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Dacogen

Generic Name: decitabine
Dosage Form: injection, powder, lyophilized, for solution

Indications and Usage for Dacogen

    Dacogen is indicated for treatment of patients with myelodysplastic syndromes (MDS) including previously treated and untreated, de novo and secondary MDS of all French-American-British subtypes (refractory anemia, refractory anemia with ringed sideroblasts, refractory anemia with excess blasts, refractory anemia with excess blasts in transformation, and chronic myelomonocytic leukemia) and intermediate-1, intermediate-2, and high-risk International Prognostic Scoring System groups.

Dacogen Dosage and Administration

    There are two regimens for Dacogen administration. With either regimen it is recommended that patients be treated for a minimum of 4 cycles; however, a complete or partial response may take longer than 4 cycles. 

    Complete blood counts and platelet counts should be performed as needed to monitor response and toxicity, but at a minimum, prior to each cycle.  Liver chemistries and serum creatinine should be obtained prior to initiation of treatment.

Treatment Regimen – Option 1

    Dacogen is administered at a dose of 15 mg/m2 by continuous intravenous infusion over 3 hours repeated every 8 hours for 3 days.  This cycle should be repeated every 6 weeks.  Patients may be premedicated with standard anti-emetic therapy.

    If hematologic recovery (ANC ≥ 1,000/μL and platelets ≥ 50,000/μL) from a previous Dacogen treatment cycle requires more than 6 weeks, then the next cycle of Dacogen therapy should be delayed and dosing temporarily reduced by following this algorithm:

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Recovery requiring more than 6, but less than 8 weeks − Dacogen dosing to be delayed for up to 2 weeks and the dose temporarily reduced to 11 mg/m every 8 hours (33 mg/m2/day, 99 mg/m2/cycle) upon restarting therapy.
Recovery requiring more than 8, but less than 10 weeks − Patient should be assessed for disease progression (by bone marrow aspirates); in the absence of progression, the Dacogen dose should be delayed up to 2 more weeks and the dose reduced to 11 mg/m2 every 8 hours (33 mg/m2/day, 99 mg/m2/cycle) upon restarting therapy, then maintained or increased in subsequent cycles as clinically indicated.

Treatment Regimen – Option 2

    Dacogen is administered at a dose of 20 mg/m2 by continuous intravenous infusion over 1 hour repeated daily for 5 days.  This cycle should be repeated every 4 weeks.  Patients may be premedicated with standard anti-emetic therapy.  

    If myelosuppression is present, subsequent treatment cycles of Dacogen should be delayed until there is hematologic recovery (ANC ≥ 1,000/μL platelets ≥ 50,000/μL ).

Patients with Non-hematologic Toxicity

    Following the first cycle of Dacogen treatment, if any of the following non-hematologic toxicities are present, Dacogen treatment should not be restarted until the toxicity is resolved:  1) serum creatinine ≥ 2 mg/dL; 2) SGPT, total bilirubin ≥ 2 times ULN; 3) and active or uncontrolled infection.

Instructions for Intravenous Administration

    Dacogen is a cytotoxic drug and caution should be exercised when handling and preparing Dacogen.  Procedures for proper handling and disposal of antineoplastic drugs should be applied.  Several guidances on this subject have been published.1,,,4

    Dacogen should be aseptically reconstituted with 10 mL of Sterile Water for Injection (USP); upon reconstitution, each mL contains approximately 5.0 mg of decitabine at pH 6.7-7.3.  Immediately after reconstitution, the solution should be further diluted with 0.9% Sodium Chloride Injection or 5% Dextrose Injection to a final drug concentration of 0.1 - 1.0 mg/mL.  Unless used within 15 minutes of reconstitution, the diluted solution must be prepared using cold (2˚C - 8˚C) infusion fluids and stored at 2˚C - 8˚C (36˚F - 46˚F) for up to a maximum of 4 hours until administration.

    Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.  Do not use if there is evidence of particulate matter or discoloration.

Dosage Forms and Strengths

    Dacogen (decitabine) for Injection is supplied as a sterile, lyophilized white to almost white powder, in a single-dose vial, packaged in cartons of 1 vial. Each vial contains 50 mg of decitabine.

Contraindications

    None

Warnings and Precautions

Neutropenia and Thrombocytopenia

    Treatment with Dacogen is associated with neutropenia and thrombocytopenia.  Complete blood and platelet counts should be performed as needed to monitor response and toxicity, but at a minimum, prior to each dosing cycle.  After administration of the recommended dosage for the first cycle, treatment for subsequent cycles should be adjusted [see Dosage and Administration (2.1, 2.2)].  Clinicians should consider the need for early institution of growth factors and/or antimicrobial agents for the prevention or treatment of infections in patients with MDS.  Myelosuppression and worsening neutropenia may occur more frequently in the first or second treatment cycles, and may not necessarily indicate progression of underlying MDS.

