Dexrazoxane: Difference between revisions

Dexrazoxane
	Adult Indications & Dosage
	Pediatric Indications & Dosage
	Contraindications
	Warnings & Precautions
	Adverse Reactions
	Drug Interactions
	Use in Specific Populations
	Administration & Monitoring
	Overdosage
	Pharmacology
	Clinical Studies
	How Supplied
	Images
	Patient Counseling Information
	Precautions with Alcohol
	Brand Names
	Look-Alike Names

VisualWikitext

Latest revision as of 22:15, 2 March 2015

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aparna Vuppala, M.B.B.S. [2]

Disclaimer

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Overview

Dexrazoxane is an antineopalstic agent that is FDA approved for the treatment of reducing the incidence and severity of cardiomyopathy associated with doxorubicin administration in women with metastatic breast cancer. Common adverse reactions include alopecia, Nausea, Vomiting, fatigue/Malaise, anorexia, stomatitis, fever, infection, diarrhea, Pain at injection site, sepsis, neurotoxicity, hemorrhage, extravasation, streaking/Erythema, phlebitis, esophagitis, dysphagia..

Adult Indications and Dosage

FDA-Labeled Indications and Dosage (Adult)

Cardiomyopathy

Dexrazoxane for injection is indicated for reducing the incidence and severity of cardiomyopathy associated with doxorubicin administration in women with metastatic breast cancer who have received a cumulative doxorubicin dose of 300 mg/m2 and who will continue to receive doxorubicin therapy to maintain tumor control. Do not use with the initiation of doxorubicin therapy

Recommended Dose

Administer dexrazoxane for injection by slow I.V. push or rapid drip intravenous infusion from a bag.
The recommended dosage ratio of dexrazoxane for injection to doxorubicin is 10:1 (e.g., 500 mg/m2 dexrazoxane for injection to 50 mg/m2 doxorubicin). Do not administer doxorubicin before dexrazoxane for injection. Administer doxorubicin within 30 minutes after the completion of dexrazoxane for injection infusion.

Dose Modifications

Dosing in Patients with Renal Impairment

Reduce dexrazoxane for injection dosage in patients with moderate to severe renal impairment (creatinine clearance values less than 40 mL/min) by 50% (dexrazoxane for injection to doxorubicin ratio reduced to 5:1; such as 250 mg/m2 dexrazoxane for injection to 50 mg/m2 doxorubicin) .

Dosing in Patients with Hepatic Impairment

Since a doxorubicin dose reduction is recommended in the presence of hyperbilirubinemia, reduce the dexrazoxane for injection dosage proportionately (maintaining the 10:1 ratio) in patients with hepatic impairment.

Preparation and Administration

Preparation and Handling of Infusion Solution

Dexrazoxane for injection must be reconstituted with 0.167 Molar (M/6) sodium lactate injection, USP, to give a concentration of 10 mg dexrazoxane for injection for each mL of sodium lactate. The reconstituted solution should be given by slow I.V. push or rapid drip intravenous infusion from a bag. After completing the infusion of dexrazoxane for injection, and prior to a total elapsed time of 30 minutes (from the beginning of the dexrazoxane for injection infusion), the intravenous injection of doxorubicin should be given.
Reconstituted dexrazoxane for injection, when transferred to an empty infusion bag, is stable for 6 hours from the time of reconstitution when stored at controlled room temperature, 20° to 25°C (68° to 77°F) or under refrigeration, 2° to 8°C (36° to 46°F). DISCARD UNUSED SOLUTIONS.
The reconstituted dexrazoxane for injection solution may be diluted with either 0.9% Sodium Chloride Injection, USP or 5% Dextrose Injection, USP to a concentration range of 1.3 to 5 mg/mL in intravenous infusion bags. The resultant solutions are stable for 6 hours when stored at controlled room temperature, 20° to 25°C (68° to 77°F) or under refrigeration, 2° to 8°C (36° to 46°F). DISCARD UNUSED SOLUTIONS.
Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Solutions containing a precipitate should be discarded.
Use caution when handling and preparing the reconstituted solution. The use of gloves is recommended. If dexrazoxane for injection powder or solutions contact the skin or mucosae, wash exposed area immediately and thoroughly with soap and water. Follow special handling and disposal procedures.

Administration

Do not mix dexrazoxane for injection with other drugs.
The reconstituted solution should be given by slow I.V. push or rapid drip intravenous infusion from a bag. After completing the infusion of dexrazoxane for injection, and prior to a total elapsed time of 30 minutes (from the beginning of the dexrazoxane for injection infusion), the intravenous injection of doxorubicin should be given.

Off-Label Use and Dosage (Adult)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Dexrazoxane in adult patients.

Non–Guideline-Supported Use

There is limited information regarding Off-Label Non–Guideline-Supported Use of dexrazoxane in adult patients.

Pediatric Indications and Dosage

FDA-Labeled Indications and Dosage (Pediatric)

There is limited information regarding Dexrazoxane FDA-Labeled Indications and Dosage (Pediatric) in the drug label.

Off-Label Use and Dosage (Pediatric)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Dexrazoxane in pediatric patients.

Non–Guideline-Supported Use

There is limited information regarding Off-Label Non–Guideline-Supported Use of Dexrazoxane in pediatric patients.

Contraindications

Do not use dexrazoxane for injection with non-anthracycline chemotherapy regimens.

Warnings

Myelosuppression

Dexrazoxane for injection may add to the myelosuppression caused by chemotherapeutic agents. Obtain a complete blood count prior to and during each course of therapy, and administer dexrazoxane for injection and chemotherapy only when adequate hematologic parameters are met.

Concomitant Chemotherapy

Only use dexrazoxane for injection in those patients who have received a cumulative doxorubicin dose of 300 mg/m2 and are continuing with doxorubicin therapy. Do not use with chemotherapy initiation as dexrazoxane for injection may interfere with the antitumor activity of the chemotherapy regimen. In a trial conducted in patients with metastatic breast cancer who were treated with fluorouracil, doxorubicin, and cyclophosphamide (FAC) with or without dexrazoxane for injection starting with their first cycle of FAC therapy, patients who were randomized to receive dexrazoxane for injection had a lower response rate (48% vs. 63%) and shorter time to progression than patients who were randomized to receive placebo.

Cardiac Toxicity

Treatment with dexrazoxane for injection does not completely eliminate the risk of anthracycline-induced cardiac toxicity. Monitor cardiac function before and periodically during therapy to assess left ventricular ejection fraction (LVEF). In general, if test results indicate deterioration in cardiac function associated with doxorubicin, the benefit of continued therapy should be carefully evaluated against the risk of producing irreversible cardiac damage.

Secondary Malignancies

Secondary malignancies such as acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) have been reported in studies of pediatric patients who have received dexrazoxane for injection in combination with chemotherapy. Dexrazoxane for injection is not indicated for use in pediatric patients. Some adult patients who received dexrazoxane for injection in combination with anti-cancer agents known to be carcinogenic have also developed secondary malignancies, including AML and MDS.

Razoxane is the racemic mixture, of which dexrazoxane is the S(+)-enantiomer. Secondary malignancies (primarily acute myeloid leukemia) have been reported in patients treated chronically with oral razoxane. In these patients, the total cumulative dose of razoxane ranged from 26 grams to 480 grams and the duration of treatment was from 42 to 319 weeks. One case of T-cell lymphoma, one case of B-cell lymphoma, and six to eight cases of cutaneous basal cell or squamous cell carcinoma have also been reported in patients treated with razoxane. Long-term administration of razoxane to rodents was associated with the development of malignancies .

