Cyclophosphamide 200mg Powder for Injection USP Taj Pharma

  1. Name of the medicinal product

Cyclophosphamide 200mg Powder for Injection USP Taj Pharma
Cyclophosphamide 300mg Powder for Injection USP Taj Pharma
Cyclophosphamide 500mg Powder for Injection USP Taj Pharma
Cyclophosphamide 1000mg Powder for Injection USP Taj Pharma
Cyclophosphamide 2000mg Powder for Injection USP Taj Pharma

  1. Qualitative and quantitative composition

a) Cyclophosphamide 200mg Powder for Injection USP
Each sterile vial contains:
Cyclophosphamide USP
Equivalent to Anhydrous Cyclophosphamide             200mg

b) Cyclophosphamide 300mg Powder for Injection USP
Each sterile vial contains:
Cyclophosphamide USP
Equivalent to Anhydrous Cyclophosphamide             300mg

c) Cyclophosphamide 500mg Powder for Injection USP
Each sterile vial contains:
Cyclophosphamide USP
Equivalent to Anhydrous Cyclophosphamide             500mg

d) Cyclophosphamide 1000mg Powder for Injection USP
Each sterile vial contains:
Cyclophosphamide USP
Equivalent to Anhydrous Cyclophosphamide             1000mg

e) Cyclophosphamide 2000mg Powder for Injection USP
Each sterile vial contains:
Cyclophosphamide USP
Equivalent to Anhydrous Cyclophosphamide             2000mg

For the full list of excipients, see section 6.1.

  1. Pharmaceutical form

Powder for solution for injection.

  1. Clinical particulars

4.1 Therapeutic indications

Cyclophosphamide may be used alone or in combination with other chemotherapeutic agents, depending on the indication. Cyclophosphamide is indicated in the treatment of:

  • Chronic Lymphocytic Leukemia (CLL)
  • Acute Lymphocytic Leukemia (ALL)
  • As conditioning for a bone marrow transplantation, in the treatment of Acute Lymphoblastic Leukemia, Chronic Myelogenous Leukemia and Acute Myelogenous Leukemia, in combination with whole body irradiation or busulfan.
  • Hodgkin’s lymphoma, Non-Hodgkin’s lymphoma and Multiple Myeloma.
  • Metastatic ovarian, and breast, carcinoma,
  • Adjuvant treatment of breast carcinoma
  • Ewing’s sarcoma
  • Small cell lung cancer
  • Advanced or metastatic neuroblastoma,
  • Life-threatening autoimmune diseases: severe progressive forms of lupus nephritis and Wegener’s granulomatosis.

4.2 Posology and method of administration

Cyclophosphamide should only be used by clinicians experienced in the use of cancer chemotherapy. Cyclophosphamide should only be administered where there are facilities for regular monitoring of clinical, biochemical and haematological parameters before, during, and after administration and under the direction of a specialist oncology service.

Posology

Dosage must be individualised. Doses and duration of treatment and/or treatment intervals depend on the therapeutic indication, the scheme of a combination therapy, the patient’s general state of health and organ function, and the results of laboratory monitoring (in particular, blood cell monitoring).

In combination with other cytostatics of similar toxicity, a dose reduction or extension of the therapy-free intervals may be necessary.

Use of hematopoiesis stimulating agents (colony-stimulating factors and erythropoiesis stimulating agents) may be considered to reduce the risk of myelosuppressive complications and/or help facilitate the delivery of the intended dosing.

Prior, during and immediately after the administration, adequate amounts of fluid should be ingested or infused to force diuresis in order to reduce the risk of urinary tract toxicity. Therefore, Cyclophosphamide should be administered in the morning. See section 4.4.

It is within the responsibility of the physician to decide on the use of Cyclophosphamide according to the operative treatment guidelines.

