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CARDIOXANE 500 MG POWDER FOR SOLUTION FOR INFUSION

Active substance(s): DEXRAZOXANE HYDROCHLORIDE / DEXRAZOXANE HYDROCHLORIDE

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SUMMARY OF PRODUCT CHARACTERISTICS
1

NAME OF THE MEDICINAL PRODUCT
CARDIOXANE® 500mg, powder for solution for infusion

2

QUALITATIVE AND QUANTITATIVE COMPOSITION

One vial of powder contains 500 mg of dexrazoxane as its hydrochloride salt.
For the full list of excipients, see section 6.1.

3

PHARMACEUTICAL FORM
Powder for solution for infusion.
Sterile, pyrogen free, white to off-white, lyophilised powder.

4

CLINICAL PARTICULARS

4.1

Therapeutic indications

Cardioxane is indicated in adults for the prevention of chronic cumulative
cardiotoxicity caused by anthracycline use in advanced and/or metastatic breast
cancer patients who have received a prior cumulative dose of 300 mg/m2 of
doxorubicin or a prior cumulative dose of 540 mg/m2 of epirubicin when further
anthracycline treatment is required.

4.2

Posology and method of administration

Posology
Cardioxane is administered by a short intravenous infusion (15 minutes),
approximately 30 minutes prior to anthracycline administration at a dose equal to
10 times the doxorubicin-equivalent dose and 10 times the epirubicin-equivalent dose.
Thus it is recommended that Cardioxane is given at a dose of 500 mg/m2 when the
commonly used dosage schedule for doxorubicin of 50 mg/m2 is employed or
600 mg/m2 when the commonly used dosage schedule for epirubicin of 60 mg/m2 is
employed.

Paediatric population
The safety and efficacy of Cardioxane in children aged 0 to 18 years have not been
established. Currently available data are described in section 4.3, 4.4, 4.8, 5.1 and 5.2.

Renal impairment
In patients with moderate to severe renal impairment (creatinine clearance
< 40 ml/min) the dexrazoxane dose should be reduced by 50% (see section 4.4).
Hepatic impairment
The dosage ratio should be kept, i.e. if the anthracycline dose is reduced the
dexrazoxane dose should be reduced accordingly.
Method of administration
Intravenous use
For instructions on reconstitution and dilution of the medicinal product before administration,
see section 6.6.

4.3

Contraindications

Cardioxane is contraindicated in children aged 0 to 18 years who are planned to
receive a cumulative dose of less than 300 mg/m2 of doxorubicin or the equivalent
cumulative dose of another anthracycline (see sections 4.4 and 4.8).
Cardioxane is also contraindicated in the following circumstances:
- Hypersensitivity to dexrazoxane
- Breast-feeding (see section 4.6)
- Concomitant vaccination with yellow fever vaccine (see section 4.5)

4.4

Special warnings and precautions for use

Myelosuppression

Myelosuppressive effects that may be additive to those of chemotherapy were
reported with Cardioxane (see section 4.8). Cell counts at nadir may be lower in
patients treated with dexrazoxane. Haematological monitoring is thus necessary.
Leucopenia and thrombocytopenia generally reverse quickly upon cessation of
treatment with Cardioxane.
At higher doses of chemotherapy, where the Cardioxane dose exceeds 1000 mg/m2,
myelosuppression may increase significantly.
Second primary malignancies

Since dexrazoxane is a cytotoxic agent, with topoisomerase II inhibition activity,
combination of dexrazoxane with chemotherapy may lead to an increased risk of
second primary malignancy.
Oncology patients have an increased risk of second primary malignancies, regardless of
treatment. Patients who have received cancer therapy also have an increased risk of second
primary malignancy.

