"The U.S. Food and Drug Administration today expanded the approved use of Opdivo (nivolumab) to treat patients with advanced (metastatic) squamous non-small cell lung cancer (NSCLC) with progression on or after platinum-based chemotherapy.
1. Effectiveness of the Cytotoxic Regimen
Limited data are currently available regarding the preservation of antitumor efficacy when ETHYOL (amifostine) is administered prior to cisplatin therapy in settings other than advanced ovarian cancer. Although some animal data suggest interference is possible, in most tumor models the antitumor effects of chemotherapy are not altered by amifostine. ETHYOL (amifostine) should not be used in patients receiving chemotherapy for other malignancies in which chemotherapy can produce a significant survival benefit or cure (e.g., certain malignancies of germ cell origin), except in the context of a clinical study.
2. Effectiveness of Radiotherapy
ETHYOL (amifostine) should not be administered in patients receiving definitive radiotherapy, except in the context of a clinical trial, since there are at present insufficient data to exclude a tumor-protective effect in this setting. ETHYOL (amifostine) was studied only with standard fractionated radiotherapy and only when ≥ 75% of both parotid glands were exposed to radiation. The effects of ETHYOL (amifostine) on the incidence of xerostomia and on toxicity in the setting of combined chemotherapy and radiotherapy and in the setting of accelerated and hyperfractionated therapy have not been systematically studied.
Patients who are hypotensive or in a state of dehydration should not receive ETHYOL (amifostine) . Patients receiving ETHYOL (amifostine) at doses recommended for chemotherapy should have antihypertensive therapy interrupted 24 hours preceding administration of ETHYOL (amifostine) . Patients receiving ETHYOL (amifostine) at doses recommended for chemotherapy who are taking antihypertensive therapy that cannot be stopped for 24 hours preceding ETHYOL (amifostine) treatment, should not receive ETHYOL (amifostine) .
Prior to ETHYOL (amifostine) infusion patients should be adequately hydrated. During ETHYOL (amifostine) infusion patients should be kept in a supine position. Blood pressure should be monitored every 5 minutes during the infusion, and thereafter as clinically indicated. It is important that the duration of the 910 mg/m2 infusion not exceed 15 minutes, as administration of ETHYOL (amifostine) as a longer infusion is associated with a higher incidence of side effects. For infusion durations less than 5 minutes, blood pressure should be monitored at least before and immediately after the infusion, and thereafter as clinically indicated. If hypotension occurs, patients should be placed in the Trendelenburg position and be given an infusion of normal saline using a separate i.v. line. During and after ETHYOL (amifostine) infusion, care should be taken to monitor the blood pressure of patients whose antihypertensive medication has been interrupted since hypertension may be exacerbated by discontinuation of antihypertensive medication and other causes such as i.v. hydration.
Guidelines for interrupting and restarting ETHYOL (amifostine) infusion if a decrease in systolic blood pressure should occur are provided in the DOSAGE AND ADMINISTRATION section. Hypotension may occur during or shortly after ETHYOL (amifostine) infusion, despite adequate hydration and positioning of the patient (see ADVERSE REACTIONS and PRECAUTIONS). Hypotension has been reported to be associated with dyspnea, apnea, hypoxia, and in rare cases seizures, unconsciousness, respiratory arrest and renal failure.
4. Cutaneous Reactions
Serious cutaneous reactions have been associated rarely with ETHYOL (amifostine) administration. Serious cutaneous reactions have included erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, toxoderma and exfoliative dermatitis. These reactions have been reported more frequently when ETHYOL is used as a radioprotectant (see ADVERSE REACTIONS). Some of these reactions have been fatal or have required hospitalization and/or discontinuance of therapy Patients should be carefully. monitored prior to, during and after ETHYOL (amifostine) administration. Serious cutaneous reactions may develop weeks after initiation of ETHYOL (amifostine) administration (see PRECAUTIONS).
Allergic manifestations including anaphylaxis and severe cutaneous reactions have been associated rarely with ETHYOL (amifostine) administration.
6. Nausea and Vomiting
Antiemetic medication should be administered prior to and in conjunction with ETHYOL (see DOSAGE AND ADMINISTRATlON). When ETHYOL (amifostine) is administered with highly emetogenic chemotherapy, the fluid balance of the patient should be carefully monitored.