The doses below can be regarded as general guidelines:

Hematologic and solid tumours

  1. For daily treatment:

3 – 6 mg/kg body weight (= 120 – 240 mg/m2 body surface area), injected intravenously

  1. For intermittent treatment:

10 – 15 mg/kg body weight (= 400 – 600 mg/m2 body surface area), injected intravenously, with therapy-free intervals of 2 to 5 days.

  1. For high-dose- intermittent treatment:

20 – 40 mg/kg body weight (= 800 – 1600 mg/m2 body surface area), injected intravenously, with therapy-free intervals of 21 to 28 days.

As preparation for a bone marrow transplantation

2 days 60 mg/kg or 4 days 50 mg/kg body weight injected intravenously.

If a busulfan-cyclophosphamide (Bu/Cy) regimen is applied, the first dose of cyclophosphamide must be administered at least 24 hours after the last dose of busulfan (see section 4.4 and 4.5).

Autoimmune diseases

Per month 500 – 200 mg/m2 body surface area.

Patients with Hepatic Impairment

Severe hepatic impairment may be associated with a decreased activation of cyclophosphamide. This may alter the effectiveness of the cyclophosphamide treatment and should be considered when selecting the dose and interpreting response to the dose selected. (See section 4.4).

The dose must be reduced in patients with severe hepatic impairment. A dose reduction of 25 % is recommended in patients with serum bilirubin concentrations of 3.1 – 5 mg/100 ml (= 0.053 – 0.086 mmol/l).

Patients with Renal Impairment

In patients with renal impairment, particularly in patients with severe renal impairment, decreased renal excretion may result in increased plasma levels of cyclophosphamide and its metabolites. This may result in increased toxicity and should be considered when determining the dosage in such patients. (See section 4.4). A dose reduction of 50% for a glomerular filtration rate below 10 mL/minute is recommended.

Cyclophosphamide and its metabolites are dialyzable, although there may be differences in clearance depending upon the dialysis system being used. In patients requiring dialysis, use of a consistent interval between cyclophosphamide administration and dialysis should be considered. See section 4.4.

Elderly

In elderly patients, monitoring for toxicities and the need for dose adjustment should reflect the higher frequency of decreased hepatic, renal, cardiac, or other organ function, and concomitant diseases or other drug therapy in this population.

Paediatric population

Cyclophosphamide has been administered to children. The safety profile of cyclophosphamide in paediatric patients is similar to that of the adult population.

Dose modification due to myelosuppression

A leukocyte and platelet count should be regularly performed during treatment with cyclophosphamide. It is recommended to adjust the dose, if required, if signs of myelosuppression become evident.

Please refer to the table below. Urinary sediment should also be checked regularly for the presence of erythrocytes.

Leukocyte count/μl Platelet count /μl Dosage
> 4000 > 100 000 100% of the planned dose
2500 – 4000 50 000 – 100 000 50 % of the planned dose
< 2500 < 50 000 Omit until values normalise or decide individually

In combination therapy further dose reductions may have to be considered.

Method of administration

Cyclophosphamide is inert until activated by enzymes in the liver. However, as with all cytotoxic agents, it is recommended that reconstitution should be performed by trained personnel, in a designated area.

Precaution to be taken before manipulating or administering the product

Those handling the preparation should wear protective glovesCare should be taken to avoid splashing material into the eyes. The material should not be handled by women who are pregnant or who are breast-feeding.

The choice of solvent for reconstituting Cyclophosphamide containing cyclophosphamide depends on the route of administration to be used.

Infusion:

If the solution is to be used for IV infusion, Cyclophosphamide (containing cyclophosphamide) is reconstituted by adding sterile water for injection or 0.9% sterile sodium chloride solution.

Reconstituted Cyclophosphamide should be further diluted in 5% dextrose or 0.9% sodium chloride solution prior to infusion.

Direct injection:

If the solution is to be used for direct injection, Cyclophosphamide (containing cyclophosphamide) is reconstituted by adding 0.9% sterile sodium chloride solution.

Please note that only Cyclophosphamide reconstituted in 0.9% sterile sodium chloride solution is suitable for bolus injection.