Acute Myeloid Leukaemia (AML) has been reported uncommonly in adult breast
cancer patients post-marketing (see section 4.8).
In paediatric patients, second primary malignancies, including acute myeloid leukaemia
(AML) and myelodysplastic syndrome (MDS), have been reported in clinical trials in both
dexrazoxane and control groups. Although second primary malignancies were numerically
higher in the dexrazoxane arm, there was no statistical difference between groups. Overall,
the rates of second primary malignancies in the available paediatric studies in the
dexrazoxane group are similar to rates determined for relevant populations in other studies
(historical data). However, the long term effect of dexrazoxane on second primary
malignancies is not known and cannot be estimated from the available data. In clinical trials,
second primary malignancies, in particular AML and myelodysplastic syndrome (MDS), have
been reported in paediatric patients with Hodgkin’s disease and acute lymphoblastic
leukaemia receiving chemotherapy regimens including several cytotoxics (e.g. etoposide,
doxorubicin, cyclophosphamide) (see section 4.8).

Interference with chemotherapy
Since both dexrazoxane and anthracyclines are topoisomerase inhibitors, it has been
suggested that dexrazoxane may interfere with the anti-tumour efficacy of anthracyclines
based on mechanism of action. However, in most adult studies no significant difference has
been identified in response rate and overall survival between dexrazoxane and control groups.
A significant decrease in tumour response rate was reported in one study of advanced breast
cancer patients treated with doxorubicin and dexrazoxane compared to patients treated with
doxorubicin and placebo. In this study placebo response rate was considered to be high
(60.5%), which may be a contributing factor to the observed difference in response rate.
Despite the difference in response rates, there was no significant difference in time to
progression or overall survival between patients that had received either dexrazoxane or
placebo in this study.
No paediatric study has reported a difference in oncological outcome (event free survival)
between groups treated with dexrazoxane and those treated with anthracycline alone.

Patients with renal impairment
Clearance of dexrazoxane and its active metabolites may be reduced in patients with
decreased creatinine clearance (see Section 4.2).
Liver disorders
Since liver dysfunction was occasionally observed in patients treated with Cardioxane
(see section 4.8), it is recommended that routine liver function tests be performed
before and during administration of dexrazoxane in patients with known liver function
disorders.

Patients with cardiac disorders
Standard cardiac monitoring associated with doxorubicin or epirubicin treatment
should be continued.
There are no data that support the use of dexrazoxane in patients with myocardial
infarction within the past 12 months, pre-existing heart failure (including clinical
heart failure secondary to anthracycline treatment), uncontrolled angina or
symptomatic valvular heart disease.
Thromboembolism
Combination of dexrazoxane with chemotherapy may lead to an increased risk of
thromboembolism (see section 4.8).
Women of child-bearing potential / Contraception in males and females
Since dexrazoxane is a cytotoxic agent, sexually active men and women should use
effective contraception during treatment. Women and men should continue using
effective methods of contraception for at least 6 months after cessation of treatment
with dexrazoxane (see section 4.6).
Geriatric patients (age 65 years or above)
There are no clinical trials comparing the efficacy or safety of dexrazoxane in
geriatric patients to that in younger patients. However, in general, caution is required
when treating elderly patients due to their greater use of other medicinal products,
higher rates of concomitant diseases and possible reduced hepatic, renal or cardiac
function.
Anaphylactic reaction
Anaphylactic reaction including angioedema, skin reactions, bronchospasm,
respiratory distress, hypotension and loss of consciousness have been observed in
patients treated with Cardioxane and anthracyclines (see section 4.8). Previous history
of allergy to dexrazoxane should be carefully considered prior to administration (see
section 4.3).

4.5

Interaction with other medicinal products and other forms of interaction

Cardioxane is excreted unchanged via the kidney, as well as metabolized by
dihydropyrimidine amidohydrolase (DHPase) in the liver and kidney to ring-opened
metabolites. Co-administration of doxorubicin (50 to 60 mg/m2) or epirubicin (60 to
100 mg/m2) did not affect Cardioxane pharmacokinetics significantly.
In studies, Cardioxane did not affect the pharmacokinetics of doxorubicin. There is
limited evidence from studies that suggests that epirubicin clearance may be increased
when dexrazoxane is pre-administered, this occurred at high doses of epirubicin (120135 mg/m2).
Cardioxane may increase haematological toxicity induced by chemotherapy or
radiation, requiring careful monitoring of haematological parameters during the first
two treatment cycles (see section 4.4).

