Recognition and Treatment of Lymphomatous Meningitis in Patients

White Paper
Recognition and Treatment of
Lymphomatous Meningitis in
Patients with Late-Stage Lymphoma
Indication
DepoCyt® (cytarabine liposome injection) is indicated for the intrathecal treatment of lymphomatous meningitis.
Important Safety Information
WARNING: CHEMICAL ARACHNOIDITIS ADVERSE REACTIONS
Chemical arachnoiditis, a syndrome manifested primarily by nausea, vomiting, headache
and fever, was a common adverse event in all clinical studies. If left untreated, chemical
arachnoiditis may be fatal. Patients receiving DepoCyt should be treated concurrently with
dexamethasone to mitigate the symptoms of chemical arachnoiditis. [See Warnings and
Precautions (5.1, 5.2) in full prescribing information]
Contraindications
DepoCyt® (cytarabine liposome injection) is contraindicated in patients who are hypersensitive to cytarabine or any component of the formulation, and in patients with active
meningeal infection.
Warnings and Precautions
Dosing
In-line filters must not be used when administering DepoCyt. DepoCyt is administered directly into the cerebrospinal fluid (CSF) via an intraventricular reservoir or by direct injection into the lumbar sac. DepoCyt should be injected slowly over a period of 1-5 minutes.
Following drug administration by lumbar puncture, the patient should be instructed to lie
flat for 1 hour. Patients should be observed by the physician for immediate toxic reactions.
Chemical Arachnoiditis
Chemical arachnoiditis, a syndrome manifested primarily by nausea, vomiting, headache
and fever, has been a common adverse event in all studies. If chemical arachnoiditis is suspected, exclude other inflammatory, infectious, or neoplastic conditions. If left untreated,
chemical arachnoiditis may be fatal. The incidence and severity of chemical arachnoiditis
can be reduced by coadministration of dexamethasone. Patients receiving DepoCyt should
be treated concurrently with dexamethasone to mitigate the symptoms of chemical arachnoiditis.
• Toxic effects may be related to a single dose or to cumulative administration. Because
toxic effects can occur at any time during therapy (although they are most likely to occur
within 5 days of drug administration), patients receiving intrathecal therapy with DepoCyt should be monitored continuously for the development of neurotoxicity. If patients
develop neurotoxicity, reduce subsequent doses of DepoCyt. If neurotoxicity persists,
discontinue DepoCyt.
• Hydrocephalus has also been reported, possibly precipitated by arachnoiditis.
• Arachnoiditis is an expected and well-documented side effect of both neoplastic meningitis and of intrathecal chemotherapy. The incidence of severe and life-threatening
arachnoiditis in patients receiving DepoCyt was 19% (48/257) in all patients and 30%
(10/33) in patients with lymphomatous meningitis. In the early dose-finding study, chemical arachnoiditis was observed in 100% of cycles without dexamethasone prophylaxis.
When concurrent dexamethasone was administered, chemical arachnoiditis was observed
in 33% of cycles.
(Continued on next page)
(Continued from previous page)
Neurotoxicity
• Intrathecal administration of cytarabine may cause myelopathy and other neurologic
toxicity and can rarely lead to a permanent neurologic deficit. Administration of intrathecal cytarabine in combination with other chemotherapeutic agents or with cranial/
spinal irradiation may increase this risk of neurotoxicity.
• Blockage to CSF flow may result in increased free cytarabine concentrations in the
CSF and an increased risk of neurotoxicity. Therefore, as with any intrathecal cytotoxic
therapy, consideration should be given to the need for assessment of CSF flow before
treatment is started.
• Following intrathecal administration of DepoCyt, central nervous system toxicity,
including persistent extreme somnolence, hemiplegia, visual disturbances including
blindness which may be total and permanent, deafness and cranial nerve palsies have
been reported. Symptoms and signs of peripheral neuropathy, such as pain, numbness,
paresthesia, weakness, and impaired bowel and bladder control have also been observed.
In some cases, a combination of neurological signs and symptoms has been reported as
Cauda Equina Syndrome.
• If patients develop neurotoxicity, reduce subsequent doses of DepoCyt or discontinue
DepoCyt. Headache, nausea, and fever are expected in early signs of neurotoxicity.
Transient Elevations in CSF Protein and CSF White Blood Cells
Transient elevations in CSF protein and white blood cell counts have been observed in
patients following DepoCyt administration.
Embryo-Fetal Toxicity
Cytarabine, the active component of DepoCyt, can cause fetal harm if a pregnant woman is
exposed to the drug systemically. The systemic exposure of cytarabine following intrathecal administration of DepoCyt is negligible. Cytarabine was teratogenic in mice and rats.
Cytarabine was embryotoxic in mice when administered during the period of organogenesis.
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 harm to a fetus.
Adverse Reactions
After intrathecal administration of cytarabine the most frequently reported reactions (≥ 10%)
are headache NOS, nausea, vomiting NOS, arachnoiditis, weakness, confusion, pyrexia,
fatigue, constipation, back pain, gait abnormal NOS, convulsions NOS, dizziness NOS,
lethargy, pain in limb, insomnia, urinary tract infection NOS, neck pain, death NOS, pain,
memory impairment, dehydration, anemia NOS, diarrhea NOS, appetite decreased NOS,
thrombocytopenia, edema peripheral, arthralgia, neck stiffness, vision blurred, muscle
weakness, neutropenia, hypoesthesia, agitation, and dyspnea NOS.
Please see full prescribing information attached, including Boxed WARNINGS, or go to
www.depocyt.com.
Distributed by Sigma-Tau Pharmaceuticals, Inc.
Manufactured by Pacira Pharmaceuticals, Inc.
White Paper
Recognition and Treatment of
Lymphomatous Meningitis in
Patients with Late-Stage Lymphoma
Lymphomatous meningitis (LM), a rare subset of neoplastic meningitis, is a devastating complication of lymphoma that results in significant neurologic deficit, decreased
Karnofsky performance status (KPS), and poor survival.1,2 Although this disease is
progressive and treatment is palliative, early diagnosis and intervention may protect
neurologic function and may improve KPS. This white paper presents the signs,
symptoms, and risk factors of LM, as well as treatment with DepoCyt® (cytarabine
liposome injection).
L
ymphomatous meningitis (LM) occurs when malignant cells infiltrate
the cerebrospinal fluid (CSF) and the
leptomeninges. The brain and spinal
cord are contained by the meninges,
a three-layered membrane consisting of the
pia, the arachnoid, and the dura (see Figure 1).
The pia is the most delicate and vascular of the
three, lying directly on the brain’s surface. Between it and the layer above, the arachnoid, is
the subarachnoid space, where a large percentage of the CSF flows and is held. Just above the
arachnoid, is the dura, a thick, fibrous sheath
that forms the outermost layer.3,4 When malignant cells penetrate the dura, the entire neuraxis
is at risk and progressive deterioration in neurologic function occurs. Although the course
may be variable, without treatment, prognosis
is grave, with life expectancy approximately
less than three months5. However, with early
diagnosis and prompt treatment, survival may
be extended to a few months.
