DOSAGE AND ADMINISTRATION
Usage and Administration Precautions
Liposomal encapsulation can substantially affect a drug's functional properties relative to those of the unencapsulated drug. Therefore DO NOT SUBSTITUTE one drug for the other.
Do not administer as a bolus injection or an undiluted solution. Rapid infusion may increase the risk of infusion-related reactions [see Warnings and Precautions]. DOXIL must not be given by the intramuscular or subcutaneous route.
Until specific compatibility data are available, it is not recommended that DOXIL be mixed with other drugs.
DOXIL should be considered an irritant and precautions should be taken to avoid extravasation. With intravenous administration of DOXIL, extravasation may occur with or without an accompanying stinging or burning sensation, even if blood returns well on aspiration of the infusion needle. If any signs or symptoms of extravasation have occurred, the infusion should be immediately terminated and restarted in another vein. The application of ice over the site of extravasation for approximately 30 minutes may be helpful in alleviating the local reaction.
Patients With Ovarian Cancer
DOXIL (doxorubicin HCl liposome injection) should be administered intravenously at a dose of 50 mg/m2 (doxorubicin HCl equivalent) at an initial rate of 1 mg/min to minimize the risk of infusion reactions. If no infusion-related adverse reactions are observed, the rate of infusion can be increased to complete administration of the drug over one hour. The patient should be dosed once every 4 weeks, for as long as the patient does not progress, shows no evidence of cardiotoxicity [see Warnings and Precautions], and continues to tolerate treatment. A minimum of 4 courses is recommended because median time to response in clinical trials was 4 months. To manage adverse reactions such as hand-foot syndrome (HFS), stomatitis, or hematologic toxicity the doses may be delayed or reduced [see Dosage and Administration]. Pretreatment with or concomitant use of antiemetics should be considered.
Patients With AIDS-Related Kaposi's Sarcoma
DOXIL (doxorubicin HCl liposome injection) should be administered intravenously at a dose of 20 mg/m2 (doxorubicin HCl equivalent). An initial rate of 1 mg/min should be used to minimize the risk of infusion-related reactions. If no infusion-related adverse reactions are observed, the infusion rate should be increased to complete the administration of the drug over one hour. The dose should be repeated once every three weeks, for as long as patients respond satisfactorily and tolerate treatment.
Patients With Multiple Myeloma
Bortezomib is administered at a dose of 1.3 mg/m2 as intravenous bolus on days 1, 4, 8 and 11, every three weeks. DOXIL 30 mg/m2 should be administered as a 1-hr intravenous infusion on day 4 following bortezomib. With the first DOXIL dose, an initial rate of 1 mg/min should be used to minimize the risk of infusion-related reactions. If no infusion-related adverse reactions are observed, the infusion rate should be increased to complete the administration of the drug over one hour. Patients may be treated for up to 8 cycles until disease progression or the occurrence of unacceptable toxicity.
Dose Modification Guidelines
DOXIL exhibits nonlinear pharmacokinetics at 50 mg/m2; therefore, dose adjustments may result in a non-proportional greater change in plasma concentration and exposure to the drug [see Clinical Pharmacology].
Patients should be carefully monitored for toxicity. Adverse reactions, such as HFS, hematologic toxicities, and stomatitis may be managed by dose delays and adjustments. Following the first appearance of a Grade 2 or higher adverse reactions, the dosing should be adjusted or delayed as described in the following tables. Once the dose has been reduced, it should not be increased at a later time.
Recommended Dose Modification Guidelines
Table 1: Hand-Foot Syndrome (HFS)
Toxicity Grade |
Dose Adjustment |
1
(mild erythema, swelling, or desquamation not interfering with daily activities) |
Redose unless patient has experienced previous Grade 3 or 4 HFS. If so, delay up to 2 weeks and decrease dose by 25%. Return to original dose interval. |
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|
2
(erythema, desquamation, or swelling interfering with, but not precluding normal physical activities; small blisters or ulcerations less than 2 cm in diameter) |
Delay dosing up to 2 weeks or until resolved to Grade 0–1. If after 2 weeks there is no resolution, DOXIL should be discontinued. If resolved to Grade 0–1 within 2 weeks, and there are no prior Grade 3–4 HFS, continue treatment at previous dose and return to original dose interval. If patient experienced previous Grade 3–4 toxicity, continue treatment with a 25% dose reduction and return to original dose interval. |
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|
3
(blistering, ulceration, or swelling interfering with walking or normal daily activities; cannot wear regular clothing) |
Delay dosing up to 2 weeks or until resolved to Grade 0–1. Decrease dose by 25% and return to original dose interval. If after 2 weeks there is no resolution, DOXIL should be discontinued. |
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|
4
(diffuse or local process causing infectious complications, or a bed ridden state or hospitalization) |
Delay dosing up to 2 weeks or until resolved to Grade 0–1. Decrease dose by 25% and return to original dose interval. If after 2 weeks there is no resolution, DOXIL should be discontinued. |
Table 2: Hematological Toxicity
Grade |
ANC |
Platelets |
Modification |
1
|
1,500 – 1,900 |
75,000 – 150,000 |
Resume treatment with no dose reduction |
2
|
1,000 – <1,500 |
50,000 – <75,000 |
Wait until ANC ≥ 1,500 and platelets ≥ 75,000; redose with no dose reduction |
3
|
500 – 999 |
25,000 – <50,000 |
Wait until ANC ≥ 1,500 and platelets ≥ 75,000; redose with no dose reduction |
4
|
<500 |
<25,000 |
Wait until ANC ≥ 1,500 and platelets ≥ 75,000; redose at 25% dose reduction or continue full dose with cytokine support |
Table 3: Stomatitis
Toxicity Grade |
Dose Adjustment |
1
(painless ulcers, erythema, or mild soreness) |
Redose unless patient has experienced previous Grade 3 or 4 toxicity. If so, delay up to 2 weeks and decrease dose by 25%. Return to original dose interval. |
|
|
2
(painful erythema, edema, or ulcers, but can eat) |
Delay dosing up to 2 weeks or until resolved to Grade 0–1. If after 2 weeks there is no resolution, DOXIL should be discontinued. If resolved to Grade 0–1 within 2 weeks and there was no prior Grade 3–4 stomatitis, continue treatment at previous dose and return to original dose interval. If patient experienced previous Grade 3–4 toxicity, continue treatment with a 25% dose reduction and return to original dose interval.