Cardioxane should not be mixed with any other medicinal products during infusion.
Concomitant use contraindicated:
Yellow fever vaccine: Risk of fatal generalised vaccine disease (see section 4.3).
Concomitant use not recommended:
Other live attenuated vaccines: risk of systemic, possible fatal disease. This risk is increased
in subjects who are already immunosuppressed by their underlying disease. Use an
inactivated vaccine where this exists (poliomyelitis).
Phenytoin: cytotoxic agents may reduce the absorption of phenytoin leading to an
exacerbation of convulsions. Dexrazoxane is not recommended in combination with
phenytoin.
Concomitant use to assess carefully:

Ciclosporin, tacrolimus: Excessive immunosuppression with risk of
lymphoproliferative disease.
Paediatric population
Interaction studies have only been performed in adults.

4.6

Fertility, pregnancy and lactation

Women of childbearing potential/contraception in males and females
Both sexually active men and women should use effective methods of contraception
during treatment. For women and men the contraception should be continued for at
least 6 months after cessation of treatment with Cardioxane (see section 4.4).
Pregnancy
There are no adequate data from the use of dexrazoxane in pregnant women. Animal
studies showed embryotoxic and teratogenic effects (see section 5.3). The potential
risk for humans is unknown. Cardioxane is used with anthracyclines known to have
cytotoxic, mutagenic and embryotoxic properties. Cardioxane should not be used
during pregnancy unless clearly necessary.
Breast-feeding
There are no animal studies on the transfer of the active substance and/or its
metabolites into milk. It is unknown whether dexrazoxane and/or its metabolites are
excreted in human milk. Because of the potential for serious adverse reactions in
infants exposed to Cardioxane, breast-feeding is contraindicated during Cardioxane
treatment (see section 4.3).
Fertility
The effect of Cardioxane on the fertility of humans has not been studied.

There are limited fertility data from animal studies available, but testicular changes were
observed in rats and dogs following repeat dosing (see Section 5.3).

4.7

Effects on ability to drive and use machines

Cardioxane has moderate influence on the ability to drive and use machines. Patients
should be advised to be cautious when driving or using machines if they experience
fatigue during treatment with Cardioxane.

4.8

Undesirable effects

Summary of the safety profile
Cardioxane is administered together with anthracycline chemotherapy and, consequently, the
relative contributions of anthracycline and Cardioxane to the adverse reaction profile may be
unclear. The most common adverse reactions are haematological and gastroenterological
reactions, primarily anaemia, leukopenia, nausea, vomiting and stomatitis, as well as asthenia
and alopecia. Myelosuppressive effects of Cardioxane may be additive to those of
chemotherapy (see section 4.4).
Tabulated list of adverse reactions
The following table includes reactions from clinical trials and from post-marketing use. Due
to the spontaneous nature of post-marketing reporting, such events are listed with frequency
“not known” if they were not already identified as reactions from clinical trials.

Adverse reactions are ranked under headings of frequency, the most frequent first,
using the following convention: very common (≥ 1/10); common (≥ 1/100 to < 1/10);
uncommon (≥ 1/1,000 to < 1/100); not known (cannot be estimated from the available
data).
Table 1
Infections and infestations
Uncommon

Infection, sepsis

Neoplasms benign, malignant and unspecified (including cysts and polyps)
Uncommon

Acute myeloid leukaemia

Blood and lymphatic system disorders
Very common

Anaemia, leukopenia

Common

Neutropenia, thrombocytopenia, febrile neutropenia, granulocytopenia, febrile
bone marrow aplasia, white blood cell count decreased

Uncommon

Eosinophil count increased, neutrophil count increased, platelet count increased,
white blood cell count increased, lymphocyte count decreased, monocyte count
decreased

