Azacitidine: Package Insert and Label Information

AZACITIDINE- azacitidine injection, powder, lyophilized, for solution
Meitheal Pharmaceuticals Inc.

1 INDICATIONS AND USAGE

1.1 Myelodysplastic Syndromes (MDS)

Azacitidine for Injection is indicated for treatment of patients with the following French-American-British (FAB) myelodysplastic syndrome subtypes: refractory anemia (RA) or refractory anemia with ringed sideroblasts (if accompanied by neutropenia or thrombocytopenia or requiring transfusions), refractory anemia with excess blasts (RAEB), refractory anemia with excess blasts in transformation (RAEB-T), and chronic myelomonocytic leukemia (CMMoL).

2 DOSAGE AND ADMINISTRATION

2.1 First Treatment Cycle

The recommended starting dose for the first treatment cycle, for all patients regardless of baseline hematology laboratory values, is 75 mg/m2 subcutaneously or intravenously, daily for 7 days. Premedicate patients for nausea and vomiting.

Obtain complete blood counts, liver chemistries and serum creatinine prior to the first dose.

2.2 Subsequent Treatment Cycles

Repeat cycles every 4 weeks. The dose may be increased to 100 mg/m2 if no beneficial effect is seen after 2 treatment cycles and if no toxicity other than nausea and vomiting has occurred. It is recommended that patients be treated for a minimum of 4 to 6 cycles. However, complete or partial response may require additional treatment cycles. Treatment may be continued as long as the patient continues to benefit.

Monitor patients for hematologic response and renal toxicities [see Warnings and Precautions (5.3)], and delay or reduce dosage if necessary as described below.

2.3 Dosage Adjustment Based on Hematology Laboratory Values

  • For patients with baseline (start of treatment) WBC greater than or equal to 3.0 x109 /L, ANC greater than or equal to 1.5 x109 /L, and platelets greater than or equal to 75.0 x109 /L, adjust the dose as follows, based on nadir counts for any given cycle:
    Nadir Counts % Dose in the Next Course
    ANC (x109 /L)Less than 0.50.5 –1.5Greater than 1.5 Platelets (x109 /L)Less than 2525-50Greater than 50 50%67%100%
  • For patients whose baseline counts are WBC less than 3.0 x109 /L, ANC less than 1.5 x109 /L, or platelets less than 75.0 x109 /L, base dose adjustments on nadir counts and bone marrow biopsy cellularity at the time of the nadir as noted below, unless there is clear improvement in differentiation (percentage of mature granulocytes is higher and ANC is higher than at onset of that course) at the time of the next cycle, in which case continue the current dose.
    WBC or PlateletNadir% decrease in Bone MarrowBiopsy Cellularity at Time of Nadir(%)
    countsfrom baseline 30-60 15-30 Less than 15
    50 – 75Greater than 75 % Dose in the Next Course
    100 50 33
    75 50 33

    If a nadir as defined in the table above has occurred, give the next course 28 days after the start of the preceding course, provided that both the WBC and the platelet counts are greater than 25% above the nadir and rising. If a greater than 25% increase above the nadir is not seen by day 28, reassess counts every 7 days. If a 25% increase is not seen by day 42, reduce the scheduled dose by 50%.

2.4 Dosage Adjustment Based on Serum Electrolytes and Renal Toxicity

If unexplained reductions in serum bicarbonate levels to less than 20 mEq/L occur, reduce the dosage by 50% for the next course. Similarly, if unexplained elevations of BUN or serum creatinine occur, delay the next cycle until values return to normal or baseline and reduce the dose by 50% for the next course [see Warnings and Precautions (5.3)].

2.5 Use in Geriatric Patients

Azacitidine and its metabolites are known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, select the dose carefully and monitor renal function [see Warnings and Precautions (5.3) and Use in Specific Populations (8.5)].

2.6 Preparation of Azacitidine for Injection

Azacitidine for injection is a cytotoxic drug. Follow applicable special handling and disposal procedures.1

The azacitidine for injection vial is single-dose and does not contain any preservatives. Discard unused portions of each vial properly [see How Supplied/Storage and Handling (16)]. Do not save any unused portions for later administration.