Embryo-Fetal Toxicity

Dexrazoxane for injection can cause fetal harm when administered to pregnant women. Dexrazoxane administration during the period of organogenesis resulted in maternal toxicity, embryotoxicity and teratogenicity in rats and rabbits at doses significantly lower than the clinically recommended dose. 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 hazard to a fetus.
Advise female patients of reproductive potential to avoid becoming pregnant and to use highly effective contraception during treatment

Adverse Reactions

Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, the adverse reaction rates observed cannot be directly compared to rates in other trials and may not reflect the rates observed in clinical practice.

The adverse reaction profile described in this section was identified from randomized, placebo-controlled, double-blind studies in patients with metastatic breast cancer who received the combination of the FAC chemotherapy regimen with or without dexrazoxane for injection. The dose of doxorubicin was 50 mg/m2 in each of these trials. Treatment was administered every three weeks until disease progression or cardiac toxicity.

Patients in clinical trials who received FAC with dexrazoxane for injection experienced more severe leukopenia, granulocytopenia, and thrombocytopenia than patients receiving FAC without dexrazoxane for injection .

Table 1 below lists the incidence of adverse reactions for patients receiving FAC with either dexrazoxane for injection or placebo in the breast cancer studies. Adverse experiences occurring during courses 1 through 6 are displayed for patients receiving dexrazoxane for injection or placebo with FAC beginning with their first course of therapy (columns 1 and 3, respectively). Adverse experiences occurring at course 7 and beyond for patients who received placebo with FAC during the first six courses and who then received either dexrazoxane for injection or placebo with FAC are also displayed (columns 2 and 4, respectively).

The adverse reactions listed below in Table 1 demonstrate that the frequency of adverse reaction “Pain on Injection” has been greater for dexrazoxane for injection arm, as compared to placebo.

This image is provided by the National Library of Medicine.

Postmarketing Experience

There is limited information regarding Postmarketing Experience of dexrazoxane in the drug label.

Drug Interactions

No drug interactions have been identified

Use in Specific Populations

Pregnancy

Pregnancy Category (FDA): D There is no FDA guidance on usage of Dexrazoxane in women who are pregnant.
Pregnancy Category (AUS):

There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of dexrazoxane in women who are pregnant.

Labor and Delivery

There is no FDA guidance on use of dexrazoxane during labor and delivery.

Nursing Mothers

It is not known whether dexrazoxane or its metabolites are excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from dexrazoxane, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother..

Pediatric Use

The safety and effectiveness of dexrazoxane in pediatric patients have not been established .

Geriatic Use

Clinical studies of dexrazoxane for injection did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently than younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy..

Gender

Females of Reproductive Potential

Contraception

Dexrazoxane for injection can cause fetal harm when administered during pregnancy. Advise female patients of reproductive potential to use highly effective contraception during treatment.

Race

There is no FDA guidance on the use of dexrazoxane with respect to specific racial populations.

Renal Impairment

Greater exposure to dexrazoxane may occur in patients with compromised renal function. Reduce the dexrazoxane for injection dose by 50% in patients with creatinine clearance values < 40 mL/min.

Hepatic Impairment

There is no FDA guidance on the use of dexrazoxane in patients with hepatic impairment.

Females of Reproductive Potential and Males

There is no FDA guidance on the use of dexrazoxane in women of reproductive potentials and males.

Immunocompromised Patients

There is no FDA guidance one the use of dexrazoxane in patients who are immunocompromised.

Administration and Monitoring

Administration

Intravenous

Monitoring

Dexrazoxane may increase the myelosuppresive effects of chemotherapeutic agents. Perform hematological monitoring.

IV Compatibility

There is limited information regarding IV Compatibility of dexrazoxane in the drug label.

Overdosage

There are no data on overdosage in the cardioprotective trials; the maximum dose administered during the cardioprotective trials was 1000 mg/m2 every three weeks.
Disposition studies with dexrazoxane for injection have not been conducted in cancer patients undergoing dialysis, but retention of a significant dose fraction (> 0.4) of the unchanged drug in the plasma pool, minimal tissue partitioning or binding, and availability of greater than 90% of the systemic drug levels in the unbound form suggest that it could be removed using conventional peritoneal or hemodialysis.

There is no known antidote for dexrazoxane. Instances of suspected overdose should be managed with good supportive care until resolution of myelosuppression and related conditions is complete. Management of overdose should include treatment of infections, fluid regulation, and maintenance of nutritional requirements

Pharmacology

Mechanism of Action

The mechanism by which dexrazoxane for injection exerts its cytoprotective activity is not fully understood. Dexrazoxane is a cyclic derivative of EDTA that penetrates cell membranes. Results of laboratory studies suggest that dexrazoxane is converted intracellularly to a ring-opened chelating agent that interferes with iron-mediated free radical generation thought to be responsible, in part, for [[cardiomyopathy]|anthracycline-induced cardiomyopathy]].

Structure

Dexrazoxane for injection, a cardioprotective agent for use in conjunction with doxorubicin, is a sterile, pyrogen-free lyophilizate intended for intravenous administration.

Chemically, dexrazoxane is (S)-4,4'-(1-methyl-1,2-ethanediyl)bis-2,6-piperazinedione. The structural formula is as follows:

Dexrazoxane, an intracellular chelating agent, is a derivative of EDTA. Dexrazoxane is a whitish crystalline powder that melts at 191° to 197°C. It is sparingly soluble in water and 0.1 N HCl, slightly soluble in ethanol and methanol, and practically insoluble in nonpolar organic solvents. The pKa is 2.1. Dexrazoxane has an octanol/water partition coefficient of 0.025 and degrades rapidly above a pH of 7.0.

Each 250 mg vial contains dexrazoxane hydrochloride equivalent to 250 mg dexrazoxane. Hydrochloric Acid, NF is added for pH adjustment. When reconstituted as directed with the 25 mL vial of 0.167 Molar (M/6) Sodium Lactate Injection, USP diluent provided, each mL contains: 10 mg dexrazoxane. The pH of the resultant solution is 3.5 to 5.5.

Each 500 mg vial contains dexrazoxane hydrochloride equivalent to 500 mg dexrazoxane. Hydrochloric Acid, NF is added for pH adjustment. When reconstituted as directed with the 50 mL vial of 0.167 Molar (M/6) Sodium Lactate Injection, USP diluent provided, each mL contains: 10 mg dexrazoxane. The pH of the resultant solution is 3.5 to 5.5

Pharmacodynamics

There is limited information regarding Pharmacodynamics of dexrazoxane in the drug label.

Pharmacokinetics

The pharmacokinetics of dexrazoxane have been studied in advanced cancer patients with normal renal and hepatic function. The pharmacokinetics of dexrazoxane can be adequately described by a two-compartment open model with first-order elimination. Dexrazoxane has been administered as a 15 minute infusion over a dose range of 60 to 900 mg/m2 with 60 mg/m2 of doxorubicin, and at a fixed dose of 500 mg/m2 with 50 mg/m2 doxorubicin. The disposition kinetics of dexrazoxane are dose-independent, as shown by linear relationship between the area under plasma concentration-time curves and administered doses ranging from 60 to 900 mg/m2. The mean peak plasma concentration of dexrazoxane was 36.5 mcg/mL at 15 minute after intravenous administration of 500 mg/m2 dose of dexrazoxane for injection over 15 to 30 minutes prior to the 50 mg/m2 doxorubicin dose.

