Prescription Drugs

CLINICAL PHARMACOLOGY Mechanism of Action Granisetron is a selective 5-hydroxytryptamine3 (5-HT3) receptor antagonist with little or no affinity for other serotonin receptors, including 5-HT1; 5-HT1A; 5-HT1B/C; 5-HT2; for alpha1-, alpha2- or beta-adrenoreceptors; for dopamine-D2; or for histamine-H1; benzodiazepine; picrotoxin or opioid receptors. Serotonin receptors of the 5-HT3 type are located peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone of the area postrema. During chemotherapy-induced vomiting, mucosal enterochromaffm cells release serotonin, which stimulates 5-HT3 receptors. This evokes vagal afferent discharge and may induce vomiting. Animal studies demonstrate that, in binding to 5-HT3 receptors, granisetron blocks serotonin stimulation and subsequent vomiting after emetogenic stimuli such as cisplatin. In the ferret animal model, a single granisetron injection prevented vomiting due to high-dose cisplatin or arrested vomiting within 5 to 30 seconds. In most human studies, granisetron has had little effect on blood pressure, heart rate or ECG. No evidence of an effect on plasma prolactin or aldosterone concentrations has been found in other studies. KYTRIL Injection exhibited no effect on oro-cecal transit time in normal volunteers given a single intravenous infusion of 50 mcg/kg or 200 mcg/kg. Single and multiple oral doses slowed colonic transit in normal volunteers. Pharmacokinetics Chemotherapy-Induced Nausea and Vomiting In adult cancer patients undergoing chemotherapy and in volunteers, mean pharmacokinetic data obtained from an infusion of a single 40 mcg/kg dose of KYTRIL Injection are shown in Table 3. Table 3: Pharmacokinetic Parameters in Adult Cancer Patients Undergoing Chemotherapy and in Volunteers, Following a Single Intravenous 40 mcg/kg Dose of KYTRIL Injection Peak Plasma Concentration (ng/mL) Terminal Phase Plasma Half-Life (h) Total Clearance (L/h/kg) Volume of Distribution (L/kg) Cancer Patients Mean 63.8* 8.95* 0.38* 3.07* Range 18.0 to 176 0.90 to 31.1 0.14 to 1.54 0.85 to 10.4 Volunteers 21 to 42 years Mean 64.3† 4.91† 0.79† 3.04† Range 11. 2 to 182 0.88 to 15.2 0.20 to 2.56 1.68 to 6.13 65 to 81 years Mean 57.0† 7.69† 0.44† 3.97† Range 14.6 to 153 2.65 to 17.7 0.17 to 1.06 1.75 to 7.01 * 5-minute infusion. †3-minute infusion. Distribution Plasma protein binding is approximately 65% and granisetron distributes freely between plasma and red blood cells. Metabolism Granisetron metabolism involves N-demethylation and aromatic ring oxidation followed by conjugation. In vitro liver microsomal studies show that granisetron's major route of metabolism is inhibited by ketoconazole, suggestive of metabolism mediated by the cytochrome P-450 3 A subfamily. Animal studies suggest that some of the metabolites may also have 5-HT3 receptor antagonist activity. Elimination Clearance is predominantly by hepatic metabolism. In normal volunteers, approximately 12% of the administered dose is eliminated unchanged in the urine in 48 hours. The remainder of the dose is excreted as metabolites, 49% in the urine, and 34% in the feces. Subpopulations Gender There was high inter- and intra-subject variability noted in these studies. No difference in mean AUC was found between males and females, although males had a higher Cmax generally. Elderly The ranges of the pharmacokinetic parameters in elderly volunteers (mean age 71 years), given a single 40 mcg/kg intravenous dose of KYTRIL Injection, were generally similar to those in younger healthy volunteers; mean values were lower for clearance and longer for half-life in the elderly patients (see Table 3). Pediatric Patients A pharmacokinetic study in pediatric cancer patients (2 to 16 years of age), given a single 40 mcg/kg intravenous dose of KYTRIL Injection, showed that volume of distribution and total clearance increased with age. No relationship with age was observed for peak plasma concentration or terminal phase plasma half-life. When volume of distribution and total clearance are adjusted for body weight, the pharmacokinetics of granisetron are similar in pediatric and adult cancer patients. Renal Failure Patients Total clearance of granisetron was not affected