daunorubicin/cytarabine liposomal

Daunorubicin

Absorption: IV administration results in complete bioavailability.

Distribution: Well distributed to tissues.

Metabolism/Excretion: Extensively metabolized by the liver to an active metabolite with antineoplastic activity (daunorubicinol); 9% excreted as unchanged drug and active metabolite in urine.

Half-Life: 31.5 hr.

Cytarabine

Absorption: IV administration results in complete availability.

Distribution: Well distributed to tissues.

Metabolism/Excretion: Metabolized mostly by the liver to an inactive metabolite; 71% excreted as unchanged drug and inactive metabolite in urine.

Half-Life: 40.4 hr.

Time/Action Profile ⬆ ⬇

(plasma concentrations)

ROUTE	ONSET	PEAK	DURATION
IV	rapid	end of infusion	unknown

Contraind./Precautions ⬆ ⬇

Contraindicated in:

Hypersensitivity to daunorubicin, cytarabine, or any other component of the formulation;
End-stage renal disease;
Bilirubin level >3 mg/dL;
OB: Pregnancy;
Lactation: Lactation.

Use Cautiously in:

Previous anthracycline therapy, underlying cardiovascular disease, history of radiation to mediastinum, or concurrent use of cardiotoxic drugs (↑ risk of cardiotoxicity);
Wilson disease (↑ risk of copper toxicity; contains copper);
Rep: Women of reproductive potential and men with female partners of reproductive potential;
Pedi: Children <1 yr (safety and effectiveness not established);
Geri: ↑risk of bleeding in older adults.

Adv. Reactions/Side Effects ⬆ ⬇

CV: arrhythmias, chest pain, hypertension, hypotension, peripheral edema, CARDIOTOXICITY

Derm: petechiae, pruritus, rash

EENT: visual impairment, conjunctivitis, deafness, dry eye, eye edema

F and E: hyponatremia, hypokalemia

GI: abdominal pain, constipation, diarrhea, hemorrhoids, mucositis, nausea, vomiting, ↑liver enzymes, dyspepsia, hyperbilirubinemia

GU: renal impairment, ↓fertility (men)

Hemat: anemia, hemorrhage, neutropenia, thrombocytopenia

Local: phlebitis at IV site

Metab: ↓appetite, hypoalbuminemia

MS: pain

Neuro: anxiety, delirium, dizziness, fatigue, headache, sleep disorders, hallucinations

Resp: cough, dyspnea, pleural effusion, RESPIRATORY FAILURE

Misc: chills, fever, HYPERSENSITIVITY REACTIONS (INCLUDING ANAPHYLAXIS), INFECTION

Interactions ⬆ ⬇

Drug-drug:

Additive myelosuppression with other antineoplastics.
May ↓ antibody response to live-virus vaccines and ↑ the risk of adverse reactions.
↑risk of cardiotoxicity when used with other cardiotoxic drugs.
↑risk of hepatotoxicity with other hepatotoxic agents.

Route/Dosage ⬆ ⬇

This product is NOT interchangeable with other products containing daunorubicin or cytarabine.

IV (Adults and Children ≥1 yr): First induction cycle: daunorubicin 44 mg/m² and cytarabine 100 mg/m² (liposomal) on Days 1, 3, and 5; if remission not achieved, proceed to second induction cycle 2–5 wk later. Second induction cycle (only for patients failing to achieve remission with first induction cycle): daunorubicin 44 mg/m² and cytarabine 100 mg/m² (liposomal) on Days 1 and 3; First consolidation cycle: daunorubicin 29 mg/m² and cytarabine 65 mg/m² (liposomal) on Days 1 and 3 administered 5–8 wk after the start of the last induction cycle; Second consolidation cycle (only for patients who do not show disease progression or unacceptable toxicity after first consolidation cycle): daunorubicin 29 mg/m² and cytarabine 65 mg/m² (liposomal) on Days 1 and 3 administered 5–8 wk after the start of the first consolidation cycle.