Use in Pregnancy

    Dacogen can cause fetal harm when administered to a pregnant woman.  Based on its mechanism of action, Dacogen is expected to result in adverse reproductive effects.  In preclinical studies in mice and rats, decitabine was teratogenic, fetotoxic, and embryotoxic. There are no adequate and well-controlled studies of Dacogen in pregnant women.  If this drug is used during pregnancy, or if a patient becomes pregnant while receiving this drug, the patient should be apprised of the potential hazard to the fetus.  Women of childbearing potential should be advised to avoid becoming pregnant while taking Dacogen. [see Use in Specific Populations (8.1)]

Use in Women of Childbearing Potential

    Women of childbearing potential should be advised to avoid becoming pregnant while receiving Dacogen and for 1 month following completion of treatment. Women of childbearing potential should be counseled to use effective contraception during this time [see Use in Specific Populations (8.1)]. Based on its mechanism of action, Dacogen can cause fetal harm if used during pregnancy.

Use in Men

    Men should be advised not to father a child while receiving treatment with Dacogen, and for 2 months following completion of treatment [see Nonclinical Toxicology (13.1)]. Men with female partners of childbearing potential should use effective contraception during this time. Based on its mechanism of action, Dacogen alters DNA synthesis and can cause fetal harm.

Adverse Reactions

Clinical Studies Experience

    Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Most Commonly Occurring Adverse Reactions:  neutropenia, thrombocytopenia, anemia, fatigue, pyrexia, nausea, cough, petechiae, constipation, diarrhea, and hyperglycemia.

Adverse Reactions Most Frequently (≥ 1%) Resulting in Clinical Intervention in the Phase 3 Trials in the Dacogen Arm:

Discontinuation:  thrombocytopenia, neutropenia, pneumonia, Mycobacterium avium complex infection, cardio-respiratory arrest, increased blood bilirubin, intracranial hemorrhage, abnormal liver function tests.
Dose Delayed:  neutropenia, pulmonary edema, atrial fibrillation, central line infection, febrile neutropenia.
Dose Reduced:  neutropenia, thrombocytopenia, anemia, lethargy, edema, tachycardia, depression, pharyngitis.

Discussion of Adverse Reactions Information
    Dacogen was studied in 3 single-arm studies (N = 66, N = 98, N = 99) and 1 controlled supportive care study (N = 83 Dacogen, N = 81 supportive care ).  The data described below reflect exposure to Dacogen in 83 patients in the MDS trial.  In the trial, patients received 15 mg/m2 intravenously every 8 hours for 3 days every 6 weeks.  The median number of Dacogen cycles was 3 (range 0 to 9).

Table 1 presents all adverse events regardless of causality occurring in at least 5% of patients in the Dacogen group and at a rate greater than supportive care.

Table 1 Adverse Events Reported in ≥ 5% of Patients in the Dacogen Group and at a Rate Greater than Supportive Care in Phase 3 MDS Trial
  Dacogen
N = 83 (%)
Supportive Care
N = 81 (%)

 Blood and lymphatic system disorders

      Neutropenia

  75 (90)

  58 (72)

      Thrombocytopenia

  74 (89)

  64 (79)

      Anemia NOS

  68 (82)

  60 (74)

      Febrile neutropenia

  24 (29)

  5 (6)

      Leukopenia NOS

  23 (28)

  11 (14)

      Lymphadenopathy

  10 (12)

  6 (7)

      Thrombocythemia

 4 (5)

 1 (1)

 Cardiac disorders

      Pulmonary edema NOS

 5 (6)

0 (0) 

 Eye disorders

      Vision blurred

 5 (6)

 0 (0)

 Gastrointestinal disorders

      Nausea

  35 (42)

13 (16)

      Constipation

  29 (35)

11 (14)

      Diarrhea NOS

  28 (34)

13 (16)

      Vomiting NOS

  21 (25)

7 (9)

      Abdominal pain NOS

  12 (14)

5 (6)

      Oral mucosal petechiae

  11 (13)

4 (5)

      Stomatitis

  10 (12)

5 (6)

      Dyspepsia

  10 (12)

1 (1)

      Ascites

  8 (10)

2 (2)

      Gingival bleeding

 7 (8)

5 (6)

      Hemorrhoids

 7 (8)

3 (4)

      Loose stools

 6 (7)

3 (4)

      Tongue ulceration

 6 (7)

2 (2)

      Dysphagia

 5 (6)

2 (2)

      Oral soft tissue disorder NOS

 5 (6)

1 (1)

      Lip ulceration

 4 (5)

3 (4)

      Abdominal distension

 4 (5)

1 (1)

      Abdominal pain upper

 4 (5)

1 (1)

      Gastro-esophageal reflux disease

 4 (5)

0 (0)

      Glossodynia

 4 (5)

0 (0)

 General disorders and administrative site disorders

      Pyrexia

  44 (53)

23 (28)

      Edema peripheral

  21 (25)

13 (16)

      Rigors

  18 (22)

14 (17)

      Edema NOS

  15 (18)

5 (6)

      Pain NOS

  11 (13)

5 (6)

      Lethargy

  10 (12)

3 (4)

      Tenderness NOS

  9 (11)

0 (0)

      Fall

7 (8)

3 (4)

      Chest discomfort

6 (7)

3 (4)

      Intermittent pyrexia

5 (6)

3 (4)

      Malaise

4 (5)

1 (1)

      Crepitations NOS

4 (5)

1 (1)