Challenges with Diagnosis
and Treatment
Patients with LM most commonly present
with headache and cranial nerve dysfunction.
Because these initial or early symptoms are
typically subtle and their presentation similar
to many other etiologies, proper diagnosis is
challenging. Awareness of risk factors for LM
may help healthcare providers to be alert for this
disease despite its vague early symptomatology
(see Figure 2).
Achieving a diagnosis for LM involves eliminating other etiologies by implimenting a triad
of methods4:
• A thorough neurologic examination,
• Magnetic resonance imaging (MRI) with
and without gadolinium of the entire
neuraxis, and
• Lumbar puncture for CSF sampling.
The purposes of using these diagnostic tools
are to confirm lymphoma infiltration into the
subarachnoid space, as well as the location of
disease along the neuraxis and the extent of
the blockage of CSF flow. Although any of the
methods may stand alone as diagnostic criterion, most clinicians rely on a positive cytologic
examination.4
In patients with an elevated risk profile, a
thorough history and physical examination is
essential because patients may not report subtle
neurologic changes and other symptoms such
as pain because they may not feel these are
significant. Signs and symptoms by affected
neural area are outlined in Table 1.
In addition to neurologic examination, MRI
with and without gadolinium of the entire neuraxis and a lumbar puncture for CSF sampling
and cytology completes the diagnostic triad for
LM.4
MRI may detect spread of disease, as well as
any bulky metastases that may be partially or
4
Recognition and Treatment of LM • April 2015
Figure 1. Neuraxis Anatomy
5
Recognition and Treatment of LM • April 2015
Figure 2. Lymphomatous Meningitis
Risk Factors6
High-grade lymphoma and advanced
stage
Progressive recurrence
Refractory to treatment
Extensive extranodal disease
Younger age
Elevated serum lactate dehydrogenase
(LDH) levels
Presence of immunocompromised and
HIV-related lymphoma
Presence of primary central nervous
system lymphoma
completely blocking the flow of CSF. Imaging
of the entire neuraxis should be completed, because leptomeningeal spread can occur at any
area along this axis and is often present in more
than one area or before symptoms are evident.
Lumbar puncture is typically performed to
obtain CSF samples. CSF may be obtained from
a ventricle if a patient has an Ommaya reservoir.4 For diagnostic accuracy, at least 10 ml of
CSF should be extracted for cytology and 3 to 5
ml for other evaluation.4 Two taps should yield
an adequate amount of fluid for examination.
Once LM is properly identified, healthcare
professionals may be reluctant to initiate treatment due to the patient’s status as late or end of
life. However, with proper intervention, neurologic function may be preserved, and prognosis
potentially extended from a few weeks to a few
months. Oncology nurses are in an ideal position to recognize the subtle signs and prompt
further investigation for LM and other neurologic conditions.
Once a positive diagnosis for LM is determined, management includes palliation of
symptoms and attempting to slow disease progression. Radiation is used to shrink lesions
that are causing symptoms or blocking CSF
flow. Ideally, intrathecal chemotherapy is also
employed to reach metastases along the CSF
that may or may not be visible on MRI.4
Treatment with DepoCyt®
DepoCyt is a sustained-release cytarabine
liposome suspension indicated for intrathecal
treatment of LM. Although its mechanism of
action is not completely understood, cytarabine
is an antineoplastic agent that acts during the
S-phase of cell division. Intrathecal administration allows cytarabine to reach the metastatic
lymphoma cells within the CSF to reduce tumor
burden and slow progression of neurologic
damage.9 The cytotoxic agent cytarabine is encapsulated in a lipid so that it may be released
over time into the CSF.
Table 1. Symptoms Related to the Part of the Neuraxis Affected1,8
Location
Symptoms
Cranial nerves
Diplopia, dysphagia, sensory changes
(e.g., hearing loss, visual loss, altered
taste and smell), facial numbness and
weakness
Spinal cord and spinal nerves
Lower extremity weakness, h e m i h y p e s t h e s i a , paresthesias, pain (radicular or
back or neck pain), bladder or bowel dysfunction
Cerebral hemisphere
involvement
Headache, mental status change,
abnormal gait, nausea, vomiting, seizure
Secondary to obstruction of
cerebrospinal fluid flow
Related to increased intracranial pressure
(e.g., headache, nausea, vomiting, neurocognitive deficits, altered mental status, weakness)
6
Recognition and Treatment of LM • April 2015
Table 2. Intrathecal Treatments for Lymphomatous Meningitis5
Half-Life in
Intrathecal Dosing
Treatment
Indications
Cerebrospinal
Regimen (Induction)
Fluid
Methotrexate
Prophylaxis and treatment
12 mg every 2–5 days 7.2 hours
of meningeal leukemia
Unencapsulated Prophylaxis and treatment
30 mg/m2 every 4 days 3.4 hours
cytarabine
of meningeal leukemia
DepoCyt®
Treatment of lymphomatous 50 mg every 14 days
Up to 82.4 hours
meningitis
Once DepoCyt is administered to a patient,
the liposome membranes reorganize and distribute throughout the CSF, releasing cytarabine
molecules over two weeks. A sustained release
formula allows for fewer treatments (one dose
versus four doses) compared to unencapsulated
cytarabine.
Intrathecal Administration for LM
Intrathecal (IT) chemotherapy is used for patients with central nervous system malignancies
and provide direct and consistent drug levels
in the cerebrospinal fluid. IT administration
should be administered only under the supervision of a qualified physician experienced in the
use of cancer chemotherapeutic agents. Only
preservative-free solutions are used and labeled
“For Intrathecal Administration Only.”
Table 2 shows the half-lives and dosage
schedules of commonly used IT treatments for
LM: methotrexate, unencapsulated cytarabine,
and DepoCyt.
Intrathecal administration can be accomplished in one of two ways: via lumbar puncture
or injection into an intraventricular port, such as
an Ommaya reservoir. Unlike unencapsulated
cytarabine, which tends to pool near the injection site, the liposome encapsulation allows
DepoCyt to distribute throughout the CSF with
use of either injection site.10,11
Dosing Schedule
The recommended dose of DepoCyt is 50
mg and includes induction, consolidation, and
maintenance phases. During the induction
phase, DepoCyt is administered every 14 days
for 2 doses (weeks 1 and 3). The schedule for
the consolidation phase is every 14 days for
three doses (weeks 5, 7, and 9) followed by
an additional dose at week 13. During maintenance the frequency is reduced to every 28 days
for 4 doses (see Figure 3).
DepoCyt offers an effective dosing regimen
for intrathecal treatment of lymphomatous
meningitis—once every two weeks—compared
to twice weekly unencapsulated cytarabine or
methotrexate (see Figures 4 and 5).
