Ganciclovir: Package Insert and Label Information (Page 3 of 6)

6.2 Postmarketing Experience

The following adverse reactions have been identified during post-approval use of Ganciclovir Injection The following adverse reactions have been identified during post-approval use of Ganciclovir Injection or ganciclovir capsules. 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 drug exposure.

: hemolytic anemia, agranulocytosis, granulocytopenia Blood and lymphatic disorders: hemolytic anemia, agranulocytosis, granulocytopenia

cardiac arrest, conduction disorder, torsade de pointes, ventricular tachycardia Cardiac disorders: cardiac arrest, conduction disorder, torsade de pointes, ventricular tachycardia

congenital anomaly Congenital, familial and genetic disorders: congenital anomaly

inappropriate antidiuretic hormone secretion Endocrine disorders: inappropriate antidiuretic hormone secretion

cataracts, dry eyes Eye disorders: cataracts, dry eyes

intestinal ulcer Gastrointestinal disorders: intestinal ulcer

cholelithiasis, cholestasis, hepatic failure, hepatitis Hepatobiliary disorders: cholelithiasis, cholestasis, hepatic failure, hepatitis

anaphylactic reaction, allergic reaction, vasculitis Immune system disorders: anaphylactic reaction, allergic reaction, vasculitis

blood triglycerides increased Investigations: blood triglycerides increased

acidosis, hypercalcemia, hyponatremia Metabolism and nutrition disorders: acidosis, hypercalcemia, hyponatremia

arthritis, rhabdomyolysis Musculoskeletal and connective tissue disorders: arthritis, rhabdomyolysis

dysesthesia, dysphasia, extrapyramidal disorder, facial paralysis, amnesia, anosmia, myelopathy, cerebrovascular accident, third cranial nerve paralysis, aphasia, encephalopathy, intracranial hypertension Nervous system disorders: dysesthesia, dysphasia, extrapyramidal disorder, facial paralysis, amnesia, anosmia, myelopathy, cerebrovascular accident, third cranial nerve paralysis, aphasia, encephalopathy, intracranial hypertension

irritability, hallucinations Psychiatric disorders: irritability, hallucinations

renal tubular disorder, hemolytic uremic syndrome Renal and urinary disorders: renal tubular disorder, hemolytic uremic syndrome

infertility, testicular hypotrophy Reproductive system and breast disorders: infertility, testicular hypotrophy

bronchospasm, pulmonary fibrosis Respiratory, thoracic and mediastinal disorders: bronchospasm, pulmonary fibrosis

: exfoliative dermatitis, Stevens-Johnson syndrome Skin and subcutaneous tissues disorders: exfoliative dermatitis, Stevens-Johnson syndrome

peripheral ischemia Vascular disorders: peripheral ischemia

7 DRUG INTERACTIONS

Drug-drug interaction studies were conducted in patients with normal renal function. Patients with impaired renal function may have increased concentrations of ganciclovir and the coadministered drug following concomitant administration of Ganciclovir Injection Drug-drug interaction studies were conducted in patients with normal renal function. Patients with impaired renal function may have increased concentrations of ganciclovir and the coadministered drug following concomitant administration of Ganciclovir Injection and drugs excreted by the same pathway as ganciclovir. Therefore, these patients should be closely monitored for toxicity of ganciclovir and the coadministered drug.

Established and other potentially significant drug interactions conducted with ganciclovir are listed in Table 6 . Established and other potentially significant drug interactions conducted with ganciclovir are listed in Table 6 [see Clinical Pharmacology (12.3)] .

Table 6. Established and Other Potentially Significant Drug Interactions with Ganciclovir
Name of the Concomitant Drug Change in the Concentration of Ganciclovir or Concomitant Drug Clinical Comment
Imipenem-cilastatin Unknown Coadministration with imipenem-cilastatin is not recommended because generalized seizures have been reported in patients who received ganciclovir and imipenem-cilastatin.
Cyclosporine or amphotericin B Unknown Monitor renal function when Ganciclovir Injection is coadministered with cyclosporine or amphotericin B because of potential increase in serum creatinine [see Warnings and Precautions (5.2)].
Mycophenolate mofetil (MMF) ↔ Ganciclovir (in patients with normal renal function) ↔ MMF (in patients with normal renal function) Based on increased risk, patients should be monitored for hematological and renal toxicity.
Other drugs associated with myelosuppresion or nephrotoxicity (e.g., dapsone, doxorubicin, flucytosine, hydroxyurea, pentamidine, tacrolimus, trimethoprim/ sulfamethoxazole, vinblastine, vincristine and zidovudine) Unknown Because of potential for higher toxicity, coadministration with Ganciclovir Injection should be considered only if the potential benefits are judged to outweigh the risks.
Didanosine ↔ Ganciclovir ↑ Didanosine Patients should be closely monitored for didanosine toxicity (e.g., pancreatitis).
Probenecid ↑ Ganciclovir Ganciclovir Injection dose may need to be reduced. Monitor for evidence of ganciclovir toxicity.