The important pharmacokinetic parameters of dexrazoxane are summarized in Table 2:

Distribution

Following a rapid distributive phase (0.2 to 0.3 hours), dexrazoxane reaches post-distributive equilibrium within 2 to 4 hours. The estimated mean steady-state volume of distribution of dexrazoxane is 22.4 L/m2 after 500 mg/m2 of dexrazoxane for injection dose followed by 50 mg/m2 of doxorubicin, suggesting distribution throughout total body water (25 L/m2).

In vitro studies have shown that dexrazoxane is not bound to plasma proteins.

Metabolism

Qualitative metabolism studies with dexrazoxane have confirmed the presence of unchanged drug, a diacid-diamide cleavage product, and two monoacid-monoamide ring products in the urine of animals and man. The metabolite levels were not measured in the pharmacokinetic studies.

Excretion

Urinary excretion plays an important role in the elimination of dexrazoxane. Forty-two percent of a 500 mg/m2 dose of dexrazoxane for injection was excreted in the urine. Renal clearance averages 3.35 L/h/m2 after the 500 mg/m2 dexrazoxane for injection dose followed by 50 mg/m2 of doxorubicin.

Specific Populations

Pediatric

Pharmacokinetics following dexrazoxane for injection administration have not been evaluated in pediatric patients.

Effect of Renal Impairment

The pharmacokinetics of dexrazoxane were assessed following a single 15 minute IV infusion of 150 mg/m2 of dexrazoxane for injection. Dexrazoxane clearance was reduced in subjects with renal dysfunction. Compared with controls, the mean AUC0-inf value was 2-fold greater in subjects with moderate (CLCR 30 to 50 mL/min) to severe (CLCR < 30 mL/min) renal dysfunction. Modeling demonstrated that equivalent exposure (AUC-inf) could be achieved if dosing were reduced by 50% in subjects with creatinine clearance values < 40 mL/min compared with control subjects (CLCR > 80 mL/min).

Effect of Hepatic Impairment

Pharmacokinetics following dexrazoxane for injection administration have not been evaluated in patients with hepatic impairment. The dexrazoxane for injection dose is dependent upon the dose of doxorubicin .

Drug Interactions

There was no significant change in the pharmacokinetics of doxorubicin (50 mg/m2) and its predominant metabolite, doxorubicin, in the presence of dexrazoxane (500 mg/m2) in a crossover study in cancer patients.

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment of Fertility

No long-term carcinogenicity studies have been carried out with dexrazoxane in animals. Nevertheless, a study by the National Cancer Institute has reported that long-term dosing with razoxane (the racemic mixture of dexrazoxane, ICRF-187, and its enantiomer ICRF-186) is associated with the development of malignancies in rats and possibly in mice.

Dexrazoxane was not mutagenic in the bacterial reverse mutation (Ames) test, but was found to be clastogenic to human lymphocytes in vitro and to mouse bone marrow erythrocytes in vivo(micronucleus test).

Dexrazoxane for injection has the potential to impair fertility in male patients based on effects in repeat-dose toxicology studies. Testicular atrophy was seen with dexrazoxane administration at doses as low as 30 mg/kg weekly for 6 weeks in rats (1/3 the human dose on a mg/m2 basis) and as low as 20 mg/kg weekly for 13 weeks in dogs (approximately equal to the human dose on a mg/m2 basis).

Clinical Studies

The ability of dexrazoxane for injection to prevent/reduce the incidence and severity of doxorubicin-induced cardiomyopathy was evaluated in three prospectively randomized placebo-controlled studies. In these studies, patients were treated with a doxorubicin-containing regimen and either dexrazoxane for injection or placebo starting with the first course of chemotherapy. There was no restriction on the cumulative dose of doxorubicin. Cardiac function was assessed by measurement of the LVEF, utilizing resting multigated nuclear medicine (MUGA) scans, and by clinical evaluations. Patients receiving dexrazoxane for injection had significantly smaller mean decreases from baseline in LVEF and lower incidences of congestive heart failure than the control group; however, in the largest study, patients with advanced breast cancer receiving FAC with dexrazoxane for injection had a lower response rate (48% vs. 63%) and a shorter time to progression than patients who received FAC versus placebo.

In the clinical trials, patients who were initially randomized to receive placebo were allowed to receive dexrazoxane for injection after a cumulative dose of doxorubicin above 300 mg/m2. Retrospective historical analyses showed that the risk of experiencing a cardiac event (see Table 3 for definition) at a cumulative dose of doxorubicin above 300 mg/m2 was greater in the patients who did not receive dexrazoxane for injection beginning with their seventh course of FAC than in the patients who did receive dexrazoxane for injection (HR=13.08; 95% CI: 3.72, 46.03; p < 0.001). Overall, 3% of patients treated with dexrazoxane for injection developed CHF compared with 22% of patients not receiving dexrazoxane for injection.

How Supplied

Dexrazoxane for Injection is available in the following strengths as sterile, pyrogen-free lyophilizates.
NDC 67457-207-25

250 mg single-dose vial with a green flip-top seal, packaged in single vial packs. (This package also contains a 25 mL vial of 0.167 Molar (M/6) Sodium Lactate Injection, USP.)

NDC 67457-208-50

500 mg single-dose vial with a blue flip-top seal, packaged in single vial packs. (This package also contains a 50 mL vial of 0.167 Molar (M/6) Sodium Lactate Injection, USP.)

Store at 20° to 25°C (68° to 77°F). [See USP Controlled Room Temperature.] Reconstituted solutions of dexrazoxane for injection are stable for 6 hours at controlled room temperature or under refrigeration, 2° to 8°C (36° to 46°F). DISCARD UNUSED SOLUTIONS.

Follow special handling and disposal procedures.

Storage

There is limited information regarding Dexrazoxane Storage in the drug label.

Images

Drug Images

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Package and Label Display Panel

{{#ask: Label Page::Dexrazoxane |?Label Name |format=template |template=DrugLabelImages |mainlabel=- |sort=Label Page }}

Patient Counseling Information

Myelosuppression

Treatment with dexrazoxane for injection is associated with leukopenia, neutropenia, and thrombocytopenia. Perform hematological monitoring

Embryo-Fetal Toxicity

Counsel patients on pregnancy planning and prevention. Advise female patients of reproductive potential that dexrazoxane for injection can cause fetal harm and to use highly effective contraception during treatment.

Precautions with Alcohol

Alcohol-dexrazoxane interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

Brand Names

Zinecard
Totect

Look-Alike Drug Names

There is limited information regarding Dexrazoxane Look-Alike Drug Names in the drug label.

Drug Shortage Status

Price

References

The contents of this FDA label are provided by the National Library of Medicine.