Administration of DepoCyt®
DepoCyt must be slowly administered (over a
period of one to five minutes), directly into the
CSF via direct injection into the lumbar sac or an
Figure 3. DepoCyt® Dosing Schedule
7
Recognition and Treatment of LM • April 2015
intraventricular reservoir. Dexamethasone must
be administered concurrently with each dose as
prophylaxis for chemical arachnoiditis (inflammation of the arachnoid membrane). The patient should be instructed to lie flat for one hour
and observed for immediate toxic reactions. See
the attached DepoCyt Prescribing Information
for important precautions.
Efficacy Studies of DepoCyt®
Two clinical studies showed that this treatment resulted in higher complete cytologic
responses in patients with LM treated with
Figure 4. Does Site of Administration
Matter?10,11
Administration into the Lumbar Sac
DepoCyt compared to those patients treated with unencapsultaed cytarabine. These
two randomized, multicenter clinical trials of
DepoCyt were in 57 patients with LM. Patients
were treated with 50 mg of DepoCyt administered every two weeks or 50 mg of unencapsulated intrathecal cytarabine administered
twice weekly.9 Study 1 was a four-week trial
and Study 2 involved six, two-week induction
cycles followed by four maintenance cycles.
In both studies, the primary end point was
complete cytologic response, which was defined as (a) conversion of positive to negative
CSF cytology, and (b) the absence of progressive neurologic deficit. As Table 3 shows, both
studies reported higher complete cytologic
responses for DepoCyt when compared to unencapsulated cytarabine. Study 2 results were
not statistically significant.9
Figure 5. DepoCyt® Versus
Unencapsulated Cytarabine
1 dose versus 4 doses
Free Cytarabine
DepoCyt®
Intraventricular Administration
Free Cytarabine
DepoCyt®
Drawings courtesy of Dr. Michael Glantz.
8
Recognition and Treatment of LM • April 2015
Table 3. Complete Cytologic Response
Rates in Patients with LM
in Studies 1 and 2*9
DepoCyt®
Unencapsulated
Cytarabine
Study 1
Study 1
7/17 (41%) 1/16 (6%)
95% CI
Study 2
Study 2
(18%, 67%)
(0%, 30%)
4/12 (33%)
2/12 (17%)
95% CI
(10%, 65%)
(2%, 48%)
*Complete cytologic response was prospectively defined
as (a) conversion of positive to negative cerebrospinal fluid
cytology, and (b) the absence of neurologic progression.
DepoCyt® Safety Information
DepoCyt is contraindicated in patients who
are hypersensitive to cytarabine or any component of the formulation, and in patients with
active meningeal infection.
In controlled clinical trials, the most common
severe adverse event was chemical arachnoiditis (inflammation of the arachnoid membrane).
Dexamethasone should be concomitantly administered with DepoCyt to reduce the risk and
severity of chemical arachnoiditis (see BOXED
WARNING within the complete prescribing
information attached to this white paper). Hydrocephalus (abnormal buildup of CSF in and
around the brain) has also been reported, possibly precipitated by arachnoiditis.
Arachnoiditis is an expected and well-documented side effect of both neoplastic meningitis
and of intrathecal chemotherapy. The incidence
of severe and life-threatening arachnoiditis in
patients receiving DepoCyt was 19% (48/257)
in all patients and 30% (10/33) in patients
with lymphomatous meningitis. In the early
dose-finding study, chemical arachnoiditis was
observed in 100% of cycles without dexamethasone prophylaxis. When concurrent dexamethasone was administered, chemical arachnoiditis
was observed in 33% of cycles.
After intrathecal administration of cytarabine
the most frequently reported reactions (≥ 10%)
are headache, nausea, vomiting, arachnoiditis,
weakness, confusion, pyrexia, fatigue, constipation, back pain, abnormal gait, convulsions,
dizziness, lethargy, pain in limb, insomnia,
urinary tract infection, neck pain, death, pain,
memory impairment, dehydration, anemia, diarrhea, decreased appetite, thrombocytopenia,
peripheral edema, arthralgia, neck stiffness,
blurred vission, muscle weakness, neutropenia,
hypoesthesia, agitation, and dyspnea.
Cytarabine, the active component of DepoCyt, can cause fetal harm if a pregnant woman
is exposed to the drug systemically. The systemic exposure of cytarabine following intrathecal administration of DepoCyt is negligible.
Cytarabine was teratogenic in mice and rats.
Cytarabine was embryotoxic in mice when
administered during the period of organogenesis. 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 harm to a fetus.
Conclusions
Early diagnosis and prompt treatment of LM
is essential to preserve neurologic function and
slow disease progression. In patients who have
risk factors for LM, a thorough patient history
that evaluates for changes in neurologic function, MRI of the complete neuraxis, and CSF
cytology and evaluation are considered ideal
for accurate diagnosis.
Although LM occurs during late-stage disease and treatment is palliative, proper diagnosis and treatment may help patients with LM.
DepoCyt features fewer doses, and in patients
with LM, resulted in greater complete cytologic
responses compared to unencapsulated cytarabine alone. Nurses should be alert for the early
signs of neurologic decline in patients who have
risk factors for LM so that treatment may be
considered for immediate initiation.
This white paper was developed by ONS:Edge in collaboration with Sigma-Tau Pharmaceuticals, Inc. All
content belongs to and is copyrighted by Sigma-Tau
Pharmaceuticals, Inc. ONS:Edge assists with distribution and promotion.
ONS:Edge thanks reviewer Alixis Van Horn, RN, MSN,
APRN-C(c), Director, Neurology Day Rehabilitation Program, Whittier Health Network, Boston, MA, and medical
writer Laura J. Pinchot of ONS:Edge for their expertise.
Alixis Van Horn is a paid speaker for Sigma-Tau Pharmaceuticals, Inc.
For more information about this paper or to download
copies, visit www.onsedge.com. ONS:Edge can be contacted by email at [email protected] or by phone
at 877-588-EDGE (3343) or 412-859-6108.
9
Recognition and Treatment of LM • April 2015
References
1. Demopoulos A. Leptomeningeal metastases.
Curr Neurol Neurosci Rep. 2004;4:196-204.
2. Kesari S, Batchelor TT. Leptomeningeal
metastases. Neurol Clin. 2003;21:25-66.
3. Garcia-Marco JA, Panizo, C, Garcia ES, et
al. Efficacy and safety of liposomal cytarabine in lymphoma patients with central nervous system involvement from lymphoma.
Cancer. 2009;115(9):1892-1898. doi: 10.1002/
cncr.24204
4. Van Horn A. Lymphomatous meningitis:
Early diagnosis and treatment. Clin J Oncol Nurs. 2009;13(1):90-94. doi: 10.1188/09.
CJON.90-94.