Immune system disorders

Not known

Anaphylactic reaction, hypersensitivity

Metabolism and nutrition disorders
Common

Anorexia

Nervous system disorders
Common

Paraesthesia, dizziness, headache, peripheral neuropathy

Uncommon

Syncope

Ear and labyrinth disorders
Uncommon

Vertigo, ear infection

Cardiac disorders
Common

Ejection fraction decreased, tachycardia

Vascular disorders
Common

Phlebitis

Uncommon

Venous thrombosis, lymphoedema

Not known

Embolism

Respiratory, thoracic and mediastinal disorders
Common

Dyspnoea, cough, pharyngitis, respiratory tract infections

Not known

Pulmonary embolism

Gastrointestinal disorders
Very common

Nausea, vomiting, stomatitis

Common

Diarrhoea, constipation, abdominal pain, dyspepsia

Uncommon

Gingivitis, oral candidiasis

Hepatobiliary disorders
Common

Transaminases increased

Skin and subcutaneous tissue disorders
Very common

Alopecia

Common

Nail disorder, erythema

Uncommon

Cellulitis

General disorders and administration site conditions
Very common

Asthenia

Common

Mucosal inflammation, pyrexia, fatigue, malaise, injection site reaction
(including pain, swelling, burning sensation, erythema, pruritus, thrombosis),
oedema

Uncommon

Thirst

Clinical trial data
The above table shows adverse reactions reported in clinical studies and having a
reasonable possibility of a causal relationship with Cardioxane. These data are derived
from clinical trials in cancer patients where Cardioxane was used in combination with

anthracycline-based chemotherapy, and where in some cases a control group of
patients receiving chemotherapy alone can be referred to.
Patients receiving chemotherapy and Cardioxane (n=375):

Of these 76% were treated for breast cancer and 24% for a variety of advanced
cancers.

Cardioxane treatment: a mean dose of 1010 mg/m² (median: 1000 mg/m²) in
combination with doxorubicin, and a mean dose of 941 mg/m² (median:
997 mg/m²) in combination with epirubicin.

Chemotherapy treatment received by patients treated for breast cancer: 45%
combination therapy with doxorubicin 50 mg/m² (mainly with 5-fluorouracil
and cyclophosphamide): 17% with epirubicin alone; 14% combination therapy
with epirubicin 60 or 90 mg/m² (mainly with 5-fluorouracil and
cyclophosphamide).
Patients receiving chemotherapy alone (n=157)

All were treated for breast cancer

Chemotherapy treatment received: 43% single agent epirubicin 120 mg/m²; 33%
combination therapy with 50 mg/m² doxorubicin (mainly with 5-fluorouracil
and cyclophosphamide); 24% combination therapy with epirubicin at 60 or
90 mg/m² (mainly with 5-fluorouracil and cyclophosphamide).
Description of selected adverse drug reactions
Second primary malignancies
AML has been reported uncommonly in adult breast cancer patients post-marketing.
Safety profile at maximum tolerated dose
Dexrazoxane's maximum tolerated dose (MTD) when given as monotherapy by short
infusion every three weeks for cardioprotection has not been specifically studied. In
studies of dexrazoxane as a cytotoxic, its MTD is shown to be dependent on posology
and dosing schedule, and varies from 3750 mg/m2 when short infusions are given in
divided doses over 3 days to 7420 mg/m2 when given weekly for 4 weeks, with
myelosuppression and abnormal liver function tests becoming dose-limiting. The
MTD is lower in patients who have been heavily pre-treated with chemotherapy, and
those with pre-existing immunosuppression (e.g. AIDS).
The following are adverse reactions reported when Cardioxane was given at doses
around the MTD: neutropenia, thrombocytopenia, nausea, vomiting, and increase in
hepatic parameters. Other toxic effects were malaise, low grade fever, increased
urinary clearance of iron and zinc, anaemia, abnormal blood clotting, transient
elevation of serum triglyceride and amylase levels, and a transient decrease in serum
calcium level.
Paediatric population
The safety experience in children is based primarily on literature reports of clinical trials in
acute lymphoblastic leukaemia, non-Hodgkin’s lymphoma, Hodgkin’s disease and
osteosarcoma, and post-marketing data.

In paediatric patients, second primary malignancies, including acute myeloid leukaemia
(AML) and myelodysplastic syndrome (MDS), have been reported in clinical trials in both
dexrazoxane and control groups. Although second primary malignancies were numerically
higher in the dexrazoxane arms, there was with no statistical difference between groups. In
addition, the long term effect of dexrazoxane on secondary primary malignancies is not
known (cannot be estimated from the available data) (see section 4.4).

Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is
important. It allows continued monitoring of the benefit/risk balance of the medicinal
product. Healthcare professionals are asked to report any suspected adverse reactions
via the Yellow Card Scheme; www.mhra.gov.uk/yellowcard or search for MHRA
Yellow Card in the Google Play or Apple App Store.
4.9

Overdose
The signs and symptoms of overdose are likely to consist of leucopenia,
thrombocytopenia, nausea, vomiting, diarrhoea, skin reactions and alopecia. There is
no specific antidote and symptomatic treatment should be provided.
Management should include prophylaxis and treatment of infections, fluid regulation,
and maintenance of nutrition.

5

PHARMACOLOGICAL PROPERTIES

5.1

Pharmacodynamic properties

Pharmacotherapeutic group: Detoxifying agents for antineoplastic treatment, ATC
code: V03AF02
Mechanism of action
The exact mechanism by which dexrazoxane exerts its cardioprotective effect has not
been fully elucidated, however based on the available evidence the following
mechanism has been suggested. The dose-dependent cardiotoxicity observed during
anthracycline administration is due to anthracycline-induced iron-dependent free
radical oxidative stress on the relatively unprotected cardiac muscle. Dexrazoxane, an
analogue of EDTA (ethylene diamine tetra-acetic acid), is hydrolysed in cardiac cells
to the ring-opened product ICRF-198. Both dexrazoxane (ICRF-187) and ICRF-198
are capable of chelating metal ions. It is generally thought that they can provide
cardioprotection by scavenging metal ions thus preventing the Fe3+-anthracycline
complex from redox cycling and forming reactive radicals.
Clinical efficacy and safety

The evidence from clinical trials to date suggests increasing cardioprotective benefit
from dexrazoxane as the cumulative anthracycline dose is increased.
Dexrazoxane does not protect against non-cardiac toxicities induced by
anthracyclines.
The majority of controlled clinical studies were performed in patients with advanced breast
cancer and employed a dosing ratio of dexrazoxane:doxorubicin of 20:1 or 10:1. In two
clinical studies that used the higher dose ratio (one in breast cancer and one in small cell lung
cancer) a higher rate of death was reported in the groups treated with dexrazoxane plus
chemotherapy compared to those treated with chemotherapy alone or with placebo. The dose
ratio was subsequently reduced to 10:1 in both studies, and no significant differences in
survival were reported in patients treated at the lower dose ratio. However, a number of
studies that used the higher dose ratio throughout have not reported any difference in survival.
Paediatric Population:

There are limited data on efficacy in children. Data are mainly derived from COG
(Children’s Oncology Group) studies, published in BL Asselin et al: J. Clin. Oncol.
2016 and CL Schwartz et al Pediatr. Blood Cancer 2016.
Study P9404 (BL Asselin et al: J. Clin. Oncol. 2016) evaluated the cardioprotective efficacy,
and safety of dexrazoxane added to chemotherapy that included a cumulative doxorubicin
dose of 360 mg/m2 to treat children and adolescents with newly diagnosed T-cell acute
lymphoblastic leukemia (T-ALL) or lymphoblastic non-Hodgkin lymphoma (L-NHL).
Between June 1996 and September 2001, patients were randomised to receive doxorubicin
treatment with (n=273) or without (n=264) dexrazoxane (dexrazoxane: doxorubicin ratio
10:1). Dexrazoxane was given as a bolus infusion immediately before every dose of
doxorubicin. Cardiac effects were assessed by echocardiographic measurements of left
ventricular function and structure.
Baseline characteristics of the overall study population were as follows: median age at
diagnosis 9.2 years, male (75.8%), White (66%), T-ALL (67%). The treatment used was
modified from study protocol DFCI ALL-87-01 with or without high-dose methotrexate and
all patients received cranial radiation.
Heart failure was not reported among patients at any time during treatment or follow-up. Of
the five patients in whom grade 3 or 4 cardiac toxicity occurred while receiving therapy; two
had arrhythmias (n = 1 in the dexrazoxane group), and three had decreased LV fractional
shortening (all were in the no-dexrazoxane group). All five received high-dose methotrexate
and had a serious infection when the cardiac toxicity occurred. All patients recovered and
completed chemotherapy, including doxorubicin. cTnT levels at both baseline and during
treatment were available for 160 patients. The probability of having elevated cTnT was lower
in the dexrazoxane group (odds ratio, 0.23; 95% CI, 0.05 to 1.11; p = 0.067).
At baseline, mean z scores for LV fractional shortening and LV thickness-to-dimension ratio
were similar between treatment groups. The mean z score for LV wall thickness at baseline in
the dexrazoxane-treated group was significantly lower than in the no-dexrazoxane group. The
LV wall thickness was worse after treatment in the no-dexrazoxane treatment group than it
was in the dexrazoxane-treated group. After doxorubicin treatment, mean z scores were lower