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+|drugClass=antineopalstic agent
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+|indication=reducing the incidence and severity of [[cardiomyopathy]] associated with [[doxorubicin]] administration in women with [[metastatic breast cancer]]
 |adverseReactions=[[alopecia]], [[Nausea]], [[Vomiting]], [[fatigue]]/[[Malaise]], [[anorexia]], [[stomatitis]], [[fever]], [[infection]], [[diarrhea]], [[Pain at injection site]], [[sepsis]], [[neurotoxicity]], [[hemorrhage]], [[extravasation]], [[streaking]]/[[Erythema]], [[phlebitis]], [[esophagitis]], [[dysphagia]].
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+|fdaLIADAdult=
+=====Cardiomyopathy=====
 *Dexrazoxane for injection is indicated for reducing the incidence and severity of [[cardiomyopathy]] associated with [[doxorubicin]] administration in women with [[metastatic breast cancer]] who have received a cumulative [[doxorubicin]] dose of 300 mg/m2 and who will continue to receive [[doxorubicin]] therapy to maintain tumor control. Do not use with the initiation of [[doxorubicin]] therapy
 =====Recommended Dose=====
@@ Line 36: / Line 37: @@
 ======Preparation and Handling of Infusion Solution======
-*Dexrazoxane for injection must be reconstituted with 0.167 Molar (M/6) sodium lactate injection, USP, to give a concentration of 10 mg dexrazoxane for injection for each mL of sodium lactate. The reconstituted solution should be given by slow I.V. push or rapid drip intravenous infusion from a bag. After completing the infusion of dexrazoxane for injection, and prior to a total elapsed time of 30 minutes (from the beginning of the dexrazoxane for injection infusion), the intravenous injection of [[doxorubicin]] should be given.
+*Dexrazoxane for injection must be reconstituted with 0.167 Molar (M/6) [[sodium lactate]] injection, USP, to give a concentration of 10 mg dexrazoxane for injection for each mL of [[sodium lactate]]. The reconstituted solution should be given by slow I.V. push or rapid drip intravenous infusion from a bag. After completing the infusion of dexrazoxane for injection, and prior to a total elapsed time of 30 minutes (from the beginning of the dexrazoxane for injection infusion), the intravenous injection of [[doxorubicin]] should be given.
 *Reconstituted dexrazoxane for injection, when transferred to an empty infusion bag, is stable for 6 hours from the time of reconstitution when stored at controlled room temperature, 20° to 25°C (68° to 77°F) or under refrigeration, 2° to 8°C (36° to 46°F). DISCARD UNUSED SOLUTIONS.
-*The reconstituted dexrazoxane for injection solution may be diluted with either 0.9% Sodium Chloride Injection, USP or 5% Dextrose Injection, USP to a concentration range of 1.3 to 5 mg/mL in intravenous infusion bags. The resultant solutions are stable for 6 hours when stored at controlled room temperature, 20° to 25°C (68° to 77°F) or under refrigeration, 2° to 8°C (36° to 46°F). DISCARD UNUSED SOLUTIONS.
+*The reconstituted dexrazoxane for injection solution may be diluted with either [[saline|0.9% Sodium Chloride]] Injection, USP or 5% Dextrose Injection, USP to a concentration range of 1.3 to 5 mg/mL in intravenous infusion bags. The resultant solutions are stable for 6 hours when stored at controlled room temperature, 20° to 25°C (68° to 77°F) or under refrigeration, 2° to 8°C (36° to 46°F). DISCARD UNUSED SOLUTIONS.
 *Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Solutions containing a precipitate should be discarded.
-*Use caution when handling and preparing the reconstituted solution. The use of gloves is recommended. If dexrazoxane for injection powder or solutions contact the skin or mucosae, wash exposed area immediately and thoroughly with soap and water. Follow special handling and disposal procedures.1
+*Use caution when handling and preparing the reconstituted solution. The use of gloves is recommended. If dexrazoxane for injection powder or solutions contact the skin or mucosae, wash exposed area immediately and thoroughly with soap and water. Follow special handling and disposal procedures.
 =====Administration=====
 *Do not mix dexrazoxane for injection with other drugs.
 *The reconstituted solution should be given by slow I.V. push or rapid drip intravenous infusion from a bag. After completing the infusion of dexrazoxane for injection, and prior to a total elapsed time of 30 minutes (from the beginning of the dexrazoxane for injection infusion), the intravenous injection of [[doxorubicin]] should be given.
 <!--Off-Label Use and Dosage (Adult)-->
 <!--Guideline-Supported Use (Adult)-->
-|offLabelAdultGuideSupport
+|offLabelAdultGuideSupport=There is limited information regarding <i>Off-Label Guideline-Supported Use</i> of Dexrazoxane in adult patients.
-There is limited information regarding <i>Off-Label Guideline-Supported Use</i> of dexrazoxane  in adult patients.
+|offLabelAdultNoGuideSupport=There is limited information regarding <i>Off-Label Non–Guideline-Supported Use</i> of dexrazoxane  in adult patients.
-<!--Non–Guideline-Supported Use (Adult)-->
-|offLabelAdultNoGuideSupport======Condition1=====
-* Dosing Information
-:* Dosage
-=====Condition2=====
-There is limited information regarding <i>Off-Label Non–Guideline-Supported Use</i> of dexrazoxane  in adult patients.
 <!--Pediatric Indications and Dosage-->
 <!--FDA-Labeled Indications and Dosage (Pediatric)-->
-|fdaLIADPed *The safety and effectiveness of dexrazoxane in pediatric patients have not been established
+|offLabelPedGuideSupport=There is limited information regarding <i>Off-Label Guideline-Supported Use</i> of Dexrazoxane in pediatric patients.
-<!--Off-Label Use and Dosage (Pediatric)-->
+|offLabelPedNoGuideSupport=There is limited information regarding <i>Off-Label Non–Guideline-Supported Use</i> of Dexrazoxane in pediatric patients.
-<!--Guideline-Supported Use (Pediatric)-->
-|offLabelPedGuideSupport *The safety and effectiveness of dexrazoxane in pediatric patients have not been established
-<!--Non–Guideline-Supported Use (Pediatric)-->
-|offLabelPedNoGuideSupport *The safety and effectiveness of dexrazoxane in pediatric patients have not been established
-<!--Contraindications-->
 |contraindications=* Do not use dexrazoxane for injection with non-anthracycline chemotherapy regimens.
 <!--Warnings-->
 |warnings=
 =====Myelosuppression=====
-*Dexrazoxane for injection may add to the [[myelosuppression]] caused by chemotherapeutic agents. Obtain a complete blood count prior to and during each course of therapy, and administer dexrazoxane for injection and chemotherapy only when adequate hematologic parameters are met.
+*Dexrazoxane for injection may add to the [[myelosuppression]] caused by [[chemotherapeutic agents]]. Obtain a complete blood count prior to and during each course of therapy, and administer dexrazoxane for injection and [[chemotherapy]] only when adequate hematologic parameters are met.
 =====Concomitant Chemotherapy=====
-*Only use dexrazoxane for injection in those patients who have received a cumulative [[doxorubicin]] dose of 300 mg/m2 and are continuing with [[doxorubicin]] therapy. Do not use with chemotherapy initiation as dexrazoxane for injection may interfere with the antitumor activity of the chemotherapy regimen. In a trial conducted in patients with [[metastatic breast cancer]] who were treated with [[fluorouracil]], [[doxorubicin]], and [[cyclophosphamide]] (FAC) with or without dexrazoxane for injection starting with their first cycle of FAC therapy, patients who were randomized to receive dexrazoxane for injection had a lower response rate (48% vs. 63%) and shorter time to progression than patients who were randomized to receive placebo.