      Catheter site erythema

4 (5)

1 (1)

      Catheter site pain

4 (5)

0 (0)

      Injection site swelling

4 (5)

0 (0)

 Hepatobiliary disorders

      Hyperbilirubinemia

  12 (14)

  4 (5)

 Infections and infestations

      Pneumonia NOS

  18 (22)

  11 (14)

      Cellulitis

  10 (12)

  6 (7)

      Candidal infection NOS

  8 (10)

  1 (1)

      Catheter related infection

7 (8)

0 (0)

      Urinary tract infection NOS

6 (7)

1 (1)

      Staphylococcal infection

6 (7)

0 (0)

      Oral candidiasis

5 (6)

2 (2)

      Sinusitis NOS

4 (5)

2 (2)

      Bacteremia

4 (5)

0 (0)

 Injury, poisoning and procedural complications

      Transfusion reaction

6 (7)

3 (4)

      Abrasion NOS

4 (5)

1 (1)

 Investigations

      Cardiac murmur NOS

  13 (16)

  9 (11)

      Blood alkaline phosphatase NOS increased 

  9 (11)

  7 (9)

      Aspartate aminotransferase increased

  8 (10)

  7 (9)

      Blood urea increased

  8 (10)

  1 (1)

      Blood lactate dehydrogenase increased

7 (8)

5 (6)

      Blood albumin decreased

6 (7)

0 (0)

      Blood bicarbonate increased

5 (6)

1 (1)

      Blood chloride decreased

5 (6)

1 (1)

      Protein total decreased

4 (5)

3 (4)

      Blood bicarbonate decreased

4 (5)

1 (1)

      Blood bilirubin decreased

4 (5)

1 (1)

 Metabolism and nutrition disorders

      Hyperglycemia NOS

  27 (33)

16 (20)

      Hypoalbuminemia

  20 (24)

14 (17)

      Hypomagnesemia

  20 (24)

6 (7)

      Hypokalemia

  18 (22)

10 (12)

      Hyponatremia

  16 (19)

13 (16)

      Appetite decreased NOS

  13 (16)

12 (15)

      Anorexia

  13 (16)

8 (10)

      Hyperkalemia

  11 (13)

3 (4)

      Dehydration

5 (6)

4 (5)

 Musculoskeletal and connective tissue disorders

      Arthralgia

  17 (20)

  8 (10)

      Pain in limb

  16 (19)

  8 (10)

      Back pain

  14 (17)

  5 (6)

      Chest wall pain

6 (7)

1 (1)

      Musculoskeletal discomfort

5 (6)

0 (0)

      Myalgia

4 (5)

1 (1)

 Nervous system disorders

      Headache

  23 (28)

  11 (14)

      Dizziness

  15 (18)

  10 (12)

      Hypoesthesia

  9 (11)

  1 (1)

 Psychiatric disorders

      Insomnia

  23 (28)

  11 (14)

      Confusional state

  10 (12)

  3 (4)

      Anxiety

  9 (11)

  8 (10)

 Renal and urinary disorders

      Dysuria

5 (6)

3 (4)

      Urinary frequency

4 (5)

1 (1)

 Respiratory, thoracic and Mediastinal disorders

      Cough

  33 (40)

25 (31)

      Pharyngitis

  13 (16)

6 (7)

      Crackles lung

  12 (14)

1 (1)

      Breath sounds decreased

  8 (10)

7 (9)

      Hypoxia

  8 (10)

4 (5)

      Rales

7 (8)

2 (2)

      Postnasal drip

4 (5)

2 (2)

 Skin and subcutaneous tissue disorders

      Ecchymosis

  18 (22)

  12 (15)

      Rash NOS

  16 (19)

  7 (9)

      Erythema

  12 (14)

  5 (6)

      Skin lesion NOS

  9 (11)

  3 (4)

      Pruritis

  9 (11)

  2 (2)

      Alopecia

7 (8)

1 (1)

      Urticaria NOS

5 (6)

1 (1)

      Swelling face

5 (6)

0 (0)

 Vascular disorders

      Petechiae

  32 (39)

  13 (16)

      Pallor

  19 (23)

  10 (12)

      Hypotension NOS

5 (6)

4 (5)

      Hematoma NOS

4 (5)

3 (4)

    Discussion of Clinically Important Adverse Reactions

    In the controlled trial using Dacogen dosed at 15 mg/m2, administered by continuous intravenous infusion over 3 hours repeated every 8 hours for 3 days, the highest incidence of Grade 3 or Grade 4 adverse events in the Dacogen arm were neutropenia (87%), thrombocytopenia (85%), febrile neutropenia (23%) and leukopenia (22%).  Bone marrow suppression was the most frequent cause of dose reduction, delay and discontinuation.  Six patients had fatal events associated with their underlying disease and myelosuppression (anemia, neutropenia, and thrombocytopenia) that were considered at least possibly related to drug treatment [See Warnings and Precautions (5.1)]. Of the 83  Dacogen -treated patients, 8 permanently discontinued therapy for adverse events; compared to 1 of 81 patients in the supportive care arm.