Availability ⬆ ⬇

Lyophilized cake for injection: daunorubicin 44 mg and cytarabine 100 mg/vial

Assessment ⬆ ⬇

Obtain ECG and assess cardiac function by multigated radionuclide angiography (MUGA) scan or echocardiogram before each consolidation cycle. Repeat MUGA or echocardiogram determinations of left ventricular ejection fraction (LVEF) prior to consolidation and as clinically required. Discontinue therapy in patients with impaired cardiac function unless benefit outweighs risk. Therapy is not recommended in patients with less than normal LVEF.
Monitor for signs and symptoms of hypersensitivity reactions (rash, dyspnea, swelling). If any level of symptoms occur, hold infusion and manage symptoms. If mild symptoms occur, when symptoms resolve, reinitiate infusion at half prior rate. Consider premedication with antihistamines and/or corticosteroids for subsequent doses. If moderate symptoms occur, do not reinitiate infusion. For subsequent doses, premedicate with antihistamines and/or corticosteroids prior to initiating infusion at same rate. If severe or life-threatening symptoms occur, permanently discontinue infusion. Monitor until symptoms resolve.
Monitor for signs and symptoms of hemorrhage (epistaxis; blood in emesis, urine, or stool). Administer platelet transfusions as needed.
Assess IV site frequently for inflammation or infiltration. Instruct patient to notify nurse immediately if pain or irritation at injection site occurs. If extravasation occurs, infusion must be stopped and restarted in another vein to avoid damage to SUBQ tissue. Notify health care professional immediately. Daunorubicin is a vesicant. Standard treatments include local injections of steroids and application of ice compresses.

Lab Test Considerations:

Verify negative pregnancy status before starting therapy.
- Assess CBC with platelet count and liver and renal function before each consolidation cycle. Do not start consolidation until the absolute neutrophil count recovers to 500/mm³ and platelet count recovers to >50,000/mm³ in the absence of unacceptable toxicity. Administer second consolidation cycle 5–8 wk after start of 1st consolidation cycle in patients who do not show disease progression or unacceptable toxicity.
- May cause hyponatremia, hypokalemia, hypoalbuminemia, hyperbilirubinemia, and ↑ ALT.

Implementation ⬆ ⬇

IV Administration:

Vyxeos has different dose recommendations than daunorubicin, cytarabine, and cytarabine liposome. It is not interchangeable with any of these products. Verify drug name and dose prior to preparation and administration to avoid dosing errors.
High Alert: Fatalities have occurred with chemotherapeutic agents. Before administering, clarify all ambiguous orders; double-check single, daily, and course-of-therapy dose limits; have second practitioner independently double-check original order, calculations, and infusion pump settings. Calculate lifetime cumulative anthracycline exposure prior to each cycle.
Solution should be prepared in a biologic cabinet. Wear gloves, gown, and mask while handling IV medication. Discard IV equipment in specially designated containers.
Premedicate with antiemetics before infusion.
Allow vials to reach room temperature for 30 min before preparing. Reconstitution: Reconstitute vial with 19 mL sterile water for injection; immediately after start a 5-min timer. Swirl contents for 5 min; gently invert every 30 seconds. Do not heat or shake. Allow solution to rest for 15 min after reconstitution. Reconstituted solution is opaque, purple, homogeneous dispersion, essentially free from visible particulates; do not administer solutions that are discolored or contain particulate matter. Concentration: After reconstitution (but before final dilution), each mL will contain 2.2 mg of daunorubicin and 5 mg of cytarabine. Gently invert each vial 5 times prior to withdrawing reconstituted solution for further dilution. If not diluted into infusion bag immediately, store in refrigerator for up to 4 hr. Diluent: Withdraw dose and dilute further with 500 mL 0.9% NaCl or D5W. Discard unused portion. Invert bag to mix gently. Solution is deep purple, translucent, homogeneous dispersion, free from visible particulates; do not administer solutions that are discolored or contain particulate matter. Diluted solution is stable for 4 hr if refrigerated; if reconstituted solution was refrigerated for 4 hr, solution must be used immediately.
Rate: Infuse over 90 min through a central venous catheter or a peripherally inserted central catheter. An in-line membrane filter may be used if minimum pore diameter of the filter is ≥15 microns. Flush line after administration with 0.9% NaCl or D5W.
Y-Site Incompatibility: Do not administer in same IV line with other agents.

Patient/Family Teaching ⬆ ⬇

Explain purpose of medication to patient. If a planned dose is missed, administer as soon as possible and adjust dosing schedule to maintain treatment interval.
Inform patients of risk of fatal bleeding. Advise of need for periodic monitoring of blood counts and importance of keeping scheduled appointments for blood work and necessary transfusions. Advise patients to contact a health care professional if new onset fever or symptoms of infection (sore throat, pain on urination, chills) or signs of bruising or bleeding occur.
Advise patient to notify health care professional immediately if signs and symptoms of HF (peripheral edema, dyspnea, rales/crackles, weight gain, jugular venous distention) or hypersensitivity reactions occur.
Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications during therapy.
Rep: May cause fetal harm. Advise women of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breastfeeding. Advise women of reproductive potential and men with partners of reproductive potential to use effective contraception during therapy and for at least 6 mo following last dose and to avoid breastfeeding for at least 2 wk following last dose. Inform male patients that fertility may be impaired.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