in patients with severe renal failure who received a single 40 mcg/kg intravenous dose of KYTRIL Injection. Hepatically Impaired Patients A pharmacokinetic study in patients with hepatic impairment due to neoplastic liver involvement showed that total clearance was approximately halved compared to patients without hepatic impairment. Given the wide variability in pharmacokinetic parameters noted in patients, dosage adjustment in patients with hepatic functional impairment is not necessary. Postoperative Nausea and Vomiting In adult patients (age range, 18 to 64 years) recovering from elective surgery and receiving general balanced anesthesia, mean pharmacokinetic data obtained from a single 1 mg dose of KYTRIL Injection administered intravenously over 30 seconds are shown in Table 4. Table 4: Pharmacokinetic Parameters in 16 Adult Surgical Patients Following a Single Intravenous 1 mg Dose of KYTRIL Injection Terminal Phase Plasma Half-Life (h) Total Clearance (L/h/kg) Volume of Distribution (L/kg) Mean 8.63 0.28 2.42 Range 1.77 to 17.73 0.07 to 0.71 0.71 to 4.13 The pharmacokinetics of granisetron in patients undergoing surgery were similar to those seen in cancer patients undergoing chemotherapy. Clinical Studies Chemotherapy-Induced Nausea and Vomiting Single-Day Chemotherapy Cisplatin-Based Chemotherapy In a double-blind, placebo-controlled study in 28 cancer patients, KYTRIL Injection, administered as a single intravenous infusion of 40 mcg/kg, was significantly more effective than placebo in preventing nausea and vomiting induced by cisplatin chemotherapy (see Table 5). Table 5: Prevention of Chemotherapy-Induced Nausea and Vomiting — Single-Day Cisplatin Therapy1 KYTRIL Injection Placebo P-Value Number of Patients 14 14 Response Over 24 Hours Complete Response2 93% 7% < 0.001 No Vomiting 93% 14% < 0.001 No More Than Mild Nausea 93% 7% < 0.001 1 Cisplatin administration began within 10 minutes of KYTRIL Injection infusion and continued for 1.5 to 3.0 hours. Mean cisplatin dose was 86 mg/m2 in the KYTRIL Injection group and 80 mg/m2 in the placebo group. 2 No vomiting and no moderate or severe nausea. KYTRIL Injection was also evaluated in a randomized dose response study of cancer patients receiving cisplatin ≥ 75 mg/m2. Additional chemotherapeutic agents included: anthracyclines, carboplatin, cytostatic antibiotics, folic acid derivatives, methylhydrazine, nitrogen mustard analogs, podophyllotoxin derivatives, pyrimidine analogs, and vinca alkaloids. KYTRIL Injection doses of 10 and 40 mcg/kg were superior to 2 mcg/kg in preventing cisplatin-induced nausea and vomiting, but 40 mcg/kg was not significantly superior to 10 mcg/kg (see Table 6). Table 6 Prevention of Chemotherapy-Induced Nausea and Vomiting — Single-Day High-Dose Cisplatin Therapy1 KYTRIL Injection (mcg/kg) P-Value (vs. 2 mcg/kg) 2 10 40 10 40 Number of Patients 52 52 53 Response Over 24 Hours Complete Response2 31% 62% 68% < 0.002 < 0.002 No Vomiting 38% 65% 74% < 0.002 < 0.002 No More Than Mild Nausea 58% 75% 79% NS 0.007 1 Cisplatin administration began within 10 minutes of KYTRIL Injection infusion and continued for 2.6 hours (mean). Mean cisplatin doses were 96 to 99 mg/m2. 2 No vomiting and no moderate or severe nausea. KYTRIL Injection was also evaluated in a double-blind, randomized dose response study of 353 patients stratified for high ( ≥ 80 to 120 mg/m2) or low (50 to 79 mg/m2) cisplatin dose. Response rates of patients for both cisplatin strata are given in Table 7. Table 7: Prevention of Chemotherapy-Induced Nausea and Vomiting — Single-Day High-Dose and Low-Dose Cisplatin Therapy1 KYTRIL Injection (mcg/kg) P-Value (vs. 5 mcg/kg) 5 10 20 40 10 20 40 High-Dose Cisplatin Number of Patients 40 49 48 47 Response Over 24 Hours Complete Response2 18% 41% 40% 47% 0.018 0.025 0.004 No Vomiting 28% 47% 44% 53% NS NS 0.016 No Nausea 15% 35% 38% 43% 0.036 0.019 0.005 Low-Dose Cisplatin Number of Patients 42 41 40 46 Response Over 24 Hours Complete Response2 29% 56% 58% 41% 0.012 0.009 NS No Vomiting 36% 63% 65% 43% 0.012 0.008 NS No Nausea 29% 56% 38% 33% 0.012 NS NS 1 Cisplatin administration began within 10 minutes of KYTRIL Injection infusion and continued for 2 hours (mean). Mean cisplatin doses were 64 and 98 mg/m2 for low and high strata. 