PALONOSETRON- palonosetron hydrochloride injection, solution
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Palonosetron hydrochloride injection is indicated in adults for prevention of:
- acute and delayed nausea and vomiting associated with initial and repeat courses of moderately emetogenic cancer chemotherapy (MEC).
- acute nausea and vomiting associated with initial and repeat courses highly emetogenic cancer chemotherapy (HEC).
- postoperative nausea and vomiting (PONV) for up to 24 hours following surgery. Efficacy beyond 24 hours has not been demonstrated.
As with other antiemetics, routine prophylaxis is not recommended in patients in whom there is little expectation that nausea and/or vomiting will occur postoperatively. In patients where nausea and vomiting must be avoided during the postoperative period, palonosetron hydrochloride is recommended even where the incidence of postoperative nausea and/or vomiting is low.
Palonosetron hydrochloride injection is indicated in pediatric patients 1 month to less than 17 years of age for prevention of:
- acute nausea and vomiting associated with initial and repeat courses of emetogenic cancer chemotherapy, including highly emetogenic cancer chemotherapy.
Prevention of Chemotherapy-Induced Nausea and Vomiting
The recommended dosage of palonosetron hydrochloride injection for prevention of nausea and vomiting associated with HEC and MEC in adults and associated with emetogenic chemotherapy, including HEC in pediatric patients 1 month to less than 17 years of age is shown in Table 1.
|Age||Dose *||Infusion Time|
|Adults||0.25 mg as a single dose||Infuse over 30 seconds beginning approximately 30 minutes before the start of chemotherapy|
|Pediatrics(1 month to less than 17 years)||20 micrograms per kilogram (max 1.5 mg) as a single dose||Infuse over 15 minutes beginning approximately 30 minutes before the start of chemotherapy|
Postoperative Nausea and Vomiting
The recommended dosage of palonosetron hydrochloride injection in adults for PONV is 0.075 mg administered as a single intravenous dose over 10 seconds immediately before the induction of anesthesia.
- Palonosetron hydrochloride injection is supplied ready for intravenous administration at a concentration of 0.05 mg/mL (50 mcg/mL).
- Do not mix palonosetron hydrochloride injection with other drugs.
- Flush the infusion line with normal saline before and after administration of palonosetron hydrochloride injection.
- Inspect palonosetron hydrochloride injection visually for particulate matter and discoloration before administration.
- Discard unused portion.
Palonosetron hydrochloride injection is sterile, clear, and colorless solution:
- 0.25 mg palonosetron in 5 mL (0.05 mg/mL) in a single-dose vial
Palonosetron hydrochloride is contraindicated in patients known to have hypersensitivity to palonosetron [see Warnings and Precautions (5.1)].
Hypersensitivity reactions, including anaphylaxis and anaphylactic shock, have been reported with administration of palonosetron hydrochloride injection [see Adverse Reactions (6.2)]. These reactions occurred in patients with or without known hypersensitivity to other 5-HT3 receptor antagonists. If hypersensitivity reactions occur, discontinue palonosetron hydrochloride injection and initiate appropriate medical treatment. Do not reinitiate palonosetron hydrochloride injection in patients who have previously experienced symptoms of hypersensitivity [see Contraindications (4)].
The development of serotonin syndrome has been reported with 5-HT 3 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 another 5-HT 3 receptor antagonist alone has also been reported. The majority of reports of serotonin syndrome related to 5-HT 3 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 palonosetron hydrochloride and other serotonergic drugs. If symptoms of serotonin syndrome occur, discontinue palonosetron hydrochloride and initiate supportive treatment. Patients should be informed of the increased risk of serotonin syndrome, especially if palonosetron hydrochloride is used concomitantly with other serotonergic drugs [ see Drug Interactions (7.1)].
Serious or otherwise clinically significant adverse reactions reported in other sections of labeling:
- Hypersensitivity Reactions [see Warnings and Precautions (5.1)]
- Serotonin Syndrome [see Warnings and Precautions (5.2)]
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.