Serum calcium levels should be monitored in patients at risk of hypocalcemia, such as those with nephrotic syndrome or patients receiving multiple doses of ETHYOL (see ADVERSE REACTIONS). If necessary, calcium supplements can be administered.
Patients should be adequately hydrated prior to the ETHYOL (amifostine) infusion and blood pressure should be monitored (see DOSAGE AND ADMINISTRATION).
The safety of ETHYOL (amifostine) administration has not been established in elderly patients, or in patients with preexisting cardiovascular or cerebrovascular conditions such as ischemic heart disease, arrhythmias, congestive heart failure, or history of stroke or transient ischemic attacks. ETHYOL (amifostine) should be used with particular care in these and other patients in whom the common ETHYOL (amifostine) adverse effects of nausea/vomiting and hypotension may be more likely to have serious consequences.
Prior to chemotherapy, ETHYOL (amifostine) should be administered as a 15-minute infusion (see DOSAGE AND ADMINISTRATION). Blood pressure should be monitored every 5 minutes during the infusion, and thereafter as clinically indicated.
Prior to radiation therapy, ETHYOL (amifostine) should be administered as a 3-minute infusion (see DOSAGE AND ADMINISTRATION). Blood pressure should be monitored at least before and immediately after the infusion, and thereafter as clinically indicated.
Based on cutaneous evaluation, cutaneous reactions may require permanent discontinuation of ETHYOL (amifostine) or urgent dermatologic consultation and biopsy (see below).
Cutaneous evaluation of the patient prior to each ETHYOL (amifostine) administration should be performed with particular attention paid to the development of the following:
-Any rash involving the lips or involving mucosa not known to be due to another etiology (e.g., radiation mucositis, herpes simplex, etc.)
-Erythematous, edematous, or bullous lesions on the palms of the hands or soles of the feet and/or other cutaneous reactions on the trunk (front, back, abdomen)
-Cutaneous reactions with associated fever or other constitutional symptoms
Cutaneous reactions must be clearly differentiated from radiation-induced dermatitis and from cutaneous reactions related to an alternate etiology. ETHYOL (amifostine) should also be permanently discontinued for serious or severe cutaneous reactions (see WARNINGS and ADVERSE REACTIONS) or for cutaneous reactions associated with fever or other constitutional symptoms not known to be due to another etiology. ETHYOL (amifostine) should be withheld and dermatologic consultation and biopsy considered for cutaneous reactions or mucosal lesions of unknown etiology appearing outside of the injection site or radiation port and for erythematous, edematous or bullous lesions on the palms of the hand or soles of the feet. Reinitiation of ETHYOL (amifostine) should be at the physician's discretion based on medical judgment and appropriate dermatologic evaluation.
In case of severe acute allergic reactions ETHYOL (amifostine) should be immediately and permanently discontinued. Epinephrine and other appropriate measures should be available for treatment of serious allergic events such as anaphylaxis.
Carcinogenesis, Mutagenesis, Impairment of Fertility
No long term animal studies have been performed to evaluate the carcinogenic potential of ETHYOL (amifostine) . ETHYOL (amifostine) was negative in the Ames test and in the mouse micronucleus test. The free thiol metabolite was positive in the Ames test with S9 microsomal fraction in the TA1535 Salmonella typhimuriumstrain and at the TK locus in the mouse L5178Y cell assay. The metabolite was negative in the mouse micronucleus test and negative for clastogenicity in human lymphocytes.
Pregnancy Category C. ETHYOL (amifostine) has been shown to be embryotoxic in rabbits at doses of 50 mg/kg, approximately sixty percent of the recommended dose in humans on a body surface area basis. There are no adequate and well-controlled studies in pregnant women. ETHYOL (amifostine) should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
No information is available on the excretion of ETHYOL (amifostine) or its metabolites into human milk. Because many drugs are excreted in human milk and because of the potential for adverse reactions in nursing infants, it is recommended that breast feeding be discontinued if the mother is treated with ETHYOL (amifostine) .
The safety and effectiveness in pediatric patients have not been established.
The clinical studies did not include sufficient number of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between elderly and younger patients. In general, dose selection for an elderly patient should be cautious, reflecting the greater frequency of decreased hepatic, renal, or cardiac function and of concomitant disease or other drug therapy in elderly patients.This monograph has been modified to include the generic and brand name in many instances.
Last reviewed on RxList: 8/18/2008
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