CARMUSTINE

CARMUSTINE — carmustine
Heritage Pharmaceuticals Inc. d/b/a Avet Pharmaceuticals Inc.

1 INDICATIONS AND USAGE

Carmustine for Injection, USP is indicated as palliative therapy as a single agent or in established combination therapy in the following:

• Brain tumors glioblastoma, brainstem glioma, medulloblastoma, astrocytoma, ependymoma, and metastatic brain tumors.
• Multiple myeloma in combination with prednisone.
• Relapsed or refractory Hodgkin’s lymphoma in combination with other approved drugs.
• Relapsed or refractory Non-Hodgkin’s lymphomas in combination with other approved drugs.

2 DOSAGE AND ADMINISTRATION

2.1 Dosage

The recommended dose of Carmustine for Injection, USP as a single agent in previously untreated patients is 150 to 200 mg/m² intravenously every 6 weeks. Administer as a single dose or divided into daily injections such as 75 to 100 mg/m² on two successive days. Lower the dose when Carmustine for Injection is used with other myelosuppressive drugs or in patients in whom bone marrow reserve is depleted. Administer Carmustine for Injection for the duration according to the established regimen. Premedicate each dose with anti-emetics.

Adjust doses subsequent to the initial dose according to the hematologic response of the patient to the preceding dose. The following schedule is suggested as a guide to dosage adjustment:

Nadir After Prior Dose		Percentage of Prior Dose to be Given
Leukocytes/mm3	Platelets/mm3
>4000	>100,000	100%
3000-3999	75,000-99,999	100%
2000-2999	25,000-74,999	70%
<2000	<25,000	50%

The hematologic toxicity can be delayed and cumulative. Monitor blood counts weekly. Do not administer a repeat course of Carmustine for Injection, USP until circulating blood elements have returned to acceptable levels (platelets above 100 Gi/L, leukocytes above 4 Gi/L and absolute neutrophil count above 1 Gi/L). The usual interval between courses is 6 weeks.

Evaluate renal function prior to administration and periodically during treatment. For patients with compromised renal function, monitor for toxicity more frequently. Discontinue Carmustine for Injection, USP if the creatinine clearance is less than 10 mL/min. Do not administer Carmustine for Injection, USP to patients with compromised renal function. Monitor transaminases and bilirubin periodically during treatment. [see Adverse Reactions (6)].

2.2 Preparation and Administration of Intravenous Solution

• Dissolve Carmustine for Injection, USP with 3 mL of the supplied sterile diluent (Dehydrated Alcohol Injection, USP).
• Aseptically add 27 mL Sterile Water for Injection, USP.
  • Each mL of resulting solution contains 3.3 mg of Carmustine for Injection in 10% ethanol. Such solutions should be protected from light.
  • The reconstituted solution is a clear, colorless to yellowish solution.
• Once reconstituted, the solution must be further diluted with Sodium Chloride Injection, USP or 5% Dextrose Injection, USP.
  • Examine reconstituted vials for crystal formation prior to use. If crystals are observed, they may be re-dissolved by warming the vial to room temperature with agitation.
  • Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.
  • After reconstitution as recommended, Carmustine for Injection is stable for 24 hours under refrigeration (2°-8°C, 36°-46°F) in glass container. Examine reconstituted vials for crystal formation prior to use. If crystals are observed, they may be redissolved by warming the vial to room temperature with agitation.
  • Vials reconstituted as directed and further diluted with 500 mL Sodium Chloride Injection, USP or 5% Dextrose Injection, USP, in glass or polypropylene containers to a concentration of 0.2 mg/mL, should be stored at room temperature, protected from light and utilized within 8 hours. These solutions are also stable 24 hours under refrigeration (2°-8°C, 36°-46°F) and an additional 6 hours at room temperature protected from light.
• Administer reconstituted solution by slow intravenous infusion over at least two hours. Administration of Carmustine for Injection over a period of less than two hours can lead to pain and burning at the site of injection. Monitor the injected area during the administration. The rate of administration of the intravenous infusion should not be more than 1.66 mg/m² /min.
• See Section 16.2 for important instructions on the storage and handling of the injection. Carmustine for Injection is a cytotoxic drug. Follow applicable special handling and disposal procedures.¹
• The lyophilized dosage formulation contains no preservatives and is not intended for use as a multiple dose vial. Discard unused portion.

Accidental contact of reconstituted Carmustine for Injection, USP with the skin has caused transient hyperpigmentation of the affected areas. Wear impervious gloves to minimize the risk of dermal exposure impervious gloves when handling vials containing Carmustine for Injection. Immediately wash the skin or mucosa thoroughly with soap and water if Carmustine for Injection lyophilized material or solution contacts the skin or mucosa¹.

3 DOSAGE FORMS AND STRENGTHS

For injection: 100 mg of carmustine as a lyophilized powder in a single-dose vial for reconstitution and a vial containing 3 mL sterile diluent (Dehydrated Alcohol Injection, USP).

4 CONTRAINDICATIONS

Carmustine for Injection is contraindicated in patients with previous hypersensitivity to Carmustine for Injection or its components.

5 WARNINGS AND PRECAUTIONS

5.1 Myelosuppression

Bone marrow toxicity is a dose-limiting, common and severe toxic effect of Carmustine for Injection occurring 4-6 weeks after drug administration (thrombocytopenia occurs at about 4 weeks post-administration persisting for 1 to 2 weeks; leukopenia occurs at 5 to 6 weeks after a dose of Carmustine for Injection persisting for 1 to 2 weeks; thrombocytopenia is generally more severe than leukopenia; anemia is less frequent and less severe compared to thrombocytopenia and/or leukopenia) Complete blood count should therefore be monitored weekly for at least six weeks after a dose. Repeat doses of Carmustine for Injection should not be given more frequently than every six weeks. The bone marrow toxicity of Carmustine for Injection is cumulative and therefore the dosage adjustment must be considered on the basis of nadir blood counts from prior dose [see Adverse Reactions (6)]. Greater myelotoxicity (e.g., leukopenia and neutropenia) has been reported when carmustine was combined with cimetidine [see Drug Interactions (7)].