+*Only use dexrazoxane for injection in those patients who have received a cumulative [[doxorubicin]] dose of 300 mg/m2 and are continuing with [[doxorubicin]] therapy. Do not use with chemotherapy initiation as dexrazoxane for injection may interfere with the antitumor activity of the [[chemotherapy regimen]]. In a trial conducted in patients with [[metastatic breast cancer]] who were treated with [[fluorouracil]], [[doxorubicin]], and [[cyclophosphamide]] (FAC) with or without dexrazoxane for injection starting with their first cycle of FAC therapy, patients who were randomized to receive dexrazoxane for injection had a lower response rate (48% vs. 63%) and shorter time to progression than patients who were randomized to receive placebo.
 =====Cardiac Toxicity=====
-*Treatment with dexrazoxane for injection does not completely eliminate the risk of [[anthracycline]]-induced cardiac toxicity. Monitor cardiac function before and periodically during therapy to assess left [[ventricular ejection fraction]] ([[LVEF]]). In general, if test results indicate deterioration in cardiac function associated with [[doxorubicin]], the benefit of continued therapy should be carefully evaluated against the risk of producing irreversible cardiac damage.
+*Treatment with dexrazoxane for injection does not completely eliminate the risk of [[anthracycline|anthracycline-induced cardiac toxicity]]. Monitor cardiac function before and periodically during therapy to assess [[LEVF|left ventricular ejection fraction]] ([[LVEF]]). In general, if test results indicate deterioration in cardiac function associated with [[doxorubicin]], the benefit of continued therapy should be carefully evaluated against the risk of producing irreversible cardiac damage.
 =====Secondary Malignancies=====
-*Secondary malignancies such as [[acute myeloid leukemia]] (AML) and [[myelodysplastic syndrome]] (MDS) have been reported in studies of pediatric patients who have received dexrazoxane for injection in combination with chemotherapy. Dexrazoxane for injection is not indicated for use in pediatric patients. Some adult patients who received dexrazoxane for injection in combination with anti-cancer agents known to be carcinogenic have also developed secondary malignancies, including [[AML]] and [[MDS]].
+*Secondary malignancies such as [[acute myeloid leukemia]] (AML) and [[myelodysplastic syndrome]] (MDS) have been reported in studies of pediatric patients who have received dexrazoxane for injection in combination with [[chemotherapy]]. Dexrazoxane for injection is not indicated for use in pediatric patients. Some adult patients who received dexrazoxane for injection in combination with [[chemotherapy|anti-cancer agents]] known to be carcinogenic have also developed secondary malignancies, including [[AML]] and [[MDS]].
-*[[Razoxane]] is the racemic mixture, of which dexrazoxane is the S(+)-enantiomer. Secondary malignancies (primarily [[acute myeloid leukemia]]) have been reported in patients treated chronically with oral razoxane. In these patients, the total cumulative dose of [[razoxane]] ranged from 26 grams to 480 grams and the duration of treatment was from 42 to 319 weeks. One case of [[T-cell lymphoma]], one case of [[B-cell lymphoma]], and six to eight cases of [[cutaneous basal cell]] or [[squamous cell carcinoma]] have also been reported in patients treated with razoxane. Long-term administration of [[razoxane]] to rodents was associated with the development of malignancies .
+*[[Razoxane]] is the racemic mixture, of which dexrazoxane is the S(+)-enantiomer. Secondary malignancies (primarily [[acute myeloid leukemia]]) have been reported in patients treated chronically with oral [[razoxane]]. In these patients, the total cumulative dose of [[razoxane]] ranged from 26 grams to 480 grams and the duration of treatment was from 42 to 319 weeks. One case of [[T-cell lymphoma]], one case of [[B-cell lymphoma]], and six to eight cases of [[cutaneous basal cell]] or [[squamous cell carcinoma]] have also been reported in patients treated with razoxane. Long-term administration of [[razoxane]] to rodents was associated with the development of malignancies .
 =====Embryo-Fetal Toxicity=====
-*Dexrazoxane for injection can cause fetal harm when administered to pregnant women. Dexrazoxane administration during the period of organogenesis resulted in maternal toxicity, embryotoxicity and teratogenicity in rats and rabbits at doses significantly lower than the clinically recommended dose. 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 hazard to a fetus.
+*Dexrazoxane for injection can cause fetal harm when administered to pregnant women. Dexrazoxane administration during the period of [[organogenesis]] resulted in maternal toxicity, [[embryotoxicity]] and [[teratogenicity]] in rats and rabbits at doses significantly lower than the clinically recommended dose. 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 hazard to a fetus.
-*Advise female patients of reproductive potential to avoid becoming pregnant and to use highly effective contraception during treatment
+*Advise female patients of reproductive potential to avoid becoming pregnant and to use highly effective [[contraception]] during treatment
 <!--Adverse Reactions-->
 <!--Clinical Trials Experience-->
+|clinicalTrials=*Because clinical trials are conducted under widely varying conditions, the adverse reaction rates observed cannot be directly compared to rates in other trials and may not reflect the rates observed in clinical practice.
-|clinicalTrials=
+*The adverse reaction profile described in this section was identified from randomized, placebo-controlled, double-blind studies in patients with [[breast cancer|metastatic breast cancer]] who received the combination of the FAC [[chemotherapy]] regimen with or without dexrazoxane for injection. The dose of [[doxorubicin]] was 50 mg/m2 in each of these trials. Treatment was administered every three weeks until disease progression or cardiac toxicity.
-*Because clinical trials are conducted under widely varying conditions, the adverse reaction rates observed cannot be directly compared to rates in other trials and may not reflect the rates observed in clinical practice.
-*The adverse reaction profile described in this section was identified from randomized, placebo-controlled, double-blind studies in patients with metastatic breast cancer who received the combination of the FAC chemotherapy regimen with or without dexrazoxane for injection. The dose of [[doxorubicin]] was 50 mg/m2 in each of these trials. Treatment was administered every three weeks until disease progression or cardiac toxicity.
 *Patients in clinical trials who received FAC with dexrazoxane for injection experienced more severe [[leukopenia]], [[granulocytopenia]], and [[thrombocytopenia]] than patients receiving FAC without dexrazoxane for injection .
-*Table 1 below lists the incidence of adverse reactions for patients receiving FAC with either dexrazoxane for injection or placebo in the breast cancer studies. Adverse experiences occurring during courses 1 through 6 are displayed for patients receiving dexrazoxane for injection or placebo with FAC beginning with their first course of therapy (columns 1 and 3, respectively). Adverse experiences occurring at course 7 and beyond for patients who received placebo with FAC during the first six courses and who then received either dexrazoxane for injection or placebo with FAC are also displayed (columns 2 and 4, respectively).
+*Table 1 below lists the incidence of adverse reactions for patients receiving FAC with either dexrazoxane for injection or placebo in the [[breast cancer]] studies. Adverse experiences occurring during courses 1 through 6 are displayed for patients receiving dexrazoxane for injection or placebo with FAC beginning with their first course of therapy (columns 1 and 3, respectively). Adverse experiences occurring at course 7 and beyond for patients who received placebo with FAC during the first six courses and who then received either dexrazoxane for injection or placebo with FAC are also displayed (columns 2 and 4, respectively).
 *The adverse reactions listed below in Table 1 demonstrate that the frequency of adverse reaction “Pain on Injection” has been greater for dexrazoxane for injection arm, as compared to placebo.