    In a single-arm MDS study (N=99) Dacogen was dosed at 20 mg/m2 intravenous, infused over one hour daily for 5 consecutive days of a 4 week cycle. Table 2 presents all adverse events regardless of causality occurring in at least 5% of patients.

Table 2 Adverse Events Reported in ≥ 5% of Patients in a Single-arm Study*
  Dacogen
N = 99 (%)
*
In this single arm study, investigators reported adverse events based on clinical signs and symptoms rather
than predefined laboratory abnormalities. Thus not all laboratory abnormalities were recorded as adverse events.

 Blood and lymphatic system disorders

      Anemia

31 (31%)

      Febrile neutropenia

20 (20%)

      Leukopenia

6 (6% )

      Neutropenia

38 (38% )

      Pancytopenia

5 (5% )

      Thrombocythemia

5 (5% )

      Thrombocytopenia

27 (27%)

 Cardiac disorders

      Cardiac failure congestive

5 (5% )

      Tachycardia

8 (8% )

 Ear and labyrinth disorders

      Ear pain

6 (6% )

 Gastrointestinal disorders

      Abdominal pain

  14 (14%)

      Abdominal pain upper

6 (6% )

      Constipation

  30 (30%)

      Diarrhea

  28 (28%)

      Dyspepsia

  10 (10%)

      Dysphagia

5 (5% )

      Gastro-esophageal reflux disease

5 (5% )

      Nausea

  40 (40%)

      Oral pain

5 (5% )

      Stomatitis

  11 (11%)

      Toothache

6 (6% )

      Vomiting

  16 (16%)

 General disorders and administration site conditions

      Asthenia

  15 (15%)

      Chest pain

6 (6% )

      Chills

  16 (16%)

      Fatigue

  46 (46%)

      Mucosal inflammation

9 (9% )

      Edema

5 (5% )

      Edema peripheral

  27 (27%)

      Pain

5 (5% )

      Pyrexia

  36 (36%)

 Infections and infestations

      Cellulitis

9 (9% )

      Oral candidiasis

6 (6% )

      Pneumonia

  20 (20%)

      Sinusitis

6 (6% )

      Staphylococcal bacteremia

8 (8% )

      Tooth abscess

5 (5% )

      Upper respiratory tract infection

  10 (10%)

      Urinary tract infection

7 (7% )

 Injury, poisoning and procedural complications

      Contusion

9 (9% )

 Investigations

      Blood bilirubin increased

6 (6% )

      Breath sounds abnormal

5 (5% )

      Weight decreased

9 (9% )

 Metabolism and nutrition disorders

      Anorexia

23 (23%)

      Decreased appetite

8 (8% )

      Dehydration

8 (8% )

      Hyperglycemia

6 (6% )

      Hypokalemia

12 (12%)

      Hypomagnesemia

5 (5% )

 Musculoskeletal and connective tissue disorders

      Arthralgia

  17 (17%)

      Back pain

  18 (18%)

      Bone pain

6 (6% )

      Muscle spasms

7 (7% )

      Muscular weakness

5 (5% )

      Musculoskeletal pain

5 (5% )

      Myalgia

9 (9% )

      Pain in extremity

  18 (18%)

 Nervous system disorders

      Dizziness

  21 (21%)

      Headache

  23 (23%)

 Psychiatric disorders

      Anxiety

9 (9% )

      Confusional state

8 (8% )

      Depression

9 (9% )

      Insomnia

  14 (14%)

 Respiratory, thoracic and mediastinal disorders

      Cough

  27 (27%)

      Dyspnea

  29 (29%)

      Epistaxis

  13 (13%)

      Pharyngolaryngeal pain

8 (8% )

      Pleural effusion

5 (5% )

      Sinus congestion

5 (5% )

 Skin and subcutaneous tissue disorders

      Dry skin

8 (8% )

      Ecchymosis

9 (9% )

      Erythema

5 (5% )

      Night sweats

5 (5% )

      Petechiae

  12 (12%)

      Pruritus

9 (9% )

      Rash

  11 (11%)

      Skin lesion

5 (5% )

 Vascular disorders

      Hypertension

6 (6% )

      Hypotension

  11 (11%)


    Discussion of Clinically Important Adverse Reactions

    In the single-arm study (N=99) when Dacogen was dosed at 20 mg/m2 intravenous, infused over one hour daily for 5 consecutive days, the highest incidence of Grade 3 or Grade 4 adverse events were neutropenia (37%), thrombocytopenia (24%) and anemia (22%).  Seventy-eight percent of patients had dose delays, the median duration of this delay was 7 days and the largest percentage of delays was due to hematologic toxicities.  Hematologic toxicities and infections were the most frequent causes of dose delays and discontinuation.  Eight patients had fatal events due to infection and/or bleeding (seven of which occurred in the clinical setting of myelosuppression) that were considered at least possibly related to drug treatment.  Nineteen of 99 patients permanently discontinued therapy for adverse events.

    No overall difference in safety was detected between patients > 65 years of age and younger patients in these myelodysplasia trials.  No significant gender differences in safety or efficacy were detected.  Patients with renal or hepatic dysfunction were not studied.  Insufficient numbers of non-white patients were available to draw conclusions in these clinical trials.