than age-expected norms for all children, but were not significantly different between groups;
the mean score was always closer to normal for the dexrazoxane group. The mean z scores for
left ventricular fractional shortening, LV wall thickness, and LV thickness-to-dimension ratio
at three years in dexrazoxane treated children were not significantly different from the scores
for healthy children; whereas in the no-dexrazoxane group these z scores all remained
significantly reduced compared to healthy children. The mean left ventricular fractional
shortening, wall thickness, and thickness-to-dimension ratio z scores measured 3 years after
diagnosis were worse in the doxorubicin-alone group (n = 55 per group; P ≤ 0.01 for all
comparisons).
The 5-year event-free survival (with standard error) did not differ between groups: 76.7%
(2.7%) for the dexrazoxane group versus 76.0% (2.7%) for the doxorubicin-only group (p =
0.9) (see also sections 4.2, 4.3, 4.4 and 4.8). The frequencies of severe grade 3 or 4
haematologic toxicity, infection, central nervous system events, and toxic deaths were similar
in both groups.
In a non-randomised study (P9754, CL Schwartz et al Pediatr. Blood Cancer 2016) in patients
with non-metastatic osteosarcoma (median age 13 years, range 3-30 years) where all patients
receiving doxorubicin (450-600 mg/m2) also received dexrazoxane (dexrazoxane: doxorubicin
ratio 10:1) (242 patients exposed to at least 450 mg/m2 doxorubicin and 101 exposed to
600 mg/m2), Grade 1 or 2 left ventricular dysfunction occurred in five patients, and was
transient in at least four of these. In two of these patients, doxorubicin was subsequently
discontinued. No grade 3, 4 or 5 cardiomyopathy (ventricular dysfunction) was observed. One
additional patient had grade 3 serum cTnT elevation with 600 mg/m2 doxorubicin without
documented myocardial dysfunction. Left ventricular fractional shortening values from
104 evaluable patients were converted to z-scores (FSZ) to review change in cardiac function
since time of enrolment. It was found that FSZ decreased in a statistically significant fashion
with increasing time, with that change being -0.017 ± 0.009 of a standardised unit (z-score of
1) per week (estimated annual change of 0.9 FSZ units). Assignment to standard therapy
(450 mg/m2 doxorubicin) or intensification (600 mg/m2 doxorubicin) was unrelated to change
in FSZ. In terms of clinical cardiotoxicity, biomarker measures and FSZ analysis, the risk of
acute cardiomyopathy was low, given the cumulative doses of 450 mg/m2 to 600 mg/m2 of
doxorubicin (see also sections 4.2, 4.3, 4.4 and 4.8).

5.2

Pharmacokinetic properties

After intravenous administration to cancer patients, serum kinetics of dexrazoxane
generally follow an open two-compartment model with first-order elimination. The
maximum plasma concentration observed after a 12-15 minute infusion of
1000 mg/m2 is around 80 µg/ml with area under the plasma concentration-time curve
(AUC) of 130 ± 27 mg.h/l. The plasma concentrations declined thereafter with an
average half-life value of 2.2 ± 0.42 hours. The total body clearance of dexrazoxane
in adults is estimated at 14.4 ± 2.8 l/h.
Distribution
The apparent volume of distribution is 44.0 ± 3.9 l, suggesting that dexrazoxane
distributes mainly in the total body water. Plasma protein binding of dexrazoxane is
low (2%) and it does not penetrate into the cerebrospinal fluid to a clinically
significant extent.

Biotransformation and metabolism
Cardioxane and its metabolites were detected in the plasma and urine of animals and
man.
Elimination
Urinary excretion plays an important role in the elimination of dexrazoxane. The total
urinary excretion of unchanged dexrazoxane is in the order of 40%.
Special populations
Paediatric patients
The very limited pharmacokinetic data in children suggests that although absolute values of
clearance are higher, values normalised for body surface area are not significantly different
from those of adults.

Geriatric patients
No studies have been conducted in the elderly and dexrazoxane. Clearance may be
reduced in elderly patients and patients with low creatinine clearance.
Hepatic impairment
No studies have been conducted in subjects with hepatic impairment.
Renal impairment
Compared with normal subjects (creatinine clearance (CLCR) >80 ml/min), exposure was 2fold greater in subjects with moderate (CLCR of 30 to 50 ml/min) to severe (CLCR
<30 ml/min) renal impairment. Modelling suggested that equivalent exposure (AUC0-inf) could
be achieved if dosing were reduced by 50% in subjects with CLCR less than 40 ml/min
compared with control subjects (CLCR >80 ml/min).

5.3

Preclinical safety data

Repeat dose toxicity
Preclinical studies indicate that, with repeated dexrazoxane administration, the primary target
organs are those of rapid cell division: bone marrow, lymphoid tissue, testes and
gastrointestinal mucosa. Dexrazoxane administration has been associated with testicular
atrophy in rats starting at intravenous dose levels of 25 mg/kg and at a dose level of
20 mg/kg/week in dogs.
The Cardioxane dosing schedule is a primary factor in the degree of tissue toxicity produced.
A single high dose is better tolerated than the same dose administered several times a day.
Mutagenicity
Dexrazoxane has been shown to possess mutagenic and genotoxic activity in both in vitro and
in vivo studies.
Carcinogenicity
The carcinogenic potential of dexrazoxane has not been investigated. However prolonged
administration of high doses of razoxane, the racemic mixture of which dexrazoxane is the S
(+)-enantiomer, has been associated with the development of hematopoietic neoplasms in

female mice, lymphocytic neoplasms in female mice and uterine adenocarcinomas in female
rats.
Reproductive toxicity- teratogenicity
There are limited fertility data from animal studies available, but testicular changes were
observed in rats and dogs following repeat dosing.
Animal reproductive studies reveal that razoxane is embryotoxic in mice, rats and rabbits and
also teratogenic in rats and mice (see section 4.6).

6

PHARMACEUTICAL PARTICULARS

6.1

List of excipients

None

6.2

Incompatibilities

In the absence of compatibility studies, this medicinal product must not be mixed with other
medicinal products except those mentioned in section 6.6.

6.3

Shelf life
Before opening:
3 years
After reconstitution and dilution:
Chemical and physical in-use stability of reconstituted and subsequently
diluted CARDIOXANE is 4 hours at 25ºC.
From a microbiological point of view, reconstituted and subsequently diluted
CARDIOXANE should be used immediately. If not used immediately, storage
times and conditions prior to use are the responsibility of the user, and should
not be longer than 4 hours at 2ºC to 8ºC (in the refrigerator) with protection
from light.

6.4

Special precautions for storage

Before opening: Do not store above 25°C. In order to protect from light store in the
original package.
For storage conditions after reconstitution and dilution of the medicinal product, see section
6.3.

6.5

Nature and contents of container

Vials (Type I brown glass), containing 500 mg of powder, closed with a stopper (chlorobutyl
rubber) and either a cap (aluminium) with a flip-off component (polypropylene) or a tear-off
cap (aluminium) with a pre-cut strip. The product is further enclosed in an outer carton. It is
supplied in packs of 1 and 4 vials. Not all pack sizes may be marketed.

6.6

Special precautions for disposal

Recommendations for safe handling
Prescribers should refer to national or recognised guidelines on handling cytotoxic
agents when using Cardioxane. Reconstitution should only be carried out by trained
staff in a cytotoxic designated area. The preparation should not be handled by
pregnant staff.
Use of gloves and other protective clothing to prevent skin contact is recommended.
Skin reactions have been reported following contact with Cardioxane. If Cardioxane
powder or solution comes into contact with the skin or mucosal surfaces, the affected
area should immediately be rinsed thoroughly with water.
Preparation for intravenous administration
Reconstitution of Cardioxane
For reconstitution the contents of each vial should be dissolved in 25 ml water for
injections. The vial contents will dissolve within a few minutes with gentle shaking.
The resultant solution has a pH of approximately 1.6. This solution should be further
diluted before administration to the patient.
Dilution of Cardioxane
To avoid the risk of thrombophlebitis at the injection site, Cardioxane should be
diluted prior to infusion with one of the solutions mentioned in the table below.
Preferably solutions with a higher pH should be used. The final volume is
proportional to the number of vials of Cardioxane used and the amount of infusion
fluid for dilution, which can be between 25 ml and 100 ml per vial.
The table below summarises the final volume and the approximate pH of reconstituted
and diluted product for one vial and four vials of Cardioxane. The minimum and
maximum volumes of infusion fluids to be used per vial are shown below.
Infusion fluid
used for dilution

Volume of fluid used Final
Final
pH
to dilute 1 vial of
volume
volume
(approximate)
reconstituted
from 1 vial from
Cardioxane
4 vials
Ringer lactate
25 ml
50 ml
200 ml
2.2
100 ml
125 ml
500 ml
3.3
0.16 M sodium
25 ml
50 ml
200 ml
2.9
lactate*
100 ml
125 ml
500 ml
4.2
*
Sodium lactate 11.2% should be diluted by a factor of 6 to reach a concentration
of 0.16 M.

The use of larger dilution volumes (with a maximum of 100 ml of additional infusion
fluid per 25 ml reconstituted Cardioxane) is usually recommended to increase the pH
of the solution. Smaller dilution volumes (with a minimum of 25 ml of additional
infusion fluid per 25 ml reconstituted Cardioxane) can be used if needed, based on the
haemodynamic status of the patient.
Cardioxane is for single use only. Reconstituted and subsequently diluted product
should be used immediately or within 4 hours if stored between 2°C and 8°C.
Parenteral drug products should be inspected visually for particulate matter whenever
the solution and container permit. Cardioxane is normally a colourless to yellow
solution immediately on reconstitution, but some variability in colour may be
observed over time, which does not indicate loss of activity if the product has been
stored as recommended. It is however recommended to dispose of the product if the
colour immediately on reconstitution is not colourless to yellow.
Disposal
Any unused medicinal product or waste material should be disposed of in accordance
with local requirements. Adequate care and precautions should be taken in the
disposal of items used to reconstitute and dilute Cardioxane.

7

MARKETING AUTHORISATION HOLDER
Clinigen Healthcare Ltd.
Pitcairn House
Crown Square
First Avenue, Burton-on-Trent
Staffordshire
DE14 2WW
United Kingdom

8

MARKETING AUTHORISATION NUMBER(S)
PL 31644/0002

9

DATE OF FIRST AUTHORISATION/RENEWAL OF THE
AUTHORISATION

Date of first authorisation: 7 July 2006
Date of the latest renewal: 9 October 2015

10

DATE OF REVISION OF THE TEXT
22/08/2017

Expand Transcript

Source: Medicines and Healthcare Products Regulatory Agency

Disclaimer: Every effort has been made to ensure that the information provided here is accurate, up-to-date and complete, but no guarantee is made to that effect. Drug information contained herein may be time sensitive. This information has been compiled for use by healthcare practitioners and consumers in the United States. The absence of a warning for a given drug or combination thereof in no way should be construed to indicate that the drug or combination is safe, effective or appropriate for any given patient. If you have questions about the substances you are taking, check with your doctor, nurse or pharmacist.

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