Dactinomycin

Dactinomycin for injection is an actinomycin indicated for the treatment of:

• adult and pediatric patients with Wilms tumor, as part of a multi-phase, combination chemotherapy regimen. (
  1.1 Wilms Tumor

  Dactinomycin for injection is indicated for the treatment of adult and pediatric patients with Wilms tumor, as part of a multi-phase, combination chemotherapy regimen.
  )
• adult and pediatric patients with rhabdomyosarcoma, as part of a multiphase, combination chemotherapy regimen. (
  1.2 Rhabdomyosarcoma

  Dactinomycin for injection is indicated for the treatment of adult and pediatric patients with rhabdomyosarcoma, as part of a multi-phase, combination chemotherapy regimen.
  )
• adult and pediatric patients with Ewing sarcoma, as part of a multi-phase, combination chemotherapy regimen. (
  1.3 Ewing Sarcoma

  Dactinomycin for injection is indicated for the treatment of adult and pediatric patients with Ewing sarcoma, as part of a multi-phase, combination chemotherapy regimen.
  )
• adult and pediatric patients with metastatic, nonseminomatous testicular cancer, as part of a multi-phase, combination chemotherapy regimen. (
  1.4 Metastatic Nonseminomatous Testicular Cancer

  Dactinomycin for injection is indicated for the treatment of adult and pediatric patients with metastatic, nonseminomatous testicular cancer, as part of a multi-phase, combination chemotherapy regimen.
  )
• post-menarchal patients with gestational trophoblastic neoplasia, as a single agent or as part of a combination chemotherapy regimen. (
  1.5 Gestational Trophoblastic Neoplasia

  Dactinomycin for injection is indicated for the treatment of post-menarchal patients with gestational trophoblastic neoplasia, as a single agent or as part of a combination chemotherapy regimen.
  )
• adult patients with locally recurrent or locoregional solid malignancies, as a component of palliative or adjunctive regional perfusion. (
  1.6 Regional Perfusion in Locally Recurrent and Locoregional Solid Malignancies

  Dactinomycin for injection is indicated for the treatment of adult patients with locally recurrent or locoregional solid malignancies, as a component of palliative or adjunctive regional perfusion.
  )

• Wilms Tumor: The recommended dose is 45 mcg/kg intravenously once every 3 to 6 weeks for up to 26 weeks, as part of a multi-agent combination chemotherapy regimen. (
  2.1 Recommended Dosage for Wilms Tumor

  The recommended dose of dactinomycin for injection, as part of a multi-agent combination chemotherapy regimen, is 45 mcg/kg intravenously once every 3 to 6 weeks for up to 26 weeks.
  )
• Rhabdomyosarcoma: The recommended dose is 15 mcg/kg intravenously once daily for 5 days every 3 to 9 weeks for up to 112 weeks, as part of a multi-agent combination chemotherapy regimen. (
  2.2 Recommended Dosage for Rhabdomyosarcoma

  The recommended dose of dactinomycin for injection, as part of a multi-agent combination chemotherapy regimen, is 15 mcg/kg intravenously once daily for 5 days every 3 to 9 weeks for up to 112 weeks.
  )
• Ewing Sarcoma: The recommended dose is 1250 mcg/m² intravenously once every 3 weeks for 51 weeks, as part of a multi-agent combination chemotherapy regimen. (
  2.3 Recommended Dosage for Ewing Sarcoma

  The recommended dose of dactinomycin for injection, as part of a multi-agent combination chemotherapy regimen, is 1,250 mcg/m²intravenously once every 3 weeks for 51 weeks.
  )
• Metastatic Nonseminomatous Testicular Cancer: The recommended dose is 1000 mcg/m² intravenously every 3 weeks, as part of cisplatin-based, multi-drug chemotherapy regimen. (
  2.4 Recommended Dosage for Metastatic Nonseminomatous Testicular Cancer

  The recommended dose of dactinomycin for injection, as part of a cisplatin-based, multi-agent combination chemotherapy regimen, is 1,000 mcg/m²intravenously once every 3 weeks for 12 weeks.
  )
• Gestational Trophoblastic Neoplasia:
  
  
  o   
  Non-metastatic and Low-risk Metastatic Disease: The recommended dose is 12 mcg/kg intravenously daily for 5 days, as a single agent. (
  2.5 Recommended Dosage for Gestational Trophoblastic Neoplasia

  The recommended dose of dactinomycin for injection for nonmetastatic and low-risk metastatic disease is 12 mcg/kg intravenously daily for five days as a single agent.

  The recommended dose of dactinomycin for injection, as part of a multi-agent combination chemotherapy regimen, for high-risk metastatic disease is 500 mcg intravenously on Days 1 and 2 every 2 weeks for up to 8 weeks.
  )
  
  
  o
     
  High-risk Metastatic Disease: The recommended dose is 500 mcg intravenously on Days 1 and 2 every 2 weeks for up to 8 weeks, as part of a multi-agent combination chemotherapy regimen. (
  2.5 Recommended Dosage for Gestational Trophoblastic Neoplasia

  The recommended dose of dactinomycin for injection for nonmetastatic and low-risk metastatic disease is 12 mcg/kg intravenously daily for five days as a single agent.

  The recommended dose of dactinomycin for injection, as part of a multi-agent combination chemotherapy regimen, for high-risk metastatic disease is 500 mcg intravenously on Days 1 and 2 every 2 weeks for up to 8 weeks.
  )
• Regional Perfusion in Locally Recurrent and Locoregional Solid Malignancies:
  
  
  o
     
  Lower Extremity or Pelvis: The recommend dose is 50 mcg/kg once with melphalan. (
  2.6 Recommended Dosage for Regional Perfusion in Locally Recurrent and Locoregional Solid Malignancies

  The recommended dose of dactinomycin for injection, in combination with melphalan, is 50 mcg/kg once for lower extremity or pelvis.
  
  The recommended dose of dactinomycin for injection, in combination with melphalan, is 35 mcg/kg once for upper extremity.
  
  
  
  

  Calculate the dose for obese or edematous patients based on ideal body weight.
  )
  
  
  o
     
  Upper Extremity: The recommended dose is 35 mcg/kg once with melphalan. (
  2.6 Recommended Dosage for Regional Perfusion in Locally Recurrent and Locoregional Solid Malignancies

  The recommended dose of dactinomycin for injection, in combination with melphalan, is 50 mcg/kg once for lower extremity or pelvis.
  
  The recommended dose of dactinomycin for injection, in combination with melphalan, is 35 mcg/kg once for upper extremity.
  
  
  
  

  Calculate the dose for obese or edematous patients based on ideal body weight.
  )

For injection: 500 mcg as a sterile, amorphous yellow to orange, lyophilized powder in a single-dose vial.

• Lactation: Advise not to breastfeed. (
  8.2 Lactation

  Risk Summary

  
  
  There are no data on the presence of dactinomycin or its metabolites in human milk or their effects on the breastfed infant or on milk production. Because of the potential for serious adverse reactions in breastfed infants from dactinomycin, advise women not to breastfeed during treatment with dactinomycin for injection and, based on limited published data regarding the dactinomycin half-life, for 14 days after the final dose.
  )

• Secondary Malignancy or Leukemia: Increased risk of secondary malignancies following treatment. (
  5.1 Secondary Malignancy or Leukemia

  The risk of developing secondary malignancies, including leukemia, is increased following treatment with dactinomycin.
  )
• Veno-occlusive Disease: Can cause severe or fatal VOD. Monitor for elevations in AST, ALT, total bilirubin, hepatomegaly, weight gain, or ascites. Consider delaying next dose. (
  5.2 Veno-occlusive Disease

  Severe and fatal hepatic veno-occlusive disease (VOD) can occur with dactinomycin. Risk factors for the development of VOD include age younger than 4 years or concomitant radiotherapy. After treatment with dactinomycin for injection, monitor frequently for signs and symptoms of VOD; these include elevations in AST, ALT, total bilirubin, hepatomegaly, weight gain, or ascites. If patients develop VOD, considering delaying next dose of dactinomycin. Resume, reduce dose or permanently discontinue based on severity of reaction and disease being treated.
  )
• Extravasation: Immediately interrupt the injection or infusion and apply ice. (
  2.7 Preparation and Administration

  o Dactinomycin for injection is a cytotoxic drug. Follow applicable special handling and disposal procedures.¹
  
  o Visually inspect the vials for particulate matter and discoloration, whenever solution and container permit.
  
  
  
  

  Preparation

  
  
  • Reconstitute each vial by adding 1.1 mL of Sterile Water for Injection without preservative using aseptic techniques.
  
  • The reconstituted product should be a clear, gold-colored solution at a concentration of 500 mcg/mL.
  
  • Further dilute the reconstituted product with 5% Dextrose Injection or 0.9% Sodium Chloride Injection to yield concentrations greater than 10 mcg/mL.
  
  • Store at room temperature for no more than 4 hours from reconstitution to completion of injection or infusion. Discard after 4 hours.
  
  • Dactinomycin for injection does not contain a preservative. Discard any unused portions.
  
  
  
  

  Administration

  
  
  • Administer the diluted reconstituted product intravenously over 10 to 15 minutes.
  
  • Do not use in-line filters with a cellulose ester membrane.
  
  
  
  

  Management of Extravasation

  
  
  • Discontinue dactinomycin for injection for burning or stinging sensation or other evidence indicating perivenous infiltration or extravasation.
  
  • Manage confirmed or suspected extravasation as follows:
  
  o Terminate the injection or infusion immediately and restart in another vein.
  
  o Intermittent application of ice to the site for 15 minutes 4 times daily for 3 days

  [see Warnings and Precautions (5.3)].
  ,
  5.3 Extravasation

  Extravasation of dactinomycin for injection can result in severe local tissue injury manifesting as blistering, ulcerations and persistent pain requiring wide excision surgery followed by split-thickness skin grafting. If any signs or symptoms of extravasation occur, immediately interrupt the injection or infusion. Apply ice to the site intermittently for 15 minutes, 4 times a day for 3 days

  [see Dosage and Administration (2.7)]

  . Observe closely and consult plastic surgery if necessary based on severity of reaction.
  )
• Myelosuppression: Monitor blood cell counts before each cycle. Delay next dose if severe myelosuppression has not improved. (
  5.4 Myelosuppression

  Severe and fatal myelosuppression, which may include neutropenia, thrombocytopenia and anemia, can occur with dactinomycin for injection. The nadir in neutrophil counts generally occurs 14 to 21 days after administration. Obtain complete blood counts prior to each treatment cycle. Delay next dose of dactinomycin for injection if severe myelosuppression has not improved. Consider dose reduction for patients with prolonged myelosuppression based on severity of reaction and disease being treated.
  )
• Immunizations: Vaccination with live viral vaccines is not recommended before or during treatment. (
  5.5 Immunizations

  The safety with live viral vaccines following dactinomycin for injection has not been studied and vaccination with live virus vaccines is not recommended before or during treatment.
  )
• Severe Mucocutaneous Reactions: Discontinue treatment (
  5.6 Severe Mucocutaneous Reactions

  Severe mucocutaneous reactions, such as Steven-Johnson syndrome and Toxic Epidermal Necrolysis (TEN), can occur with dactinomycin for injection. Permanently discontinue dactinomycin for injection in patients who experience a severe mucocutaneous reaction.
  )
• Renal Toxicity: Monitor creatinine and electrolytes frequently. (
  5.7 Renal Toxicity

  Abnormalities of renal function can occur with dactinomycin for injection. Monitor creatinine and electrolytes frequently during dactinomycin for injection therapy.
  )
• Hepatotoxicity: Monitor transaminases, alkaline phosphatase and bilirubin prior to and during treatment. (
  5.8 Hepatotoxicity

  Hepatotoxicity can occur with dactinomycin for injection. Monitor AST, ALT, alkaline phosphatase, and bilirubin prior to and during dactinomycin for injection therapy.
  )
• Potentiation of Radiation Toxicity and Radiation Recall:
  
  Reduce dose by 50% during concomitant radiation. Use caution when administering within two months of radiation. (
  5.9 Potentiation of Radiation Toxicity and Radiation Recall

  Dactinomycin for injection can increase radiation-induced gastrointestinal toxicity, myelosuppression, or erythema and vesiculation of the skin or buccal and pharyngeal mucosa. Reduce the dose of dactinomycin for injection by 50% during concomitant radiation.

  Radiation recall, affecting previously treated radiation fields, can occur in patients who receive dactinomycin for injection after prior radiation therapy. Although the risk can occur with distant radiation exposure, the risk appears highest when dactinomycin for injection is administered within two months of prior radiation.
  )
• Embryo-fetal Toxicity: Can cause fetal harm. Advise patients of the potential risk to a fetus and to use effective contraception. (
  5.10 Embryo-Fetal Toxicity

  Based on findings from animal studies and its mechanism of action, dactinomycin for injection can cause fetal harm when administered to a pregnant woman. In animal reproduction studies, administration of dactinomycin to pregnant animals during the period of organogenesis was teratogenic, resulting in malformations at doses lower than the recommended human dose.

  Advise pregnant women of the potential risk to the fetus. Advise females of reproductive potential to use effective contraception during treatment with dactinomycin for injection and for at least 6 months after the final dose. Advise males with female partners of reproductive potential to use effective contraception during treatment with dactinomycin for injection and for 3 months after the final dose

  [see Use in Specific Populations (8.1, 8.3)]

  .
  ,
  8.1 Pregnancy

  Risk Summary

  Based on findings from animal studies and its mechanism of action dactinomycin can cause fetal harm when administered to a pregnant woman

  [see

  Clinical Pharmacology (12.1)

  ]

  . In animal reproduction studies, administration of dactinomycin to pregnant animals during the period of organogenesis was teratogenic, resulting in malformations at doses lower than the recommended human dose

  (see Data)

  . Advise pregnant women of the potential risk to a fetus

  [see

  Use in Special Populations (8.3)

  ].

  
  
  
  
  In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.
  
  
  
  

  Data

  
  
  

  Animal Data

  
  
  Dactinomycin was teratogenic in animals. Administration of dactinomycin to pregnant rats, rabbits, and hamsters during the period of organogenesis, increased the incidence of fetal malformations and caused embryotoxicity at doses (based on body surface area) as low as 0.2 times the clinical dose of 1,250 mcg/m².
  ,
  8.3 Females and Males of Reproductive Potential

  Pregnancy Testing

  
  
  Verify the pregnancy status of females of reproductive potential prior to initiating dactinomycin

  [see Use in Specific Population (8.1)].
  
  

  
  
  

  Contraception

  
  
  Dactinomycin can cause fetal harm when administered to a pregnant woman

  [see Use in Specific Populations (8.1)].
  
  

  
  
  

  Females

  
  
  Advise females of reproductive potential to use effective contraception during treatment with dactinomycin and for at least 6 months after the final dose.
  
  
  
  

  Males

  
  
  Because of the potential for genotoxicity, advise males with female partners of reproductive potential to use effective contraception during treatment with dactinomycin and for 3 months after the final dose

  [

  see

  Nonclinical Toxicology (13.1)

  ].
  )