2.7 Instructions for Subcutaneous Administration

Reconstitute azacitidine for injection aseptically with 4 mL sterile water for injection. Inject the diluent slowly into the vial. Vigorously shake or roll the vial until a uniform suspension is achieved. The suspension will be cloudy. The resulting suspension will contain azacitidine 25 mg per mL. Do not filter the suspension after reconstitution. Doing so could remove the active substance.

Preparation for Immediate Subcutaneous Administration

For doses requiring more than 1 vial, divide the dose equally between the syringes (e.g., dose 150 mg = 6 mL, 2 syringes with 3 mL in each syringe) and inject into two separate sites. Due to retention in the vial and needle, it may not be feasible to withdraw all of the suspension from the vial. The product may be held at room temperature for up to 1 hour, but must be administered within 1 hour after reconstitution.

Preparation for Delayed Subcutaneous Administration

The reconstituted product may be kept in the vial or drawn into a syringe. For doses requiring more than 1 vial, divide the dose equally between the syringes (e.g., dose 150 mg = 6 mL, 2 syringes with 3 mL in each syringe) and inject into two separate sites. Due to retention in the vial and needle, it may not be feasible to withdraw all of the suspension from the vial. The product must be refrigerated immediately. When azacitidine for injection is reconstituted using water for injection that has not been refrigerated, the reconstituted product may be held under refrigerated conditions (2º to 8ºC, 36º to 46ºF) for up to 8 hours. When azacitidine for injection is reconstituted using refrigerated (2º to 8ºC, 36º to 46ºF) water for injection, the reconstituted product may be stored under refrigerated conditions (2º to 8ºC, 36º to 46ºF) for up to 22 hours. After removal from refrigerated conditions, the suspension may be allowed to equilibrate to room temperature for up to 30 minutes prior to administration.

Subcutaneous Administration

To provide a homogeneous suspension, the contents of the dosing syringe must be re-suspended immediately prior to administration. To re-suspend, vigorously roll the syringe between the palms until a uniform, cloudy suspension is achieved.

Azacitidine for injection suspension is administered subcutaneously. Rotate sites for each injection (thigh, abdomen, or upper arm). New injections should be given at least one inch from an old site and never into areas where the site is tender, bruised, red, or hard.

Suspension Stability

Azacitidine for injection reconstituted with non-refrigerated water for injection for subcutaneous administration may be stored for up to 1 hour at 25°C (77°F) or for up to 8 hours between 2° and 8°C (36° and 46°F); when reconstituted with refrigerated (2º to 8ºC, 36º to 46ºF) water for injection, it may be stored for 22 hours between 2° and 8°C (36° and 46°F).

2.8 Instructions for Intravenous Administration

Reconstitute the appropriate number of azacitidine for injection vials to achieve the desired dose. Reconstitute each vial with 10 mL sterile water for injection. Vigorously shake or roll the vial until all solids are dissolved. The resulting solution will contain azacitidine 10 mg per mL. The solution should be clear. Parenteral drug product should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.

Withdraw the required amount of azacitidine for injection solution to deliver the desired dose and inject into a 50 -100 mL infusion bag of either 0.9% Sodium Chloride Injection or Lactated Ringer’s Injection.

Intravenous Solution Incompatibility

Azacitidine for injection is incompatible with 5% Dextrose solutions, Hespan, or solutions that contain bicarbonate. These solutions have the potential to increase the rate of degradation of azacitidine for injection and should therefore be avoided.

Intravenous Administration

Azacitidine for injection solution is administered intravenously. Administer the total dose over a period of 10 to 40 minutes. The administration must be completed within 1 hour of reconstitution of the azacitidine for injection vial.

Solution Stability

Azacitidine for injection reconstituted for intravenous administration may be stored at 25°C (77°F), but administration must be completed within 1 hour of reconstitution.

