Anzatax

Anzatax

paclitaxel

Manufacturer:

Hospira

Distributor:

Zuellig Pharma

Marketer:

Pfizer
Full Prescribing Info
Contents
Paclitaxel.
Description
Anzatax Injection Concentrate is a sterile solution containing 6 mg/mL paclitaxel. Paclitaxel is an anticancer agent from the taxane class of drugs. It is a white powder. Paclitaxel is extremely hydrophobic, and is therefore formulated in PEG 35 castor oil and ethanol.
Paclitaxel is described chemically as (2S,5R,7S,10R,13S)-10,20-bis(acetoxy)-2- benzoyloxy-1,7-dihydroxy-9-oxo-5,20-epoxytax-11-en-13-yl (3S)-3-benzoylamino-3-phenyl-D-lactate.
Molecular weight: 853.9.
CAS number: 33069-62-4.
Anzatax Injection Concentrate has a pH of 6 to 7.
Excipients with known effect: Ethanol.
Excipients/Inactive Ingredients: Citric acid, PEG 35 castor oil, Ethanol.
Action
Pharmacotherapeutic Group Anticancer agent from the taxane class of drugs.
Pharmacology: Pharmacodynamics Mechanism of action: Paclitaxel is an antimicrotubule antineoplastic agent. It promotes microtubule assembly by enhancing the polymerisation of tubulin, the protein subunit of spindle microtubules, even in the absence of the mediators normally required for microtubule assembly (e.g., guanosine triphosphate [GTP]), thereby inducing the formation of stable, non-functional microtubules. While the precise mechanism of action of the drug is not completely known, paclitaxel disrupts the dynamic equilibrium within the microtubule system and blocks cells in the late G2 phase and M phase of the cell cycle, inhibiting cell replication and impairing function of nervous tissue.
Clinical trials: No data available.
Pharmacokinetics: Distribution: After paclitaxel is administered intravenously, its plasma concentration declines biphasically.
The first phase shows rapid decline representing distribution of paclitaxel to the peripheral compartment and elimination. This initial phase is followed by a relatively slow elimination of paclitaxel from the peripheral compartment.
Mean steady state volume of distribution following single dose infusion of 135 and 175 mg/m2 has ranged from 198 to 688 L/m2, indicating extensive extravascular distribution and/or tissue binding.
The serum protein binding of paclitaxel is 89% following a 3-hour infusion of 175 mg/m2 paclitaxel.
Metabolism: The liver is thought to be the primary site of metabolism for paclitaxel.
Excretion: In patients treated with doses of 135 and 175 mg/m2 given as 3- and 24-hour infusions, mean terminal half-life has ranged from 3.0 to 52.7 hours and total body clearance has ranged from 11.6 to 24.0 L/hour/m2.
Following 3-hour infusions of 175 mg/m2, mean terminal half-life was estimated to be 9.9 hours; mean total body clearance was 12.4 L/hour/m2.
The mean cumulative urinary recovery of unchanged paclitaxel has been reported as 1.8 to 12.6% of the dose.
Toxicology: Preclinical safety data: Genotoxicity: In vitro studies (chromosome abnormalities in human lymphocytes) and in vivo (micronucleus test using mice) mammalian test systems have shown paclitaxel to be mutagenic. When testing using the Ames test or the CHO/HGPRT gene mutation assay, paclitaxel did not induce mutagenicity.
Carcinogenicity: No studies have examined the carcinogenic potential of paclitaxel, however, drugs similar to paclitaxel are carcinogens.
Indications/Uses
Anzatax Injection Concentrate is indicated for the first-line therapy of advanced metastatic ovarian cancer in combination with a platinum agent.
Anzatax Injection Concentrate is indicated for the treatment of metastatic ovarian cancer and metastatic breast cancer, after failure of standard therapy.
Anzatax Injection Concentrate is indicated for the first-line therapy in combination with a platinum compound or as a single agent for the treatment of non-small cell lung cancer (NSCLC) in patients who are not candidates for potentially curative surgery and/or radiation therapy.
