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Dexrazoxane

Pronunciation

(deks ray ZOKS ane)

Index Terms

  • Dexrazoxane HCl
  • ICRF-187

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution Reconstituted, Intravenous:

Totect: 500 mg (1 ea) [pyrogen free]

Zinecard: 250 mg (1 ea); 500 mg (1 ea) [pyrogen free]

Generic: 250 mg (1 ea); 500 mg (1 ea)

Brand Names: U.S.

  • Totect
  • Zinecard

Pharmacologic Category

  • Antidote
  • Antidote, Extravasation
  • Chemoprotective Agent

Pharmacology

Derivative of ethylenediaminetetraacetic acid (EDTA); a potent intracellular chelating agent. As a cardioprotectant, dexrazoxane appears to be converted intracellularly to a ring-opened chelating agent that interferes with iron-mediated oxygen free radical generation thought to be responsible, in part, for anthracycline-induced cardiomyopathy. In the management of anthracycline extravasation, dexrazoxane may act by reversibly inhibiting topoisomerase II, protecting tissue from anthracycline cytotoxicity, thereby decreasing tissue damage.

Distribution

Distributes to heart, liver, and kidneys; Vd: Children: 0.96 L/kg; Adults: 22 to 25 L/m2

Metabolism

Hydrolyzed by dihydropyrimidine aminohydrolase and dihydrocrotase

Excretion

Urine (42%)

Half-Life Elimination

2.1 to 2.5 hours

Protein Binding

None

Special Populations: Renal Function Impairment

Clearance is reduced in patients with renal function impairment.. The mean AUC was 2-fold higher in patients with moderate (CrCl 30 to 50 mL/minute) to severe (CrCl <30 mL/minute) renal impairment.

Use: Labeled Indications

Prevention of cardiomyopathy associated with doxorubicin (Zinecard, generic products): To reduce the incidence and severity of cardiomyopathy associated with doxorubicin administration in women with metastatic breast cancer who have received a cumulative doxorubicin dose of 300 mg/m2 and will benefit from continuing doxorubicin therapy to maintain tumor control. Not recommended for use with initial doxorubicin therapy.

Extravasation of anthracyclines (Totect): Treatment of extravasation resulting from intravenous anthracycline chemotherapy.

Use: Unlabeled

Cardioprotectant for doxorubicin in malignancies other than metastatic breast cancer; cardioprotectant for epirubicin in advanced breast cancer; cardioprotectant for doxorubicin in acute lymphoblastic leukemia (ALL) treatment in children

Contraindications

Zinecard:

US labeling: Use with chemotherapy regimens that do not contain an anthracycline

Canadian labeling: Hypersensitivity to dexrazoxane or any component of the formulation; use with chemotherapy regimens that do not contain an anthracycline;; use as a chemotherapeutic agent

Totect: There are no contraindications listed in the manufacturer’s labeling.

Dosing: Adult

Prevention of doxorubicin cardiomyopathy: IV: A 10:1 ratio of dexrazoxane:doxorubicin (dexrazoxane 500 mg/m2:doxorubicin 50 mg/m2). Note: Cardiac monitoring should continue during dexrazoxane therapy; doxorubicin/dexrazoxane should be discontinued in patients who develop a decline in LVEF or clinical CHF.

Treatment of anthracycline extravasation: IV: 1000 mg/m2 on days 1 and 2 (maximum dose: 2000 mg), followed by 500 mg/m2 on day 3 (maximum dose: 1000 mg); begin treatment as soon as possible, within 6 hours of extravasation

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Prevention of doxorubicin cardiomyopathy associated with acute lymphoblastic leukemia treatment (high-risk patients; off-label use): IV: A 10:1 ratio of dexrazoxane:doxorubicin (eg, dexrazoxane 300 mg/m2:doxorubicin 30 mg/m2) was used in patients with high-risk acute lymphoblastic leukemia; dexrazoxane is administered immediately prior to the doxorubicin dose (Lipshultz, 2010; Moghrabi, 2007; Silverman, 2010)

Dosing: Renal Impairment

Note: Renal function may be estimated using the Cockcroft-Gault formula.

Mild (CrCl ≥40 mL/minute) impairment: No dosage adjustment necessary.

Moderate-to-severe (CrCl <40 mL/minute) impairment:

Prevention of cardiomyopathy: Reduce dose by 50%, using a 5:1 dexrazoxane:doxorubicin ratio (dexrazoxane 250 mg/m2:doxorubicin 50 mg/m2)

Anthracycline extravasation: Reduce dose by 50%

Dosing: Hepatic Impairment

Prevention of cardiomyopathy: Since doxorubicin dosage is reduced in hyperbilirubinemia, a proportional reduction in dexrazoxane dosage is recommended (maintain a 10:1 ratio of dexrazoxane:doxorubicin)

Anthracycline extravasation: There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied).

Reconstitution

Hazardous agent; use appropriate precautions for handling and disposal (NIOSH 2014 [group 2]).