-[[File:Dexrazoxane02.png|thumb|none|600px|This image is provided by the National Library of Medicine.]]
+[[File:Dexrazoxane02.png|thumb|none|400px|This image is provided by the National Library of Medicine.]]
 <!--Postmarketing Experience-->
 |postmarketing=There is limited information regarding <i>Postmarketing Experience</i> of dexrazoxane  in the drug label.
 <!--Drug Interactions-->
-|drugInteractions=
+|drugInteractions=* No drug interactions have been identified
-* No drug interactions have been identified
 <!--Use in Specific Populations-->
-|useInPregnancyFDA D
+|FDAPregCat=D
-=====Risk Summary=====
-*Dexrazoxane for injection can cause fetal harm when administered to pregnant women. Dexrazoxane administration resulted in maternal toxicity, embryotoxicity and teratogenicity in rats and rabbits at doses significantly lower than the clinically recommended dose. 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 hazard to a fetus .
-=====Animal Data=====
-*Dexrazoxane resulted in maternal toxicity in rats at doses of ≥ 2 mg/kg (1/40 the human dose on a mg/m2 basis) and embryotoxicity and teratogenicity at 8 mg/kg (approximately 1/10 the human dose on a mg/m2 basis) when given daily to pregnant rats during the period of organogenesis. Teratogenic effects in the rat included [[imperforate anus]], [[microphthalmia]], and anophthalmia. In offspring allowed to develop to maturity, fertility was impaired in the male and female rats treated in utero during organogenesis at 8 mg/kg. In rabbits, doses of ≥ 5 mg/kg (approximately 1/10 the human dose on a mg/m2 basis) daily during the period of organogenesis caused maternal toxicity and doses of 20 mg/kg (1/2 the human dose on a mg/m2 basis) were embryotoxic and teratogenic. Teratogenic effects in the rabbit included several skeletal malformations such as short tail, rib and thoracic malformations, and soft tissue variations including subcutaneous, eye and cardiac hemorrhagic areas, as well as agenesis of the gallbladder and of the intermediate lobe of the lung.
 |useInPregnancyAUS=*There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of dexrazoxane  in women who are pregnant.
 |useInLaborDelivery=There is no FDA guidance on use of dexrazoxane  during labor and delivery.
-|useInNursing=*It is not known whether dexrazoxane or its metabolites are excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from dexrazoxane, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother..
+|useInNursing=*It is not known whether dexrazoxane or its metabolites are excreted in [[Breast milk|human milk]]. Because many drugs are excreted in [[Breast milk|human milk]] and because of the potential for serious adverse reactions in nursing infants from dexrazoxane, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother..
 |useInPed=*The safety and effectiveness of dexrazoxane in pediatric patients have not been established .
 |useInGeri=*Clinical studies of dexrazoxane for injection did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently than younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy..
 |useInGender=
 =====Females of Reproductive Potential=====
-*Contraception
+*[[Contraception]]
-:*Dexrazoxane for injection can cause fetal harm when administered during pregnancy. Advise female patients of reproductive potential to use highly effective contraception during treatment.
+:*Dexrazoxane for injection can cause fetal harm when administered during pregnancy. Advise female patients of reproductive potential to use highly effective [[contraception]] during treatment.
 |useInRace=There is no FDA guidance on the use of dexrazoxane  with respect to specific racial populations.
-|useInRenalImpair=*Greater exposure to dexrazoxane may occur in patients with compromised renal function. Reduce the dexrazoxane for injection dose by 50% in patients with [[creatinine]] clearance values < 40 mL/min.
+|useInRenalImpair=*Greater exposure to dexrazoxane may occur in patients with compromised renal function. Reduce the dexrazoxane for injection dose by 50% in patients with [[creatinine clearance]] values < 40 mL/min.
-|useInHepaticImpair=There is no FDA guidance on the use of dexrazoxane  in patients with hepatic impairment.
+|useInHepaticImpair=There is no FDA guidance on the use of dexrazoxane  in patients with [[hepatic impairment]].
 |useInReproPotential=There is no FDA guidance on the use of dexrazoxane  in women of reproductive potentials and males.
 |useInImmunocomp=There is no FDA guidance one the use of dexrazoxane  in patients who are [[immunocompromised]].
 <!--Administration and Monitoring-->
-|administration=* Oral
+|administration=* Intravenous
+|monitoring=*Dexrazoxane may increase the myelosuppresive effects of chemotherapeutic agents. Perform hematological monitoring.
-* Intravenous
-|monitoring=There is limited information regarding <i>Monitoring</i> of dexrazoxane  in the drug label.
-* Description
 <!--IV Compatibility-->
@@ Line 172: / Line 131: @@
 <!--Overdosage-->
 |overdose=*There are no data on overdosage in the cardioprotective trials; the maximum dose administered during the cardioprotective trials was 1000 mg/m2 every three weeks.
-*Disposition studies with dexrazoxane for injection have not been conducted in cancer patients undergoing dialysis, but retention of a significant dose fraction (> 0.4) of the unchanged drug in the plasma pool, minimal tissue partitioning or binding, and availability of greater than 90% of the systemic drug levels in the unbound form suggest that it could be removed using conventional peritoneal or hemodialysis.
+*Disposition studies with dexrazoxane for injection have not been conducted in cancer patients undergoing [[dialysis]], but retention of a significant dose fraction (> 0.4) of the unchanged drug in the plasma pool, minimal tissue partitioning or binding, and availability of greater than 90% of the systemic drug levels in the unbound form suggest that it could be removed using conventional peritoneal or [[hemodialysis]].
-*There is no known antidote for dexrazoxane. Instances of suspected overdose should be managed with good supportive care until resolution of [[myelosuppression]] and related conditions is complete. Management of overdose should include treatment of infections, fluid regulation, and maintenance of nutritional requirements
+*There is no known antidote for dexrazoxane. Instances of suspected overdose should be managed with good supportive care until resolution of [[myelosuppression]] and related conditions is complete. Management of overdose should include treatment of [[infections]], fluid regulation, and maintenance of nutritional requirements
 <!--Pharmacology-->
 <!--Drug box 2-->
-|drugBox=[[File:Dexrazoxane00.png|thumb|none|600px|This image is provided by the National Library of Medicine.]]
+|drugBox=[[File:Dexrazoxane00.png|thumb|none|400px|This image is provided by the National Library of Medicine.]]
 <!--Mechanism of Action-->
-|mechAction=*The mechanism by which dexrazoxane for injection exerts its cytoprotective activity is not fully understood. Dexrazoxane is a cyclic derivative of EDTA that penetrates cell membranes. Results of laboratory studies suggest that dexrazoxane is converted intracellularly to a ring-opened chelating agent that interferes with iron-mediated free radical generation thought to be responsible, in part, for [[anthracycline]]-induced [[cardiomyopathy]].
+|mechAction=*The mechanism by which dexrazoxane for injection exerts its cytoprotective activity is not fully understood. Dexrazoxane is a cyclic derivative of [[EDTA]] that penetrates cell membranes. Results of laboratory studies suggest that dexrazoxane is converted intracellularly to a ring-opened [[chelating agent]] that interferes with iron-mediated free radical generation thought to be responsible, in part, for [[cardiomyopathy]|anthracycline-induced cardiomyopathy]].
 <!--Structure-->