Chemotherapy-Induced Nausea and Vomiting
In double-blind randomized clinical trials for the prevention of nausea and vomiting induced by MEC or HEC, 1374 adult patients received a single dose of palonosetron hydrochloride injection, ondansetron (Studies 1 and 3) or dolasetron (Study 2) administered 30 minutes prior to chemotherapy [see Clinical Studies (14.1)]. Adverse reactions were similar in frequency and severity in all 3 treatment groups. Common adverse reactions reported in at least 2% of patients in these trials are shown in Table 2.
|Adverse Reaction||Palonosetron hydrochloride injection 0.25 mg intravenously (N=633)||Ondansetron 32 mg intravenously (N=410)||Dolasetron 100 mg intravenously (N=194)|
|Abdominal Pain||< 1%||< 1%||2%|
Less common adverse reactions, reported in 1% or less of patients, in Studies 1, 2 and 3 were:
- Cardiovascular: non-sustained tachycardia, bradycardia, hypotension, hypertension, myocardial ischemia, extrasystoles, sinus tachycardia, sinus arrhythmia, supraventricular extrasystoles and QT prolongation.
- Dermatological: allergic dermatitis, rash
- Hearing and Vision: motion sickness, tinnitus, eye irritation and amblyopia
- Gastrointestinal System: diarrhea, dyspepsia, abdominal pain, dry mouth, hiccups and flatulence
- General: weakness, fatigue, fever, hot flash, flu-like syndrome
- Liver: transient, asymptomatic increases in AST and/or ALT and bilirubin. These changes occurred predominantly in patients receiving highly emetogenic chemotherapy
- Metabolic: hyperkalemia, electrolyte fluctuations, hyperglycemia, metabolic acidosis, glycosuria, appetite decrease, anorexia
- Musculoskeletal: arthralgia
- Nervous System: dizziness, somnolence, insomnia, hypersomnia, paresthesia
- Psychiatric: anxiety, euphoric mood
- Urinary System: urinary retention
- Vascular: vein discoloration, vein distention
In other studies, 2 subjects experienced severe constipation following a single palonosetron hydrochloride injection dose of approximately 0.75 mg (three times the recommended dose).
Pediatrics Aged 2 Months to 17 Years
In a pediatric clinical trial, 163 pediatric cancer patients with a mean age of 8 years received a single 20 mcg/kg (maximum 1.5 mg) intravenous infusion of palonosetron hydrochloride injection 30 minutes before beginning the first cycle of emetogenic chemotherapy [see Clinical Studies (14.2)]. Adverse reactions were evaluated in pediatric patients receiving palonosetron hydrochloride injection for up to 4 chemotherapy cycles. The following adverse reactions were reported in less than 1% of patients:
- Nervous System: headache, dizziness, dyskinesia.
- General: infusion site pain.
- Dermatological: allergic dermatitis, skin disorder.
Postoperative Nausea and Vomiting
The most common adverse reactions reported in at least 2% of adults receiving palonosetron hydrochloride injection 0.075 mg intravenously immediately before induction of anesthesia in 3 randomized placebo-controlled trials [see Clinical Studies (14.3)] are shown in Table 3. Rates of adverse reactions between palonosetron hydrochloride injection and placebo groups were similar. Some events are known to be associated with, or may be exacerbated by, concomitant perioperative and intraoperative medications administered in this surgical population. A thorough QT/QTc study demonstrated palonosetron hydrochloride injection does not prolong the QT interval to any clinically relevant extent [see Clinical Pharmacology (12.2)].
|Adverse Reaction||Palonosetron hydrochloride injection 0.075 mg intravenously (N=336)||Placebo (N=369)|
|Electrocardiogram QT prolongation||5%||3%|
Less common adverse reactions, reported in 1% of less of patients, in these PONV clinical trials were:
- Cardiovascular: QTc prolongation, sinus bradycardia, tachycardia, blood pressure decreased, hypotension, hypertension, arrhythmia, ventricular extrasystoles, generalized edema, ECG T wave amplitude decreased, platelet count decreased. The frequency of these adverse effects did not appear to be different from placebo.
- Dermatological: pruritus
- Gastrointestinal System: flatulence, dry mouth, upper abdominal pain, salivary hypersecretion, dyspepsia, diarrhea, intestinal hypomotility, anorexia
- General: chills
- Liver: increases in AST and/or ALT, hepatic enzyme increased
- Metabolic: hypokalemia, anorexia
- Nervous System: dizziness
- Respiratory: hypoventilation, laryngospasm
- Urinary System: urinary retention
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