5. National Comprehensive Cancer Network.
NCCN clinical practice guidelines in oncology: Central nervous system cancer, version
2.2014. Accessed February 24, 2014. http://
www.nccn.org/professionals/physician_gls/
pdf/cns.pdf. .
6. Chamberlain MC, Nolan C, Abrey LE.
Leukemic and lymphomatous meningitis
incidence, prognosis and treatment. J Neurooncol. 2005;75:71-83.
7. Jemal A, Siegel R, Ward E, Murray T, Xu J,
Thun M. Cancer Statistics, 2007. CA Cancer
J Clin. 2007;57:43-66.
8. Kim L, Glantz MJ. Neoplastic meningitis.
Curr Treat Options Oncol. 2001;2:517-527.
9. DepoCyt prescribing information. SigmaTau Pharmaceuticals, Inc.; 2014.
10. Glantz MJ, LaFollette S, Jaeckle KA, et
al. Randomized trial of slow-release versus
a standard formulation of cytarabine for
the intrathecal treatment of lymphomatous
meningitis. JCO. 1999;17:3110-3116.
11. Kim S, Chatelut E, Kim JC, et al. Extended CSF cytarabine exposure following
intrathecal administration of DTC 101. JCO.
1993;11:2186-2193
10
Recognition and Treatment of LM • April 2015
Attach DepoCyt® Prescribing Information Here
125 Enterprise Drive, Suite 110
Pittsburgh, PA 15275-1214
ONSEDGE.com
Distributed by Sigma-Tau Pharmaceuticals, Inc.
Manufactured by Pacira Pharmaceuticals, Inc.
This white paper was prepared by ONS Edge in
collaboration with Sigma-Tau Pharmaceuticals,
Inc., Gaithersburg, MD.
Copyright © Sigma-Tau Pharmaceuticals, Inc.,
2015. All rights reserved. 15-dep-162 3/15
Initiate dexamethasone 4 mg twice a day either by mouth or intravenously
for 5 days beginning on the day of DepoCyt injection. If drug related
neurotoxicity develops, reduce DepoCyt to 25 mg. If neurotoxicity persists,
discontinue DepoCyt. (2.4)
HIGHLIGHTS OF PRESCRIBING INFORMATION
These highlights do not include all the information needed to use
DEPOCYT® safely and effectively. See full prescribing information for
DEPOCYT.
DEPOCYT (cytarabine liposome injection)
For Intrathecal Use Only
Initial U.S. Approval: 1999
WARNING: CHEMICAL ARACHNOIDITIS ADVERSE REACTIONS
See full prescribing information for complete boxed warning
Chemical arachnoiditis, a syndrome manifested primarily by nausea,
vomiting, headache and fever, was a common adverse event in all clinical
studies. If left untreated, chemical arachnoiditis may be fatal. Patients
receiving DepoCyt should be treated concurrently with dexamethasone to
mitigate the symptoms of chemical arachnoiditis. (5.1, 5.2))
----------------------------INDICATIONS AND USAGE--------------------------DepoCyt is indicated for the intrathecal treatment of lymphomatous
meningitis. (1)
---------------------DOSAGE FORMS AND STRENGTHS--------------------- Single-dose vial containing 50 mg/5 mL (10 mg/mL) of cytarabine
liposome injection (3)
-------------------------------CONTRAINDICATIONS----------------------------- Hypersensitive to cytarabine or any component of the formulation with
active meningeal infection. (4)
-----------------------WARNINGS AND PRECAUTIONS----------------------- Neurotoxicity: Myelopathy and other neurologic toxicity may occur.
Reduce the dose or discontinue DepoCyt. (5.2)
 Embryo-fetal Toxicity: May cause fetal harm. Advise women of potential
harm to a fetus and to avoid pregnancy if receiving DepoCyt. (5.4)
------------------------------ADVERSE REACTIONS------------------------------Most common adverse reactions (incidence ≥20%) are headache,
----------------------DOSAGE AND ADMINISTRATION----------------------arachnoiditis, confusion, abnormal gait, convulsions, weakness, pyrexia,
DepoCyt is for intrathecal use only. (2.3)
fatigue, nausea, vomiting, constipation, and back pain. (6.1)

Induction therapy: DepoCyt, 50 mg, administer intrathecally
(intraventricular or lumbar puncture) every 14 days for 2 doses
To report SUSPECTED ADVERSE REACTIONS, contact Sigma-Tau
(weeks 1 and 3) (2.4)
Pharmaceuticals, Inc. at 1-888-393-4584 or FDA at 1-800-FDA-1088 or

Consolidation therapy: DepoCyt, 50 mg, administer intrathecally
www.fda.gov/medwatch.
(intraventricular or lumbar puncture) every 14 days for 3 doses
(weeks 5, 7 and 9) followed by 1 additional dose at week 13 (2.4)
See 17 for PATIENT COUNSELING INFORMATION

Maintenance: DepoCyt, 50 mg, administer intrathecally
Revised: 12/2014
(intraventricular or lumbar puncture) every 28 days for 4 doses
(weeks 17, 21, 25 and 29) (2.4)
______________________________________________________________________________________________________________________________
FULL PRESCRIBING INFORMATION: CONTENTS*
WARNING: CHEMICAL ARACHNOIDITIS
1 INDICATIONS AND USAGE
2 DOSAGE AND ADMINISTRATION
2.1 Preparation and Administration Precautions
2.2 Preparation and Administration
2.3 Dosing Precautions
2.4 Dosing Regimen
3 DOSAGE FORMS AND STRENGTHS
4 CONTRAINDICATIONS
5 WARNINGS AND PRECAUTIONS
5.1 Chemical Arachnoiditis
5.2 Neurotoxicity
5.3 Transient Elevations in CSF Protein and CSF White Blood Cells
5.4 Embryo-fetal Toxicity
6 ADVERSE REACTIONS
6.1 Most Frequently Reported Reactions
6.2 Clinical Trials Experience
7
8
10
11
12
13
14
15
16
17
DRUG INTERACTIONS
USE IN SPECIFIC POPULATIONS
8.1 Pregnancy Category D
8.3 Nursing Mothers
8.4 Pediatric Use
8.6 Hepatic and Renal Impairment
OVERDOSAGE
DESCRIPTION
CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
12.3 Pharmacokinetics
NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
CLINICAL STUDIES
14.1 Study 1 - Solid Tumors, Lymphoma, or Leukemia
14.2 Study 2 – Lymphoma
REFERENCES
HOW SUPPLIED/STORAGE AND HANDLING
PATIENT COUNSELING INFORMATION
*Sections or subsections omitted from the full prescribing
information are not listed.
____________________________________________________________________________________________________________________________________
FULL PRESCRIBING INFORMATION
WARNING: CHEMICAL ARACHNOIDITIS ADVERSE REACTIONS
Chemical arachnoiditis, a syndrome manifested primarily by nausea, vomiting, headache and fever, was a
common adverse event in all clinical studies. If left untreated, chemical arachnoiditis may be fatal. Patients
receiving DepoCyt should be treated concurrently with dexamethasone to mitigate the symptoms of chemical
arachnoiditis. [see Warnings and Precautions (5.1, 5.2)]
1
INDICATIONS AND USAGE
DepoCyt® (cytarabine liposome injection) is indicated for the intrathecal treatment of lymphomatous
meningitis.