8 USE IN SPECIFIC POPULATIONS

8.1 Pregnancy

Risk Summary

In animal studies, ganciclovir caused maternal and fetal toxicity and embryo-fetal mortality in pregnant mice and rabbits as well as teratogenicity in rabbits at exposures two times the exposure at the recommended human dose (RHD) [see Data]. Although placental transfer of ganciclovir has been shown to occur based on ex vivo experiments with human placenta and in at least one case report in a pregnant woman, no adequate human data are available to establish whether Ganciclovir Injection poses a risk to pregnancy outcomes. The background risk of major birth defects and miscarriage for the indicated populations is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in the clinically recognized pregnancies is 2-4% and 15-20%, respectively.

Clinical Considerations

Disease-associated maternal and/or embryo-fetal risk

Most maternal CMV infections are asymptomatic or they may be associated with a self-limited mononucleosis-like syndrome. However, in immunocompromised patients (i.e., transplant patients or patients with AIDS), CMV infections may be symptomatic and may result in significant maternal morbidity and mortality. The transmission of CMV to the fetus is a result of maternal viremia and transplacental infection. Perinatal infection can also occur from exposure of the neonate to CMV shedding in the genital tract. Approximately 10% of children with congenital CMV infection are symptomatic at birth. Mortality in symptomatic infants is about 10% and approximately 50-90% of symptomatic surviving newborns experience significant morbidity, including mental retardation, sensorineural hearing loss, microcephaly, seizures, and other medical problems. The risk of congenital CMV infection resulting from primary maternal CMV infection may be higher and of greater severity than that resulting from maternal reactivation of CMV infection.

Data

Animal Data

Daily intravenous doses of ganciclovir were administered to pregnant mice (108 mg/kg/day) and rabbits (60 mg/kg/day), and also to female mice (90 mg/kg) prior to mating, during gestation, and during lactation. Fetal resorptions were present in at least 85% of rabbits and mice. Additional effects observed in rabbits included fetal growth retardation, embryolethality, teratogenicity, and/or maternal toxicity. Teratogenic changes included cleft palate, anophthalmia/microphthalmia, aplastic organs (kidney and pancreas), hydrocephaly, and brachygnathia. In pre/postnatal development studies in mice, there were maternal/fetal toxicity and embryolethality which included fetal effects of hypoplasia of the testes and seminal vesicles in the male offspring, as well as pathologic changes in the nonglandular region of the stomach. The systemic exposure (AUC) of ganciclovir during these studies was approximately 2 times (pregnant mice and rabbits) and 1.7 times (pre/postnatal mice) the exposure in humans at the RHD [see Nonclinical Toxicology (13.1)] .

8.2 Lactation

Risk Summary

No data are available regarding the presence of ganciclovir in human milk, the effects on the breastfed infant, or the effects on milk production. When ganciclovir was administered to lactating rats, ganciclovir was present in milk [see Data]. Advise nursing mothers that breastfeeding is not recommended during treatment with Ganciclovir Injection because of the potential for serious adverse reactions in nursing infants [see Warnings and Precautions (5.1, 5.3, 5.4, 5.5), Nonclinical Toxicology (13.1)] . Furthermore, the Centers for Disease Control and Prevention recommends that HIV-infected mothers not breastfeed their infants to avoid potential postnatal transmission of HIV.

Data

Animal Data

Ganciclovir administered intravenously (at 0.13 mg/h) to lactating rats (on lactation day 15) resulted in passive transfer into milk. The milk-to-serum ratio for ganciclovir at steady state was 1.6 ± 0.33.

8.3 Females and Males of Reproductive Potential

Pregnancy Testing

Females of reproductive potential should undergo pregnancy testing before initiation of treatment with Ganciclovir Injection Females of reproductive potential should undergo pregnancy testing before initiation of treatment with Ganciclovir Injection [see Dosage and Administration (2.2), Use in Specific Populations (8.1)] .