Note: Preparation and storage are product specific; refer to individual product labeling for further details. Discard unused solutions. Do not mix in the same container with other medications.

Totect: Reconstitute 500 mg vial with 50 mL of the supplied diluent (0.167 Molar sodium lactate injection) to a final concentration of 10 mg/mL. Prior to infusion, further dilute reconstituted dexrazoxane solution in NS 1000 mL.

Zinecard: Reconstitute vial with sterile water for injection to a concentration of dexrazoxane 10 mg/mL. Prior to infusion, further dilute reconstituted dexrazoxane solution in lactated Ringer’s injection to a final concentration of 1.3-3 mg/mL.

Dexrazoxane generic formulation (Mylan): Reconstitute with the supplied diluent (0.167 Molar sodium lactate injection) to a final concentration of 10 mg/mL. Prior to infusion, further dilute reconstituted dexrazoxane solution with D5W or NS to a final concentration of 1.3 to 5 mg/mL.

Administration

Prevention of doxorubicin cardiomyopathy: Administer doxorubicin within 30 minutes after completion of the dexrazoxane infusion (do not administer doxorubicin before dexrazoxane).

Zinecard: Administer by rapid drip infusion over 15 minutes; do not administer by IV push

Dexrazoxane generic formulation (Mylan): Administer by slow IV push or rapid drip infusion

Treatment of anthracycline extravasation: Stop vesicant infusion immediately and disconnect IV line (leave needle/cannula in place); gently aspirate extravasated solution from the IV line (do NOT flush the line); remove needle/cannula; elevate extremity. Administer dexrazoxane IV over 1-2 hours; begin infusion as soon as possible, within 6 hours of extravasation. Day 2 and 3 doses should be administered at approximately the same time (± 3 hours) as the dose on day 1. Infusion solution should be at room temperature prior to administration. Infuse in a large vein in an area remote from the extravasation. For IV administration only; not for local infiltration into extravasation.

Apply dry cold compresses for 20 minutes 4 times daily for 1-2 days (Pérez Fidalgo, 2012); withhold cooling beginning 15 minutes before dexrazoxane infusion; continue withholding cooling until 15 minutes after infusion is completed. Do not use DMSO in combination with dexrazoxane; may lessen efficacy.

Hazardous agent - use appropriate precautions for handling and disposal (NIOSH 2014 [group 2]).

Compatibility

Stable in NS (Totect, generic formulations reconstituted with 0.167 M sodium lactate), D5W (generic formulations reconstituted with 0.167 M sodium lactate), LR (Zinecard)

Storage

Note: Preparation and storage are product specific; refer to individual product labeling for further details. Discard unused solutions.

Totect: Store intact vials at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Protect from light. When reconstituted with the supplied diluent to a final concentration of 10 mg/mL the reconstituted solution is stable for 2 hours. Solutions for infusion in NS are stable for 4 hours when stored at <25°C (77°F).

Zinecard: Store intact vials at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). When reconstituted with sterile water for injection, the reconstituted solution is stable for 30 minutes at room temperature or 3 hours refrigerated at 2°C to 8°C (36°F to 46°F). Solutions diluted for infusion in LR are stable for 1 hour when stored at room temperature or 4 hours refrigerated.

Dexrazoxane generic formulation (Mylan): Store intact vials at 20°C to 25°C (68°F to 77°F). Reconstituted solutions and solutions diluted for infusion in NS or D5W are stable for 6 hours when stored at room temperature or refrigerated at 2°C to 8°C (36°F to 46°F).

Additional stability information: When studied as a 24-hour continuous infusion for the prevention of cardiomyopathy, solutions prepared with sodium lactate diluent and diluted to a final concentration of 0.1 or 0.5 mg/mL in D5W were found to retain ≥90% of their initial concentration when stored at room temperature (ambient light conditions) for ≤24 hours (Tetef, 2001).

Drug Interactions

BCG (Intravesical): Myelosuppressive Agents may diminish the therapeutic effect of BCG (Intravesical). Avoid combination

CloZAPine: Myelosuppressive Agents may enhance the adverse/toxic effect of CloZAPine. Specifically, the risk for neutropenia may be increased. Monitor therapy

Deferiprone: Myelosuppressive Agents may enhance the neutropenic effect of Deferiprone. Avoid combination

Dimethyl Sulfoxide: May diminish the therapeutic effect of Dexrazoxane. Avoid combination

Dipyrone: May enhance the adverse/toxic effect of Myelosuppressive Agents. Specifically, the risk for agranulocytosis and pancytopenia may be increased Avoid combination

DOXOrubicin (Conventional): Dexrazoxane may diminish the therapeutic effect of DOXOrubicin (Conventional). Management: Do not administer dexrazoxane for cardioprotection at the time of doxorubicin initiation. This recommendation does not apply to the use of dexrazoxane for other indications (e.g., extravasation), or to the use of dexrazoxane later in treatment. Consider therapy modification

Adverse Reactions

Note: Most adverse reactions are thought to be attributed to chemotherapy, except for increased myelosuppression, pain at injection site, and phlebitis.

