DepoCyt® (cytarabine liposome injection) is a sterile, injectable suspension of the antimetabolite cytarabine, encapsulated into multivesicular lipid-based particles. Chemically, cytarabine is 4-amino-1-β-D-arabinofuranosyl-2(1H)-pyrimidinone, also known as cytosine arabinoside (C₉H₁₃N₃O₅, molecular weight 243.22).

The following is an artist's rendition of a DepoCyt particle:

Nonconcentric vesicles, each with an internal, aqueous chamber containing encapsulated cytarabine solution, surrounded by a bilayer lipid membrane.

DepoCyt is available in 5 mL, ready-to-use, single-use vials containing 50 mg of cytarabine. DepoCyt is formulated as a sterile, non-pyrogenic, white to off-white suspension of cytarabine in Sodium Chloride 0.9% w/v in Water for Injection. DepoCyt is preservative-free. Cytarabine, the active ingredient, is present at a concentration of 10 mg/mL, and is encapsulated in the particles. Inactive ingredients at their respective approximate concentrations are cholesterol, 4.1 mg/mL; triolein, 1.2 mg/mL; dioleoylphosphatidylcholine (DOPC), 5.7 mg/mL; and dipalmitoylphosphatidylglycerol (DPPG), 1.0 mg/mL. The pH of the product falls within the range from 5.5 to 8.5.

Last updated on RxList: 5/18/2007

DepoCyt® (cytarabine liposome injection) is indicated for the intrathecal treatment of lymphomatous meningitis.

Preparation of DepoCyt® (cytarabine liposome injection)

DepoCyt is a cytotoxic anticancer drug and, as with other potentially toxic compounds, caution should be used in handling DepoCyt. The use of gloves is recommended. If DepoCyt suspension contacts the skin, wash immediately with soap and water. If it contacts mucous membranes, flush thoroughly with water (see HANDLING AND DISPOSAL). DepoCyt particles are more dense than the diluent and have a tendency to settle with time. Vials of DepoCyt should be allowed to warm to room temperature and gently agitated or inverted to re-suspend the particles immediately prior to withdrawal from the vial. Avoid aggressive agitation. No further reconstitution or dilution is required.

DepoCyt Administration

DepoCyt should be withdrawn from the vial immediately before administration. DepoCyt is a single-use vial and does not contain any preservative; DepoCyt should be used within 4 hours of withdrawal from the vial. Unused portions of each vial should be discarded properly (see HANDLING AND DISPOSAL). Do not save any unused portions for later administration. Do not mix DepoCyt with any other medications.

In-line filters must not be used when administering DepoCyt. DepoCyt is administered directly into the CSF via an intraventricular reservoir or by direct injection into the lumbar sac. DepoCyt should be injected slowly over a period of 1-5 minutes. Following drug administration by lumbar puncture, the patient should be instructed to lie flat for 1 hour. Patients should be observed by the physician for immediate toxic reactions.

Patients should be started on dexamethasone 4 mg bid either PO or IV for 5 days beginning on the day of DepoCyt injection.

DepoCyt must only be administered by the intrathecal route.

Further dilution of DepoCyt is not recommended.

Dosing Regimen

For the treatment of lymphomatous meningitis, DepoCyt 50 mg (one vial of DepoCyt) is recommended to be given according to the following schedule:

Induction therapy: DepoCyt, 50 mg, administered intrathecally (intraventricular or lumbar puncture) every 14 days for 2 doses (weeks 1 and 3).

Consolidation therapy: DepoCyt, 50 mg, administered intrathecally (intraventricular or lumbar puncture) every 14 days for 3 doses (weeks 5, 7 and 9) followed by 1 additional dose at week 13.

Maintenance: DepoCyt, 50 mg, administered intrathecally (intraventricular or lumbar puncture) every 28 days for 4 doses (weeks 17, 21, 25 and 29).

If drug related neurotoxicity develops, the dose should be reduced to 25 mg. If it persists, treatment with DepoCyt should be discontinued.

Handling and Disposal

Procedures for proper handling and disposal of anticancer drugs should be considered. Several guidelines on this subject have been published.^1-8 There is no general agreement that all of the procedures recommended in the guidelines are necessary or appropriate.

DepoCyt® (cytarabine liposome injection) is supplied as a sterile, white to off-white suspension in 5 mL glass, single use vials.

Refrigerate at 2° to 8°C (36° to 46°F). Protect from freezing and avoid aggressive agitation.