Anzatax Injection Concentrate is indicated for adjuvant treatment of node positive breast cancer administered sequentially to doxorubicin and cyclophosphamide.
Anzatax Injection Concentrate is indicated for the first-line therapy of metastatic cancer of the breast, in combination with trastuzumab (Herceptin), in patients who have tumors that over-express HER-2.
Dosage/Direction for Use
Dosage: All patients should be premedicated before paclitaxel is administered to prevent severe hypersensitivity reactions (see Precautions). Before every treatment cycle, patients should be premedicated with: dexamethasone 20 mg orally 12 hours and 6 hours prior to starting the paclitaxel infusion.
Promethazine 25 mg to 50 mg intravenously or other suitable H1-antagonist, 30 minutes prior to starting the paclitaxel infusion.
Cimetidine 300 mg or ranitidine 50 mg by intravenous infusion over 15 minutes, starting 30 minutes prior to the paclitaxel infusion.
For primary treatment of ovarian cancer, it is recommended that paclitaxel be used at a dose of: 175 mg/m2, administered intravenously over 3 hours, followed by cisplatin 75 mg/m2. The infusion should be repeated every three weeks.
135 mg/m2, administered intravenously over 24 hours, followed by cisplatin 75 mg/m2. The infusion should be repeated every three weeks.
For the treatment of metastatic ovarian cancer or metastatic breast cancer, it is recommended that paclitaxel be used as a single agent at a dose of 175 mg/m2. Paclitaxel should be administered as an intravenous infusion over 3 hours. The infusion should be repeated every 3 weeks as tolerated. Patients have tolerated treatment with up to 9 cycles of paclitaxel therapy, but the optimal course of therapy remains to be established.
For primary or secondary treatment of NSCLC, the recommended dose of paclitaxel is 175 mg/m2 administered intravenously over 3 hours with a 3-week interval between courses.
For node positive breast cancer, the recommended dose of paclitaxel is 175 mg/m2 administered intravenously over 3 hours every 3 weeks for four courses following doxorubicin and cyclophosphamide combination therapy.
For over-expression of HER-2 breast cancer, paclitaxel 175 mg/m2 administered intravenously over 3 hours with a 3-week interval between courses. Paclitaxel may be started the day following the first dose of trastuzumab or immediately after the subsequent doses of trastuzumab if the preceding dose of trastuzumab was well tolerated.
Method of administration: Dilution: Anzatax Injection Concentrate MUST BE DILUTED PRIOR TO INTRAVENOUS INFUSION. It should be diluted in 5% glucose or 0.9% sodium chloride intravenous infusion.
Dilution should be made to a final concentration of 0.3 to 1.2 mg/mL.
After the final dilution of Anzatax Injection Concentrate, the bottle should be swirled gently to disperse the paclitaxel. DO NOT SHAKE.
Avoid contact of paclitaxel solutions with plasticised polyvinyl chloride (PVC) equipment, infusion lines or devices used when preparing infusion solutions. Prepare and store diluted paclitaxel solutions in glass bottles or non-PVC infusion bags. These precautions are to avoid leaching of the plasticiser DEHP (di-[2-ethylhexyl] phthalate) from PVC infusion bags or sets. Paclitaxel solutions should be administered through polyethylene lined administration sets (e.g., Gemini 20 giving set), using an IMED pump.
Although solutions of paclitaxel for infusion prepared as outlined previously are chemically stable for 3 days at room temperature (25°C) and 14 days at 2°C to 8°C, it is recommended that the solution for infusion should be administered immediately after preparation as it does not contain an antimicrobial agent. The infusion should be completed within 24 hours of preparation of the solution and any residue discarded, according to the guidelines for the disposal of cytotoxic drugs (see Special precautions for disposal under Cautions for Usage). Use in one patient on one occasion only.
Compounding centres which: 1. Are licensed by the TGA to reconstitute and/or further dilute cytotoxic products; and 2. Have validated aseptic procedure and regular monitoring of aseptic technique may apply the following shelf lives when stored under the specified conditions: (See table.)