Contraception

Females

Because of the mutagenic and teratogenic potential of Ganciclovir Injection, females of reproductive potential should be advised to use effective contraception during treatment and for at least 30 days following treatment with Ganciclovir Injection Because of the mutagenic and teratogenic potential of Ganciclovir Injection, females of reproductive potential should be advised to use effective contraception during treatment and for at least 30 days following treatment with Ganciclovir Injection [see Dosage and Administration (2.2), Warnings and Precautions (5.4), Nonclinical Toxicology (13.1)] .

Males

Because of its mutagenic potential, males should be advised to practice barrier contraception during and for at least 90 days following treatment with Ganciclovir Injection [see Warnings and Precautions (5.4), Nonclinical Toxicology (13.1)].

Infertility

Ganciclovir Injection at the recommended doses may cause temporary or permanent female and male infertility Ganciclovir Injection at the recommended doses may cause temporary or permanent female and male infertility [see Warnings and Precautions (5.3), Nonclinical Toxicology (13.1)] .

Data

Human Data

In a small, open-label, non-randomized clinical study, adult male renal transplant patients receiving valganciclovir (the prodrug of ganciclovir) for CMV prophylaxis for up to 200 days post-transplantation were compared to an untreated control group. Patients were followed-up for six months after valganciclovir discontinuation. Among 24 evaluable patients in the valganciclovir group, the mean sperm density at the end of treatment visit decreased by 11 million/mL from baseline; whereas, among 14 evaluable patients in the control group the mean sperm density increased by 33 million/mL. However, at the follow-up visit among 20 evaluable patients in the valganciclovir group, the mean sperm density was comparable to that observed among 10 evaluable patients in the untreated control group (the mean sperm density at the end of follow-up visit increased by 41 million/mL from baseline in the valganciclovir group and by 43 million/mL in the untreated group).

8.4 Pediatric Use

Safety and efficacy of Ganciclovir Injection Safety and efficacy of Ganciclovir Injection have not been established in pediatric patients.

A total of 120 pediatric patients with serious CMV infections participated in clinical trials. Granulocytopenia and thrombocytopenia were the most common adverse reactions. The pharmacokinetic characteristics of ganciclovir after administration of Ganciclovir Injection were studied in 27 neonates (aged 2 to 49 days) and 10 pediatric patients, aged 9 months to 12 years. In neonates, the pharmacokinetic parameters after ganciclovir intravenous doses of 4 mg/kg (n=14) and 6 mg/kg (n=13) were C 5.5 ± 1.6 and 7.0 ± 1.6 mcg/mL, systemic clearance 3.14 ± 1.75 and 3.56 ± 1.27 mL/min/kg, and t of 2.4 hours (harmonic mean) for both doses, respectively. A total of 120 pediatric patients with serious CMV infections participated in clinical trials. Granulocytopenia and thrombocytopenia were the most common adverse reactions. The pharmacokinetic characteristics of ganciclovir after administration of Ganciclovir Injection were studied in 27 neonates (aged 2 to 49 days) and 10 pediatric patients, aged 9 months to 12 years. In neonates, the pharmacokinetic parameters after ganciclovir intravenous doses of 4 mg/kg (n=14) and 6 mg/kg (n=13) were C max 5.5 ± 1.6 and 7.0 ± 1.6 mcg/mL, systemic clearance 3.14 ± 1.75 and 3.56 ± 1.27 mL/min/kg, and t 1/2 of 2.4 hours (harmonic mean) for both doses, respectively.

In pediatric patients 9 months to 12 years of age, the pharmacokinetic characteristics of ganciclovir were the same after single and multiple (every 12 hours) intravenous doses (5 mg/kg). The steady-state volume of distribution was 0.64 ± 0.22 L/kg, C was 7.9 ± 3.9 mcg/mL, systemic clearance was 4.7 ± 2.2 mL/min/kg, and t was 2.4 ± 0.7 hours. In pediatric patients 9 months to 12 years of age, the pharmacokinetic characteristics of ganciclovir were the same after single and multiple (every 12 hours) intravenous doses (5 mg/kg). The steady-state volume of distribution was 0.64 ± 0.22 L/kg, C max was 7.9 ± 3.9 mcg/mL, systemic clearance was 4.7 ± 2.2 mL/min/kg, and t 1/2 was 2.4 ± 0.7 hours.

Although the pharmacokinetics of Ganciclovir Injection in pediatric patients were similar to those observed in adults, the safety and efficacy of ganciclovir at these exposures in pediatric patients have not been established.Although the pharmacokinetics of Ganciclovir Injection in pediatric patients were similar to those observed in adults, the safety and efficacy of ganciclovir at these exposures in pediatric patients have not been established.

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