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Included as part of the PRECAUTIONS section.

Anaphylaxis/Hypersensitivity Reactions

Anaphylaxis/hypersensitivity reactions have been reported with the use of antibacterial agents, including CUBICIN, and may be life-threatening. If an allergic reaction to CUBICIN occurs, discontinue the drug and institute appropriate therapy [see ADVERSE REACTIONS].

Myopathy and Rhabdomyolysis

Myopathy, defined as muscle aching or muscle weakness in conjunction with increases in creatine phosphokinase (CPK) values to greater than 10 times the upper limit of normal (ULN), has been reported with the use of CUBICIN. Rhabdomyolysis, with or without acute renal failure, has been reported [see ADVERSE REACTIONS].

Patients receiving CUBICIN should be monitored for the development of muscle pain or weakness, particularly of the distal extremities. In patients who receive CUBICIN, CPK levels should be monitored weekly, and more frequently in patients who received recent prior or concomitant therapy with an HMG-CoA reductase inhibitor or in whom elevations in CPK occur during treatment with CUBICIN.

In patients with renal impairment, both renal function and CPK should be monitored more frequently than once weekly [see Use In Specific Populations and CLINICAL PHARMACOLOGY].

In Phase 1 studies and Phase 2 clinical trials, CPK elevations appeared to be more frequent when CUBICIN was dosed more than once daily. Therefore, CUBICIN should not be dosed more frequently than once a day.

CUBICIN should be discontinued in patients with unexplained signs and symptoms of myopathy in conjunction with CPK elevations to levels > 1,000 U/L (~5 x ULN), and in patients without reported symptoms who have marked elevations in CPK, with levels > 2,000 U/L ( ≥ 10 x ULN). In addition, consideration should be given to suspending agents associated with rhabdomyolysis, such as HMG-CoA reductase inhibitors, temporarily in patients receiving CUBICIN [see DRUG INTERACTIONS].

Eosinophilic Pneumonia

Eosinophilic pneumonia has been reported in patients receiving CUBICIN [see ADVERSE REACTIONS]. In reported cases associated with CUBICIN, patients developed fever, dyspnea with hypoxic respiratory insufficiency, and diffuse pulmonary infiltrates. In general, patients developed eosinophilic pneumonia 2 to 4 weeks after starting CUBICIN and improved when CUBICIN was discontinued and steroid therapy was initiated. Recurrence of eosinophilic pneumonia upon re-exposure has been reported. Patients who develop these signs and symptoms while receiving CUBICIN should undergo prompt medical evaluation, and CUBICIN should be discontinued immediately. Treatment with systemic steroids is recommended.

Peripheral Neuropathy

Cases of peripheral neuropathy have been reported during the CUBICIN postmarketing experience [see ADVERSE REACTIONS]. Therefore, physicians should be alert to signs and symptoms of peripheral neuropathy in patients receiving CUBICIN.

Clostridium difficile-Associated Diarrhea

Clostridium difficile-associated diarrhea (CDAD) has been reported with the use of nearly all systemic antibacterial agents, including CUBICIN, and may range in severity from mild diarrhea to fatal colitis [see ADVERSE REACTIONS]. Treatment with antibacterial agents alters the normal flora of the colon, leading to overgrowth of C. difficile.

C. difficile produces toxins A and B, which contribute to the development of CD AD. Hypertoxin-producing strains of C. difficile cause increased morbidity and mortality, since these infections can be refractory to antimicrobial therapy and may require colectomy. CD AD must be considered in all patients who present with diarrhea following antibacterial use. Careful medical history is necessary because CD AD has been reported to occur more than 2 months after the administration of antibacterial agents.

If CD AD is suspected or confirmed, ongoing antibacterial use not directed against C. difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibacterial treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated.

Persisting or Relapsing S. aureus Bacteremia/Endocarditis

Patients with persisting or relapsing S. aureus bacteremia/endocarditis or poor clinical response should have repeat blood cultures. If a blood culture is positive for S. aureus, minimum inhibitory concentration (MIC) susceptibility testing of the isolate should be performed using a standardized procedure, and diagnostic evaluation of the patient should be performed to rule out sequestered foci of infection. Appropriate surgical intervention (e.g., debridement, removal of prosthetic devices, valve replacement surgery) and/or consideration of a change in antibacterial regimen may be required.

Failure of treatment due to persisting or relapsing S. aureus bacteremia/endocarditis may be due to reduced daptomycin susceptibility (as evidenced by increasing MIC of the S. aureus isolate) [see Clinical Trials].