Click on icon to see table/diagram/image

Solutions prepared this way have been shown to be chemically stable for these periods. Administration should be completed within 24 hours of the start of the infusion and any residue discarded according to the guidelines for the disposal of cytotoxic drugs. Do not use paclitaxel if any precipitation forms or if the diluted solution appears cloudy.
Filtration: A microporous membrane of 0.22 microns or less in size is recommended as the in-line filter for all infusions of paclitaxel. The IMED 0.2 micron add on filter set composed of polysulfone and the IVEX II 0.2 micron filter composed of cellulose have both been found to be suitable for Anzatax Injection Concentrate.
Paclitaxel is a cytotoxic anticancer drug and as with other potentially toxic compounds, caution should be exercised in handling paclitaxel. The use of gloves is recommended. Following topical exposure, tingling, burning, redness have been observed. If paclitaxel solution contacts the skin, wash the skin immediately and thoroughly with soap and water. If paclitaxel contacts mucous membranes, the membranes should be flushed thoroughly with water. Upon inhalation, dyspnoea, chest pain, burning eyes, sore throat and nausea have been reported. Given the possibility of extravasation, it is advisable to closely monitor the infusion site for possible infiltration during drug administration.
The published guidelines related to procedures for the proper handling and disposal of cytotoxic drugs should be followed.
Care must be taken whenever handling cytotoxic products. Always take steps to prevent exposure. This included appropriate equipment, such as wearing gloves and washing hands with soap and water after handling such products.
Dosage adjustment: Repetition of a course of paclitaxel is not recommended until the patient's neutrophil count is at least 1.5 x 109 cells/L (1,500 cells/mm3) and the platelet count is at least 100 x 109 cells/L (100,000 cells/mm3). If there is severe neutropenia (neutrophil count less than 0.5 x 109 cells/L for 7 or more days) or severe peripheral neuropathy during paclitaxel therapy, the dose of paclitaxel in subsequent courses should be reduced by 20% (see Precautions).
Overdosage
At present, there is no specific treatment for paclitaxel overdosage. Probable consequences of an overdose are mucositis, severe bone marrow suppression and peripheral neurotoxicity and treatment should be supportive.
Overdoses in paediatric patients may be associated with acute ethanol toxicity.
Contraindications
Anzatax Injection Concentrate must not be used in patients who have exhibited hypersensitivity reactions to paclitaxel.
Anzatax Injection Concentrate must not be used in patients who have a history of hypersensitivity reactions to PEG 35 castor oil or drugs formulated in PEG 35 castor oil (e.g., cyclosporin for injection concentrate and teniposide for injection concentrate).
Anzatax Injection Concentrate should not be administered in patients with solid tumours who have a baseline neutrophil counts of <1.5 x 109 cells/L.
Special Precautions
General: Paclitaxel should be administered under the supervision of a physician experienced in the use of chemotherapeutic agents. Appropriate management of complications is possible only when adequate diagnostic and treatment facilities are readily available.
Paclitaxel should be given before a platinum compound when it is given in combination with a platinum compound.
Premedication: In order to minimise the possibility of hypersensitivity reactions due to histamine release, patients should be premedicated before every treatment cycle of paclitaxel. Premedication should include corticosteroids (e.g., dexamethasone), antihistamines (e.g., diphenhydramine or promethazine) and an H2-receptor antagonist (e.g., cimetidine or ranitidine) (see Dosage & Administration). The characteristic symptoms of hypersensitivity reactions are dyspnoea and hypotension both requiring treatment, angioedema and widespread urticaria. In clinical trials, 2% of patients treated with paclitaxel experienced severe hypersensitivity. One of these reactions was fatal in a patient treated without premedication. Anzatax Injection Concentrate must not be used in patients who have exhibited hypersensitivity reactions to paclitaxel.
Neutropenia (see Adverse Reactions): As the dose limiting toxicity of paclitaxel is dose related bone marrow suppression (primarily neutropenia), paclitaxel should not be administered to patients with a pretreatment neutrophil count of less than 1.5 x 109 cells/L (1,500 cells/mm3) or platelet count of less than 100 x 109 cells/L. Blood counts should be frequently monitored during treatment with paclitaxel. Further cycles of paclitaxel should not be administered until the patient's neutrophil count is greater than 1.5 x 109 cells/L (1,500 cells/mm3) and the platelet count is greater than 100 x 109 cells/L (100,000 cells/mm3).
If there is severe neutropenia during a course of paclitaxel (i.e., neutrophil count less than 0.5 x 109 cells/L [500 cells/mm3]), the dose of paclitaxel in subsequent cycles should be reduced by 20%. Previous radiation therapy may induce more severe myelosuppression. There is little information available from such patients at doses above 135 mg/m2.
Cardiovascular toxicity: Hypotension, hypertension and bradycardia have been observed during paclitaxel administration, but generally do not require treatment. Frequent monitoring of vital signs, particular during the first hours of paclitaxel infusion is recommended (see also Adverse Reactions).
Electrocardiographic monitoring is recommended for patients with serious conduction abnormalities and should be commenced for patients who develop abnormal cardiovascular symptoms or signs during monitoring of vital signs.
Severe cardiac conduction abnormalities have been reported rarely during paclitaxel therapy. If patients develop significant conduction abnormalities during paclitaxel administration, appropriate therapy should be administered and continuous electrocardiographic monitoring should be commenced and performed during subsequent therapy with paclitaxel (see Adverse Reactions). Severe cardiovascular events were observed more frequently in patients with NSCLC than breast or ovarian cancer.
When paclitaxel is used in combination with trastuzumab or doxorubicin for treatment of metastatic breast cancer, monitoring of cardiac function is recommended.
Anaphylaxis and severe hypersensitivity reactions: Severe hypersensitivity (anaphylactoid reactions characterised by dyspnoea and hypotension requiring treatment), angioedema and generalised urticaria have occurred rarely in premedicated patients receiving paclitaxel. Rare fatal reactions have occurred in patients despite pre-treatment. Cross-hypersensitivity between Anzatax and other taxane products has been reported and may include severe reactions such as anaphylaxis. Patients with a previous history of hypersensitivity to other taxanes should be closely monitored during initiation of Anzatax therapy.
Patients receiving paclitaxel should be under continuous observation for at least the first 30 minutes following the start of the infusion and frequently thereafter. In case of a severe hypersensitivity reaction, paclitaxel infusion should be discontinued immediately and appropriate treatment given as indicated for anaphylaxis. The patient should not be rechallenged with the drug. Minor hypersensitivity reactions such as flushing, skin reactions etc. do not require interruption of therapy (see also Adverse Reactions).
Gastrointestinal: In patients receiving paclitaxel who complain of abdominal pain with other signs and symptoms, bowel perforation should be excluded.
Administration: Anzatax Injection Concentrate is administered by intravenous infusion only; it must not be administered by the intracerebral, intrapleural or intraperitoneal routes.
Anzatax Injection Concentrate must be diluted before intravenous infusion. Prior to intravenous infusion of paclitaxel, it must be ensured that the indwelling catheter is in the correct position as extravasation, necrosis and/or thrombophlebitis may result with incorrect administration (see Dosage & Administration).
Patients receiving paclitaxel should be under continuous observation for at least the first 30 minutes following the start of the infusion and frequently thereafter. In case of a severe hypersensitivity reaction, paclitaxel infusion should be discontinued immediately and appropriate treatment given as indicated for anaphylaxis. The patient should not be rechallenged with the drug. Minor hypersensitivity reactions such as flushing, skin reactions, etc. do not require interruption of therapy (see also Adverse Reactions).
In some patients, temporary discontinuation of the infusion is sufficient to resolve the symptoms. Other patients may require therapy with bronchodilators, adrenaline, antihistamines and corticosteroids, either alone or in combination.
Injection site reaction: A specific treatment for extravasation reaction is unknown at this time. Given the possibility of extravasation, it is advisable to closely monitor the infusion site for possible infiltration during drug administration.
Nervous system: Patients with pre-existing neuropathy should be carefully monitored. Peripheral neuropathy is frequently reported in patients receiving paclitaxel and the severity is dose dependent. A 20% reduction in paclitaxel dose is recommended for patients who develop peripheral neuropathy during therapy (see Adverse Reactions).
In NSCLC patients, the administration of paclitaxel in combination with cisplatin resulted in a greater incidence of neurotoxicity than usually seen in patients receiving single agent paclitaxel.
Paclitaxel contains ethanol, 396 mg/mL; consideration should be given to possible CNS and other effects of alcohol.
Children may be more sensitive than adults to the effects of ethanol.
Effects on laboratory tests: No data available.
Use in hepatic impairment: The effect of hepatic impairment on the pharmacokinetics of paclitaxel has not been established. However, as the liver is thought to be the primary site for metabolism of the drug, paclitaxel should be given cautiously to patients with decreased liver function. Paclitaxel has been shown to cause a dose related elevation of liver enzymes.
When paclitaxel is given as a 24-hour infusion to patients with moderate to severe hepatic impairment, increased myelosuppression may be seen as compared to patients with mildly elevated liver function tests given 24-hour infusions.
Use in renal impairment: The effect of renal impairment on the pharmacokinetics of paclitaxel has not been established.
Effects on ability to drive and use machines: The effects of this medicine on a person's ability to drive and use machines were not assessed as part of its registration.
Use in Children: The safety and effectiveness of paclitaxel in paediatric patients has not been established. There have been reports of central nervous system (CNS) toxicity (rarely associated with death) in a clinical trial in paediatric patients in which paclitaxel was infused intravenously over 3 hours at doses ranging from 350 mg/m2 to 420 mg/m2. The toxicity is most likely attributable to the high dose of the ethanol component of the paclitaxel vehicle given over a short infusion time. The use of concomitant antihistamines may intensify this effect. Although a direct effect of the paclitaxel itself cannot be discounted, the high doses used in this study (over twice the recommended adult dosage) must be considered in assessing the safety of paclitaxel for use in this population.
Use in the Elderly: Of 2228 patients who received paclitaxel in eight clinical studies evaluating its safety and efficacy in the treatment of advanced ovarian cancer, breast carcinoma or NSCLC and 1570 patients who were randomised to receive paclitaxel in the adjuvant breast cancer study, 649 patients (17%) were 65 years or older, including 49 patients (1%) 75 years or older. In most studies, severe myelosuppression was more frequent in elderly patients; in some studies, severe neuropathy was more common in elderly patients. In two clinical studies in NSCLC, the elderly patients treated with paclitaxel had a higher incidence of cardiovascular events. Estimates of efficacy appeared similar in elderly patients and in younger patients; however, comparative efficacy cannot be determined with confidence due to the small number of elderly patients studied. In a study of first line treatment of ovarian cancer, elderly patients had a lower median survival than younger patients, but no other efficacy parameters favoured the younger group.
Use In Pregnancy & Lactation
Effects on fertility: Following treatment with intravenous paclitaxel at a dose of 1 mg/kg (6 mg/m2), rats showed decreased fertility and toxicity in unborn offspring. Paclitaxel administered intravenously to rabbits during organogenesis at a dose of 3 mg/kg (33 mg/m2) was toxic to both mother and foetus.
Infertility in females and males: Based on findings in animal studies, Anzatax may impair fertility in females and males of reproductive potential.
Use in pregnancy – Category D: Paclitaxel is a cytotoxic agent that can produce spontaneous abortion, foetal loss and birth defects and may cause foetal harm when administered to a pregnant woman.
Studies have shown paclitaxel to be toxic to embryos and foetuses in rabbits at an intravenous dose of 3 mg/kg (33 mg/m2) given during organogenesis. Paclitaxel is toxic to rat foetuses at a dose of 1 mg/kg (6 mg/m2) and produced low fertility and foetal toxicity in rats. Examination revealed that no gross external, soft tissue or skeletal alterations occurred. There are no studies in pregnant women.
Women of childbearing potential should have a pregnancy test prior to starting treatment with Anzatax. These women should be strongly advised to use effective contraception throughout therapy and for at least six months after the last dose of Anzatax. If paclitaxel is used during pregnancy, or if the patient becomes pregnant while receiving this drug, the patient should be apprised of the potential hazard.
Category D: Drugs which have caused, are suspected to have caused or may be expected to cause, an increased incidence of human fetal malformations or irreversible damage. These drugs may also have adverse pharmacological effects.
Females and males of reproductive potential: Males: Based on findings in genetic toxicity and animal reproduction studies, males should be advised to use effective contraception in order to avoid fathering a child during treatment and for at least three months after the last dose of Anzatax.
Females: Women of childbearing potential should be advised to use effective contraception in order to avoid becoming pregnant during treatment and for at least six months after the last dose of Anzatax.
Use in lactation: It is not known whether paclitaxel is excreted in human milk. The evidence from many drugs would suggest that paclitaxel could be excreted in breast milk, though this is not known. Because infants receiving the drug could experience serious adverse effects, breastfeeding should be discontinued while the mother is undergoing treatment.
Adverse Reactions
The following is based on the experience of 812 patients treated in Phase II and III clinical trials. The frequency and severity of adverse effects are generally similar between patients receiving paclitaxel for the treatment of ovarian, breast or lung cancer. None of the observed effects were clearly influence by age. Unless stated otherwise, percent figures, where given, are based on observed incidence when using the recommended dosing regimen. If other regimes are used, the incidence of reaction may be higher.
Safety of the paclitaxel/platinum combination has been investigated in a large randomised trial in ovarian cancer and in two Phase III trials in NSCLC. Unless otherwise mentioned, the combination of paclitaxel with platinum agents did not result in any clinically relevant changes to the safety profile of single agent paclitaxel.
Adverse effects reported were those occurring during or following the first course of therapy and have, where possible, been grouped by frequency according to the following criteria. Very common: ≥1/10; Common: ≥1/100 and <1/10; Uncommon: ≥1/1000 and <1/100; Rare: ≥1/10000 and <1/1000; Very rare: <1/10000.
Cardiovascular: Very common: Hypotension.
Common: Bradycardia; ECG abnormalities (non-specific repolarisation and sinus tachycardia).
Uncommon: ECG abnormalities (premature beats), cardiomyopathy.
Rare: Myocardial infarction; congestive heart failure (typically in patients who have received other chemotherapy, notably anthracyclines).
Six severe cardiovascular events possibly related to paclitaxel administration occurred including asymptomatic ventricular tachycardia, tachycardia with bigeminy, atrioventricular block (2 patients), and syncopal episodes (2 patients-in one associated with severe hypotension and coronary stenosis resulting in death). Severe hypotensive reactions have been associated with serious hypersensitivity reactions and have required intervention.
Haematological: Very common: Myelosuppression, thrombocytopenia, leucopoenia, fever, bleeding, anaemia; neutropenia (Overall, 52% of the patients experienced severe Grade IV neutropenia and 56% had Grade III/IV severe neutropenia on their first course. Neutrophil nadirs occurred at a median of 11 days after paclitaxel administration).
Common: Febrile neutropenia (associated with an infectious episode, including UTI and URTI).
Rare: Five septic episodes, which were associated with severe neutropenia attributable to paclitaxel administration had a fatal outcome.
Patients who have received prior radiation or cisplatin therapy exhibit more frequent myelosuppression, which is generally of greater severity (see Precautions and Interactions).
Hepatobiliary: Very common: Elevated alkaline phosphatase; elevated AST; elevated ALT.
Common: Elevated bilirubin.
Rare: Hepatic necrosis (leading to death); hepatic encephalopathy (leading to death).
Hypersensitivity: Very common: Flushing; rash.
Common: Dyspnoea; hypotension; chest pains; tachycardia.
Uncommon: Significant hypersensitivity reactions requiring therapy (e.g. Hypotension, angioneurotic oedema, respiratory distress, generalised urticaria, oedema, back pains, chills.
Infections and Infestation: Very common: Infection.
Uncommon: Septic shock.
Gastrointestinal: Very common: Nausea; vomiting; diarrhoea; mucositis (These manifestations were usually mild to moderate at the recommended dose).
Rare: Bowel perforation (There have been several cases of bowel perforation associated with patients receiving paclitaxel. Patients receiving paclitaxel who complain of abdominal pain with other signs and symptoms, should have bowel perforation excluded).
Neutropenic enterocolitis has been reported.
Vascular Disorders: Very common: Hypotension.
Uncommon: Hypertension, thrombosis, thrombophlebitis.
Musculoskeletal: Very common: Arthralgia; myalgia (The symptoms were usually transient occurring two to three days after paclitaxel administration and resolving within a few days).
Neurological: Very common: Peripheral neuropathy (Peripheral neuropathy occurs and is dose dependent with 60% of patients experiencing Grade I toxicity, 10% Grade II and 2% Grade III at the recommended doses. Neuropathy was present in 87% of patients at higher doses. Severity of symptoms also increased with dose; 4% of patients experienced severe symptoms at the recommended dose versus 10% at higher doses. Neurologic symptoms may occur following the first course and symptoms may worsen with increasing exposure to paclitaxel. Peripheral neuropathy was the cause of paclitaxel discontinuation in 2% of patients. Sensory symptoms have usually improved or resolved within several months of paclitaxel discontinuation).
Rare: Optic nerve and/or visual disturbances (scintillating scotomata) particularly in patients who have received higher doses than recommended; these effects generally have been reversible; motor neuropathy with resultant minor distal weakness and autonomic neuropathy resulting in paralytic ileus and orthostatic hypotension.
Skin and Appendages: Very common: Alopecia.
Rare: Nail and skin changes (mild and transient); radiation-recall dermatitis; recall dermatitis.
Local: Phlebitis following intravenous administration has been reported.
Extravasation leading to oedema, pain, erythema and induration has been reported.
On occasions, extravasation can lead to cellulitis. Skin discolouration may also occur.
General Disorders and Administration Site Conditions: Common: Injection site reactions (including localised oedema, pain, erythema, induration, on occasion extravasation can result in cellulitis).
Injection site reactions, including reactions secondary to extravasation, were usually mild and consistent of erythema, tenderness, skin discolouration, or swelling at the injection site. These reactions have been observed more frequently with the 24-hour infusion than with the 3-hour infusion. Recurrence of skin reactions at a site of previous extravasation following administration of paclitaxel at a different site, i.e., 'recall', has been reported rarely.
Rare reports of more severe events such as phlebitis, cellulitis, induration, skin exfoliation, necrosis and fibrosis have been received as part of the continuing surveillance of paclitaxel safety. In some cases the onset of the injection site reaction either occurred during a prolonged infusion or was delayed by a week to ten days.
A specific treatment for extravasation reactions is unknown at this time. Given the possibility of extravasation, it is advisable to closely monitor the infusion site for possible infiltration during drug administration.
Radiation pneumonitis has been reported in patients receiving concurrent radiotherapy.
Post-Marketing Experience: The following additional adverse reactions have been identified during post approval use of paclitaxel. Because the reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a casual relationship to drug exposure.
Infections and Infestations: Pneumonia, sepsis.
Cardiac Disorders: Atrial fibrillations, supraventricular tachycardia, reduction of left ventricle ejection fraction, ventricular failure.
Haemotological Disorders: Acute myeloid leukaemia, myelodysplastic syndrome.
Immune System Disorders: Anaphylactic reactions (with fatal outcome), anaphylactic shock, cross-hypersensitivity between Anzatax and other taxanes has been reported.
Metabolism and Nutritional Disorders: Anorexia, tumour lysis syndrome.
Psychiatric Disorders: Confusion state.
Vascular Disorders: Shock.
Respiratory, Thoracic and Mediastinal Disorders: Dyspnoea, pleural effusion, respiratory failure, interstitial pneumonia, lung fibrosis, pulmonary embolism, cough.
Gastrointestinal Disorders: Bowel obstruction, bowel perforation, ischemic colitis, pancreatitis, mesenteric thrombosis, pseudomembranous colitis, oesophagitis, constipation, ascites.
Neurological Disorders: Autonomic neuropathy (resulting in paralytic ileus and orthostatic hypotension), grand mal seizures, convulsions, encephalopathy, dizziness, headache, ataxia, parasthesia, hyperesthesia.
Eye Disorders: Photopsia, visual floaters.
Ear and Labyrinth Disorders: Hearing loss, tinnitus, vertigo, ototoxicity.
Skin and Subcutaneous Tissue Disorders: Stevens-Johnson syndrome, epidermal necrolysis, erythema multiforme, exfoliative dermatitis, urticaria, onycholysis (patients on therapy should wear sun protection on hands and feet), scleroderma, pruritus, rash, erythema, phlebitis, cellulitis, skin exfoliation, necrosis and fibrosis.
Investigations: Increase in blood creatinine.
General Disorders and Administration Site Conditions: Asthenia, malaise, pyrexia, dehydration, oedema.
Drug Interactions
Cisplatin: Administration of cisplatin prior to paclitaxel treatment leads to greater myelosuppression than that seen when paclitaxel is given prior to cisplatin. In patients receiving cisplatin prior to paclitaxel, there is about a 33% decrease in paclitaxel clearance.
Ketoconazole: As ketoconazole may inhibit the metabolism of paclitaxel, patients receiving paclitaxel and ketoconazole should be closely monitored or the combination of these drugs should be avoided.
Doxorubicin: Sequence effects characterised by more profound neutropenic and stomatitis episodes have been observed with combination use of paclitaxel and doxorubicin when paclitaxel was administered before doxorubicin and using longer than recommended infusion times (paclitaxel administered over 24 hours; doxorubicin over 48 hours). Plasma levels of doxorubicin (and its active metabolite doxorubicinol) may be increased when paclitaxel and doxorubicin are used in combination. However, data from a trial using bolus doxorubicin and 3-hour paclitaxel infusion found no sequence effects on the pattern of toxicity.
Drugs metabolised in the liver: Caution should be exercised during concurrent administration of drugs which are metabolised in the liver (e.g., erythromycin) as such drugs may inhibit the metabolism of paclitaxel.
The metabolism of paclitaxel is catalysed by cytochrome P450 isoenzymes CYP2C8 and CYP3A4. In the absence of formal clinical drug interaction studies caution should be exercised when administering Anzatax Injection Concentrate concomitantly with known substrates or inhibitors of these isoenzymes.
In the clinical trial of paclitaxel in combination with trastuzumab (Herceptin), mean serum trough concentrations of trastuzumab were consistently elevated 1.5 fold as compared with serum concentrations of trastuzumab in combination with anthracycline plus cyclophosphamide (AC).
Arthralgia or myalgia adverse events of paclitaxel appear to be of a higher incidence in patients being treated concurrently with filgrastim (granulocyte colony stimulating factor; G-CSF).
Caution For Usage
Special precautions for disposal: Any unused medicine or waste material should be disposed of in accordance with local requirements.
Incompatibilities: Incompatibilities were either not assessed or not identified as part of the registration of this medicine.
Storage
Store below 25°C. Protect from light.
ATC Classification
L01CD01 - paclitaxel ; Belongs to the class of plant alkaloids and other natural products, taxanes. Used in the treatment of cancer.
Presentation/Packing
Conc for soln for inj (vial) (clear to pale yellow, free of visible particles) 30 mg/5 mL x 1's. 100 mg/16.7 mL x 1's. 150 mg/25 mL x 1's. 300 mg/50 mL x 1's.
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