2 No vomiting and no use of rescue antiemetic. For both the low and high cisplatin strata, the 10, 20, and 40 mcg/kg doses were more effective than the 5 mcg/kg dose in preventing nausea and vomiting within 24 hours of chemotherapy administration. The 10 mcg/kg dose was at least as effective as the higher doses. Moderately Emetogenic Chemotherapy KYTRIL Injection, 40 mcg/kg, was compared with the combination of chlorpromazine (50 to 200 mg/24 hours) and dexamethasone (12 mg) in patients treated with moderately emetogenic chemotherapy, including primarily carboplatin > 300 mg/m2, cisplatin 20 to 50 mg/m2 and cyclophosphamide > 600 mg/m2. KYTRIL Injection was superior to the chlorpromazine regimen in preventing nausea and vomiting (see Table 8). Table 8: Prevention of Chemotherapy-Induced Nausea and Vomiting—Single-Day Moderately Emetogenic Chemotherapy KYTRIL Injection Chlorpromazine1 P-Value Number of Patients 133 133 Response Over 24 Hours Complete Response2 68% 47% < 0.001 No Vomiting 73% 53% < 0.001 No More Than Mild Nausea 77% 59% < 0.001 1 Patients also received dexamethasone, 12 mg. 2 No vomiting and no moderate or severe nausea. In other studies of moderately emetogenic chemotherapy, no significant difference in efficacy was found between KYTRIL doses of 40 mcg/kg and 160 mcg/kg. Repeat-Cycle Chemotherapy In an uncontrolled trial, 512 cancer patients received KYTRIL Injection, 40 mcg/kg, prophylactically, for two cycles of chemotherapy, 224 patients received it for at least four cycles, and 108 patients received it for at least six cycles. KYTRIL Injection efficacy remained relatively constant over the first six repeat cycles, with complete response rates (no vomiting and no moderate or severe nausea in 24 hours) of 60% to 69%. No patients were studied for more than 15 cycles. Pediatric Studies A randomized double-blind study evaluated the 24-hour response of 80 pediatric cancer patients (age 2 to 16 years) to KYTRIL Injection 10, 20 or 40 mcg/kg. Patients were treated with cisplatin ≥ 60 mg/m2, cytarabine ≥ 3 g/m2, cyclophosphamide ≥ 1 g/m2 or nitrogen mustard ≥ 6 mg/m2 (see Table 9). Table 9: Prevention of Chemotherapy-Induced Nausea and Vomiting in Pediatric Patients KYTRIL Injection Dose (mcg/kg) 10 20 40 Number of Patients 29 26 25 Median Number of Vomiting Episodes 2 3 1 Complete Response Over 24 Hours1 21% 31% 32% 1 No vomiting and no moderate or severe nausea. A second pediatric study compared KYTRIL Injection 20 mcg/kg to chlorpromazine plus dexamethasone in 88 patients treated with ifosfamide ≥ 3 g/m2/day for two or three days. KYTRIL Injection was administered on each day of ifosfamide treatment. At 24 hours, 22% of KYTRIL Injection patients achieved complete response (no vomiting and no moderate or severe nausea in 24 hours) compared with 10% on the chlorpromazine regimen. The median number of vomiting episodes with KYTRIL Injection was 1.5; with chlorpromazine it was 7.0. Postoperative Nausea and Vomiting Prevention of Postoperative Nausea and Vomiting The efficacy of KYTRIL Injection for prevention of postoperative nausea and vomiting was evaluated in 868 patients, of which 833 were women, 35 men, 484 Caucasians, 348 Asians, 18 Blacks, 18 Other, with 61 patients 65 years or older. KYTRIL was evaluated in two randomized, double-blind, placebo-controlled studies in patients who underwent elective gynecological surgery or cholecystectomy and received general anesthesia. Patients received a single intravenous dose of KYTRIL Injection (0.1 mg, 1 mg or 3 mg) or placebo either 5 minutes before induction of anesthesia or immediately before reversal of anesthesia. The primary endpoint was the proportion of patients with no vomiting for 24 hours after surgery. Episodes of nausea and vomiting and use of rescue antiemetic therapy were recorded for 24 hours after surgery. In both studies, KYTRIL Injection (1 mg) was more effective than placebo in preventing postoperative nausea and vomiting (see Table 10). No additional benefit was seen in patients who received the 3 mg dose. Table 10: Prevention of Postoperative Nausea and Vomiting in Adult Patients Study and Efficacy Endpoint Placebo