea and vomiting (≥2%): Pain, headache, fever, abdominal pain and hepatic enzymes increased ( 6.1 ) To report SUSPECTED ADVERSE REACTIONS, contact Genentech at 1-800-835-2555 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. 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 patients. Chemotherapy-Induced Nausea and Vomiting The following have been reported during controlled clinical trials or in the routine management of patients. The percentage figures are based on clinical trial experience only. Table 1 gives the comparative frequencies of the two most commonly reported adverse reactions (≥3%) in patients receiving KYTRIL Injection, in single-day chemotherapy trials. These patients received chemotherapy, primarily cisplatin, and intravenous fluids during the 24-hour period following KYTRIL Injection administration. Reactions were generally recorded over seven days post-KYTRIL Injection administration. Table 1 Principal Adverse Reactions in Clinical Trials — Single-Day Chemotherapy Percent of Patients With Reaction KYTRIL Injection 40 mcg/kg (n=1268) Comparator Metoclopramide/dexamethasone and phenothiazines/dexamethasone. (n=422) Headache 14% 6% Constipation 3% 3% Additional adverse events reported in clinical trials were asthenia, somnolence and diarrhea. In over 3,000 patients receiving KYTRIL Injection (2 to 160 mcg/kg) in single-day and multiple-day clinical trials with emetogenic cancer therapies, adverse events, other than those adverse reactions listed in Table 1 , were observed; attribution of many of these events to KYTRIL is uncertain. Hepatic: In comparative trials, mainly with cisplatin regimens, elevations of AST and ALT (>2 times the upper limit of normal) following administration of KYTRIL Injection occurred in 2.8% and 3.3% of patients, respectively. These frequencies were not significantly different from those seen with comparators (AST: 2.1%; ALT: 2.4%). Cardiovascular: Hypertension (2%); hypotension, arrhythmias such as sinus bradycardia, atrial fibrillation, varying degrees of A-V block, ventricular ectopy including non-sustained tachycardia, and ECG abnormalities have been observed rarely. Central Nervous System: Agitation, anxiety, CNS stimulation and insomnia were seen in less than 2% of patients. Extrapyramidal syndrome occurred rarely and only in the presence of other drugs associated with this syndrome. Hypersensitivity: Rare cases of hypersensitivity reactions, sometimes severe (eg, anaphylaxis, shortness of breath, hypotension, urticaria) have been reported. Other: Fever (3%), taste disorder (2%), skin rashes (1%). In multiple-day comparative studies, fever occurred more frequently with KYTRIL Injection (8.6%) than with comparative drugs (3.4%, P<0.014), which usually included dexamethasone. Postoperative Nausea and Vomiting The adverse reactions listed in Table 2 were reported in ≥2% of adults receiving KYTRIL Injection 1 mg during controlled clinical trials. Table 2 Adverse Reactions in Controlled Clinical Trials in Postoperative Nausea and Vomiting (Reported in ≥ 2% of Adults Receiving KYTRIL Injection 1 mg) Percent of Patients With Reaction KYTRIL Injection 1 mg (n=267) Placebo (n=266) Pain 10.1 8.3 Headache 8.6 7.1 Fever 7.9 4.5 Abdominal Pain 6.0 6.0 Hepatic Enzymes Increased 5.6 4.1 Dizziness 4.1 3.4 Diarrhea 3.4 1.1 Flatulence 3.0 3.0 Dyspepsia 3.0 1.9 Oliguria 2.2 1.5 Coughing 2.2 1.1 Additional adverse events reported in clinical trials were constipation, anemia, insomnia, bradycardia, leukocytosis, anxiety, hypotension, infection, hypertension, and urinary tract infection. In a clinical study conducted in Japan, the types of adverse events differed notably from those reported above in Table 2 . The adverse events in the Japanese study that occurred in ≥2% of patients and were more frequent with KYTRIL 1 mg than with placebo were: fever (56% to 50%), sputum increased (2.7% to 1.7%), and dermatitis (2.7% to 0%). 6.2 Postmarketing Experience The following adverse reactions have been identified during post approval use of KYTRIL. 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 KYTRIL exposure. QT prolongation has been reported with KYTRIL [see Warnings and Precautions (5.2) and Drug Interactions (7) ] .