Decreased Efficacy in Patients with Moderate Baseline Renal Impairment

There are limited data available from the cSSSI clinical trials regarding clinical efficacy of daptomycin treatment in patients with CrCL < 50 mL/min; only 31/534 (6%) patients treated with daptomycin in the intent-to-treat (ITT) population had a baseline CrCL < 50 mL/min. Table 2 shows the number of patients by CrCL and treatment group who were clinical successes in the cSSSI trials.

Table 2. Clinical Success Rates by Treatment Group and Renal Function in the Daptomycin cSSSI Clinical Trials (Population: ITT)

In a subgroup analysis of the ITT population in the S. aureus bacteremia/endocarditis trial, clinical success rates, as determined by a treatment-blinded Adjudication Committee [see Clinical Trials], in the daptomycin-treated patients were lower in patients with baseline CrCL < 50 mL/min (Table 3). A decrease of the magnitude shown in Table 3 was not observed in comparator-treated patients.

Table 3. Adjudication Committee Success Rates at TOC Stratified by Baseline Creatinine Clearance in the S. aureus Bacteremia/Endocarditis Trial (Population: ITT)

Consider these data when selecting antibacterial therapy for use in patients with baseline moderate to severe renal impairment.

Drug-Laboratory Test Interactions

Clinically relevant plasma concentrations of daptomycin have been observed to cause a significant concentration-dependent false prolongation of prothrombin time (PT) and elevation of International Normalized Ratio (INR) when certain recombinant thromboplastin reagents are utilized for the assay [see Drug-Laboratory Interactions].

Non-Susceptible Microorganisms

The use of antibacterials may promote the overgrowth of non-susceptible microorganisms. If superinfection occurs during therapy, appropriate measures should be taken.

Prescribing CUBICIN in the absence of a proven or strongly suspected bacterial infection is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment of Fertility

Long-term carcinogenicity studies in animals have not been conducted to evaluate the carcinogenic potential of CUBICIN. However, neither mutagenic nor clastogenic potential was found in a battery of genotoxicity tests, including the Ames assay, a mammalian cell gene mutation assay, a test for chromosomal aberrations in Chinese hamster ovary cells, an in vivo micronucleus assay, an in vitro DNA repair assay, and an in vivo sister chromatid exchange assay in Chinese hamsters.

Daptomycin did not affect the fertility or reproductive performance of male and female rats when administered intravenously at doses up to 150 mg/kg/day, which is approximately 9 times the estimated human exposure level based upon AUCs.

Use In Specific Populations

Pregnancy

Teratogenic Effects: Pregnancy Category B

Reproductive and teratology studies performed in rats and rabbits at doses of up to 75 mg/kg (2 and 4 times the 6 mg/kg human dose, respectively, on a body surface area basis) revealed no evidence of harm to the fetus due to daptomycin. There are, however, no adequate and well-controlled trials in pregnant women. Because animal reproduction studies are not always predictive of human response, CUBICIN should be used during pregnancy only if the potential benefit outweighs the possible risk.

Nursing Mothers

It is not known whether daptomycin is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when CUBICIN is administered to nursing women.

Pediatric Use

Safety and effectiveness of CUBICIN in patients under the age of 18 years have not been established.

Geriatric Use

Of the 534 patients treated with CUBICIN in Phase 3 controlled clinical trials of complicated skin and skin structure infections (cSSSI), 27% were 65 years of age or older and 12% were 75 years of age or older. Of the 120 patients treated with CUBICIN in the Phase 3 controlled clinical trial of S. aureus bacteremia/endocarditis, 25% were 65 years of age or older and 16% were 75 years of age or older. In Phase 3 clinical trials of cSSSI and S. aureus bacteremia/endocarditis, clinical success rates were lower in patients ≥ 65 years of age than in patients < 65 years of age. In addition, treatment-emergent adverse events were more common in patients ≥ 65 years of age than in patients < 65 years of age.

The exposure of daptomycin was higher in healthy elderly subjects than in healthy young subjects. However, no adjustment of CUBICIN dosage is warranted for elderly patients with creatinine clearance (CLCR ≥ 30 mL/min [see DOSAGE AND ADMINISTRATION and CLINICAL PHARMACOLOGY].

Patients with Renal Impairment

Daptomycin is eliminated primarily by the kidneys; therefore, a modification of CUBICIN dosage is recommended for patients with CLcR < 30 mL/min, including patients receiving hemodialysis or continuous ambulatory peritoneal dialysis (CAPD). In patients with renal impairment, both renal function and creatine phosphokinase (CPK) should be monitored more frequently than once weekly [see DOSAGE AND ADMINISTRATION, WARNINGS AND PRECAUTIONS and CLINICAL PHARMACOLOGY].

Last reviewed on RxList: 10/17/2011
This monograph has been modified to include the generic and brand name in many instances.