3 DOSAGE FORMS AND STRENGTHS

Azacitidine for Injection is supplied as a white to off-white lyophilized powder or lyophilized cake in 100 mg single-dose vials.

4 CONTRAINDICATIONS

4.1 Advanced Malignant Hepatic Tumors

Azacitidine is contraindicated in patients with advanced malignant hepatic tumors [see Warnings and Precautions (5.2)].

4.2 Hypersensitivity to Azacitidine or Mannitol

Azacitidine is contraindicated in patients with a known hypersensitivity to azacitidine or mannitol.

5 WARNINGS AND PRECAUTIONS

5.1 Anemia, Neutropenia and Thrombocytopenia

Azacitidine causes anemia, neutropenia and thrombocytopenia. Monitor complete blood counts frequently for response and/or toxicity, at a minimum, prior to each dosing cycle. After administration of the recommended dosage for the first cycle, adjust dosage for subsequent cycles based on nadir counts and hematologic response [see Dosage and Administration (2.3)].

5.2 Hepatotoxicity in Patients with Severe Pre-existing Hepatic Impairment

Because azacitidine is potentially hepatotoxic in patients with severe pre-existing hepatic impairment, caution is needed in patients with liver disease. Patients with extensive tumor burden due to metastatic disease have been reported to experience progressive hepatic coma and death during azacitidine treatment, especially in such patients with baseline albumin <30 g/L. Azacitidine is contraindicated in patients with advanced malignant hepatic tumors [see Contraindications (4.1)]. Monitor liver chemistries prior to initiation of therapy and with each cycle.

Safety and effectiveness of azacitidine in patients with MDS and hepatic impairment have not been studied as these patients were excluded from the clinical trials.

5.3 Renal Toxicity

Renal toxicity ranging from elevated serum creatinine to renal failure and death have been reported in patients treated with intravenous azacitidine in combination with other chemotherapeutic agents for nonMDS conditions. In addition, renal tubular acidosis, defined as a fall in serum bicarbonate to <20 mEq/L in association with an alkaline urine and hypokalemia (serum potassium <3 mEq/L) developed in 5 patients with CML treated with azacitidine and etoposide. Monitor serum creatinine and electrolytes prior to initiation of therapy and with each cycle. If unexplained reductions in serum bicarbonate <20 mEq/L or elevations of BUN or serum creatinine occur, reduce or hold the dose [see Dosage and Administration (2.4)].

Patients with renal impairment may be at increased risk for renal toxicity. Also, azacitidine and its metabolites are primarily excreted by the kidney. Therefore, monitor these patients closely for toxicity [see Dosage and Administration (2.4, 2.5)]. Patients with MDS and renal impairment were excluded from the clinical studies.

5.4 Tumor Lysis Syndrome

Azacitidine may cause fatal or serious tumor lysis syndrome, including in patients with MDS. Tumor lysis syndrome may occur despite concomitant use of allopurinol. Assess baseline risk and monitor and treat as appropriate.

5.5 Embryo-Fetal Risk

Based on the mechanism of action and findings in animals, azacitidine can cause fetal harm when administered to a pregnant woman. Azacitidine administered to pregnant rats via a single intraperitoneal (IP) dose approximating 8% of the recommended human daily dose caused fetal death and anomalies [see Use in Specific Populations (8.1)].

Advise females with reproductive potential to avoid pregnancy during treatment with azacitidine [see Use in Specific Populations (8.3)]. Men should be advised to not father a child while receiving treatment with azacitidine.

6 ADVERSE REACTIONS

The following adverse reactions are described in other labeling sections:

  • Anemia, Neutropenia and Thrombocytopenia [see Warnings and Precautions (5.1)]
  • Hepatotoxicity in Patients with Severe Pre-existing Hepatic Impairment [see Warnings and Precautions (5.2)]
  • Renal Toxicity [see Warnings and Precautions (5.3)]
  • Tumor Lysis Syndrome [see Warnings and Precautions (5.4)]
  • Embryo-Fetal Risk [see Warnings and Precautions (5.5)]

Most Commonly Occurring Adverse Reactions (Subcutaneous or Intravenous Route)

Nausea, anemia, thrombocytopenia, vomiting, pyrexia, leukopenia, diarrhea, injection site erythema, constipation, neutropenia, ecchymosis. The most common adverse reactions by intravenous route also included petechiae, rigors, weakness and hypokalemia.