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|
|
3
(painful erythema, edema, or ulcers, and cannot eat) |
Delay dosing up to 2 weeks or until resolved to Grade 0–1. Decrease dose by 25% and return to original dose interval. If after 2 weeks there is no resolution, DOXIL should be discontinued. |
|
|
4
(requires parenteral or enteral support) |
Delay dosing up to 2 weeks or until resolved to Grade 0–1. Decrease dose by 25% and return to DOXIL original dose interval. If after 2 weeks there is no resolution, DOXIL should be discontinued. |
Multiple Myeloma
For patients treated with DOXIL in combination with bortezomib who experience hand-foot syndrome or stomatitis, the DOXIL dose should be modified as described in Tables 1 and 3 above. Table 4 describes dosage adjustments for DOXIL and bortezomib combination therapy. For bortezomib dosing and dosage adjustments, see manufacturer's prescribing information.
Table 4: Dosage adjustments for DOXIL + bortezomib combination therapy
Patient status |
DOXIL |
bortezomib |
Fever ≥38°C and ANC <1,000/mm3
|
Do not dose this cycle if before Day 4; if after Day 4, reduce next dose by 25%. |
Reduce next dose by 25% |
|
|
|
On any day of drug administration after Day 1 of each cycle: Platelet count <25,000/mm3 Hemoglobin <8g/dL ANC <500/mm3
|
Do not dose this cycle if before Day 4; if after Day 4 reduce next dose by 25% in the following cycles if bortezomib is reduced for hematologic toxicity. |
Do not dose; if 2 or more doses are not given in a cycle, reduce dose by 25% in following cycles. |
|
|
|
Grade 3 or 4 non-hematologic drug related toxicity |
Do not dose until recovered to Grade <2 and reduce dose by 25% for all subsequent doses. |
Do not dose until recovered to Grade <2 and reduce dose by 25% for all subsequent doses. |
|
|
|
Neuropathic pain or peripheral neuropathy |
No dosage adjustments. |
See bortezomib manufacturer's prescribing information for dosage adjustments in patients with neuropathic pain. |
Patients With Impaired Hepatic Function
Limited clinical experience exists in treating patients with hepatic impairment with DOXIL. Based on experience with doxorubicin HCl, it is recommended that the DOXIL dosage be reduced if the bilirubin is elevated as follows: serum bilirubin 1.2 to 3.0 mg/dL - give ½ normal dose; serum bilirubin > 3 mg/dL - give ¼ normal dose.
No information, including dosage adjustments, is available for patients with multiple myeloma with hepatic impairment.
Preparation for Intravenous Administration
Each 10-mL vial contains 20 mg doxorubicin HCl at a concentration of 2 mg/mL.
Each 30-mL vial contains 50 mg doxorubicin HCl at a concentration of 2 mg/mL.
DOXIL doses up to 90 mg must be diluted in 250 mL of 5% Dextrose Injection, USP prior to administration. Doses exceeding 90 mg should be diluted in 500 mL of 5% Dextrose Injection, USP prior to administration. Aseptic technique must be strictly observed since no preservative or bacteriostatic agent is present in DOXIL. Diluted DOXIL should be refrigerated at 2°C to 8°C (36°F to 46°F) and administered within 24 hours.
Do not use with in-line filters.
Do not mix with other drugs.
Do not use with any diluent other than 5% Dextrose Injection.
Do not use any bacteriostatic agent, such as benzyl alcohol.
DOXIL is not a clear solution but a translucent, red liposomal dispersion.
Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Do not use if a precipitate or foreign matter is present.
Rapid flushing of the infusion line should be avoided.
Procedure for Proper Handling and Disposal
Caution should be exercised in the handling and preparation of DOXIL.
The use of gloves is required.
If DOXIL comes into contact with skin or mucosa, immediately wash thoroughly with soap and water.
DOXIL should be considered an irritant and precautions should be taken to avoid extravasation. With intravenous administration of DOXIL, extravasation may occur with or without an accompanying stinging or burning sensation, even if blood returns well on aspiration of the infusion needle. If any signs or symptoms of extravasation have occurred, the infusion should be immediately terminated and restarted in another vein. DOXIL must not be given by the intramuscular or subcutaneous route.
DOXIL should be handled and disposed of in a manner consistent with other anticancer drugs. Several guidelines on this subject exist [see References].
DOSAGE FORMS AND STRENGTHS
- Single use vial: 20 mg/10 mL
- Single use vial: 50 mg/25 mL
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