    Serious Adverse Events that occurred in patients receiving Dacogen regardless of causality, not previously reported in Tables 1 and 2 include:

Blood and Lymphatic System Disorders:  myelosuppression, splenomegaly.
Cardiac Disorders:  myocardial infarction, cardio-respiratory arrest, cardiomyopathy, atrial fibrillation, supraventricular tachycardia.
Gastrointestinal Disorders:  gingival pain, upper gastrointestinal hemorrhage.
General Disorders and Administrative Site Conditions:  chest pain, catheter site hemorrhage.
Hepatobiliary Disorders:  cholecystitis.
Infections and Infestations:  fungal infection, sepsis, bronchopulmonary aspergillosis, peridiverticular abscess, respiratory tract infection, pseudomonal lung infection, Mycobacterium avium complex infection.
Injury, Poisoning and Procedural Complications:  post procedural pain, post procedural hemorrhage.
Nervous System Disorders:  intracranial hemorrhage.
Psychiatric Disorders:  mental status changes.
Renal and Urinary Disorders:  renal failure, urethral hemorrhage.
Respiratory, Thoracic and Mediastinal Disorders:  hemoptysis, lung infiltration, pulmonary embolism, respiratory arrest, pulmonary mass.
Allergic Reaction:  Hypersensitivity (anaphylactic reaction) to Dacogen has been reported in a Phase 2 trial.

Post-marketing Experience

    The following adverse reactions have been identified during post-approval use of Dacogen.  Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Cases of Sweet’s Syndrome (acute febrile neutrophilic dermatosis) have been reported.

Drug Interactions

    Drug interaction studies with decitabine have not been conducted.  In vitro studies in human liver microsomes suggest that decitabine is unlikely to inhibit or induce cytochrome P450 enzymes.  In vitro metabolism studies have suggested that decitabine is not a substrate for human liver cytochrome P450 enzymes.  As plasma protein binding of decitabine is negligible (<1%), interactions due to displacement of more highly protein bound drugs from plasma proteins are not expected.

USE IN SPECIFIC POPULATIONS

Pregnancy

Pregnancy Category D [see Warnings and Precautions (5.2)]

    Dacogen can cause fetal harm when administered to a pregnant woman.  There are no adequate and well-controlled studies of Dacogen in pregnant women.

    The developmental toxicity of decitabine was examined in mice exposed to single IP (intraperitoneal) injections (0, 0.9 and 3.0 mg/m2, approximately 2% and 7% of the recommended daily clinical dose, respectively) over gestation days 8, 9, 10 or 11.  No maternal toxicity was observed but reduced fetal survival was observed after treatment at 3 mg/m2 and decreased fetal weight was observed at both dose levels.  The 3 mg/m2 dose elicited characteristic fetal defects for each treatment day, including supernumerary ribs (both dose levels), fused vertebrae and ribs, cleft palate, vertebral defects, hind-limb defects and digital defects of fore- and hind-limbs.  In rats given a single IP injection of 2.4, 3.6 or 6 mg/m2 (approximately 5, 8, or 13% the daily recommended clinical dose, respectively) on gestation days 9-12, no maternal toxicity was observed.  No live fetuses were seen at any dose when decitabine was injected on gestation day 9.  A significant decrease in fetal survival and reduced fetal weight at doses greater than 3.6 mg/m2 was seen when decitabine was given on gestation day 10.  Increased incidences of vertebral and rib anomalies were seen at all dose levels, and induction of exophthalmia, exencephaly, and cleft palate were observed at 6.0 mg/m2.  Increased incidence of foredigit defects was seen in fetuses at doses greater than 3.6 mg/m2.  Reduced size and ossification of long bones of the fore-limb and hind-limb were noted at 6.0 mg/m2.  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 hazard to the fetus.  Women of child bearing potential should be advised to avoid becoming pregnant while taking Dacogen.

Nursing Mothers

    It is not known whether decitabine or its metabolites are excreted in human milk. Because many drugs are excreted in human milk, and because of the potential for serious adverse reactions from Dacogen in nursing infants, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

Pediatric Use

    The safety and effectiveness of Dacogen in pediatric patients have not been established.

Geriatric Use

    Of the total number of patients exposed to Dacogen in the controlled clinical trial, 61 of 83 patients were age 65 and over, while 21 of 83 patients were age 75 and over.  No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

Renal Impairment

    There are no data on the use of Dacogen in patients with renal dysfunction; therefore, Dacogen should be used with caution in these patients.

Hepatic Impairment

    There are no data on the use of Dacogen in patients with hepatic dysfunction; therefore, Dacogen should be used with caution in these patients.

Overdosage

    There is no known antidote for overdosage with Dacogen.  Higher doses are associated with increased myelosuppression including prolonged neutropenia and thrombocytopenia.  Standard supportive measures should be taken in the event of an overdose.

Dacogen Description

    Dacogen (decitabine) for Injection contains decitabine (5-aza-2’-deoxycitidine), an analogue of the natural nucleoside 2’-deoxycytidine.  Decitabine is a fine, white to almost white powder with the molecular formula of C8H12N4O4 and a molecular weight of 228.21.  Its chemical name is 4-amino-1-(2-deoxy-β-D-erythro-pentofuranosyl)-1,3,5-triazin-2(1H)-one and it has the following structural formula:

    Decitabine is slightly soluble in ethanol/water (50/50), methanol/water (50/50) and methanol; sparingly soluble in water and soluble in dimethylsulfoxide (DMSO).