KYTRIL 0.1 mg KYTRIL 1 mg KYTRIL 3 mg Study 1 Number of Patients 133 132 134 128 No Vomiting 0 to 24 hours 34% 45% 63%** 62%** No Nausea 0 to 24 hours 22% 28% 50%** 42%** No Nausea or Vomiting 0 to 24 hours 18% 27% 49%** 42%** No Use of Rescue Antiemetic Therapy 0 to 24 hours 60% 67% 75%* 77%* Study 2 Number of Patients 111 - 110 114 No Vomiting 0 to 24 hours 56% - 77%** 75%* No Nausea 0 to 24 hours 37% - 59%** 56%* *P < 0.05 **P < 0.001 versus placebo Note: No Vomiting = no vomiting and no use of rescue antiemetic therapy; No Nausea = no nausea and no use of rescue antiemetic therapy Gender/Race There were too few male and Black patients to adequately assess differences in effect in either population. Treatment of Postoperative Nausea and Vomiting The efficacy of KYTRIL Injection for treatment of postoperative nausea and vomiting was evaluated in 844 patients, of which 731 were women, 113 men, 777 Caucasians, 6 Asians, 41 Blacks, 20 Other, with 107 patients 65 years or older. KYTRIL Injection was evaluated in two randomized, double-blind, placebo-controlled studies of adult surgical patients who received general anesthesia with no prophylactic antiemetic agent, and who experienced nausea or vomiting within 4 hours postoperatively. Patients received a single intravenous dose of KYTRIL Injection (0.1 mg, 1 mg or 3 mg) or placebo after experiencing postoperative nausea or vomiting. Episodes of nausea and vomiting and use of rescue antiemetic therapy were recorded for 24 hours after administration of study medication. KYTRIL Injection was more effective than placebo in treating postoperative nausea and vomiting (see Table 11). No additional benefit was seen in patients who received the 3 mg dose. Table 11: Treatment of Postoperative Nausea and Vomiting in Adult Patients Study and Efficacy Endpoint Placebo KYTRIL 0.1 mg KYTRIL 1 mg KYTRIL 3 mg Study 3 Number of Patients 133 128 133 125 No Vomiting 0 to 6 hours 26% 53%*** 58%*** 60%*** 0 to 24 hours 20% 38%*** 46%*** 49o/0*** No Nausea 0 to 6 hours 17% 40%*** 41%*** 42%*** 0 to 24 hours 13% 27%** 30%** 37%*** No Use of Rescue Antiemetic Therapy 0 to 6 hours - - - - 0 to 24 hours 33% 51%** 61%*** 61%*** Study 4 Number of Patients (All Patients) 162 163 - - No Vomiting 0 to 6 hours 20% 32%* - - 0 to 24 hours 14% 23%* - - No Nausea 0 to 6 hours 13% 18% - - 0 to 24 hours 9% 14% - - No Nausea or Vomiting 0 to 6 hours 13% 18% - - 0 to 24 hours 9% 14% - - No Use of Rescue Antiemetic Therapy 0 to 6 hours 0 to 24 hours 24% 34%* - - Number of Patients (Treated for Vomiting)1 86 103 - - No Vomiting 0 to 6 hours 21% 27% - - 0 to 24 hours 14% 20% - - *P < 0.05 **P < 0.01 ***P < 0.001 versus placebo 1 Protocol Specified Analysis: Patients who had vomiting prior to treatment Note: No vomiting = no vomiting and no use of rescue antiemetic therapy; No nausea = no nausea and no use of rescue antiemetic therapy Gender/Race There were too few male and Black patients to adequately assess differences in effect in either population.

KYTRIL® (granisetron hydrochloride) Injection, for Intravenous Use DESCRIPTION KYTRIL (granisetron hydrochloride) Injection is a serotonin-3 (5-HT3) receptor antagonist. Chemically it is endo-N-(9-methyl-9-azabicyclo [3.3.1] non-3-yl)-1-methyl-1H-indazole-3-carboxamide hydrochloride with a molecular weight of 348.9 (312.4 free base). Its empirical formula is C18H24N4O•HCl, while its chemical structure is: granisetron hydrochloride Granisetron hydrochloride is a white to off-white solid that is readily soluble in water and normal saline at 20°C. KYTRIL Injection is a clear, colorless, sterile nonpyrogenic, aqueous solution for intravenous administration. KYTRIL 1 mg/mL is available in 1 mL single-use and 4 mL multi-use vials. KYTRIL 0.1 mg/mL is available in a 1 mL single-use vial. 1 mg/mL: Each 1 mL contains 1.12 mg granisetron hydrochloride equivalent to granisetron, 1 mg; sodium chloride, 9 mg; citric acid, 2 mg; and benzyl alcohol, 10 mg, as a preservative. The solution's pH ranges from 4.0 to 6.0. 0.1 mg/mL: Each 1 mL contains 0.112 mg granisetron hydrochloride equivalent to granisetron, 0.1 mg; sodium chloride, 9 mg; citric acid, 2 mg. Contains no preservative. The solution's pH ranges from 4.0 to 6.0.