Available as individual carton containing one ready to use vial. NDC 57665-331-01.

Do not use beyond expiration date printed on the label.

REFERENCES:

1.   NIOSH Alert: Preventing occupational exposures to antineoplastic and other hazardous drugs in healthcare settings. 2004. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2004-165.

2.   OSHA Technical Manual, TED 1-0.15A, Section VI: Chapter 2. Controlling Occupational Exposure to Hazardous Drugs. OSHA, 1999. http://www.osha.gov/dts/osta/otm/otm_vi/otm_vi_2.html

3.   NIH [2002]. 1999 recommendations for the safe handling of cytotoxic drugs. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, NIH Publication No. 92-2621.

4.   American Society of Health-System Pharmacists. (2006) ASHP Guidelines on Handling Hazardous Drugs.

5.   Polovich, M., White, J. M., & Kelleher, L.O. (eds.) 2005. Chemotherapy and biotherapy guidelines and recommendations for practice (2nd. ed.) Pittsburgh, PA: Oncology Nursing Society.

Rx only
For additional information, contact Enzon Medical Information at: 866-792-5172
Manufactured by: SkyePharma Inc. San Diego, CA 92121
Distributed by: ENZON Pharmaceuticals, Inc. Bridgewater, NJ 08807
U.S. Patent Nos. 5,807,572; 5,723,147 October 2003
FDA rev date: 4/19/2007

Last updated on RxList: 5/18/2007

The toxicity database consists of the observations made during Phase 1-4 studies. The most common adverse reactions in all patients and in patients with lymphoma are shown in Table 2 below.

Arachnoiditis is an expected and well-documented side effect of both neoplastic meningitis and of intrathecal chemotherapy. The incidence of severe and life-threatening arachnoiditis in patients receiving DepoCyt was 19% (48/257) in all patients and 30% (10/33) in patients with lymphomatous meningitis.. The incidence of symptoms possibly reflecting meningeal irritation are shown in Table3.

In the early dose-finding study, chemical arachnoiditis was observed in 100% of cycles without dexamethasone prophylaxis. When concurrent dexamethasone was administered, chemical arachnoiditis was observed in 33% of cycles. Patients receiving DepoCyt should be treated concurrently with dexamethasone to mitigate the symptoms of chemical arachnoiditis (see DOSAGE AND ADMINISTRATION).

Table 2. Incidence of adverse reactions occurring in > 10% of patients in all Phase 1-4 adult study patients and in patients with lymphomatous meningitis receiving DepoCyt 50 mg or an active comparator

Table 3. Incidence of adverse reactions possibly reflecting meningeal irritation occurring in > 10% of all studied adult patients receiving DepoCyt 50 mg or an active comparator*

No formal drug interaction studies of DepoCyt and other drugs were conducted. Concomitant administration of DepoCyt with other antineoplastic agents administered by the intrathecal route has not been studied. With intrathecal cytarabine and other cytotoxic agents administered intrathecally, enhanced neurotoxicity has been associated with coadministration of drugs.

Laboratory Test Interactions

Since DepoCyt particles are similar in size and appearance to white blood cells, care must be taken in interpreting CSF examinations following DepoCyt administration.

Last updated on RxList: 5/18/2007

(see DESCRIPTION: boxed WARNING)

DepoCyt should be administered only under the supervision of a qualified physician experienced in the use of cancer chemotherapeutic agents. Appropriate management of complications is possible only when adequate diagnostic and treatment facilities are readily available. Chemical arachnoiditis, a syndrome manifested primarily by nausea, vomiting, headache, and fever, has been a common adverse event in all studies. If left untreated, chemical arachnoiditis may be fatal. The incidence and severity of chemical arachnoiditis can be reduced by coadministration of dexamethasone. Patients receiving DepoCyt should be treated concurrently with dexamethasone to mitigate the symptoms of chemical arachnoiditis (see DOSAGE AND ADMINISTRATION).

During the clinical studies, 2 deaths related to DepoCyt were reported. One patient died after developing encephalopathy 36 hours after an intraventricular dose of DepoCyt, 125 mg. This patient was receiving concurrent whole-brain irradiation and had previously received systemic chemotherapy with cyclophosphamide, doxorubicin, and fluorouracil, as well as intraventricular methotrexate. The other patient received DepoCyt 50 mg by the intraventricular route and developed focal seizures progressing to status epilepticus. This patient died approximately 8 weeks after the last dose of study medication. The death of one additional patient was considered possibly related to DepoCyt. He was a 63 year old with extensive lymphoma involving the nasopharynx, brain, and meninges with multiple neurologic deficits who died of apparent disease progression 4 days after his second dose of DepoCyt.