    Dacogen (decitabine) for Injection is a white to almost white sterile lyophilized powder supplied in a clear colorless glass vial. Each 20 mL, single dose, glass vial contains 50 mg decitabine, 68 mg monobasic potassium phosphate (potassium dihydrogen phosphate) and 11.6 mg sodium hydroxide.

Dacogen - Clinical Pharmacology

Mechanism of Action

    Decitabine is believed to exert its antineoplastic effects after phosphorylation and direct incorporation into DNA and inhibition of DNA methyltransferase, causing hypomethylation of DNA and cellular differentiation or apoptosis.  Decitabine inhibits DNA methylation in vitro, which is achieved at concentrations that do not cause major suppression of DNA synthesis.  Decitabine-induced hypomethylation in neoplastic cells may restore normal function to genes that are critical for the control of cellular differentiation and proliferation.  In rapidly dividing cells, the cytotoxicity of decitabine may also be attributed to the formation of covalent adducts between DNA methyltransferase and decitabine incorporated into DNA.  Non-proliferating cells are relatively insensitive to decitabine.

Pharmacodynamics

    Decitabine has been shown to induce hypomethylation both in vitro and in vivo.  However, there have been no studies of decitabine-induced hypomethylation and pharmacokinetic parameters.

Pharmacokinetics

    Pharmacokinetic parameters were evaluated in patients. Eleven patients received 20 mg/m2 infused over 1 hour intravenously (treatment Option 2). Fourteen patients received 15 mg/m2 infused over 3 hours (treatment Option 1). PK parameters are shown in Table 3.  Plasma concentration-time profiles after discontinuation of infusion showed a biexponential decline.  The CL of decitabine was higher following treatment Option 2.  Upon repeat doses there was no systemic accumulation of decitabine or any changes in PK parameters.  Population PK analysis (N=35) showed that the cumulative AUC per cycle for treatment Option 2 was 2.3-fold lower than the cumulative AUC per cycle following treatment Option 1.

Table 3 Mean (CV% or 95% CI) Pharmacokinetic Parameters of Decitabine
Dose Cmax
(ng/mL)
AUC0-∞
(ng·h/mL)
T1/2
(h)
CL
(L/h/m2)
AUCCumulative***
(ng·h/mL)
  *N=14, **N=11, ***N=35 Cumulative AUC per cycle

  15 mg/m2 3-hr infusion every 8 hours for 3 days (Option 1)*

73.8
(66)

163
(62)

0.62
(49)

125
(53)

1332
(1010-1730)

  20 mg/m2 1-hr infusion daily for 5 days (Option 2)**

147
(49)

115
(43)

  0.54
(43)

210
(47)

570
(470-700)

    The exact route of elimination and metabolic fate of decitabine is not known in humans.  One of the pathways of elimination of decitabine appears to be deamination by cytidine deaminase found principally in the liver but also in granulocytes, intestinal epithelium and whole blood.

Nonclinical Toxicology

Carcinogenesis, Mutagenesis and Impairment of Fertility

    Carcinogenicity studies with decitabine have not been conducted.

    The mutagenic potential of decitabine was tested in several in vitro and in vivo systems.  Decitabine increased mutation frequency in L5178Y mouse lymphoma cells, and mutations were produced in an Escherichia coli lac-I transgene in colonic DNA of decitabine-treated mice.  Decitabine caused chromosomal rearrangements in larvae of fruit flies.

    The effect of decitabine on postnatal development and reproductive capacity was evaluated in mice administered a single 3 mg/m2 IP injection (approximately 7% the recommended daily clinical dose) on day 10 of gestation.  Body weights of males and females exposed in utero to decitabine were significantly reduced relative to controls at all postnatal time points.  No consistent effect on fertility was seen when female mice exposed in utero were mated to untreated males.  Untreated females mated to males exposed in utero showed decreased fertility at 3 and 5 months of age (36% and 0% pregnancy rate, respectively).  In male mice given IP injections of 0.15, 0.3 or 0.45 mg/m2 decitabine (approximately 0.3% to 1% the recommended clinical dose) 3 times a week for 7 weeks, decitabine did not affect survival, body weight gain or hematological measures (hemoglobin and WBC counts).  Testes weights were reduced, abnormal histology was observed and significant decreases in sperm number were found at doses ≥ 0.3 mg/m2.  In females mated to males dosed with ≥ 0.3 mg/m2 decitabine, pregnancy rate was reduced and preimplantation loss was significantly increased.

Clinical Studies

Controlled Trial

    A randomized open-label, multicenter, controlled trial evaluated 170 adult patients with myelodysplastic syndromes (MDS) meeting French-American-British (FAB) classification criteria and International Prognostic Scoring System (IPSS) High-Risk, Intermediate-2 and Intermediate-1 prognostic scores. Eighty-nine patients were randomized to Dacogen therapy plus supportive care (only 83 received Dacogen), and 81 to Supportive Care (SC) alone.  Patients with Acute Myeloid Leukemia (AML) were not intended to be included.  Of the 170 patients included in the study, independent review (adjudicated diagnosis) found that 12 patients (9 in the Dacogen arm and 3 in the SC arm) had the diagnosis of AML at baseline.  Baseline demographics and other patient characteristics in the Intent-to-Treat (ITT) population were similar between the 2 groups, as shown in Table 4.