Prevention of doxorubicin cardiomyopathy (reactions listed are those which were greater in the dexrazoxane arm in a comparison of chemotherapy plus dexrazoxane vs chemotherapy alone):

Cardiovascular: Phlebitis (6%)

Central nervous system: Fatigue (61%), neurotoxicity (17%)

Dermatologic: Erythema (5%)

Hematologic & oncologic: Bone marrow depression, granulocytopenia, leukopenia, thrombocytopenia

Infection: Infection (23%), sepsis (17%)

Local: Pain at injection site pain (12%)

Miscellaneous: Fever (34%)

Postmarketing, and/or case reports: Metastases (including acute myeloid leukemia, myelodysplastic syndrome)

Anthracycline extravasation:

Cardiovascular: Peripheral edema (10%), localized phlebitis (6%)

Central nervous system: Fatigue (13%), dizziness (11%), depression (8%), headache (6%), insomnia (5%)

Dermatologic: Alopecia (14%)

Endocrine & metabolic: Hypercalcemia (7%), hyponatremia (6%), increased lactate dehydrogenase (5%)

Gastrointestinal: Nausea (43%), vomiting (19%), diarrhea (11%), abdominal pain (6%), constipation (6%), anorexia (5%)

Hematologic & oncologic: Decreased white blood cell count (73%; grade 3: 25%; grade 4: 20%), decreased neutrophils (61%; grade 3: 22%; grade 4: 24%), decreased hemoglobin (43%; grade 3: 3%), anemia (6%), febrile neutropenia (3%), neutropenia (3%), leukopenia, thrombocytopenia

Hepatic: Increased serum AST (28%), increased serum ALT (22%), increased serum bilirubin (11%), increased serum alkaline phosphatase (4%)

Infection: Postoperative infection (16%)

Local: Pain at injection site (16%)

Renal: Increased serum creatinine (14%)

Respiratory: Dyspnea (8%), pneumonia (6%), cough (5%)

Miscellaneous: Fever (21%)

Warnings/Precautions

Concerns related to adverse effects:

• Bone marrow suppression: May cause mild myelosuppression (leukopenia, neutropenia, and thrombocytopenia); myelosuppression may be additive with concurrently administered chemotherapeutic agents.

• Cardioprotection: Does not eliminate the potential for anthracycline-induced cardiac toxicity; carefully monitor cardiac function (LVEF) before and periodically during treatment.

• Secondary malignancies: Acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) have been reported in pediatric patients and some adult patients receiving dexrazoxane in combination with chemotherapy.

• Tumor response: Dexrazoxane may interfere with the antitumor effect of chemotherapy when given concurrently with fluorouracil, doxorubicin, and cyclophosphamide (FAC).

Disease-related concerns:

• Hepatic impairment: Due to dosage adjustments for doxorubicin in hepatic impairment, a proportional dose reduction in dexrazoxane is recommended to maintain the dosage ratio of 10:1.

• Renal impairment: Use with caution in patients with renal dysfunction (clearance is reduced); dosage adjustment required for CrCl <40 mL/minute.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Special handling:

• Hazardous agent: Use appropriate precautions for handling and disposal (NIOSH 2014 [group 2]).

Other warnings/precautions:

• Administration (extravasation): For IV administration; not for local infiltration into extravasation site. Do not use DMSO in patients receiving dexrazoxane for anthracycline extravasation; may diminish dexrazoxane efficacy.

• Administration sequence (cardioprotection): When used for the prevention of cardiomyopathy, doxorubicin should be administered within 30 minutes after completion of the dexrazoxane infusion (do not administer doxorubicin before dexrazoxane).

Monitoring Parameters

CBC with differential (frequent); liver function; serum creatinine; cardiac function (repeat monitoring at 400 mg/m2, 500 mg/m2 and with every 50 mg/m2 of doxorubicin thereafter); monitor site of extravasation

Pregnancy Risk Factor

D

Pregnancy Considerations

Adverse events were observed in animal reproduction studies using doses less than the equivalent human dose (based on BSA). May cause fetal harm if administered during pregnancy. Women of childbearing potential should use highly effective contraception to prevent pregnancy during treatment.

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience nausea, vomiting, diarrhea, lack of appetite, injection site pain, or hair loss. Have patient report immediately to prescriber signs of infection, signs of bleeding (vomiting blood or vomit that looks like coffee grounds, coughing up blood, blood in the urine; black, red, or tarry stools; bleeding from the gums; abnormal vaginal bleeding; bruises without a reason or that get bigger; or any bleeding that is very bad or that will not stop); shortness of breath; excessive weight gain; swelling of arms or legs; severe loss of strength and energy; burning or numbness feeling; mouth sores; or injection site irritation (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.

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