INDICATIONS KYTRIL Injection is a serotonin-3 (5-HT3) receptor antagonist indicated for: The prevention of nausea and/or vomiting associated with initial and repeat courses of emetogenic cancer therapy, including high-dose cisplatin. The prevention and treatment of postoperative nausea and vomiting in adults. As with other antiemetics, routine prophylaxis is not recommended in patients in whom there is little expectation that nausea and/or vomiting will occur postoperatively. In patients where nausea and/or vomiting must be avoided during the postoperative period, KYTRIL Injection is recommended even where the incidence of postoperative nausea and/or vomiting is low. DOSAGE AND ADMINISTRATION Prevention of Chemotherapy-Induced Nausea and Vomiting Adult Patients The recommended dosage for KYTRIL Injection is 10 mcg/kg administered intravenously within 30 minutes before initiation of chemotherapy, and only on the day(s) chemotherapy is given. Infusion Preparation KYTRIL Injection may be administered intravenously either undiluted over 30 seconds, or diluted with 0.9% Sodium Chloride or 5% Dextrose and infused over 5 minutes. Stability Intravenous infusion of KYTRIL Injection should be prepared at the time of administration. However, KYTRIL Injection has been shown to be stable for at least 24 hours when diluted in 0.9% Sodium Chloride or 5% Dextrose and stored at room temperature under normal lighting conditions. As a general precaution, KYTRIL Injection should not be mixed in solution with other drugs. Parenteral drug products should be inspected visually for particulate matter and discoloration before administration whenever solution and container permit. Pediatric Patients The recommended dose in pediatric patients 2 to 16 years of age is 10 mcg/kg [see Clinical Studies]. Pediatric patients under 2 years of age have not been studied. Prevention and Treatment of Postoperative Nausea and Vomiting Adult Patients The recommended dosage for prevention of postoperative nausea and vomiting is 1 mg of KYTRIL, undiluted, administered intravenously over 30 seconds, before induction of anesthesia or immediately before reversal of anesthesia. The recommended dosage for the treatment of nausea and/or vomiting after surgery is 1 mg of KYTRIL, undiluted, administered intravenously over 30 seconds. HOW SUPPLIED Dosage Forms and Strengths Single-Use Vials for Injection: 1 mg/mL, 0.1 mg/mL Multi-Use Vials for Injection: 4 mg/4 mL KYTRIL Injection, 1 mg/mL (free base), is supplied in 1 mL Single-Use Vials and 4 mg/4 mL Multi-Use Vials. Contains benzyl alcohol. NDC 0004-0239-09 (package of 1 Single-Use Vial) NDC 0004-0240-09 (package of 1 Multi-Use Vial) KYTRIL Injection, 0.1 mg/mL (free base), is supplied in 1 mL Single-Use Vials. Contains no preservative. NDC 0004-0242-08 (package of 5 Single-Use Vials) Store single-use vials and multi-use vials at 25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F). [See USP Controlled Room Temperature] Once the multi-use vial is penetrated, its contents should be used within 30 days. Do not freeze. Protect from light. Distributed by: Genentech USA, Inc. A Member of the Roche Group, 1 DNA Way, South San Francisco, CA 94QSO-4990.

PATIENT INFORMATION Patients should be informed that the most common adverse reactions for the indication of chemotherapy induced nausea and vomiting are headache and constipation (see Table 1). Patients should be informed that the most common adverse reactions for the indication of postoperative nausea and vomiting are pain, headache, fever, abdominal pain and hepatic enzyme increased (see Table 2). Patients should be advised of the risk of allergic reactions if they have a prior allergic reaction to a class of antiemetics known as 5-HT3 receptor antagonists. Electrocardiogram changes (QT prolongation) have been reported with the use of KYTRIL. Patients should be cautioned about the use of this drug if they have heart problems or take medications for heart problems. Patients should be informed that KYTRIL Injection (1 mg/mL) contains benzyl alcohol and may cause serious side effects in newborns. KYTRIL Injection 0.1 mg/mL contains no benzyl alcohol.