After intrathecal administration of free cytarabine the most frequently reported reactions are nausea, vomiting and fever. Intrathecal administration of free cytarabine may cause myelopathy and other neurologic toxicity and can rarely lead to a permanent neurologic deficit. Administration of intrathecal cytarabine in combination with other chemotherapeutic agents or with cranial/spinal irradiation may increase this risk of neurotoxicity.

Blockage to CSF flow may result in increased free cytarabine concentrations in the CSF and an increased risk of neurotoxicity.

Pregnancy Category D

There are no studies assessing the reproductive toxicity of DepoCyt. Cytarabine, the active component of DepoCyt, can cause fetal harm if a pregnant woman is exposed to the drug systemically. Three anecdotal cases of major limb malformations have been reported in infants after their mothers received intravenous cytarabine, alone or in combination with other agents, during the first trimester. The concern for fetal harm following intrathecal DepoCyt administration is low, however, because systemic exposure to cytarabine is negligible. Cytarabine was teratogenic in mice (cleft palate, phocomelia, deformed appendages, skeletal abnormalities) when doses ³ 2 mg/kg/day were administered i.p. during the period of organogenesis (about 0.2 times the recommended human dose on mg/m² basis), and in rats (deformed appendages) when 20 mg/kg was administered as a single i.p. dose on day 12 of gestation (about 4 times the recommended human dose on mg/m² basis). Single i.p. doses of 50 mg/kg in rats (about 10 times the recommended human dose on mg/m² basis) on day 14 of gestation also cause reduced prenatal and postnatal brain size and permanent impairment of learning ability. Cytarabine was embryotoxic in mice when administered during the period of organogenesis. Embryotoxicity was characterized by decreased fetal weight at 0.5 mg/kg/day (about 0.05 times the recommended human dose on mg/m² basis), and increased early and late resorptions and decreased live litter sizes at 8 mg/kg/day (approximately equal to the recommended human dose on mg/m² basis). There are no adequate and well controlled studies in pregnant women. If this drug is used during pregnancy or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential harm to the fetus. Despite the low apparent risk for fetal harm, women of childbearing potential should be advised to avoid becoming pregnant.

General

DepoCyt has the potential of producing serious toxicity (see DESCRIPTION: boxed WARNING). All patients receiving DepoCyt should be treated concurrently with dexamethasone to mitigate the symptoms of chemical arachnoiditis (see DOSAGE AND ADMINISTRATION). Toxic effects may be related to a single dose or to cumulative administration. Because toxic effects can occur at any time during therapy (although they are most likely within 5 days of drug administration), patients receiving intrathecal therapy with DepoCyt should be monitored continuously for the development of neurotoxicity. If patients develop neurotoxicity, subsequent doses of DepoCyt should be reduced, and DepoCyt should be discontinued if toxicity persists.

Some patients with neoplastic meningitis receiving treatment with DepoCyt may require concurrent radiation or systemic therapy with other chemotherapeutic agents; this may increase the rate of adverse events.

Anaphylactic reactions following intravenous administration of free cytarabine have been reported.

Although significant systemic exposure to free cytarabine following intrathecal treatment is not expected, some effect on bone marrow function cannot be excluded. Systemic toxicity due to intravenous administration of cytarabine consists primarily of bone marrow suppression with leukopenia, thrombocytopenia, and anemia. Accordingly, careful monitoring of the hematopoietic system is advised.

Transient elevations in CSF protein and white blood cells have been observed in patients following DepoCyt administration and have also been noted after intrathecal treatment with methotrexate or cytarabine.

Information for the Patient

Patients should be informed about the expected adverse events of headache, nausea, vomiting, and fever, and about the early signs and symptoms of neurotoxicity. The importance of concurrent dexamethasone administration should be emphasized at the initiation of each cycle of DepoCyt treatment. Patients should be instructed to seek medical attention if signs or symptoms of neurotoxicity develop, or if oral dexamethasone is not well tolerated (see DOSAGE AND ADMINISTRATION).