Adverse Reactions Most Frequently (>2%) Resulting in Clinical Intervention (Subcutaneous or Intravenous Route)

Discontinuation: leukopenia, thrombocytopenia, neutropenia.

Dose Held: leukopenia, neutropenia, thrombocytopenia, pyrexia, pneumonia, febrile neutropenia.

Dose Reduced: leukopenia, neutropenia, thrombocytopenia.

6.1 Adverse Reactions in Clinical Trials

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.

The data described below reflect exposure to azacitidine in 443 MDS patients from 4 clinical studies. Study 1 was a supportive-care controlled trial (subcutaneous administration), Studies 2 and 3 were single arm studies (one with subcutaneous administration and one with intravenous administration), and Study 4 was an international randomized trial (subcutaneous administration) [see Clinical Studies (14)].

In Studies 1, 2 and 3, a total of 268 patients were exposed to azacitidine, including 116 exposed for 6 cycles (approximately 6 months) or more and 60 exposed for greater than 12 cycles (approximately one year). Azacitidine was studied primarily in supportive-care controlled and uncontrolled trials (n=150 and n=118, respectively). The population in the subcutaneous studies (n=220) was 23 to 92 years old (mean 66.4 years), 68% male, and 94% white, and had MDS or AML. The population in the intravenous study (n=48) was 35 to 81 years old (mean 63.1 years), 65% male, and 100% white. Most patients received average daily doses between 50 and 100 mg/m2.

In Study 4, a total of 175 patients with higher-risk MDS (primarily RAEB and RAEB-T subtypes) were exposed to azacitidine. Of these patients, 119 were exposed for 6 or more cycles, and 63 for at least 12 cycles. The mean age of this population was 68.1 years (ranging from 42 to 83 years), 74% were male, and 99% were white. Most patients received daily azacitidine doses of 75 mg/m2.

Table 1 presents adverse reactions occurring in at least 5% of patients treated with azacitidine (subcutaneous) in Studies 1 and 2. It is important to note that duration of exposure was longer for the azacitidine-treated group than for the observation group: patients received azacitidine for a mean of 11.4 months while mean time in the observation arm was 6.1 months.

Table 1: Most Frequently Observed Adverse Reactions (≥ 5.0% in All Subcutaneous Azacitidine Treated Patients; Studies 1 and 2)

a Multiple terms of the same preferred terms for a patient are only counted once within each treatment group.

b Includes adverse reactions from all patients exposed to azacitidine, including patients after crossing over from observations.

c Includes adverse reactions from observation period only; excludes any adverse events after crossover to azacitidine.