OVERDOSE There is no specific antidote for KYTRIL Injection overdosage. In case of overdosage, symptomatic treatment should be given. Overdosage of up to 38.5 mg of granisetron hydrochloride injection has been reported without symptoms or only the occurrence of a slight headache. CONTRAINDICATIONS KYTRIL Injection is contraindicated in patients with known hypersensitivity (eg. anaphylaxis, shortness of breath, hypotension, urticaria) to the drug or to any of its components.

SIDE EFFECTS QT prolongation has been reported with KYTRIL [see WARNINGS AND PRECAUTIONS and DRUG INTERATIONS] 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 patients. Chemotherapy-Induced Nausea and Vomiting The following have been reported during controlled clinical trials or in the routine management of patients. The percentage figures are based on clinical trial experience only. Table 1 gives the comparative frequencies of the two most commonly reported adverse reactions ( ≥ 3%) in patients receiving KYTRIL Injection, in single-day chemotherapy trials. These patients received chemotherapy, primarily cisplatin, and intravenous fluids during the 24-hour period following KYTRIL Injection administration. Reactions were generally recorded over seven days post-KYTRIL Injection administration. Table 1: Principal Adverse Reactions in Clinical Trials — Single-Day Chemotherapy Percent of Patients With Reaction KYTRIL Injection 40 mcg/kg (n=1268) Comparator1 (n=422) Headache 14% 6% Constipation 3% 3% 1 Metoclopramide/dexamethasone and phenothiazines/dexamethasone. Additional adverse events reported in clinical trials were asthenia, somnolence and diarrhea. In over 3,000 patients receiving KYTRIL Injection (2 to 160 mcg/kg) in single-day and multiple-day clinical trials with emetogenic cancer therapies, adverse events, other than those adverse reactions listed in Table 1, were observed; attribution of many of these events to KYTRIL is uncertain. Hepatic: In comparative trials, mainly with cisplatin regimens, elevations of AST and ALT ( > 2 times the upper limit of normal) following administration of KYTRIL Injection occurred in 2.8% and 3.3% of patients, respectively. These frequencies were not significantly different from those seen with comparators (AST: 2.1%; ALT: 2.4%). Cardiovascular: Hypertension (2%); hypotension, arrhythmias such as sinus bradycardia, atrial fibrillation, varying degrees of A-V block, ventricular ectopy including non-sustained tachycardia, and ECG abnormalities have been observed rarely. Central Nervous System: Agitation, anxiety, CNS stimulation and insomnia were seen in less than 2% of patients. Extrapyramidal syndrome occurred rarely and only in the presence of other drugs associated with this syndrome. Hypersensitivity: Rare cases of hypersensitivity reactions, sometimes severe (eg, anaphylaxis, shortness of breath, hypotension, urticaria) have been reported. Other: Fever (3%), taste disorder (2%), skin rashes (1%). In multiple-day comparative studies, fever occurred more frequently with KYTRIL Injection (8.6%) than with comparative drugs (3.4%, P < 0.014), which usually included dexamethasone. Postoperative Nausea and Vomiting The adverse reactions listed in Table 2 were reported in ≥ 2% of adults receiving KYTRIL Injection 1 mg during controlled clinical trials. Table 2: Adverse Reactions in Controlled Clinical Trials in Postoperative Nausea and Vomiting (Reported in ≥ 2% of Adults Receiving KYTRIL Injection 1 mg) Percent of Patients With Reaction KYTRIL Injection 1 mg (n=267) Placebo (n=266) Pain 10.1 8.3 Headache 8.6 7.1 Fever 7.9 4.5 Abdominal Pain 6.0 6.0 Hepatic Enzymes Increased 5.6 4.1 Dizziness 4.1 3.4 Diarrhea 3.4 1.1 Flatulence 3.0 3.0 Dyspepsia 3.0 1.9 Oliguria 2.2 1.5 Coughing 2.2 1.1 Additional adverse events reported in clinical trials were constipation, anemia, insomnia, bradycardia, leukocytosis, anxiety, hypotension, infection, hypertension, and urinary tract infection. In a clinical study conducted in Japan, the types of adverse events differed notably from those reported above in Table 2. The adverse events in the Japanese study that occurred in ≥ 2% of patients and were more frequent with KYTRIL 1 mg than with placebo were: fever (56% to 50%), sputum increased (2.7% to 1.7%), and dermatitis (2.7% to 0%). Postmarketing Experience The following adverse reactions have been identified during post approval use of KYTRIL. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to KYTRIL exposure. QT prolongation has been reported with KYTRIL [see WARNINGS AND PRECAUTIONS and DRUG INTERACTIONS] DRUG INTERACTIONS Granisetron does not induce or inhibit the cytochrome P-450 drug-metabolizing enzyme system in vitro. There have been no definitive drug-drug interaction studies to examine pharmacokinetic or pharmacodynamic interaction with other drugs; however, in humans, KYTRIL Injection has been safely administered with drugs representing benzodiazepines, neuroleptics and anti-ulcer medications commonly prescribed with antiemetic treatments. KYTRIL Injection also does not appear to interact with emetogenic cancer chemotherapies. Because granisetron is metabolized by hepatic cytochrome P-450 drug-metabolizing enzymes, inducers or inhibitors of these enzymes may change the clearance and, hence, the half-life of granisetron. No specific interaction studies have been conducted in anesthetized patients. In addition, the activity of the cytochrome P-450 subfamily 3 A4 (involved in the metabolism of some of the main narcotic analgesic agents) is not modified by KYTRIL in vitro. In in vitro human microsomal studies, ketoconazole inhibited ring oxidation of KYTRIL. However, the clinical significance of in vivo pharmacokinetic interactions with ketoconazole is not known. In a human pharmacokinetic study, hepatic enzyme induction with phenobarbital resulted in a 25% increase in total plasma clearance of intravenous KYTRIL. The clinical significance of this change is not known. QT prolongation has been reported with KYTRIL. Use of KYTRIL in patients concurrently treated with drugs known to prolong the QT interval and/or are arrhythmogenic may result in clinical consequences.

WARNINGS Included as part of the PRECAUTIONS section. PRECAUTIONS Gastric or Intestinal Peristalsis KYTRIL is not a drug that stimulates gastric or intestinal peristalsis. It should not be used instead of nasogastric suction. The use of KYTRIL in patients following abdominal surgery or in patients with chemotherapy-induced nausea and vomiting may mask a progressive ileus and/or gastric distention. Cardiovascular Events An adequate QT assessment has not been conducted, but QT prolongation has been reported with KYTRIL. Therefore, KYTRIL should be used with caution in patients with pre-existing arrhythmias or cardiac conduction disorders, as this might lead to clinical consequences. Patients with cardiac disease, on cardio-toxic chemotherapy, with concomitant electrolyte abnormalities and/or on concomitant medications that prolong the QT interval are particularly at risk. Hypersensitivity Reactions Hypersensitivity reactions (eg. anaphylaxis, shortness of breath, hypotension, urticaria) may occur in patients who have exhibited hypersensitivity to other selective S-HT3 receptor antagonists Benzyl Alcohol KYTRIL 1 mg/mL contains benzyl alcohol. Benzyl alcohol, a component of KYTRIL 1 mg/mL, has been associated with serious adverse reactions and death, particularly in neonates. The "gasping syndrome," characterized by central nervous system depression, metabolic acidosis, gasping respirations, and high levels of benzyl alcohol and metabolites in blood and urine, has been associated with benzyl alcohol dosages > 99 mg/kg/day in neonates and low birth-weight neonates. Additional symptoms may include gradual neurological deterioration, seizures, intracranial hemorrhage, hematologic abnormalities, skin breakdown, hepatic and renal failure, hypotension, bradycardia, and cardiovascular collapse. Although normal therapeutic doses of this product deliver amounts of benzyl alcohol that are substantially lower than those reported in association with the "gasping syndrome," the minimum amount of benzyl alcohol at which toxicity may occur is not known. Premature and low birth-weight infants, as well as patients receiving high dosages, may be more likely to develop toxicity. Practitioners administering this and other medications containing benzyl alcohol should consider the combined daily metabolic load of benzyl alcohol from all sources. Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment of Fertility In a 24-month carcinogenicity study, rats were treated orally with granisetron 1, 5 or 50 mg/kg/day (6, 30 or 300 mg/m2/day). The 50 mg/kg/day dose was reduced to 25 mg/kg/day (150 mg/m2/day) during week 59 due to toxicity. For a 50 kg person of average height (1.46 m2 body surface area), these doses represent 16, 81 and 405 times the recommended clinical dose (0.37 mg/m2, iv) on a body surface area basis. There was a statistically significant increase in the incidence of hepatocellular carcinomas and adenomas in males treated with 5 mg/kg/day (30 mg/m2/day, 81 times the recommended human dose based on body surface area) and above, and in females treated with 25 mg/kg/day (150 mg/m2/day, 405 times the recommended human dose based on body surface area). No increase in liver tumors was observed at a dose of 1 mg/kg/day (6 mg/m2/day, 16 times the recommended human dose based on body surface area) in males and 5 mg/kg/day (30 mg/m2/day, 81 times the recommended human dose based on body surface area) in females. In a 12-month oral toxicity study, treatment with granisetron 100 mg/kg/day (600 mg/m2/day, 1622 times the recommended human dose based on body surface area) produced hepatocellular adenomas in male and female rats while no such tumors were found in the control rats. A 24-month mouse carcinogenicity study of granisetron did not show a statistically significant increase in tumor incidence, but the study was not conclusive. Because of the tumor findings in rat studies, KYTRIL Injection should be prescribed only at the dose and for the indication recommended [see INDICATIONS and DOSAGE AND ADMINISTRATION]. Granisetron was not mutagenic in an in vitro Ames test and mouse lymphoma cell forward mutation assay, and in vivo mouse micronucleus test and in vitro and ex vivo rat hepatocyte UDS assays. It, however, produced a significant increase in UDS in HeLa cells in vitro and a significant increased incidence of cells with polyploidy in an in vitro human lymphocyte chromosomal aberration test. Granisetron at subcutaneous doses up to 6 mg/kg/day (36 mg/m2/day, 97 times the recommended human dose based on body surface area) was found to have no effect on fertility and reproductive performance of male and female rats. Use In Specific Populations Pregnancy Pregnancy Category B Reproduction studies have been performed in pregnant rats at intravenous doses up to 9 mg/kg/day (54 mg/m2/day, 146 times the recommended human dose based on body surface area) and pregnant rabbits at intravenous doses up to 3 mg/kg/day (35.4 mg/m2/day, 96 times the recommended human dose based on body surface area) and have revealed no evidence of impaired fertility or harm to the fetus due to granisetron. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed. Benzyl alcohol may cross the placenta. KYTRIL Injection 1 mg/mL is preserved with benzyl alcohol and should be used in pregnancy only if the benefit outweighs the potential risk. Nursing Mothers It is not known whether granisetron is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when KYTRIL Injection is administered to a nursing woman. Pediatric Use Benzyl alcohol, a component of KYTRIL 1 mg/mL, has been associated with serious adverse reactions and death, particularly in neonates [see WARNINGS AND PRECAUTIONS]. Chemotherapy-Induced Nausea and Vomiting [See DOSAGE AND ADMINISTRATION] for use in chemotherapy-induced nausea and vomiting in pediatric patients 2 to 16 years of age. Safety and effectiveness in pediatric patients under 2 years of age have not been established. Postoperative Nausea and Vomiting Safety and efficacy have not been established in pediatric patients for the prevention of postoperative nausea and vomiting (PONV). Granisetron has been evaluated in a pediatric patient clinical trial for use in the prevention of PONV. Due to the lack of efficacy and the QT prolongation observed in this trial, use of granisetron for the prevention of PONV in children is not recommended. The trial was a prospective, multicenter, randomized, double-blind, parallel-group trial that evaluated 157 children aged 2 to 16 years who were undergoing elective surgery for tonsillectomy or adenotonsillectomy. The purpose of the trial was to assess two dose levels (20 mcg/kg and 40 mcg/kg) of intravenous granisetron in the prevention of PONV. There was no active comparator or placebo. The primary endpoint was total control of nausea and vomiting (defined as no nausea, vomiting/retching, or use of rescue medication) in the 24 hours following surgery. Efficacy was not established due to lack of a dose response. The trial also included standard 12 lead ECGs performed pre-dose and after the induction of anesthesia. ECGs were repeated at the end of surgery after the administration of granisetron and just prior to reversal of anesthesia. QT prolongation was seen at both dose levels. Five patients in this trial experienced an increase of ≥ 60 msec in QTcF. In addition, there were two patients whose QTcF was ≥ 500 msec. Interpretation of the QTcF prolongation was confounded by multiple factors, including the use of concomitant medication and the lack of either a placebo or active control. A thorough QT trial in adults has not been performed. Other adverse events that occurred in the study included: vomiting (5-8%), post-procedural hemorrhage (3-5%), and dehydration (0-5%). Pediatric patients under 2 years of age have not been studied. Geriatric Use During chemotherapy clinical trials, 713 patients 65 years of age or older received KYTRIL Injection. The safety and effectiveness were similar in patients of various ages. During postoperative nausea and vomiting clinical trials, 168 patients 65 years of age or older, of which 47 were 75 years of age or older, received KYTRIL Injection. Clinical studies of KYTRIL Injection did not include sufficient numbers of subjects aged 65 years and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients.