Docetaxel - Docetaxel injection, Solution

Patients who are dosed initially at 100 mg/m²and who experience either febrile neutropenia, neutrophils <500 cells/mm³for more than 1 week, or severe or cumulative cutaneous reactions during docetaxel injection therapy should have the dosage adjusted from 100 mg/m²to 75 mg/m². If the patient continues to experience these reactions, the dosage should either be decreased from 75 mg/m²to 55 mg/m²or the treatment should be discontinued. Conversely, patients who are dosed initially at 60 mg/m²and who do not experience febrile neutropenia, neutrophils <500 cells/mm³for more than 1 week, severe or cumulative cutaneous reactions, or severe peripheral neuropathy during docetaxel injection therapy may tolerate higher doses. Patients who develop ≥grade 3 peripheral neuropathy should have docetaxel injection treatment discontinued entirely.



Docetaxel injection in combination with doxorubicin and cyclophosphamide should be administered when the neutrophil count is ≥1500 cells/mm³. Patients who experience febrile neutropenia should receive G-CSF in all subsequent cycles. Patients who continue to experience this reaction should remain on G-CSF and have their docetaxel injection dose reduced to 60 mg/m². Patients who experience grade 3 or 4 stomatitis should have their docetaxel injection dose decreased to 60 mg/m². Patients who experience severe or cumulative cutaneous reactions or moderate neurosensory signs and/or symptoms during docetaxel injection therapy should have their dosage of docetaxel injection reduced from 75 mg/m²to 60 mg/m². If the patient continues to experience these reactions at 60 mg/m², treatment should be discontinued.



Patients who are dosed initially at 75 mg/m²and who experience either febrile neutropenia, neutrophils <500 cells/mm³for more than one week, severe or cumulative cutaneous reactions, or other grade 3/4 non-hematological toxicities during docetaxel injection treatment should have treatment withheld until resolution of the toxicity and then resumed at 55 mg/m². Patients who develop ≥grade 3 peripheral neuropathy should have docetaxel injection treatment discontinued entirely.



For patients who are dosed initially at docetaxel injection 75 mg/m²in combination with cisplatin, and whose nadir of platelet count during the previous course of therapy is <25,000 cells/mm³, in patients who experience febrile neutropenia, and in patients with serious non-hematologic toxicities, the docetaxel injection dosage in subsequent cycles should be reduced to 65 mg/m². In patients who require a further dose reduction, a dose of 50 mg/m²is recommended. For cisplatin dosage adjustments, see manufacturers’ prescribing information.



Docetaxel injection should be administered when the neutrophil count is ≥1500 cells/mm³. Patients who experience either febrile neutropenia, neutrophils <500 cells/mm³for more than one week, severe or cumulative cutaneous reactions or moderate neurosensory signs and/or symptoms during docetaxel injection therapy should have the dosage of docetaxel injection reduced from 75 mg/m²to 60 mg/m². If the patient continues to experience these reactions at 60 mg/m², the treatment should be discontinued.



Patients treated with docetaxel injection in combination with cisplatin and fluorouracil must receive antiemetics and appropriate hydration according to current institutional guidelines. In both studies, G-CSF was recommended during the second and/or subsequent cycles in case of febrile neutropenia, or documented infection with neutropenia, or neutropenia lasting more than 7 days. If an episode of febrile neutropenia, prolonged neutropenia or neutropenic infection occurs despite G-CSF use, the docetaxel injection dose should be reduced from 75 mg/m²to 60 mg/m². If subsequent episodes of complicated neutropenia occur the docetaxel injection dose should be reduced from 60 mg/m²to 45 mg/m². In case of grade 4 thrombocytopenia the docetaxel injection dose should be reduced from 75 mg/m²to 60 mg/m². Do not retreat patients with subsequent cycles of docetaxel injection until neutrophils recover to a level >1500 cells/mm³. Avoid retreating patients until platelets recover to a level >100,000 cells/mm³. Discontinue treatment if these toxicities persist.