Number (%) of Patients
System Organ Class Preferred Term a All Azacitidine b (N=220) Observation c (N=92)
Blood and lymphatic system disorders
Anemia 153 (70) 59 (64)
Anemia aggravated 12 (6) 5 (5)
Febrile neutropenia 36 (16) 4 (4)
Leukopenia 106 (48) 27 (29)
Neutropenia 71 (32) 10 (11)
Thrombocytopenia 144 (66) 42 (46)
Gastrointestinal disorders
Abdominal tenderness 26 (12) 1 (1)
Constipation 74 (34) 6 (7)
Diarrhea 80 (36) 13 (14)
Gingival bleeding 21 (10) 4 (4)
Loose stools 12 (6) 0
Mouth hemorrhage 11 (5) 1 (1)
Nausea 155 (71) 16 (17)
Stomatitis 17 (8) 0
Vomiting 119 (54) 5 (5)
General disorders and administration site conditions
Chest pain 36 (16) 5 (5)
Injection site bruising 31 (14) 0
Injection site erythema 77 (35) 0
Injection site granuloma 11 (5) 0
Injection site pain 50 (23) 0
Injection site pigmentation changes 11 (5) 0
Injection site pruritus 15 (7) 0
Injection site reaction 30 (14) 0
Injection site swelling 11 (5) 0
Lethargy 17 (8) 2 (2)
Malaise 24 (11) 1 (1)
Pyrexia 114 (52) 28 (30)
Infections and infestations
Nasopharyngitis 32 (15) 3 (3)
Pneumonia 24 (11) 5 (5)
Upper respiratory tract infection 28 (13) 4 (4)
Injury, poisoning, and procedural complications
Post procedural hemorrhage 13 (6) 1 (1)
Metabolism and nutrition disorders
Anorexia 45 (21) 6 (7)
Musculoskeletal and connective tissue disorders
Arthralgia 49 (22) 3 (3)
Chest wall pain 11 (5) 0
Myalgia 35 (16) 2 (2)
Nervous system disorders
Dizziness 41 (19) 5 (5)
Headache 48 (22) 10 (11)
Psychiatric disorders
Anxiety 29 (13) 3 (3)
Insomnia 24 (11) 4 (4)
Respiratory, thoracic and mediastinal disorders
Dyspnea 64 (29) 11 (12)
Skin and subcutaneous tissue disorders
Dry skin 11 (5) 1 (1)
Ecchymosis 67 (31) 14 (15)
Erythema 37 (17) 4 (4)
Rash 31 (14) 9 (10)
Skin nodule 11 (5) 1 (1)
Urticaria 13 (6) 1 (1)
Vascular disorders
Hematoma 19 (9) 0
Hypotension 15 (7) 2 (2)
Petechiae 52 (24) 8 (9)

Table 2 presents adverse reactions occurring in at least 5% of patients treated with azacitidine in Study 4. Similar to Studies 1 and 2 described above, duration of exposure to treatment with azacitidine was longer (mean 12.2 months) compared with best supportive care (mean 7.5 months).

Table 2: Most Frequently Observed Adverse Reactions (≥5.0% in the Azacitidine Treated Patients and the Percentage with NCI CTC Grade 3/4 Reactions; Study 4)

a Multiple reports of the same preferred term from a patient were only counted once within each treatment.

Number (%) of Patients
Any Grade Grade 3/4
System Organ Class Preferred Term a Azacitidine (N=175) Best Supportive Care Only (N=102) Azacitidine (N=175) Best Supportive Care Only (N=102)
Blood and lymphatic system disorders
Anemia 90 (51) 45 (44) 24 (14) 9 (9)
Febrile neutropenia 24 (14) 10 (10) 22 (13) 7 (7)
Leukopenia 32 (18) 2 (2) 26 (15) 1 (1)
Neutropenia 115 (66) 29 (28) 107 (61) 22 (22)
Thrombocytopenia 122 (70) 35 (34) 102 (58) 29 (28)
Gastrointestinal disorders
Abdominal pain 22 (13) 7 (7) 7 (4) 0
Constipation 88 (50) 8 (8) 2 (1) 0
Dyspepsia 10 (6) 2 (2) 0 0
Nausea 84 (48) 12 (12) 3 (2) 0
Vomiting 47 (27) 7 (7) 0 0
General disorders and administration site conditions
Fatigue 42 (24) 12 (12) 6 (3) 2 (2)
Injection site bruising 9 (5) 0 0 0
Injection site erythema 75 (43) 0 0 0
Injection site hematoma 11 (6) 0 0 0
Injection site induration 9 (5) 0 0 0
Injection site pain 33 (19) 0 0 0
Injection site rash 10 (6) 0 0 0
Injection site reaction 51 (29) 0 1 (1) 0
Pyrexia 53 (30) 18 (18) 8 (5) 1 (1)
Infections and infestations
Rhinitis 10 (6) 1 (1) 0 0
Upper respiratory tract infection 16 (9) 4 (4) 3 (2) 0
Urinary tract infection 15 (9) 3 (3) 3 (2) 0
Investigations
Weight decreased 14 (8) 0 1 (1) 0
Metabolism and nutrition disorders
Hypokalemia 11 (6) 3 (3) 3 (2) 3 (3)
Nervous system disorders
Lethargy 13 (7) 2 (2) 0 1 (1)
Psychiatric disorders
Anxiety 9 (5) 1 (1) 0 0
Insomnia 15 (9) 3 (3) 0 0
Renal and urinary disorders
Hematuria 11 (6) 2 (2) 4 (2) 1 (1)
Respiratory, thoracic and mediastinal disorders
Dyspnea 26 (15) 5 (5) 6 (3) 2 (2)
Dyspnea exertional 9 (5) 1 (1) 0 0
Pharyngolaryngeal pain 11 (6) 3 (3) 0 0
Skin and subcutaneous tissue disorders
Erythema 13 (7) 3 (3) 0 0
Petechiae 20 (11) 4 (4) 2 (1) 0
Pruritus 21 (12) 2 (2) 0 0
Rash 18 (10) 1 (1) 0 0
Vascular disorders
Hypertension 15 (9) 4 (4) 2 (1) 2 (2)

In Studies 1, 2 and 4 with subcutaneous administration of azacitidine, adverse reactions of neutropenia, thrombocytopenia, anemia, nausea, vomiting, diarrhea, constipation, and injection site erythema/reaction tended to increase in incidence with higher doses of azacitidine. Adverse reactions that tended to be more pronounced during the first 1 to 2 cycles of subcutaneous treatment compared with later cycles included thrombocytopenia, neutropenia, anemia, nausea, vomiting, injection site erythema/pain/bruising/reaction, constipation, petechiae, dizziness, anxiety, hypokalemia, and insomnia. There did not appear to be any adverse reactions that increased in frequency over the course of treatment.

Overall, adverse reactions were qualitatively similar between the intravenous and subcutaneous studies. Adverse reactions that appeared to be specifically associated with the intravenous route of administration included infusion site reactions (e.g. erythema or pain) and catheter site reactions (e.g. infection, erythema, or hemorrhage).

In clinical studies of either subcutaneous or intravenous azacitidine, the following serious adverse reactions occurring at a rate of <5% (and not described in Tables 1 or 2) were reported:

Blood and lymphatic system disorders: agranulocytosis, bone marrow failure, pancytopenia splenomegaly.

Cardiac disorders: atrial fibrillation, cardiac failure, cardiac failure congestive, cardio–respiratory arrest, congestive cardiomyopathy.

Eye disorders: eye hemorrhage

Gastrointestinal disorders: diverticulitis, gastrointestinal hemorrhage, melena, perirectal abscess.

General disorders and administration site conditions: catheter site hemorrhage, general physical health deterioration, systemic inflammatory response syndrome.

Hepatobiliary disorders: cholecystitis.

Immune system disorders: anaphylactic shock, hypersensitivity.

Infections and infestations: abscess limb, bacterial infection, cellulitis, blastomycosis, injection site infection, Klebsiella sepsis, neutropenic sepsis, pharyngitis streptococcal, pneumonia Klebsiella, sepsis, septic shock, Staphylococcal bacteremia, Staphylococcal infection, toxoplasmosis.

Metabolism and nutrition disorders: dehydration.

Musculoskeletal and connective tissue disorders: bone pain aggravated, muscle weakness, neck pain.

Neoplasms benign, malignant and unspecified: leukemia cutis.

Nervous system disorders: cerebral hemorrhage, convulsions, intracranial hemorrhage.

Renal and urinary disorders: loin pain, renal failure.

Respiratory, thoracic and mediastinal disorders: hemoptysis, lung infiltration, pneumonitis, respiratory distress.

Skin and subcutaneous tissue disorders: pyoderma gangrenosum, rash pruritic, skin induration.

Surgical and medical procedures: cholecystectomy.

Vascular disorders: orthostatic hypotension.

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