Table 4 Baseline Demographics and Other Patient Characteristics (ITT)
Demographic or Other Patient Characteristic Dacogen
N = 89
Supportive Care
N = 81

 Age (years)

 Mean (±SD)
 Median (IQR)
 (Range: min-max)

69±10
70 (65-76)
(31-85)

67±10
70 (62-74)
(30-82)

 Gender n (%)

 Male
 Female

59 (66)
30 (34)

57 (70)
24 (30)

 Race n (%)

 White
 Black
 Other

83 (93)
4 (4)
2 (2)

76 (94)
2 (2)
3 (4)

 Weeks Since MDS Diagnosis

 Mean (±SD)
 Median (IQR)
 (Range: min-max)

86±131
29 (10-87)
(2-667)

77±119
35 (7-98)
(2-865)

 Previous MDS Therapy n (%)

 Yes
 No

27 (30)
62 (70)

19 (23)
62 (77)

 RBC Transfusion Status n (%)

 Independent
 Dependent

23 (26)
66 (74)

27 (33)
54 (67)

 Platelet Transfusion Status n (%)

 Independent
 Dependent

69 (78)
20 (22)

62 (77)
19 (23)

 IPSS Classification n (%)

 Intermediate-1
 Intermediate-2
 High Risk

28 (31)
38 (43)
23 (26)

24 (30)
36 (44)
21 (26)

 FAB Classification n (%)

 RA
 RARS
 RAEB
 RAEB-t
 CMML

12 (13)
7 (8)
47 (53)
17 (19)
6 (7)

12 (15)
4 (5)
43 (53)
14 (17)
8 (10)

    Patients randomized to the Dacogen arm received Dacogen intravenously infused at a dose of 15 mg/m2 over a 3-hour period, every 8 hours, for 3 consecutive days.  This cycle was repeated every 6 weeks, depending on the patient’s clinical response and toxicity.  Supportive care consisted of blood and blood product transfusions, prophylactic antibiotics, and hematopoietic growth factors.  The study endpoints were overall response rate (complete response + partial response) and time to AML or death.  Responses were classified using the MDS International Working Group (IWG) criteria; patients were required to be RBC and platelet transfusion independent during the time of response.  Response criteria are given in Table 5.

Table 5 Response Criteria for Phase 3 MDS Trial*
  *Cheson BD, Bennett JM, et al. Report of an International Working Group to Standardize Response Criteria for MDS. Blood. 2000; 96:3671-3674.

 Complete Response (CR)
≥ 8 weeks

 Bone Marrow

 On repeat aspirates:

< 5% myeloblasts
No dysplastic changes

 Peripheral Blood

 In all samples during response:

Hgb > 11 g/dL (no transfusions or erythropoietin
ANC ≥ 1500/μL (no growth factor)
Platelets ≥ 100,000/μL (no thrombopoietic agent)
No blasts and no dysplasia
 

 Partial Response (PR)
≥ 8 weeks

 Bone Marrow

 On repeat aspirates:

≥ 50% decrease in blasts over pretreatment values
OR
Improvement to a less advanced MDS FAB classification

 Peripheral Blood

 Same as for CR

 

    The overall response rate (CR+PR) in the ITT population was 17% in Dacogen -treated patients and 0% in the SC group (p<0.001).  (SeeTable 6) The overall response rate was 21% (12/56) in Dacogen -treated patients considered evaluable for response (i.e., those patients with pathologically confirmed MDS at baseline who received at least 2 cycles of treatment).  The median duration of response (range) for patients who responded to Dacogen was 288 days (116-388) and median time to response (range) was 93 days (55-272).  All but one of the Dacogen -treated patients who responded did so by the fourth cycle.  Benefit was seen in an additional 13% of Dacogen -treated patients who had hematologic improvement, defined as a response less than PR lasting at least 8 weeks, compared to 7% of SC patients.  Dacogen treatment did not significantly delay the median time to AML or death versus supportive care.

Table 6 Analysis of Response (ITT)
Parameter Dacogen
N=89
Supportive Care
N=81
  **p-value <0.001 from two-sided Fisher's Exact Test comparing Dacogen vs. Supportive Care.
  †In the statistical analysis plan, a p-value of ≤ 0.024 was required to achieve statistical significance.

 Overall Response Rate (CR+PR)

 15 (17%)**

0 (0%)

      Complete Response (CR)

  8 (9%)

0 (0%)

      Partial Response (PR)

  7 (8%)

0 (0%)

 Duration of Response

 

 

  Median time to (CR+PR) response - Days (range)

  93 (55-272)

  NA

  Median Duration of (CR+PR) response - Days (range)

  288 (116-388)

  NA

All patients with a CR or PR were RBC and platelet transfusion independent in the absence of growth factors.