2
DOSAGE AND ADMINISTRATION
2.1
Preparation and Administration Precautions
DepoCyt is a cytotoxic anticancer drug and, as with other potentially toxic compounds, caution should be
used in handling DepoCyt. The use of gloves is recommended. If DepoCyt suspension contacts the skin,
wash immediately with soap and water. If it contacts mucous membranes, flush thoroughly with water.
2.2
Preparation and Administration
No further reconstitution or dilution is required. DepoCyt particles have a tendency to settle with time.
Vials of DepoCyt should be allowed to warm to room temperature and gently agitated or inverted to resuspend the particles immediately prior to withdrawal from the vial. Avoid aggressive agitation.
DepoCyt should be withdrawn from the vial immediately before administration. DepoCyt is a single dose
vial and does not contain any preservative. DepoCyt should be used within 4 hours of withdrawal from the
vial. Unused portions of each vial should be discarded properly [see How Supplied/ Storage and Handling
(16)]. Do not save any unused portions for later administration. Do not mix DepoCyt with any other
medications.
2.3
Dosing Precautions
In-line filters must not be used when administering DepoCyt. DepoCyt is administered directly into the
cerebrospinal fluid (CSF) via an intraventricular reservoir or by direct injection into the lumbar sac.
DepoCyt should be injected slowly over a period of 1-5 minutes. Following drug administration by lumbar
puncture, the patient should be instructed to lie flat for 1 hour. Patients should be observed by the physician
for immediate toxic reactions.
2.4
Dosing Regimen
For the treatment of lymphomatous meningitis, DepoCyt 50 mg (one vial of DepoCyt) is recommended to be
given according to the following schedule:
Induction therapy
DepoCyt, 50 mg, administered intrathecally (intraventricular or lumbar
puncture) every 14 days for 2 doses (weeks 1 and 3).
Consolidation therapy
DepoCyt, 50 mg, administered intrathecally (intraventricular or lumbar
puncture) every 14 days for 3 doses (weeks 5, 7 and 9) followed by 1
additional dose at week 13.
Maintenance
DepoCyt, 50 mg, administered intrathecally (intraventricular or lumbar
puncture) every 28 days for 4 doses (weeks 17, 21, 25 and 29).
Patients should be started on dexamethasone 4 mg twice a day either by mouth or intravenously for 5 days
beginning on the day of DepoCyt injection.
If drug related neurotoxicity develops, the dose should be reduced to 25 mg. If it persists, treatment with
DepoCyt should be discontinued.
2
3
DOSAGE FORMS AND STRENGTHS
Ready-to-use, single dose vial containing 50 mg/5 mL (10 mg/mL) of cytarabine liposome injection.
4
CONTRAINDICATIONS
DepoCyt® (cytarabine liposome injection) is contraindicated in patients who are hypersensitive to cytarabine or
any component of the formulation, and in patients with active meningeal infection.
5
WARNINGS AND PRECAUTIONS
5.1
Chemical Arachnoiditis
Chemical arachnoiditis, a syndrome manifested primarily by nausea, vomiting, headache and fever, has been
a common adverse event in all studies. If chemical arachnoiditis is suspected, exclude other inflammatory,
infectious, or neoplastic conditions. If left untreated, chemical arachnoiditis may be fatal. The incidence
and severity of chemical arachnoiditis can be reduced by coadministration of dexamethasone. Patients
receiving DepoCyt should be treated concurrently with dexamethasone to mitigate the symptoms of
chemical arachnoiditis [see Dosage and Administration (2)].
Toxic effects may be related to a single dose or to cumulative administration. Because toxic effects can
occur at any time during therapy (although they are most likely to occur within 5 days of drug
administration), patients receiving intrathecal therapy with DepoCyt should be monitored continuously for
the development of neurotoxicity. If patients develop neurotoxicity, reduce subsequent doses of DepoCyt.
If neurotoxicity persists, discontinue DepoCyt [see Warnings and Precautions (5.3)]
Hydrocephalus has also been reported, possibly precipitated by arachnoiditis.
Arachnoiditis is an expected and well-documented side effect of both neoplastic meningitis and of
intrathecal chemotherapy. The incidence of severe and life-threatening arachnoiditis in patients receiving
DepoCyt was 19% (48/257) in all patients and 30% (10/33) in patients with lymphomatous meningitis. In
the early dose-finding study, chemical arachnoiditis was observed in 100% of cycles without dexamethasone
prophylaxis. When concurrent dexamethasone was administered, chemical arachnoiditis was observed in
33% of cycles.
5.2
Neurotoxicity
Intrathecal administration of cytarabine may cause myelopathy and other neurologic toxicity and can rarely
lead to a permanent neurologic deficit. Administration of intrathecal cytarabine in combination with other
chemotherapeutic agents or with cranial/spinal irradiation may increase this risk of neurotoxicity.
Blockage to CSF flow may result in increased free cytarabine concentrations in the CSF and an increased
risk of neurotoxicity. Therefore, as with any intrathecal cytotoxic therapy, consideration should be given to
the need for assessment of CSF flow before treatment is started.
Following intrathecal administration of DepoCyt, central nervous system toxicity, including persistent
extreme somnolence, hemiplegia, visual disturbances including blindness which may be total and
permanent, deafness and cranial nerve palsies have been reported. Symptoms and signs of peripheral
neuropathy, such as pain, numbness, paresthesia, weakness, and impaired bowel and bladder control have
also been observed. In some cases, a combination of neurological signs and symptoms has been reported as
Cauda Equina Syndrome.
If patients develop neurotoxicity, reduce subsequent doses of DepoCyt or discontinue DepoCyt Headache,
nausea, and fever are expected in early signs of neurotoxicity.
5.3
Transient Elevations in CSF Protein and CSF White Blood Cells
Transient elevations in CSF protein and white blood cell counts have been observed in patients following
DepoCyt administration.
5.4
Embryo-fetal Toxicity
Cytarabine, the active component of DepoCyt, can cause fetal harm if a pregnant woman is exposed to the
drug systemically. The systemic exposure of cytarabine following intrathecal administration of DepoCyt is
3
negligible. Cytarabine was teratogenic in mice and rats. Cytarabine was embryotoxic in mice when
administered during the period of organogenesis. 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 harm to a fetus.
[See Use in Specific Populations, Sec. 8.1]
6 ADVERSE REACTIONS
The following serious adverse reactions are described in greater detail in other sections of the label:
 Chemical Arachnoiditis [see Warnings and Precautions (5.1)]
 Neurotoxicity [see Warnings and Precautions (5.2)]
 Transient elevations in CSF protein and CSF white blood cells [see Warnings and Precautions (5.3)]
6.1
Most Frequently Reported Reactions
After intrathecal administration of cytarabine the most frequently reported reactions (≥ 10%) are headache
NOS, nausea, vomiting NOS, arachnoiditis, weakness, confusion, pyrexia, fatigue, constipation, back pain,
gait abnormal NOS, convulsions NOS, dizziness NOS, lethargy, pain in limb, insomnia, urinary tract
infection NOS, neck pain, death NOS, pain, memory impairment, dehydration, anemia NOS, diarrhea NOS,
appetite decreased NOS, thrombocytopenia, edema peripheral, arthralgia, neck stiffness, vision blurred,
muscle weakness, neutropenia, hypoesthesia, agitation, and dyspnea NOS.
6.2
Clinical Trials 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. The toxicity database consists of the observations made during Phase
1-4 studies. The most common adverse reactions in all patients and in patients with lymphoma are shown in
Table 1. The incidences of symptoms possibly reflecting meningeal irritation are shown in Table 2.
Table 1. Incidence of adverse reactions occurring in > 10% of patients in all Phase 1-4 adult study patients
and in patients with lymphomatous meningitis receiving DepoCyt 50 mg or an active comparator
Lymphoma
All DepoCyt
DepoCyt
Ara-C
System Organ Class / Preferred Term
(N=257)
(N=33)
(N=28)
Nervous System Disorders
Headache NOS
144 (56%)
17 (52%)
9 (32%)
Arachnoiditis
108 (42%)
14 (42%)
10 (36%)
Confusion
86 (33%)
12 (36%)
3 (11 %)
Gait abnormal NOS
60 (23%)
7 (21 %)
8 (29%)
Convulsions NOS
52 (20%)
7 (21%)
1 (4%)
Dizziness NOS
47 (18%)
7 (21%)
6 (21%)
Memory impairment
36 (14%)
4 (12%)
1 (4%)
Hypoesthesia
26 (10%)
4 (12%)
3 (11%)
Tremor
22 (9%)
5 (15%)
5 (18%)
Peripheral neuropathy NOS
9 (4%)
4 (12%)
1 (4%)
Syncope
8 (3%)
0 (0%)
3 (11 %)
Neuropathy NOS
7 (3%)
3 (9%)
3 (11 %)
Peripheral sensory neuropathy
7 (3%)
2 (6%)
3 (11 %)
Reflexes abnormal
7 (3%)
0 (0%)
3 (11 %)
General Disorders and Administration Site
Conditions
Weakness
103 (40%)
13 (39%)
15 (54%)
Pyrexia
81 (32%)
15 (45%)
12 (43%)
Fatigue
64 (25%)
9 (27%)
13 (46%)
Lethargy
41 (16%)
4 (12%)
4 (14%)
Death NOS
35 (14%)
9 (27%)
5 (18%)
4
All DepoCyt
(N=257)
35 (14%)
27 (11 %)
12 (5%)
8 (3%)
6 (2%)
System Organ Class / Preferred Term
Pain NOS
Edema peripheral
Fall
Mucosal inflammation NOS
Edema NOS
Gastrointestinal Disorders
Nausea
Vomiting NOS
Constipation
Diarrhea NOS
Abdominal pain NOS
Dysphagia
Hemorrhoids
Musculoskeletal and Connective Tissue
Disorders
Back pain
Pain in limb
Neck pain
Arthralgia
Neck stiffness
Muscle weakness NOS
Psychiatric Disorders
Insomnia
Agitation
Depression
Anxiety
Infections and Infestations
Urinary tract infection NOS
Pneumonia NOS
Metabolism and Nutrition Disorders
Dehydration
Appetite decreased NOS
Hyponatremia
Hypokalemia
Hyperglycemia
Anorexia
Investigations
Platelet count decreased
Renal and Urinary Disorders
Incontinence NOS
Urinary retention
Respiratory, Thoracic and Mediastinal
Disorders
Dyspnea NOS
Cough
Eye Disorders
Vision blurred
Blood and Lymphatic Disorders
Anemia NOS
Thrombocytopenia
5
Lymphoma
DepoCyt
(N=33)
3 (9%)
6 (18%)
0 (0%)
4 (12%)
1 (3%)
Ara-C
(N=28)
5 (18%)
7 (25%)
3 (11%)
2 (7%)
6 (21%)
117
112
64
31
22
20
8
(46%)
(44%)
(25%)
(12%)
(9%)
(8%)
(3%)
11
11
8
9
5
3
0
(33%)
(33%)
(24%)
(27%)
(15%)
(9%)
(0%)
15
9
7
9
4
3
3
(54%)
(32%)
(25%)
(32%)
(14%)
(11 %)
(11 %)
61
39
36
29
28
25
(24%)
(15%)
(14%)
(11%)
(11%)
(10%)
7
4
5
3
2
5
(21%)
(12%)
(15%)
(9%)
(6%)
(15%)
5
8
3
4
4
2
(18%)
(29%)
(11%)
(14%)
(14%)
(7%)
35
26
21
17
(14%)
(10%)
(8%)
(7%)
6
5
6
1
(18%)
(15%)
(18%)
(3%)
7
2
4
3
(25%)
(7%)
(14%)
(11%)
35
16
(14%)
(6%)
6
2
(18%)
(6%)
5
3
(18%)
(11%)
33
29
18
17
15
14
(13%)
(11%)
(7%)
(7%)
(6%)
(5%)
6
4
4
5
4
1
(18%)
(12%)
(12%)
(15%)
(12%)
(3%)
3
3
1
2
2
5
(11%)
(11%)
(4%)
(7%)
(7%)
(18%)
8
(3%)
0
(0%)
3
(11 %)
19
14
(7%)
(5%)
3
0
(9%)
(0%)
5
3
(18%)
(11%)
25
17
(10%)
(7%)
4
3
(12%)
(9%)
6
6
(21%)
(21%)
29
(11%)
4
(12%)
4
(14%)
31
27
(12%)
(11%)
6
8
(18%)
(24%)
5
9
(18%)
(32%)
All DepoCyt
(N=257)
26 (10%)
System Organ Class / Preferred Term
Neutropenia
Skin and Subcutaneous Tissue
Disorders
Contusion
Pruritus NOS
Sweating increased
Vascular Disorders
Hypotension NOS
Hypertension NOS
Ear and Labyrinth Disorders
Hypacusis
Cardiac Disorders
Tachycardia NOS
Neoplasms Benign, Malignant and
Unspecified (Incl Cysts and Polyps)
Diffuse Large B-Cell Lymphoma NOS
Lymphoma
DepoCyt
Ara-C
(N=33)
(N=28)
12 (36%)
7 (25%)
6
6
(2%)
(2%)
1
0
(3%)
(0%)
3
4
(11 %)
(14%)
6
(2%)
1
(3%)
3
(11 %)
21
15
(8%)
(6%)
6
5
(18%)
(15%)
2
1
(7%)
(4%)
15
(6%)
6
(18%)
3
(11%)
22
(9%)
0
(0%)
5
(18%)
1
(0%)
1
(3%)
3
(11%)
Table 2. Incidence of adverse reactions possibly reflecting meningeal irritation occurring in > 10% of all
studied adult patients receiving DepoCyt 50 mg or an active comparator*
DepoCyt
MTX
Ara-C
System Organ Class / Preferred Term
(N=257)
(N=78)
(N=28)
Nervous System Disorders
Headache NOS
145 (56%)
33 (42%)
9 (32%)
Arachnoiditis
108 (42%)
15 (19%)
10 (36%)
Convulsions NOS
56 (22%)
11 (14%)
1 (4%)
Gastrointestinal Disorders
Nausea
117 (46%)
24 (31%)
15
(54%)
Vomiting NOS
112 (44%)
22 (28%)
9
(32%)
Musculoskeletal and Connective Tissue
Disorders
Back pain
61 (24%)
15 (19%)
5
(18%)
Neck pain
36 (14%)
6 (8%)
3
(11%)
Neck stiffness
28 (11%)
1 (1%)
4
(14%)
General Disorders and Administration
Site Conditions
Pyrexia
81 (32%)
15
(19%)
12
(43%)
* Hydrocephalus acquired, CSF pleocytosis and meningism occurred in ≤ 10% of all studied adult patients receiving
DepoCyt or an active comparator
During the clinical studies, 2 deaths related to DepoCyt were reported. One patient at the 125 mg dose level
died of encephalopathy 36 hours after receiving an intraventricular dose of DepoCyt. This patient, however,
was also receiving concomitant whole brain irradiation and had previously received intraventricular
methotrexate. The other patient received DepoCyt, 50 mg by the intraventricular route and developed focal
seizures progressing to status epilepticus. This patient died approximately 8 weeks after the last dose of study
medication. In the controlled lymphoma study, the patient incidence of seizures was higher in the DepoCyt
group (4/17, 23.5%) than in the cytarabine group (1/16, 6.3%). The death of 1 additional patient was
considered “possibly” related to DepoCyt. He was a 63-year-old with extensive lymphoma involving the
6
nasopharynx, brain, and meninges with multiple neurologic deficits who died of apparent disease progression 4
days after his second dose of DepoCyt.
7
DRUG INTERACTIONS
No formal assessments of pharmacokinetic drug-drug interactions between DepoCyt and other agents have been
conducted. Concomitant administration of DepoCyt with other antineoplastic agents administered by the
intrathecal route has not been studied. With intrathecal cytarabine and other cytotoxic agents administered
intrathecally, enhanced neurotoxicity has been associated with coadministration of drugs.
8
USE IN SPECIFIC POPULATIONS
8.1
Pregnancy Category D [see Warnings and Precautions (5.8)]
Risk Summary
There are no studies assessing the reproductive toxicity of DepoCyt. The systemic exposure of cytarabine
following intrathecal administration of DepoCyt is negligible. Cytarabine can cause fetal harm if a pregnant
woman is exposed to the drug systemically. Three anecdotal cases of major limb malformations have been
reported in infants after their mothers received intravenous cytarabine, alone or in combination with other
agents, during the first trimester. Advise women of childbearing potential to avoid becoming pregnant while
receiving DepoCyt. 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 harm to a fetus.
Animal Data
Cytarabine was teratogenic in mice (cleft palate, phocomelia, deformed appendages, skeletal abnormalities)
when doses ≥2 mg/kg/day were administered IP during the period of organogenesis (about 0.2 times the
recommended human dose on a mg/m2 basis), and in rats (deformed appendages) when 20 mg/kg was
administered as a single IP dose on day 12 of gestation (about 4 times the recommended human dose on a
mg/m2 basis). Single IP doses of 50 mg/kg in rats (about 10 times the recommended human dose on a
mg/m2 basis) on day 14 of gestation reduced prenatal and postnatal brain size and permanent impairment of
learning ability.
Cytarabine was embryotoxic in mice when administered during the period of organogenesis.
Embryotoxicity was characterized by decreased fetal weight at 0.5 mg/kg/day (about 0.05 times the
recommended human dose on mg/m2 basis), and increased early and late resorptions and decreased live litter
sizes at 8 mg/kg/day (approximately equal to the recommended human dose on mg/m 2 basis).
8.3
Nursing Mothers
It is not known whether cytarabine is excreted in human milk following intrathecal DepoCyt administration.
The systemic exposure to free cytarabine following intrathecal treatment with DepoCyt was negligible.
Because many drugs are excreted in human milk and because of the potential for serious adverse reactions 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.
8.4
Pediatric Use
The safety and efficacy of DepoCyt in pediatric patients has not been established.
8.6
Hepatic and Renal Impairment
The effects of hepatic or renal impairment on the pharmacokinetics of DepoCyt have not been studied.
10 OVERDOSAGE
No overdosages with DepoCyt® (cytarabine liposome injection) have been reported. An overdose with
DepoCyt may be associated with severe chemical arachnoiditis including encephalopathy. In an early
uncontrolled study without dexamethasone prophylaxis, single doses up to 125 mg were administered.
There is no antidote for overdose of intrathecal DepoCyt or unencapsulated cytarabine released from DepoCyt.
Exchange of CSF with isotonic saline has been carried out in a case of intrathecal overdose of free cytarabine,
and such a procedure may be considered in the case of DepoCyt overdose. Management of overdose should be
directed at maintaining vital functions.
7
11 DESCRIPTION
DepoCyt® (cytarabine liposome injection) is a sterile, injectable suspension of the antimetabolite cytarabine for
intrathecal administration. The chemical name of cytarabine is 4-amino-1-β-D-arabinofuranosyl-2(1H)pyrimidinone and is also known as cytosine arabinoside. It has a molecular formula of C9H13N3O5 and a
molecular weight 243.22 g/mol. Cytarabine has the following structural formula:
DepoCyt is available as a single-dose vial containing 50 mg/5 mL (10 mg/mL) of cytarabine. DepoCyt is
formulated as a sterile, non-pyrogenic, white to off-white suspension of cytarabine liposomes in 0.9% w/v
sodium chloride in water for injection. Each mL contains 10 mg cytarabine, 4.4 mg cholesterol, 1.2 mg triolein,
5.7 mg dioleoylphosphatidylcholine (DOPC), and 1.0 mg dipalmitoylphosphatidylglycerol (DPPG). DepoCyt
is preservative-free. The pH of the product falls within the range from 5.5 to 8.5.
Liposome drug products may behave differently from nonliposome drug products. DepoCyt (cytarabine
liposome injection) is not equivalent to, and cannot be substituted for, other drug products containing
cytarabine.
