Prescription Drugs

CLINICAL PHARMACOLOGY Mechanism Of Action Topoisomerase I relieves torsional strain in DNA by inducing reversible single-strand breaks. Topotecan binds to the topoisomerase I-DNA complex and prevents re-ligation of these single-strand breaks. The cytotoxicity of topotecan is thought to be due to double-strand DNA damage produced during DNA synthesis, when replication enzymes interact with the ternary complex formed by topotecan, topoisomerase I, and DNA. Mammalian cells cannot efficiently repair these double-strand breaks. Pharmacokinetics Following administration of HYCAMTIN for injection at doses of 0.5 to 1.5 mg/m² administered as a 30-minute infusion to cancer patients, topotecan exhibited multiexponential pharmacokinetics with a terminal half-life of 2 to 3 hours. Total exposure (AUC) is approximately dose-proportional. Distribution Binding of topotecan to plasma proteins is approximately 35%. Metabolism Topotecan undergoes a reversible pH-dependent hydrolysis of its lactone moiety; it is the lactone form that is pharmacologically active. At pH ≤ 4, the lactone is exclusively present, whereas the ring-opened hydroxy-acid form predominates at physiologic pH. In vitro studies in human liver microsomes indicate topotecan is metabolized to an N-demethylated metabolite. The mean metabolite:parent AUC ratio was about 3% for total topotecan and topotecan lactone following IV administration. Excretion Renal clearance is the primary route of topotecan elimination. In a mass balance/excretion trial in 4 patients with solid tumors, the overall recovery of total topotecan and its N-desmethyl metabolite in urine and feces over 9 days averaged 73.4% ± 2.3% of the administered IV dose. Mean values of 50.8% ± 2.9% as total topotecan and 3.1% ± 1.0% as N-desmethyl topotecan were excreted in the urine following IV administration. Fecal elimination of total topotecan accounted for 17.9% ± 3.6% while fecal elimination of Ndesmethyl topotecan was 1.7% ± 0.6%. An O-glucuronidation metabolite of topotecan and Ndesmethyl topotecan has been identified in the urine. Specific Populations Gender: Plasma clearance of topotecan lactone in male patients was approximately 24% higher than that in female patients, largely reflecting difference in body size. Age: Population pharmacokinetic analysis in female patients did not identify age as a significant factor. Decreased renal clearance, which is common in the elderly, is a more important determinant of topotecan clearance [see DOSAGE AND ADMINISTRATION, Use in Specific Populations]. Renal Impairment: In patients with mild renal impairment (Clcr = 40 to 60 mL/min), plasma clearance of topotecan lactone was decreased by 33% compared with patients with normal renal function (Clcr greater than 60 mL/min). In patients with moderate renal impairment (Clcr = 20 to 39 mL/min), plasma clearance of topotecan lactone was reduced by 65% compared with patients with normal renal function. Dosage adjustment is recommended for patients with moderate renal impairment. No dosage adjustment is required in patients with mild renal impairment [see DOSAGE AND ADMINISTRATION, Use In Specific Populations]. Hepatic Impairment: Plasma clearance of topotecan lactone in patients with hepatic impairment serum bilirubin levels between 1.7 and 15.0 mg/dL) was decreased by 33% compared with patients with normal hepatic function (serum bilirubin levels less than 1.7 mg/dL). Drug Interactions Effects of Topotecan on Drug-Metabolizing Enzymes: In vitro inhibition studies using marker substrates for human P450 CYP1A2, CYP2A6, CYP2C8/9, CYP2C19, CYP2D6, CYP2E, CYP3A, or CYP4A or dihydropyrimidine dehydrogenase indicate that the activities of these enzymes were not altered by topotecan. Cisplatin: Administration of cisplatin (60 or 75 mg/m² on Day 1) before topotecan (0.75 mg/m²/day on Days 1 to 5) in 9 patients with ovarian cancer had no significant effect on the Cmax and AUC of total topotecan. Topotecan (0.3 mg/m² IV daily on Days 2 to 6) had no effect on the pharmacokinetics of free platinum in 15 patients with ovarian cancer who were administered cisplatin 50 mg/m² (n = 9) or 75 mg/m² (n = 6) on Day 2 after paclitaxel 110 mg/m² on Day 1. Topotecan (0.75 mg/m² IV daily on Days 1 to 5) had no effect on dose-normalized (60 mg/m²) Cmax values of free platinum in 13 patients with ovarian cancer who were administered 60 mg/m² (n = 10) or 75 mg/m² (n = 3) cisplatin on Day 1. Clinical Studies Ovarian Cancer HYCAMTIN was studied in 2 clinical trials of 223 patients given topotecan with metastatic ovarian carcinoma. All patients had disease that had recurred on, or was unresponsive to, a platinum-containing regimen. Patients in these 2 trials received an initial dose of 1.5 mg/m² given by intravenous infusion over 30 minutes for 5 consecutive days, starting on Day 1 of a 21-day course. One trial was a randomized trial of 112 patients treated with HYCAMTIN (1.5 mg/m²/day × 5 days starting on Day 1 of a 21-day course) and 114 patients treated with paclitaxel (175 mg/m² over 3 hours on Day 1 of a 21-day course). All patients had recurrent ovarian cancer after a platinum-containing regimen or had not responded to at least 1 prior platinum-containing regimen. Patients who did not respond to the trial therapy, or who progressed, could be given the alternative treatment. The efficacy outcome measures were response rate, response duration, and time to progression. The results of the trial did not show statistically significant improvements in response rates, response duration, time to progression, and overall survival as shown in Table 4. Table 4: Efficacy of HYCAMTIN versus Paclitaxel in Ovarian Cancer Parameter HYCAMTIN (n = 112) Paclitaxel (n = 114) Overall response rate (95% CI) 21% (13% to 28%) 14% (8% to 20%) Complete response rate 5% 3% Partial response rate 16% 11% Response durationa (months) Median (95% CI) 6.0 (5.1 to 7.6) 5.0 (3.7 to 7.8) Time to progression (months) Median (95% CI) 4.4 (2.8 to 5.4) 3.4 (2.7 to 4.2) HR (HYCAMTIN:paclitaxel) (95% CI) 0.76 (0.57 to 1.02) Survival (months) Median (95% CI) 14.5 (10.7 to 16.5) 12.2 (9.7 to 15.8) HR (HYCAMTIN:paclitaxel) (95% CI) 0.97 (0.71 to 1.34) HR = hazard-ratio; CI = confidence interval. aThe calculation for duration of response was based on the interval between first response and time to progression. The median time to response was 7.6 weeks (range: 3.1 to 21.7) with HYCAMTIN compared with 6.0 weeks (range: 2.4 to 18.1) with paclitaxel. In the crossover phase, 8 of 61 (13%) patients who received HYCAMTIN after paclitaxel had a partial response and 5 of 49 (10%) patients who received paclitaxel after HYCAMTIN had a response (2 complete responses). HYCAMTIN was active in ovarian cancer patients who had developed resistance to platinum-containing therapy, defined as tumor progression while on, or tumor relapse within 6 months after completion of, a platinum-containing regimen. One complete and 6 partial responses were seen in 60 patients, for a response rate of 12%. In the same trial, there were no complete responders and 4 partial responders on the paclitaxel arm, for a response rate of 7%. HYCAMTIN was also studied in an open-label, non-comparative trial in 111 patients with recurrent ovarian cancer after treatment with a platinum-containing regimen, or who had not responded to 1 prior platinum-containing regimen. The response rate was 14% (95% CI: 7% to 20%). The median duration of response was 22 weeks (range: 4.6 to 41.9 weeks). The time to progression was 11.3 weeks (range: 0.7 to 72.1 weeks). The median survival was 67.9 weeks (range: 1.4 to 112.9 weeks). Small Cell Lung Cancer HYCAMTIN was studied in 426 patients with recurrent or progressive small cell lung cancer in 1 randomized, comparative trial and in 3 single-arm trials. Randomized Comparative Trial In a randomized, comparative, Phase 3 trial, 107 patients were treated with HYCAMTIN (1.5 mg/m²/day × 5 days starting on Day 1 of a 21-day course) and 104 patients were treated with CAV (1,000 mg/m² cyclophosphamide, 45 mg/m² doxorubicin, 2 mg vincristine administered sequentially on Day 1 of a 21-day course). All patients were considered sensitive to first-line chemotherapy (responders who then subsequently progressed greater than or equal to 60 days after completion of first-line therapy). A total of 77% of patients treated with HYCAMTIN and 79% of patients treated with CAV received platinum/etoposide with or without other agents as first-line chemotherapy. The efficacy outcome measures were response rate and duration of response. The results of the trial did not show statistically significant improvements in response rates, response duration, time to progression, and overall survival as shown in Table 5. Table 5: Efficacy of HYCAMTIN versus CAV (cyclophosphamide-doxorubicin-vincristine) in Small Cell Lung Cancer Patients Sensitive to First-Line Chemotherapy Parameter HYCAMTIN (n = 107) CAV (n = 104) Overall response rate (95% CI) 24% (16% to 32%) 18% (11% to 26%) Complete response rate 0% 1% Partial response rate 24% 17% Response durationa (months) Median (95% CI) 3.3 (3.0 to 4.1) 3.5 (3.0 to 5.3) Time to progression (months) Median (95% CI) 3.1 (2.6 to 4.1) 2.8 (2.5 to 3.2) HR (HYCAMTIN:CAV) (95% CI) 0.92 (0.69 to 1.22) Survival (months) Median (95% CI) 5.8 (4.7 to 6.8) 5.7 (5.0 to 7.0) HR (HYCAMTIN:CAV) (95% CI) 1.04 (0.78 to 1.39) HR = hazard-ratio; CI = confidence interval. aThe calculation for duration of response was based on the interval between first response and time to progression. The time to response was similar in both arms: HYCAMTIN median of 6 weeks (range: 2.4 to 15.7) versus CAV median 6 weeks (range: 5.1 to 18.1). Changes on a disease-related symptom scale in patients who received HYCAMTIN or who received CAV are presented in Table 6. It should be noted that not all patients had all symptoms, nor did all patients respond to all questions. Each symptom was rated on a 4-category scale with an improvement defined as a change in 1 category from baseline sustained over 2 courses. Limitations in interpretation of the rating scale and responses preclude formal statistical analysis. Table 6: Percentage of Patients with Symptom Improvementa: HYCAMTIN versus CAV in Patients with Small Cell Lung Cancer Symptom HYCAMTIN (n = 107) CAV (n = 104) nb (%) nb (%) Shortness of breath 68 (28) 61 (7) Interference with daily activity 67 (27) 63 (11) Fatigue 70 (23) 65 (9) Hoarseness 40 (33) 38 (13) Cough 69 (25) 61 (15) Insomnia 57 (33) 53 (19) Anorexia 56 (32) 57 (16) Chest pain 44 (25) 41 (17) Hemoptysis 15 (27) 12 (33) aDefined as improvement sustained over at least 2 courses compared with baseline. bNumber of patients with baseline and at least 1 post-baseline assessment. Single-Arm Trials HYCAMTIN was also studied in 3 open-label, non-comparative trials in a total of 319 patients with recurrent or progressive small cell lung cancer after treatment with first-line chemotherapy. In all 3 trials, patients were stratified as either sensitive (responders who then subsequently progressed greater than or equal to 90 days after completion of first-line therapy) or refractory (no response to first-line chemotherapy or who responded to first-line therapy and then progressed within 90 days of completing first-line therapy). Response rates ranged from 11% to 31% for sensitive patients and 2% to 7% for refractory patients. Median time to progression and median survival were similar in all 3 trials and the comparative trial. Cervical Cancer In a comparative trial, 147 eligible women were randomized to HYCAMTIN (0.75 mg/m²/day IV over 30 minutes × 3 consecutive days starting on Day 1 of a 21-day course) plus cisplatin (50 mg/m² on Day 1) and 146 eligible women were randomized to cisplatin (50 mg/m² IV on Day 1 of a 21-day course). All patients had histologically confirmed Stage IV-B, recurrent, or persistent carcinoma of the cervix considered not amenable to curative treatment with surgery and/or radiation. Fifty-six percent (56%) of patients treated with HYCAMTIN plus cisplatin and 56% of patients treated with cisplatin had received prior cisplatin with or without other agents as first-line chemotherapy. Median survival of eligible patients receiving HYCAMTIN plus cisplatin was 9.4 months (95% CI: 7.9 to 11.9) compared with 6.5 months (95% CI: 5.8 to 8.8) among patients randomized to cisplatin alone with a log rank P-value of 0.033 (significance level was 0.044 after adjusting for the interim analysis). The unadjusted hazard ratio for overall survival was 0.76 (95% CI: 0.59 to 0.98). Figure 1: Overall Survival Curves Comparing HYCAMTIN plus Cisplatin versus Cisplatin Monotherapy in Cervical Cancer Patients

Find Lowest Prices on HYCAMTIN (topotecan hydrochloride) for Injection WARNING BONE MARROW SUPPRESSION Do not give HYCAMTIN® to patients with baseline neutrophil counts less than 1,500 cells/mm³. In order to monitor the occurrence of bone marrow suppression, primarily neutropenia, which may be severe and result in infection and death, monitor peripheral blood counts frequently on all patients receiving HYCAMTIN [see WARNINGS AND PRECAUTIONS]. DESCRIPTION HYCAMTIN (topotecan hydrochloride) is a semi-synthetic derivative of camptothecin and is an anti-tumor drug with topoisomerase I-inhibitory activity. HYCAMTIN for Injection is supplied as a sterile, lyophilized, buffered, light yellow to greenish powder available in single-dose vials. Each vial contains topotecan hydrochloride equivalent to 4 mg of topotecan as free base. The reconstituted solution ranges in color from yellow to yellow-green and is intended for administration by intravenous infusion. Inactive ingredients are mannitol, 48 mg, and tartaric acid, 20 mg. Hydrochloric acid and sodium hydroxide may be used to adjust the pH. The solution pH ranges from 2.5 to 3.5. The chemical name for topotecan hydrochloride is (S)-10-[(dimethylamino)methyl]-4- ethyl-4,9-dihydroxy-1#-pyrano[3',4':6,7] indolizino [1,2-6]quinoline-3,14-(4#,12#)-dione monohydrochloride. It has the molecular formula C23H23N3O5*HCl and a molecular weight of 457.9. Topotecan hydrochloride has the following structural formula: It is soluble in water and melts with decomposition at 213° to 218°C.

INDICATIONS Ovarian Cancer HYCAMTIN for injection, as a single agent, is indicated for the treatment of patients with metastatic carcinoma of the ovary after disease progression on or after initial or subsequent chemotherapy. Small Cell Lung Cancer HYCAMTIN for injection, as a single agent, is indicated for the treatment of patients with small cell lung cancer with platinum-sensitive disease who progressed at least 60 days after initiation of first-line chemotherapy. Cervical Cancer HYCAMTIN for injection in combination with cisplatin is indicated for the treatment of patients with Stage IV-B, recurrent, or persistent carcinoma of the cervix not amenable to curative treatment. DOSAGE AND ADMINISTRATION Verify dose using body surface area prior to dispensing. Recommended dosage should generally not exceed 4 mg intravenously [see OVERDOSAGE]. Ovarian Cancer Recommended Dose and Schedule The recommended dose of HYCAMTIN is 1.5 mg/m² by intravenous infusion over 30 minutes daily for 5 consecutive days, starting on Day 1 of a 21-day course. Small Cell Lung Cancer Recommended Dose and Schedule The recommended dose of HYCAMTIN is 1.5 mg/m² by intravenous infusion over 30 minutes daily for 5 consecutive days, starting on Day 1 of a 21-day course. Cervical Cancer Recommended Dose and Schedule The recommended dose of HYCAMTIN is 0.75 mg/m² by intravenous infusion over 30 minutes daily on Days 1, 2, and 3 in combination with cisplatin 50 mg/m² on Day 1, repeated every 21 days. Dose Modifications Hematologic Toxicities For single-agent use, dose reduce HYCAMTIN to 1.25 mg/m² for: neutrophil counts of less than 500 cells/mm³, or administer granulocyte-colony stimulating factor (G-CSF) starting no sooner than 24 hours following the last dose of HYCAMTIN. platelet counts less than 25,000 cells/mm³ during previous cycle. For combination use with cisplatin, dose reduce HYCAMTIN to 0.60 mg/m² (and further to 0.45 mg/m² if necessary) for: febrile neutropenia (defined as neutrophil counts less than 1,000 cells/mm³ with temperature of greater than or equal to 38.0°C (100.4°F), or administer G-CSF starting no sooner than 24 hours following the last dose of HYCAMTIN. platelet counts less than 25,000 cells/mm³ during previous cycle. Renal Impairment For single-agent use, dose reduce HYCAMTIN to 0.75 mg/m² in patients with moderate renal impairment (creatinine clearance [Clcr] = 20 to 39 mL/min). Insufficient data are available in patients with severe renal impairment (Clcr less than 20 mL/min) to provide a dosage recommendation for HYCAMTIN [see Use in Specific Populations, CLINICAL PHARMACOLOGY]. Preparation And Intravenous Administration HYCAMTIN is a cytotoxic drug. Follow applicable special handling and disposable procedures.1 Preparation and Administration Reconstitute each 4-mg vial of HYCAMTIN with 4 mL Sterile Water for Injection, USP. Dilute the appropriate volume of the reconstituted solution in either 0.9% Sodium Chloride Intravenous Infusion, USP or 5% Dextrose in Water Injection, USP prior to administration. Stability Unopened vials of HYCAMTIN are stable until the date indicated on the package when stored between 20°C and 25°C (68°F and 77°F) [see USP] and protected from light in the original carton. Because the vials contain no preservative, contents should be used immediately after reconstitution. Reconstituted vials of HYCAMTIN diluted for infusion are stable at approximately 20°C to 25°C (68°F to 77°F) and ambient lighting conditions for 24 hours. HOW SUPPLIED Dosage Forms And Strengths For injection: 4 mg (topotecan free base) lyophilized powder in single-use vial for reconstitution; light yellow to greenish powder. HYCAMTIN for injection is supplied as a sterile, lyophilized, buffered, light yellow to greenish powder. HYCAMTIN for Injection is supplied in 4-mg (free base) single-dose vials. NDC 0007-4201-01 (package of 1) Storage And Handling Store at controlled room temperature between 20°C and 25°C (68°F and 77°F) [see USP]. Protect from light in original carton. Handle and dispose of HYCAMTIN for injection consistent with recommendations for the handling and disposal of hazardous drugs1 . REFERENCES 1. “ OSHA Hazardous Drugs.” OSHA. http://www.osha.gov/SLTC/hazardousdrugs/index.html. Glaxo SmithKline, Research Triangle Park, NC 27709. Revised: June 2015

OVERDOSE Overdoses (up to 10-fold of the prescribed dose) occurred in patients treated with intravenous topotecan. The primary complication of overdosage is bone marrow suppression. The observed signs and symptoms of overdose are consistent with the known adverse reactions associated with HYCAMTIN for intravenous use [see ADVERSE REACTIONS]. In addition, elevated hepatic enzymes and mucositis have been reported following overdose. One patient received a single dose of 40 mg/m² of intravenous topotecan and developed gastrointestinal toxicity, skin toxicity, and myelosuppression leading to septic shock. Another patient received a single dose of 35 mg/m² and experienced severe, reversible neutropenia. There is no known antidote for overdosage with HYCAMTIN. If an overdose is suspected, monitor the patient closely for bone marrow suppression and institute supportive-care measures (such as the prophylactic use of G-CSF and antibiotic therapy) as appropriate. CONTRAINDICATIONS HYCAMTIN is contraindicated in patients who have a history of severe hypersensitivity reactions to topotecan.

SIDE EFFECTS The following serious adverse reactions are described below and elsewhere in the labeling: Bone Marrow Suppression [see WARNINGS AND PRECAUTIONS] Neutropenic Enterocolitis [see WARNINGS AND PRECAUTIONS] Interstitial Lung Disease [see WARNINGS AND PRECAUTIONS] Extravasation and Tissue Injury[see WARNINGS AND PRECAUTIONS] 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 with rates in the clinical trials of another drug and may not reflect the rates observed in practice. Ovarian Cancer Table 1 shows the Grade 3/4 hematologic and major non-hematologic adverse reactions in the topotecan/paclitaxel comparator trial in ovarian cancer. Table 1: Adverse Reactions Experienced by ≥ 5% of Ovarian Cancer Patients Randomized to Receive HYCAMTIN or Paclitaxel Adverse Reaction HYCAMTIN (n = 112) Paclitaxel (n = 114) Hematologic Grade 3/4 % % Grade 4 neutropenia ( < 500 cells/mm ) 80 21 Grade 3/4 anemia (Hgb < 8 g/dL) 41 6 Grade 4 thrombocytopenia ( < 25,000 plts/mm³) 27 3 Febrile neutropenia 23 4 Non-hematologic Grade 3/4 % % Infections and infestations Sepsisa 5 2 Respiratory, thoracic, and mediastinal disorders Dyspnea 6 5 Gastrointestinal disorders Abdominal pain 5 4 Constipation 5 0 Diarrhea 6 1 Intestinal obstruction 5 4 Nausea 10 2 Vomiting 10 3 General disorders and administrative site conditions Fatigue 7 6 Asthenia 5 3 Painb 5 7 aDeath related to sepsis occurred in 2% of patients receiving HYCAMTIN and 0% of patients receiving paclitaxel. bPain includes body pain, skeletal pain, and back pain. Small Cell Lung Cancer Table 2 shows the Grade 3/4 hematologic and major non-hematologic adverse reactions in the topotecan/CAV (cyclophosphamide-doxorubicin-vincristine) comparator trial in small cell lung cancer. Table 2: Adverse Reactions Experienced by ≥ 5% of Small Cell Lung Cancer Patients Randomized to Receive HYCAMTIN or CAV Adverse Reaction HYCAMTIN (n = 107) CAV (n = 104) Hematologic Grade 3/4 % % Grade 4 neutropenia ( < 500 cells/mm³) 70 72 Grade 3/4 anemia (Hgb < 8 g/dL) 42 20 Grade 4 thrombocytopenia ( < 25,000 plts/mm³) 29 5 Febrile neutropenia 28 26 Non-hematologic Grade 3/4 % % Infections and infestations Sepsisa 5 5 Respiratory, thoracic, and mediastinal disorders Dyspnea 9 14 Pneumonia 8 6 Gastrointestinal disorders Abdominal pain 6 4 Nausea 8 6 General disorders and administrative site conditions Fatigue 6 10 Asthenia 9 7 Painb 5 7 aDeath related to sepsis occurred in 3% of patients receiving HYCAMTIN and 1% of patients receiving CAV. bPain includes body pain, skeletal pain, and back pain. Hepatobiliary Disorders in Ovarian and Small Cell Lung Cancer Patients Receiving HYCAMTIN: Based on the combined experience of 453 patients with metastatic ovarian carcinoma, and 426 patients with small cell lung cancer treated with HYCAMTIN, Grade 1 transient elevations in hepatic enzymes occurred in 8% of patients. Grade 3/4 elevations occurred in 4%. Grade 3/4 elevated bilirubin occurred in less than 2% of patients. Cervical Cancer In the comparative trial with HYCAMTIN plus cisplatin versus cisplatin in patients with cervical cancer, the most common dose-limiting adverse reaction was myelosuppression. Table 3 shows the hematologic and non-hematologic adverse reactions in patients with cervical cancer. Table 3: Adverse Reactions Experienced by ≥ 5% of Patients with Cervical Cancer Randomized to Receive HYCAMTIN plus Cisplatin or Cisplatin Monotherapy (Between-Arm Difference ≥ 2%)a Adverse Reaction HYCAMTIN plus Cisplatin (n = 140) % Cisplatin (n = 144) % Hematologic Neutropenia Grade 3 ( < 1,000-500 cells/mm³) 26 1 Grade 4 ( < 500 cells/mm³) 48 1 Anemia Grade 3 (Hgb < 8-6.5 g/dL) 34 19 Grade 4 (Hgb < 6.5 g/dL) 6 3 Thrombocytopenia Grade 3 ( < 50,000-10,000 cells/mm³) 26 3 Grade 4 ( < 10,000 cells/mm³) 7 0 Non-hematologicb,c General disorders and administrative site conditions Constitutionald 69 62 Paine 59 50 Gastrointestinal disorders Vomiting 40 37 Stomatitis-pharyngitis 6 0 Other 63 56 Dermatologyf 48 20 Infection-febrile neutropeniaf 28 18 Cardiovascularf 25 15 aIncludes patients who were eligible and treated. bData were collected using NCI Common Toxicity Criteria, v. 2.0. cGrades 1 through 4 only. There were 3 patients who experienced deaths with investigator-designated attribution. The first patient experienced a Grade 5 hemorrhage in which the drug-related thrombocytopenia aggravated the event. A second patient experienced bowel obstruction, cardiac arrest, pleural effusion, and respiratory failure which were not treatment-related but probably aggravated by treatment. A third patient experienced a pulmonary embolism and adult respiratory distress syndrome; the latter was indirectly treatment-related. dConstitutional includes fatigue (lethargy, malaise, asthenia), fever (in the absence of neutropenia), rigors, chills, sweating, and weight gain or loss. ePain includes abdominal pain or cramping, arthralgia, bone pain, chest pain (non-cardiac and non-pleuritic), dysmenorrhea, dyspareunia, earache, headache, hepatic pain, myalgia, neuropathic pain, pain due to radiation, pelvic pain, pleuritic pain, rectal or perirectal pain, and tumor pain. fHigh-level terms were included if the between-arm difference was ≥ 10%. Postmarketing Experience The following reactions have been identified during postmarketing use of HYCAMTIN. Because they are reported voluntarily from a population of unknown size, estimates of frequency cannot be made. These reactions have been chosen for inclusion due to a combination of their seriousness, frequency of reporting, or potential causal connection to HYCAMTIN. Blood and Lymphatic System Disorders Severe bleeding (in association with thrombocytopenia) [see WARNINGS AND PRECAUTIONS]. Immune System Disorders Allergic manifestations, anaphylactoid reactions. Gastrointestinal Disorders Abdominal pain potentially associated with neutropenic enterocolitis [see WARNINGS AND PRECAUTIONS]. Pulmonary Disorders Interstitial lung disease [see WARNINGS AND PRECAUTIONS]. Skin and Subcutaneous Tissue Disorders Angioedema, severe dermatitis, severe pruritus. General Disorders and Administration Site Conditions Extravasation [see WARNINGS AND PRECAUTIONS]. DRUG INTERACTIONS G-CSF Concomitant administration with G-CSF can prolong the duration of neutropenia. If G-CSF is used, it should be started no sooner than 24 hours following the last dose of HYCAMTIN.

WARNINGS Included as part of the PRECAUTIONS section. PRECAUTIONS Bone Marrow Suppression Bone marrow suppression (primarily neutropenia) is the dose-limiting toxicity of HYCAMTIN. Neutropenia is not cumulative over time. Severe myelotoxicity has been reported when HYCAMTIN is used in combination with cisplatin [see DRUG INTERACTIONS]. The following data on myelosuppression are based on an integrated safety database from 8 trials (N = 879) using HYCAMTIN injection at 1.5 mg/m² by intravenous infusion over 30 minutes daily for 5 consecutive days, starting on Day 1 of a 21-day course in patients with ovarian cancer and small cell lung cancer and from one trial in patients with cervical cancer (N = 147) using HYCAMTIN 0.75 mg/m² by intravenous infusion over 30 minutes daily on Days 1, 2, and 3 repeated every 21 days in combination with cisplatin 50 mg/m² on Day 1. Neutropenia Monotherapy: Grade 4 neutropenia (less than 500 cells/mm³) occurred in 78% of patients, with a median duration of 7 days and was most common during Course 1 of treatment (58% of patients). Grade 4 neutropenia associated with infection occurred in 13% of patients and febrile neutropenia occurred in 5% of patients. Sepsis occurred in 4% of patients and was fatal in 1% of patients. Pancytopenia has been reported. Combination with cisplatin: Grade 4 neutropenia occurred in 48% of patients. Thrombocytopenia Monotherapy: Grade 4 thrombocytopenia (less than 25,000/mm³) occurred in 27% of patients, with a median duration of 5 days. Combination with cisplatin: Grade 4 thrombocytopenia occurred in 7% of patients. Anemia Monotherapy: Grade 3 or 4 anemia (less than 8 g/dL) occurred in 37% of patients. Combination with cisplatin: Grade 3 or Grade 4 anemia occurred in 40% of patients. Administer HYCAMTIN only to patients with a baseline neutrophil count of greater than or equal to 1,500 cells/mm³ and a platelet count greater than or equal to 100,000/mm³. Monitor peripheral blood counts frequently during treatment with HYCAMTIN. Refer to Section 2.4 for dose modification guidelines for hematological toxicities in subsequent courses. Do not treat patients with subsequent courses of HYCAMTIN until neutrophils recover to greater than 1,000 cells/mm³, platelets recover to greater than 100,000 cells/mm³, and hemoglobin levels recover to 9.0 g/dL (with transfusion if necessary). Neutropenic Enterocolitis Topotecan can cause fatal typhlitis (neutropenic enterocolitis). Consider the possibility of typhlitis in patients presenting with fever, neutropenia, and abdominal pain. Interstitial Lung Disease Interstitial lung disease (ILD), including fatalities, has occurred with HYCAMTIN. Underlying risk factors include history of ILD, pulmonary fibrosis, lung cancer, thoracic radiation, and use of pneumotoxic drugs and/or colony stimulating factors. Monitor patients for pulmonary symptoms indicative of ILD (e.g., cough, fever, dyspnea, and/or hypoxia), and discontinue HYCAMTIN if a new diagnosis of ILD is confirmed. Embryofetal Toxicity Based on animal data, HYCAMTIN can cause fetal harm when administered to a pregnant woman. Topotecan caused embryolethality, fetotoxicity, and teratogenicity in rats and rabbits when administered during organogenesis. Advise females of reproductive potential to use effective contraception during treatment and for at least 1 month after the last dose of HYCAMTIN. Advise women of the potential risk to a fetus [see Use in Specific Populations]. Extravasation And Tissue Injury Extravasation with HYCAMTIN has been observed; severe cases have been reported. If signs or symptoms of extravasation occur, immediately stop administration of HYCAMTIN and institute recommended management procedures [see ADVERSE REACTIONS]. Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment Of Fertility Carcinogenicity testing of topotecan has not been performed. Topotecan is known to be genotoxic to mammalian cells and is a probable carcinogen. Topotecan was mutagenic to L5178Y mouse lymphoma cells and clastogenic to cultured human lymphocytes with and without metabolic activation. It was also clastogenic to mouse bone marrow. Topotecan did not cause mutations in bacterial cells. Topotecan given to female rats prior to mating at a dose of 1.4 mg/m² IV (about equal to the clinical dose on a mg/m² basis) caused superovulation possibly related to inhibition of follicular atresia. This dose given to pregnant female rats also caused increased pre-implantation loss. Studies in dogs given 0.4 mg/m² IV (about 0.25 times the clinical dose on a mg/m² basis) of topotecan daily for a month suggest that treatment may cause an increase in the incidence of multinucleated spermatogonial giant cells in the testes. Topotecan may impair fertility in women and men. Use In Specific Populations Pregnancy Risk Summary Based on animal data, HYCAMTIN can cause fetal harm when administered to a pregnant woman. Topotecan caused embryolethality, fetotoxicity, and teratogenicity in rats and rabbits when administered during organogenesis at doses similar to the clinical dose [see Data]. There are no available human data informing the drug-associated risk. Advise pregnant women of the potential risk to a fetus. The background risk of major birth defects and miscarriage for the indicated populations are unknown; however, the background risk in the US general population of major birth defects is 2% to 4% and of miscarriage is 15% to 20% of clinically recognized pregnancies. Data Animal Data: In rabbits, a dose of 0.10 mg/kg/day (about equal to the clinical dose on a mg/m² basis) given on Days 6 through 20 of gestation caused maternal toxicity, embryolethality, and reduced fetal body weight. In the rat, a dose of 0.23 mg/kg/day (about equal to the clinical dose on a mg/m² basis) given for 14 days before mating through gestation Day 6 caused fetal resorption, microphthalmia, pre-implant loss, and mild maternal toxicity. Administration of an intravenous dose of 0.10 mg/kg/day (about half the clinical dose on a mg/m² basis) given to rats on Days 6 through 17 of gestation caused an increase in post-implantation mortality. This dose also caused an increase in total fetal malformations. The most frequent malformations were of the eye (microphthalmia, anophthalmia, rosette formation of the retina, coloboma of the retina, ectopic orbit), brain (dilated lateral and third ventricles), skull, and vertebrae. Lactation Risk Summary It is not known whether this drug is present in human milk; however, topotecan is excreted in rat milk at high concentrations [see Data]. Because many drugs are present in human milk and because of the potential for serious adverse reactions in nursing infants with HYCAMTIN, advise nursing mothers to discontinue breastfeeding during treatment with HYCAMTIN. Data Animal Data: Following intravenous administration of topotecan to lactating rats at a dose of 4.72 mg/m² (about twice the clinical dose on a mg/m² basis), topotecan was excreted into milk at concentrations up to 48-fold higher than those in plasma. Females And Males Of Reproductive Potential Contraception Females: Advise female patients of reproductive potential to use effective contraception during treatment with HYCAMTIN and for one month after the last dose. Advise females to contact their healthcare provider if they become pregnant, or if pregnancy is suspected, while taking HYCAMTIN [see Use In Specific Populations] Males: HYCAMTIN may damage spermatozoa, resulting in possible genetic and fetal abnormalities. Advise males with a female sexual partner of reproductive potential to use effective contraception during and for three months after treatment with HYCAMTIN [see Nonclinical Toxicology]. Infertility Females: HYCAMTIN may have both acute and long-term effects on fertility [see Nonclinical Toxicology]. Males: Effects on spermatogenesis have been observed in animals administered HYCAMTIN. Advise males of the potential risk for impaired fertility and to seek counseling on fertility and family planning options prior to starting treatment [see Nonclinical Toxicology]. Pediatric Use Safety and effectiveness in pediatric patients have not been established. Geriatric Use Of the 879 patients with metastatic ovarian cancer or small cell lung cancer in clinical trials of HYCAMTIN, 32% (n = 281) were aged 65 years and older, while 3.8% (n = 33) were aged 75 years and older. Of the 140 patients with Stage IV-B, relapsed, or refractory cervical cancer in clinical trials of HYCAMTIN who received HYCAMTIN plus cisplatin in the randomized clinical trial, 6% (n = 9) were aged 65 years and older, while 3% (n = 4) were aged 75 years and older. No overall differences in effectiveness or safety were observed between these patients and younger adult patients, and other reported clinical experience has not identified differences in responses between the elderly and younger adult patients. Renal Impairment The systemic exposure to both topotecan lactone and total topotecan increased in patients with moderate renal impairment (Clcr = 20 to 39 mL/min) compared with patients with normal renal function (Clcr greater than 60 mL/min). Reduce the dose of HYCAMTIN in patients with moderate renal impairment (Clcr = 20 to 39 mL/min). No dosage adjustment of HYCAMTIN is recommended for patients with mild renal impairment (Clcr = 40 to 60 mL/min) [see DOSAGE AND ADMINISTRATION, CLINICAL PHARMACOLOGY]. Insufficient data are available in patients with severe renal impairment (Clcr less than 20 mL/min) to provide a dosage recommendation for HYCAMTIN.