Responses occurred in patients with an adjudicated baseline diagnosis of AML.

Single-arm Studies

    Three open-label, single-arm, multicenter studies were conducted to evaluate the safety and efficacy of Dacogen in MDS patients with any of the FAB subtypes. In one study conducted in North America, 99 patients with IPSS Intermediate-1, Intermediate-2, or high risk prognostic scores received Dacogen by intravenous infusion at a dose of 20 mg/m2 IV over 1-hour daily, on days 1-5 of week 1 every 4 weeks (1 cycle).  The results were consistent with the results of the controlled trial and summarized in Table 8.

Table 7 Baseline Demographics and Other Patient Characteristics (ITT)
Demographic or Other Patient Characteristic Dacogen
N = 99

Age (years)
Mean (±SD)
Median (Range:  min-max)

 
71±9
72 (34-87)

Gender n (%)
Male
Female

 
71 (72)
28 (28)

Race n (%)
White
Black
Asian
Other

 
86 (87)
6  (6)
4  (4)
3  (3)

Days From MDS Diagnosis to First Dose
Mean (±SD)
Median (Range:  min-max)

 
444±626
154 (7-3079)

Previous MDS Therapy n (%)
Yes
No

 
27 (27)
72 (73)

RBC Transfusion Status n (%)
Independent
Dependent

 
33 (33)
66 (67)

Platelet Transfusion Status n (%)
Independent
Dependent

 
84 (85)
15 (15)

IPSS Classification n (%)
Low Risk
Intermediate–1
Intermediate–2
High Risk

 
1  (1)
52 (53)
23 (23)
23 (23)

FAB Classification n (%)
RA
RARS
RAEB
RAEB-t
CMML

 
20 (20)
17 (17)
45 (45)
6 (6)
11 (11)

Table 8 Analysis of Response (ITT)*

Parameter

 Dacogen
N=99

Overall Response Rate (CR+PR)
     Complete Response (CR)
     Partial Response (PR)

16 (16%)
15 (15%)
1 (1%)

Duration of Response
Median time to (CR+PR) response - Days (range)
Median Duration of (CR+PR) response - Days (range)

 
162 (50-267)
443 (72-722+)

 + indicates censored observation
 * Cheson BD, Bennett JM, et al. Report of an International Working Group to
Standardize Response Criteria for MDS. Blood. 2000; 96:3671-3674.

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.
American Society of Health-System Pharmacists. ASHP Guidelines on Handling Hazardous Drugs: Am J Health-Syst Pharm. 2006;63:1172-1193.
4.
Polovich M., White JM, Kelleher LO (eds). Chemotherapy and biotherapy guidelines and recommendations for practice (2nd ed.) 2005. Pittsburgh, PA: Oncology Nursing Society.

How Supplied/Storage and Handling

    NDC 59148-046-70, 50 mg single-dose vial individually packaged in a carton.

Storage
    Store vials at 25°C (77°F); excursions permitted to 15-30°C (59-86°F).

Patient Counseling Information

Instructions for Patients

    Women of childbearing potential should be advised to avoid becoming pregnant while receiving treatment with Dacogen and for 1 month afterwards, and to use effective contraception during this time, [See Warnings and Precautions (5.3)].

    Men should be advised not to father a child while receiving treatment with Dacogen, and for 2 months afterwards. During these times, men with female partners of childbearing potential should use effective contraception [See Warnings and Precautions (5.4) and Nonclinical Toxicology (13.1)].

    Patients should be advised to monitor and report any symptoms of neutropenia, thrombocytopenia, or fever to their physician as soon as possible [See Warnings and Precautions (5.1)].

Otsuka America Pharmaceutical, Inc.
Manufactured by Pharmachemie B.V. Haarlem, The Netherlands
Manufactured for Otsuka America Pharmaceutical, Inc., Rockville, MD 20850 USA

Dacogen is a registered trademark of Astex Pharmaceuticals, Inc.,
Dublin, CA, U.S.A. used under license.

PRINCIPAL DISPLAY PANEL

NDC 59148-046-70

Dacogen ®
decitabine for injection
50 mg per vial

FOR INTRAVENOUS USE ONLY
WARNING: Cytotoxic Agent
Single use sterile vial

Rx ONLY

Dacogen 
decitabine injection, powder, lyophilized, for solution
Product Information
Product Type HUMAN PRESCRIPTION DRUG LABEL Item Code (Source) NDC:59148-046
Route of Administration INTRAVENOUS DEA Schedule     
Active Ingredient/Active Moiety
Ingredient Name Basis of Strength Strength
DECITABINE (DECITABINE) DECITABINE 50 mg  in 20 mL
Inactive Ingredients
Ingredient Name Strength
POTASSIUM PHOSPHATE, MONOBASIC  
SODIUM HYDROXIDE  
Packaging
# Item Code Package Description
1 NDC:59148-046-70 1 VIAL in 1 CARTON
1 20 mL in 1 VIAL
Marketing Information
Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date
NDA NDA021790 05/03/1996
Labeler - Otsuka America Pharmaceutical, Inc. (008314390)
Revised: 02/2014
 
Otsuka America Pharmaceutical, Inc.
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