12 CLINICAL PHARMACOLOGY
12.1 Mechanism of Action
DepoCyt® (cytarabine liposome injection) is a sustained-release formulation of the active ingredient
cytarabine designed for direct administration into the cerebrospinal fluid (CSF). Cytarabine is a cell cycle
phase-specific antineoplastic agent, affecting cells only during the S-phase of cell division. Intracellularly,
cytarabine is converted into cytarabine-5-triphosphate (ara-CTP), which is the active metabolite. The
mechanism of action is not completely understood, but it appears that ara-CTP acts primarily through
inhibition of DNA polymerase. Incorporation into DNA and RNA may also contribute to cytarabine
cytotoxicity. Cytarabine is cytotoxic to proliferating mammalian cells in culture.
12.3 Pharmacokinetics
Following intrathecal administration of DepoCyt 50 mg, peak levels of free CSF cytarabine were observed
within 1 hour of dosing and ranged from 30 to 50 mcg/mL. The terminal half-life for the free CSF
cytarabine ranged from of 5.9 to 82.4 hours. Systemic exposure to cytarabine was negligible following
intrathecal administration of DepoCyt 50 mg.
Metabolism and Elimination
The primary route of elimination of cytarabine is metabolism to the inactive compound ara-U, followed by
urinary excretion of ara-U. In contrast to systemically administered cytarabine, which is rapidly
metabolized to ara-U, conversion to ara-U in the CSF is negligible after intrathecal administration because
of the significantly lower cytidine deaminase activity in the CNS tissues and CSF. The CSF clearance rate
of cytarabine is similar to the CSF bulk flow rate of 0.24 mL/min.
13 NONCLINICAL TOXICOLOGY
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
No carcinogenicity, mutagenicity or impairment of fertility studies have been conducted with DepoCyt.
Cytarabine was mutagenic in in vitro tests and was clastogenic in vitro (chromosome aberrations and SCE
in human leukocytes) and in vivo (chromosome aberrations and SCE assay in rodent bone marrow, mouse
8
micronucleus assay). Cytarabine caused the transformation of hamster embryo cells and rat H43 cells in
vitro.
No studies assessing the impact of cytarabine on fertility are available in the literature. Cytarabine was
clastogenic to meiotic cells; a dose-dependent increase in sperm-head abnormalities and chromosomal
aberrations occurred in mice given IP cytarabine. Because the systemic exposure to free cytarabine
following intrathecal treatment with DepoCyt was negligible, the risk of impaired fertility after intrathecal
DepoCyt is likely to be low.
14 CLINICAL STUDIES
DepoCyt® (cytarabine liposome injection) was studied in 2 controlled clinical studies that enrolled patients with
neoplastic meningitis.
14.1
Study 1 – Solid Tumors, Lymphoma, or Leukemia
The first study, which was a randomized, multi-center, multi-arm study involving a total of 99 treated
patients, compared 50 mg of DepoCyt administered every 2 weeks to standard intrathecal chemotherapy
administered twice a week to patients with solid tumors, lymphoma, or leukemia. For patients with
lymphoma, standard therapy consisted of 50 mg of unencapsulated cytarabine given twice a week. Thirtythree lymphoma patients (17 DepoCyt, 16 cytarabine) were treated. Patients went off study if they had not
achieved a complete response defined as clearing of the CSF from all previously positive sites in the
absence of progression of neurological symptoms, after 4 weeks of treatment with study drug.
In the first study, complete response was prospectively defined as (1) conversion, confirmed by a blinded
central pathologist, from a positive examination of the CSF for malignant cells to a negative examination
on two separate occasions (at least 3 days apart, on day 29 and later) at all initially positive sites, together
with (2) an absence of neurological progression during the treatment period.
The complete response rates in the first study of lymphoma are shown in Table 3. Although there was a
plan for central pathology review of the data, in 4 of the 7 responding patients on the DepoCyt arm this was
not accomplished and these cases were considered to have had a complete response based on the reading of
an unblinded pathologist. The median overall survival of all treated patients was 99.5 days in the DepoCyt
group and 63 days in the cytarabine group. In both groups the majority of patients died from progressive
systemic disease, not neoplastic meningitis.
14.2
Study 2 – Lymphoma
The second study was a randomized, multi-center, multi-arm study involving a total of 124 treated patients
with either solid tumors or lymphomas. In this study, 24 patients with lymphoma were randomized and
treated with DepoCyt or cytarabine. Patients received 6 two-week induction cycles of DepoCyt 50 mg
every 2 weeks or cytarabine 50 mg twice weekly. Patients then received four maintenance cycles of
DepoCyt 50 mg every 4 weeks, or cytarabine 50 mg weekly for 4 weeks. In both studies, patients received
concurrent treatment with dexamethasone to minimize symptoms associated with chemical arachnoiditis
[see Warnings and Precautions (5) and Dosage and Administration (2)]. In this study, cytological response
was assessed in a blinded fashion utilizing a similar definition as in the first study. The results in patients
with lymphomatous meningitis are shown in Table 3.
Table 3: Complete Cytological Responses in
Patients with Lymphomatous Meningitis
DepoCyt®
Cytarabine
Study 1
7/17 (41%)
1/16 (6%)
95% CI
(18%, 67%)
(0%, 30%)
Study 2
4/12 (33%)
2/12 (17%)
95% CI
(10%, 65%)
(2%, 48%)
9
15 REFERENCES
OSHA Hazardous Drugs. OSHA. [Accessed on November 4, 2014, from
http://www.osha.gov/SLTC/hazardousdrugs/index.html].
16 HOW SUPPLIED/STORAGE AND HANDLING
DepoCyt® (cytarabine liposome injection) is supplied as a sterile, white to off-white suspension in 5 mL glass,
single dose vials.
Store refrigerated at 2° to 8°C (36° to 46°F). Protect from freezing and avoid aggressive agitation.
Available in individual carton containing one ready to use vial. NDC 57665-331-01.
Do not use beyond expiration date printed on the label.
DepoCyt is a genotoxic drug. Follow special handling and disposal procedures [see References (15)].
17 PATIENT COUNSELING INFORMATION

Advise patients of the following expected adverse events: headache, nausea, vomiting, and fever, and
about the early signs and symptoms of neurotoxicity.

Advise patients of the importance of concurrent dexamethasone administration should be emphasized at the
initiation of each cycle of DepoCyt® treatment.

Instruct patients to seek medical attention if signs or symptoms of neurotoxicity develop, or if oral
dexamethasone is not well tolerated.
For additional information, contact Sigma-Tau Pharmaceuticals, Inc. at: 1-888-393-4584.
Manufactured by:
Pacira Pharmaceuticals, Inc., San Diego, CA 92121
Distributed by: Sigma-Tau Pharmaceuticals, Inc., Gaithersburg, MD 20878
I-070-21-US-F
U.S. patent Nos.
5,807,572
5,723,147
5,455,044
5,891,467
10