Laboratory Test Interactions

Since DepoCyt particles are similar in size and appearance to white blood cells, care must be taken in interpreting CSF examinations following DepoCyt administration.

Carcinogenesis, Mutagenesis, Impairment of Fertility

No carcinogenicity, mutagenicity or impairment of fertility studies have been conducted with DepoCyt. The active ingredient of DepoCyt, cytarabine, was mutagenic in vitro tests and was clastogenic in vitro (chromosome aberrations and SCE in human leukocytes) and in vivo (chromosome aberrations and SCE assay in rodent bone marrow, mouse micronucleus assay). Cytarabine caused the transformation of hamster embryo cells and rat H43 cells in vitro. Cytarabine was clastogenic to meiotic cells; a dose-dependent increase in sperm-head abnormalities and chromosomal aberrations occurred in mice given i.p. cytarabine.

Impairment of Fertility: No studies assessing the impact of cytarabine on fertility are available in the literature. Because the systemic exposure to free cytarabine following intrathecal treatment with DepoCyt was negligible, the risk of impaired fertility after intrathecal DepoCyt is likely to be low.

Pregnancy

Pregnancy Category D (see WARNINGS).

Nursing Mothers

It is not known whether cytarabine is excreted in human milk following intrathecal DepoCyt administration. The systemic exposure to free cytarabine following intrathecal treatment with DepoCyt was negligible. Despite the low apparent risk, because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants, the use of DepoCyt is not recommended in nursing women.

Pediatric Use

The safety and efficacy of DepoCyt in pediatric patients has not been established.

Last updated on RxList: 5/18/2007

No overdosages with DepoCyt® (cytarabine liposome injection) have been reported. An overdose with DepoCyt may be associated with severe chemical arachnoiditis including encephalopathy.

In an early uncontrolled study without dexamethasone prophylaxis, single doses up to 125 mg were administered. One patient at the 125 mg dose level died of encephalopathy 36 hours after receiving an intraventricular dose of DepoCyt (see WARNINGS). This patient, however, was also receiving concomitant whole brain irradiation and had previously received intraventricular methotrexate.

There is no antidote for overdose of intrathecal DepoCyt or unencapsulated cytarabine released from DepoCyt. Exchange of CSF with isotonic saline has been carried out in a case of intrathecal overdose of free cytarabine, and such a procedure may be considered in the case of DepoCyt overdose. Management of overdose should be directed at maintaining vital functions.

DepoCyt® (cytarabine liposome injection) is contraindicated in patients who are hypersensitive to cytarabine or any component of the formulation, and in patients with active meningeal infection.

Last updated on RxList: 5/18/2007

Mechanism of Action

DepoCyt® (cytarabine liposome injection) is a sustained-release formulation of the active ingredient cytarabine designed for direct administration into the cerebrospinal fluid (CSF). Cytarabine is a cell cycle phase-specific antineoplastic agent, affecting cells only during the S-phase of cell division. Intracellularly, cytarabine is converted into cytarabine-5'-triphosphate (ara-CTP), which is the active metabolite. The mechanism of action is not completely understood, but it appears that ara-CTP acts primarily through inhibition of DNA polymerase. Incorporation into DNA and RNA may also contribute to cytarabine cytotoxicity. Cytarabine is cytotoxic to a wide variety of proliferating mammalian cells in culture.

Pharmacokinetics

Following intrathecal administration of DepoCyt 50 mg during the induction phase, peak levels of free CSF cytarabine were observed within 1 hour of dosing and ranged from 30 to 50 mcg/mL. The terminal half-life for the free CSF cytarabine ranged from of 5.9 to 82.4 hours. Systemic exposure to cytarabine was negligible following intrathecal administration of DepoCyt 50 mg.

Metabolism and Elimination

The primary route of elimination of cytarabine is metabolism to the inactive compound ara-U, followed by urinary excretion of ara-U. In contrast to systemically administered cytarabine, which is rapidly metabolized to ara-U, conversion to ara-U in the CSF is negligible after intrathecal administration because of the significantly lower cytidine deaminase activity in the CNS tissues and CSF. The CSF clearance rate of cytarabine is similar to the CSF bulk flow rate of 0.24 mL/min.

Drug Interactions

No formal assessments of pharmacokinetic drug-drug interactions between DepoCyt and other agents have been conducted.

Special Populations

The effects of gender or race on the pharmacokinetics of DepoCyt have not been studied, nor has the effect of renal or hepatic impairment.