@@ Line 190: / Line 148: @@
 Chemically, dexrazoxane is (S)-4,4'-(1-methyl-1,2-ethanediyl)bis-2,6-piperazinedione. The structural formula is as follows:
-: [[File:Dexrazoxane01.png|thumb|none|600px|This image is provided by the National Library of Medicine.]]
+: [[File:Dexrazoxane01.png|thumb|none|400px|This image is provided by the National Library of Medicine.]]
-*Dexrazoxane, an intracellular chelating agent, is a derivative of [[EDTA]]. Dexrazoxane is a whitish crystalline powder that melts at 191° to 197°C. It is sparingly soluble in water and 0.1 N HCl, slightly soluble in ethanol and methanol, and practically insoluble in nonpolar organic solvents. The pKa is 2.1. Dexrazoxane has an octanol/water partition coefficient of 0.025 and degrades rapidly above a pH of 7.0.
+*Dexrazoxane, an [[chelating agent|intracellular chelating agent]], is a derivative of [[EDTA]]. Dexrazoxane is a whitish crystalline powder that melts at 191° to 197°C. It is sparingly soluble in water and 0.1 N HCl, slightly soluble in [[ethanol]] and [[methanol]], and practically insoluble in nonpolar organic solvents. The pKa is 2.1. Dexrazoxane has an octanol/water partition coefficient of 0.025 and degrades rapidly above a pH of 7.0.
 *Each 250 mg vial contains dexrazoxane hydrochloride equivalent to 250 mg dexrazoxane. Hydrochloric Acid, NF is added for pH adjustment. When reconstituted as directed with the 25 mL vial of 0.167 Molar (M/6) Sodium Lactate Injection, USP diluent provided, each mL contains: 10 mg dexrazoxane. The pH of the resultant solution is 3.5 to 5.5.
-*Each 500 mg vial contains dexrazoxane hydrochloride equivalent to 500 mg dexrazoxane. Hydrochloric Acid, NF is added for pH adjustment. When reconstituted as directed with the 50 mL vial of 0.167 Molar (M/6) Sodium Lactate Injection, USP diluent provided, each mL contains: 10 mg dexrazoxane. The pH of the resultant solution is 3.5 to 5.5
+*Each 500 mg vial contains dexrazoxane hydrochloride equivalent to 500 mg dexrazoxane. Hydrochloric Acid, NF is added for pH adjustment. When reconstituted as directed with the 50 mL vial of 0.167 Molar (M/6) [[Sodium Lactate]] Injection, USP diluent provided, each mL contains: 10 mg dexrazoxane. The [[pH]] of the resultant solution is 3.5 to 5.5
 <!--Pharmacodynamics-->
 |PD=There is limited information regarding <i>Pharmacodynamics</i> of dexrazoxane  in the drug label.
 <!--Pharmacokinetics-->
-|PK=*The pharmacokinetics of dexrazoxane have been studied in advanced cancer patients with normal renal and hepatic function. The pharmacokinetics of dexrazoxane can be adequately described by a two-compartment open model with first-order elimination. Dexrazoxane has been administered as a 15 minute infusion over a dose range of 60 to 900 mg/m2 with 60 mg/m2 of [[doxorubicin]], and at a fixed dose of 500 mg/m2 with 50 mg/m2 [[doxorubicin]]. The disposition kinetics of dexrazoxane are dose-independent, as shown by linear relationship between the area under plasma concentration-time curves and administered doses ranging from 60 to 900 mg/m2. The mean peak plasma concentration of dexrazoxane was 36.5 mcg/mL at 15 minute after intravenous administration of 500 mg/m2 dose of dexrazoxane for injection over 15 to 30 minutes prior to the 50 mg/m2 [[doxorubicin]] dose.
+|PK=*The pharmacokinetics of dexrazoxane have been studied in advanced cancer patients with normal renal and hepatic function. The pharmacokinetics of dexrazoxane can be adequately described by a two-compartment open model with [[first-order elimination]]. Dexrazoxane has been administered as a 15 minute infusion over a dose range of 60 to 900 mg/m2 with 60 mg/m2 of [[doxorubicin]], and at a fixed dose of 500 mg/m2 with 50 mg/m2 [[doxorubicin]]. The disposition kinetics of dexrazoxane are dose-independent, as shown by [[linear relationship]] between the [[AUC|area under plasma concentration-time curves]] and administered doses ranging from 60 to 900 mg/m2. The mean peak plasma concentration of dexrazoxane was 36.5 mcg/mL at 15 minute after intravenous administration of 500 mg/m2 dose of dexrazoxane for injection over 15 to 30 minutes prior to the 50 mg/m2 [[doxorubicin]] dose.
 *The important pharmacokinetic parameters of dexrazoxane are summarized in Table 2:
-[[File:Dexrazoxane03.png|thumb|none|600px|This image is provided by the National Library of Medicine.]]
+[[File:Dexrazoxane03.png|thumb|none|400px|This image is provided by the National Library of Medicine.]]
 =====Distribution=====
-*Following a rapid distributive phase (0.2 to 0.3 hours), dexrazoxane reaches post-distributive equilibrium within 2 to 4 hours. The estimated mean steady-state volume of distribution of dexrazoxane is 22.4 L/m2 after 500 mg/m2 of dexrazoxane for injection dose followed by 50 mg/m2 of [[doxorubicin]], suggesting distribution throughout total body water (25 L/m2).
+*Following a rapid distributive phase (0.2 to 0.3 hours), dexrazoxane reaches post-distributive equilibrium within 2 to 4 hours. The estimated mean [[volume of distribution|steady-state volume of distribution]] of dexrazoxane is 22.4 L/m2 after 500 mg/m2 of dexrazoxane for injection dose followed by 50 mg/m2 of [[doxorubicin]], suggesting distribution throughout total body water (25 L/m2).
-*In vitro studies have shown that dexrazoxane is not bound to plasma proteins.
+*In vitro studies have shown that dexrazoxane is not bound to [[plasma proteins]].
 =====Metabolism=====
-*Qualitative metabolism studies with dexrazoxane have confirmed the presence of unchanged drug, a diacid-diamide cleavage product, and two monoacid-monoamide ring products in the urine of animals and man. The metabolite levels were not measured in the pharmacokinetic studies.
+*Qualitative metabolism studies with dexrazoxane have confirmed the presence of unchanged drug, a diacid-diamide cleavage product, and two monoacid-monoamide ring products in the [[urine]] of animals and man. The metabolite levels were not measured in the pharmacokinetic studies.
 =====Excretion=====
@@ Line 225: / Line 183: @@
 ======Effect of Renal Impairment======
-*The pharmacokinetics of dexrazoxane were assessed following a single 15 minute IV infusion of 150 mg/m2 of dexrazoxane for injection. Dexrazoxane clearance was reduced in subjects with renal dysfunction. Compared with controls, the mean AUC0-inf value was 2-fold greater in subjects with moderate (CLCR 30 to 50 mL/min) to severe (CLCR < 30 mL/min) renal dysfunction. Modeling demonstrated that equivalent exposure ([[AUC]]-inf) could be achieved if dosing were reduced by 50% in subjects with [[creatinine clearance]] values < 40 mL/min compared with control subjects (CLCR > 80 mL/min).
+*The pharmacokinetics of dexrazoxane were assessed following a single 15 minute IV infusion of 150 mg/m2 of dexrazoxane for injection. Dexrazoxane clearance was reduced in subjects with renal dysfunction. Compared with controls, the mean AUC0-inf value was 2-fold greater in subjects with moderate ([[creatinine clearance|CLCR]] 30 to 50 mL/min) to severe ([[creatinine clearance|CLCR]] < 30 mL/min) renal dysfunction. Modeling demonstrated that equivalent exposure ([[AUC]]-inf) could be achieved if dosing were reduced by 50% in subjects with [[creatinine clearance]] values < 40 mL/min compared with control subjects (CLCR > 80 mL/min).
 ======Effect of Hepatic Impairment======
@@ Line 233: / Line 191: @@
 ======Drug Interactions======
-*There was no significant change in the pharmacokinetics of [[doxorubicin]] (50 mg/m2) and its predominant metabolite, [[doxorubicin]]ol, in the presence of dexrazoxane (500 mg/m2) in a crossover study in cancer patients.
+*There was no significant change in the pharmacokinetics of [[doxorubicin]] (50 mg/m2) and its predominant metabolite, [[doxorubicin]], in the presence of dexrazoxane (500 mg/m2) in a crossover study in cancer patients.
 <!--Nonclinical Toxicology-->
 |nonClinToxic=
 =====Carcinogenesis, Mutagenesis, Impairment of Fertility=====
 *No long-term carcinogenicity studies have been carried out with dexrazoxane in animals. Nevertheless, a study by the National Cancer Institute has reported that long-term dosing with razoxane (the racemic mixture of dexrazoxane, ICRF-187, and its enantiomer ICRF-186) is associated with the development of malignancies in rats and possibly in mice.
-*Dexrazoxane was not mutagenic in the bacterial reverse mutation (Ames) test, but was found to be clastogenic to human lymphocytes in vitro and to mouse bone marrow erythrocytes in vivo(micronucleus test).
+*Dexrazoxane was not mutagenic in the bacterial reverse mutation ([[Ames test|Ames]]) test, but was found to be clastogenic to [[lymphocytes|human lymphocytes]] in vitro and to mouse bone marrow erythrocytes in vivo([[micronucleus test]]).
-*Dexrazoxane for injection has the potential to impair fertility in male patients based on effects in repeat-dose toxicology studies. Testicular atrophy was seen with dexrazoxane administration at doses as low as 30 mg/kg weekly for 6 weeks in rats (1/3 the human dose on a mg/m2 basis) and as low as 20 mg/kg weekly for 13 weeks in dogs (approximately equal to the human dose on a mg/m2 basis).
+*Dexrazoxane for injection has the potential to impair [[fertility]] in male patients based on effects in repeat-dose toxicology studies. [[Testicular atrophy]] was seen with dexrazoxane administration at doses as low as 30 mg/kg weekly for 6 weeks in rats (1/3 the human dose on a mg/m2 basis) and as low as 20 mg/kg weekly for 13 weeks in dogs (approximately equal to the human dose on a mg/m2 basis).
 <!--Clinical Studies-->
-|clinicalStudies=*The ability of dexrazoxane for injection to prevent/reduce the incidence and severity of [[doxorubicin]]-induced cardiomyopathy was evaluated in three prospectively randomized placebo-controlled studies. In these studies, patients were treated with a [[doxorubicin]]-containing regimen and either dexrazoxane for injection or placebo starting with the first course of chemotherapy. There was no restriction on the cumulative dose of [[doxorubicin]]. Cardiac function was assessed by measurement of the LVEF, utilizing resting multigated nuclear medicine (MUGA) scans, and by clinical evaluations. Patients receiving dexrazoxane for injection had significantly smaller mean decreases from baseline in LVEF and lower incidences of congestive heart failure than the control group; however, in the largest study, patients with advanced breast cancer receiving FAC with dexrazoxane for injection had a lower response rate (48% vs. 63%) and a shorter time to progression than patients who received FAC versus placebo.
+|clinicalStudies=*The ability of dexrazoxane for injection to prevent/reduce the incidence and severity of [[cardiomyopathy|doxorubicin-induced cardiomyopathy]] was evaluated in three prospectively randomized placebo-controlled studies. In these studies, patients were treated with a [[doxorubicin]]-containing regimen and either dexrazoxane for injection or placebo starting with the first course of chemotherapy. There was no restriction on the cumulative dose of [[doxorubicin]]. Cardiac function was assessed by measurement of the [[LVEF]], utilizing resting [[MUGA scan|multigated nuclear medicine]] (MUGA) scans, and by clinical evaluations. Patients receiving dexrazoxane for injection had significantly smaller mean decreases from baseline in [[LVEF]] and lower incidences of [[congestive heart failure]] than the control group; however, in the largest study, patients with [[advanced breast cancer]] receiving FAC with dexrazoxane for injection had a lower response rate (48% vs. 63%) and a shorter time to progression than patients who received FAC versus placebo.
-*In the clinical trials, patients who were initially randomized to receive placebo were allowed to receive dexrazoxane for injection after a cumulative dose of [[doxorubicin]] above 300 mg/m2. Retrospective historical analyses showed that the risk of experiencing a cardiac event (see Table 3 for definition) at a cumulative dose of [[doxorubicin]] above 300 mg/m2 was greater in the patients who did not receive dexrazoxane for injection beginning with their seventh course of FAC than in the patients who did receive dexrazoxane for injection (HR=13.08; 95% CI: 3.72, 46.03; p < 0.001). Overall, 3% of patients treated with dexrazoxane for injection developed CHF compared with 22% of patients not receiving dexrazoxane for injection.
+*In the clinical trials, patients who were initially randomized to receive placebo were allowed to receive dexrazoxane for injection after a cumulative dose of [[doxorubicin]] above 300 mg/m2. Retrospective historical analyses showed that the risk of experiencing a cardiac event (see Table 3 for definition) at a cumulative dose of [[doxorubicin]] above 300 mg/m2 was greater in the patients who did not receive dexrazoxane for injection beginning with their seventh course of FAC than in the patients who did receive dexrazoxane for injection (HR=13.08; 95% CI: 3.72, 46.03; p < 0.001). Overall, 3% of patients treated with dexrazoxane for injection developed [[CHF]] compared with 22% of patients not receiving dexrazoxane for injection.
-[[File:Dexrazoxane04.png|thumb|none|600px|This image is provided by the National Library of Medicine.]]
+[[File:Dexrazoxane04.png|thumb|none|400px|This image is provided by the National Library of Medicine.]]
 <!--How Supplied-->
 |howSupplied=*Dexrazoxane for Injection is available in the following strengths as sterile, pyrogen-free lyophilizates.
@@ Line 259: / Line 218: @@
 *500 mg single-dose vial with a blue flip-top seal, packaged in single vial packs. (This package also contains a 50 mL vial of 0.167 Molar (M/6) Sodium Lactate Injection, USP.)
 *Store at 20° to 25°C (68° to 77°F). [See USP Controlled Room Temperature.] Reconstituted solutions of dexrazoxane for injection are stable for 6 hours at controlled room temperature or under refrigeration, 2° to 8°C (36° to 46°F). DISCARD UNUSED SOLUTIONS.
@@ Line 267: / Line 224: @@
 <!--Patient Counseling Information-->
 |fdaPatientInfo=
 =====Myelosuppression=====
@@ Line 279: / Line 237: @@
 <!--Brand Names-->
-|brandNames=* ®<ref>{{Cite web | title =  | url =  }}</ref>
+|brandNames=* Zinecard
+* Totect
 <!--Look-Alike Drug Names-->
-|lookAlike=* A® — B®<ref name="www.ismp.org">{{Cite web  | last =  | first =  | title = http://www.ismp.org | url = http://www.ismp.org | publisher =  | date =  }}</ref>
+|lookAlike=
 <!--Drug Shortage Status-->
+|useInPregnancyFDA D
+=====Risk Summary=====
+*Dexrazoxane for injection can cause fetal harm when administered to pregnant women. Dexrazoxane administration resulted in maternal toxicity, [[embryotoxicity]] and [[teratogenicity]] in rats and rabbits at doses significantly lower than the clinically recommended dose. 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 hazard to a fetus .
+=====Animal Data=====
+*Dexrazoxane resulted in maternal toxicity in rats at doses of ≥ 2 mg/kg (1/40 the human dose on a mg/m2 basis) and [[embryotoxicity]] and [[teratogenicity]] at 8 mg/kg (approximately 1/10 the human dose on a mg/m2 basis) when given daily to pregnant rats during the period of [[organogenesis]]. Teratogenic effects in the rat included [[imperforate anus]], [[microphthalmia]], and [[anophthalmia]]. In offspring allowed to develop to maturity, [[fertility]] was impaired in the male and female rats treated in utero during [[organogenesis]] at 8 mg/kg. In rabbits, doses of ≥ 5 mg/kg (approximately 1/10 the human dose on a mg/m2 basis) daily during the period of [[organogenesis]] caused maternal toxicity and doses of 20 mg/kg (1/2 the human dose on a mg/m2 basis) were embryotoxic and teratogenic. Teratogenic effects in the rabbit included several skeletal malformations such as short tail, rib and thoracic malformations, and soft tissue variations including subcutaneous, eye and cardiac hemorrhagic areas, as well as agenesis of the gallbladder and of the intermediate lobe of the lung.
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