Recommended dose modifications for toxicities in patients treated with docetaxel injection in combination with cisplatin and fluorouracil are shown in Table 1.

Table 1: Recommended Dose Modifications for Toxicities in Patients Treated with Docetaxel Injection in Combination with Cisplatin and Fluorouracil

Toxicity	Dosage Adjustment
Diarrhea grade 3	First episode: reduce fluorouracil dose by 20%. Second episode: then reduce docetaxel injection dose by 20%.
Diarrhea grade 4	First episode: reduce docetaxel injection and fluorouracil doses by 20%. Second episode: discontinue treatment.
Stomatitis/mucositis grade 3	First episode: reduce fluorouracil dose by 20%. Second episode: stop fluorouracil only, at all subsequent cycles. Third episode: reduce docetaxel injection dose by 20%.
Stomatitis/mucositis grade 4	First episode: stop fluorouracil only, at all subsequent cycles. Second episode: reduce docetaxel injection dose by 20%.

Liver dysfunction: In case of AST/ALT >2.5 to ≤5 × ULN and AP ≤2.5 × ULN, or AST/ALT >1.5 to ≤5 × ULN and AP >2.5 to ≤5 × ULN, docetaxel injection should be reduced by 20%.



In case of AST/ALT >5 × ULN and/or AP >5 × ULN docetaxel injection should be stopped.



The dose modifications for cisplatin and fluorouracil in the gastric cancer study are provided below.

Peripheral Neuropathy: A neurological examination should be performed before entry into the study, and then at least every 2 cycles and at the end of treatment. In the case of neurological signs or symptoms, more frequent examinations should be performed and the following dose modifications can be made according to NCI-CTCAE grade:

• Grade 2: Reduce cisplatin dose by 20%.
• Grade 3: Discontinue treatment.

Ototoxicity: In the case of grade 3 toxicity, discontinue treatment.



Nephrotoxicity: In the event of a rise in serum creatinine ≥grade 2 (>1.5 × normal value) despite adequate rehydration, CrCl should be determined before each subsequent cycle and the following dose reductions should be considered (see Table 2).



For other cisplatin dosage adjustments, also refer to the manufacturers’ prescribing information.

Table 2: Dose Reductions for Evaluation of Creatinine Clearance

CrCl = Creatinine clearance
Creatinine Clearance Result Before Next Cycle	Cisplatin Dose Next Cycle
CrCl ≥60 mL/min	Full dose of cisplatin was given. CrCl was to be repeated before each treatment cycle.
CrCl between 40 and 59 mL/min	Dose of cisplatin was reduced by 50% at subsequent cycle. If CrCl was >60 mL/min at end of cycle, full cisplatin dose was reinstituted at the next cycle. If no recovery was observed, then cisplatin was omitted from the next treatment cycle.
CrCl <40 mL/min	Dose of cisplatin was omitted in that treatment cycle only. If CrCl was still <40 mL/min at the end of cycle, cisplatin was discontinued. If CrCl was >40 and <60 mL/min at end of cycle, a 50% cisplatin dose was given at the next cycle. If CrCl was >60 mL/min at end of cycle, full cisplatin dose was given at next cycle.

For diarrhea and stomatitis, see Table 1.



In the event of grade 2 or greater plantar-palmar toxicity, fluorouracil should be stopped until recovery. The fluorouracil dosage should be reduced by 20%.



For other greater than grade 3 toxicities, except alopecia and anemia, chemotherapy should be delayed (for a maximum of 2 weeks from the planned date of infusion) until resolution to grade ≤1 and then recommenced, if medically appropriate.



For other fluorouracil dosage adjustments, also refer to the manufacturers’ prescribing information.



Avoid using concomitant strong CYP3A4 inhibitors (e.g., ketoconazole, itraconazole, clarithromycin, atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin and voriconazole). There are no clinical data with a dose adjustment in patients receiving strong CYP3A4 inhibitors. Based on extrapolation from a pharmacokinetic study with ketoconazole in 7 patients, consider a 50% docetaxel dose reduction if patients require coadministration of a strong CYP3A4 inhibitor.