Clinical Studies

DepoCyt® (cytarabine liposome injection) was studied in 2 controlled clinical trials that enrolled patients with neoplastic meningitis. The first study, which was a randomized, multi-center, multi-arm study involving a total of 99 treated patients, compared 50 mg of DepoCyt administered every 2 weeks to standard intrathecal chemotherapy administered twice a week to patients with solid tumors, lymphoma, or leukemia. For patients with lymphoma, standard therapy consisted of 50 mg of unencapsulated cytarabine given twice a week. Thirty-three lymphoma patients (17 DepoCyt, 16 cytarabine) were treated. Patients went off study if they had not achieved a complete response defined as clearing of the CSF from all previously positive sites in the absence of progression of neurological symptoms, after 4 weeks of treatment with study drug.

In the first study, complete response was prospectively defined as (1) conversion, confirmed by a blinded central pathologist, from a positive examination of the CSF for malignant cells to a negative examination on two separate occasions (at least 3 days apart, on day 29 and later) at all initially positive sites, together with (2) an absence of neurological progression during the treatment period.

The complete response rates in the first study of lymphoma are shown in Table 1. Although there was a plan for central pathology review of the data, in 4 of the 7 responding patients on the DepoCyt arm this was not accomplished and these cases were considered to have had a complete response based on the reading of an unblinded pathologist. The median overall survival of all treated patients was 99.5 days in the DepoCyt group and 63 days in the cytarabine group. In both groups the majority of patients died from progressive systemic disease, not neoplastic meningitis.

The second study was a randomized, multi-center, multi-arm study involving a total of 124 treated patients with either solid tumors or lymphomas. In this study, 24 patients with lymphoma were randomized and treated with DepoCyt or cytarabine, Patients received 6 two-week induction cycles of DepoCyt 50 mg every 2 weeks or cytarabine 50 mg twice weekly. Patients then received four maintenance cycles of DepoCyt 50 mg every 4 weeks, or cytarabine 50 mg weekly for 4 weeks. In both studies, patients received concurrent treatment with dexamethasone to minimize symptoms associated with chemical arachnoiditis (see WARNINGS and DOSAGE AND ADMINISTRATION). In this study, cytological response was assessed in a blinded fashion utilizing a similar definition as in the first study. The results in patients with lymphomatous meningitis are shown in Table 1.

Table 1: Complete Cytological Responses in Patients with Lymphomatous Meningitis

Last updated on RxList: 5/18/2007

Patients should be informed about the expected adverse events of headache, nausea, vomiting, and fever, and about the early signs and symptoms of neurotoxicity. The importance of concurrent dexamethasone administration should be emphasized at the initiation of each cycle of DepoCyt treatment. Patients should be instructed to seek medical attention if signs or symptoms of neurotoxicity develop, or if oral dexamethasone is not well tolerated (see DOSAGE AND ADMINISTRATION).

Last updated on RxList: 5/18/2007

IMPORTANT NOTE: This is a summary and does not contain all possible information about this product. For complete information about this product or your specific health needs, ask your health care professional. Always seek the advice of your health care professional if you have any questions about this product or your medical condition. This information is not intended as individual medical advice and does not substitute for the knowledge and judgment of your health care professional. This information does not contain any assurances that this product is safe, effective, or appropriate for you.

CYTARABINE LIPOSOME - INJECTION

(sye-TARE-ah-been lye-poe-SEW-mull)

COMMON BRAND NAME(S): Depocyt

WARNING: This medication sometimes causes an inflammation of the brain (arachnoiditis), which may rarely be fatal. Before your treatment with this medication, your doctor will direct you to take another drug (dexamethasone) to help prevent this side effect or to make it less serious if it does occur. Follow your doctor's directions carefully. Tell your doctor immediately if any of these side effects occur: nausea, vomiting, headache, neck pain/stiffness, back pain, fever.

USES: Cytarabine liposome is a long-acting (sustained-release) chemotherapy drug used to treat cancer in the area around the spinal cord (lymphomatous meningitis). It works by slowing or stopping the growth of cancer cells.

HOW TO USE: This medication is given by injection into the spinal fluid over 1 to 5 minutes by your doctor. It is usually given every 14 days or as directed. Health care professionals must follow all instructions for proper mixing and use of this drug. If you have questions about using this medication properly, consult your pharmacist.

After receiving this medication, you will be instructed to lie flat for 1 hour.

The dosage and length of treatment depends on your medical condition and response to treatment. After several months, your doctor may only give this drug every 28 days (maintenance dose).

To reduce the risk of serious side effects, your doctor will give you other medication(s) such as dexamethasone before and for several days following your treatment. It is very important that you use this medication as directed. Tell you doctor immediately if you cannot take the dexamethasone (e.g., because of vomiting), if you vomit just after taking dexamethasone, or if you miss a dose.

SIDE EFFECTS: Nausea, vomiting, or fever may occur. If any of these effects persist or worsen, tell your doctor promptly.

Many people using this medication have serious side effects. However, your doctor has prescribed this drug because he or she has judged that the benefit to you is greater than the risk of side effects.

Tell your doctor immediately if any of these serious side effects occur: headache, tingling/numbness, muscle pain, back pain, neck pain/stiffness, seizures, swelling.

Tell your doctor immediately if any of these unlikely but very serious side effects occur: loss of bladder/bowel control, unusual weakness/tiredness, easy bruising/bleeding, signs of infection (e.g., persistent sore throat), mental/mood changes (e.g., confusion).

Seek immediate medical attention if any of these rare but very serious side effects occur: weakness/loss of movement on one side of the body, vision/hearing changes.

A very serious allergic reaction to this drug is rare. However, seek immediate medical attention if you notice any symptoms of a serious allergic reaction, including: rash, itching, swelling, severe dizziness, trouble breathing.

This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.

Contact your doctor for medical advice about side effects. The following numbers do not provide medical advice, but in the US you may report side effects to the Food and Drug Administration (FDA) at 1-800-FDA-1088. In Canada, you may call Health Canada at 1-866-234-2345.

PRECAUTIONS: Before using cytarabine, tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies.

This medication should not be used if you have certain medical conditions. Before using this medicine, consult your doctor or pharmacist if you have: brain infection (e.g., bacterial/fungal/viral meningitis).

Before using this medication, tell your doctor or pharmacist your medical history, especially of: previous chemotherapy, previous radiation therapy.

Do not have immunizations/vaccinations without the consent of your doctor, and avoid contact with people who have recently received oral polio vaccine or flu vaccine inhaled through the nose.

Wash your hands well to prevent the spread of infections. Avoid contact with people who have illnesses that may spread to others (e.g., flu, chickenpox).

To lower your chance of getting cut, bruised, or injured, use caution with sharp objects like razors and nail cutters, and avoid activities such as contact sports.

This drug is not recommended for use during pregnancy. It may harm the unborn baby. If you become pregnant or think you may be pregnant, tell your doctor immediately.

It is not known whether this medication passes into breast milk. However, it may have undesirable effects on a nursing infant. Therefore, breast-feeding while using this medication is not recommended. Consult your doctor before breast-feeding.

DRUG INTERACTIONS: Your doctor or pharmacist may already be aware of any possible drug interactions and may be monitoring you for them. Do not start, stop, or change the dosage of any medicine before checking with your doctor or pharmacist first.

Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of: digoxin, other cancer chemotherapy drugs.

This product can affect the results of certain lab tests (e.g., white blood cell counts in CSF), possibly causing false test results. Make sure laboratory personnel and all your doctors know you use this drug.

This document does not contain all possible interactions. Therefore, before using this product, tell your doctor or pharmacist of all the products you use. Keep a list of all your medications with you, and share the list with your doctor and pharmacist.

OVERDOSE: If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US National Poison Hotline at 1-800-222-1222. Canada residents can call a provincial poison control center.

NOTES: Laboratory and/or medical tests (e.g., complete blood count) should be performed periodically to monitor your progress or check for side effects. Consult your doctor for more details.

MISSED DOSE: If you miss a dose or your dosing schedule is interrupted, contact your doctor promptly to establish a new dosing schedule.

STORAGE: Refrigerate the medication vial between 36-46 degrees F (2-8 degrees C). Do not freeze. Warm the medication to room temperature before preparing the dose. Swirl gently to mix. Do not shake. Prepare this drug immediately before use if possible. Do not prepare this drug more than 4 hours before use. Discard any unused portion of the vial.

Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

MEDICAL ALERT: Your condition can cause complications in a medical emergency. For information about enrolling in MedicAlert, call 1-800-854-1166 (USA) or 1-800-668-1507 (Canada).

Information last revised July 2008 Copyright(c) 2008 First DataBank, Inc.