Cyclophosphamide (containing cyclophosphamide) reconstituted in water is hypotonic and should not be injected directly.

For detailed instruction on reconstitution please refer to section 6.6.

Intravenous use

Intravenous administration should preferably be conducted as an infusion.

To reduce the likelihood of adverse reactions that appear to be administration rate-dependent (e.g. facial swelling, headache, nasal congestion, scalp burning), cyclophosphamide should be injected or infused very slowly. Duration of the infusion (ranging from 30 minutes to 2 hours) should be appropriate for the volume and type of carrier fluid to be infused.

Before intravenous use, the substance must be completely dissolved.

Drug products for intravenous use must be inspected visually for particulate matter and discolouration prior to administration whenever solution and container permit.

4.3 Contraindications

Cyclophosphamide is contra-indicated in patients with:

  • hypersensitivity to cyclophosphamide, any of its metabolites
  • acute infections
  • bone marrow aplasia or bone marrow depression prior to treatment
  • urinary tract infection
  • acute urothelial toxicity from cytotoxic chemotherapy or radiation therapy
  • urinary outflow obstruction
  • breastfeeding (see section 4.6)

Cyclophosphamide should not be used in the management of non-malignant disease, except for immunosuppression in life-threatening situations.

4.4 Special warnings and precautions for use

WARNINGS

Anaphylactic Reactions, Cross-sensitivity with Other Alkylating Agents

Anaphylactic reactions including those with fatal outcomes have been reported in association with cyclophosphamide. Possible cross-sensitivity with other alkylating agents has been reported.

Myelosuppression, Immunosuppression, Infections

Treatment with cyclophosphamide may cause myelosuppression (anaemia, leukopenia, neutropenia and thrombocytopenia) and significant suppression of immune responses, which may result in severe, sometimes fatal, infections, sepsis and septic shock. Infections reported with cyclophosphamide include pneumonias, as well as other bacterial, fungal, viral, protozoal, and parasitic infections.

Latent infections can be reactivated. Reactivation has been reported for various bacterial, fungal, viral, protozoal, and parasitic infections.

Infections occurring during treatment with cyclophosphamide, including neutropenic fever, must be treated appropriately. Antimicrobial prophylaxis may be indicated in certain cases of neutropenia (at the discretion of the managing physician). In case of neutropenic fever, antibiotics and/or antimycotics must be given. Cyclophosphamide must be administered with the necessary caution (or not at all) in patients with severe functional impairment of bone marrow and patients with severe immunosuppression.

Close haematological monitoring is required for all patients during treatment. Haematological parameters must be checked prior to each administration and regularly during treatment. More frequent monitoring may be required if leukocyte counts drop below 3000 cells/microlitre (cells/mm³). Dose adjustment due to myelosuppression is recommended (see section 4.2).

Unless essential, cyclophosphamide should not be administered to patients with a leukocyte count below 2500 cells/microlitre (cells/ mm3) and/or a platelet count below 50,000 cells/microlitre (cells/mm3).

In principle, the fall in the peripheral blood cell and thrombocyte count and the time taken to recover may increase with increasing doses of cyclophosphamide.

The nadirs of the reduction in leukocyte count and thrombocyte count are usually reached in weeks 1 and 2 of treatment. The bone marrow recovers relatively quickly, and the levels of peripheral blood cell counts normalise, as a rule, after approximately 20 days.

Cyclophosphamide treatment may not be indicated, or should be interrupted, or the dose reduced, in patients who have or who develop a serious infection.

Severe myelosuppression must be expected particularly in patients pre-treated with and/or receiving concomitant chemotherapy and/or radiation therapy.

Urinary Tract and Renal Toxicity

Hemorrhagic cystitis, pyelitis, ureteritis, and haematuria have been reported with cyclophosphamide therapy. Bladder ulceration/necrosis, fibrosis/contracture and secondary cancer may develop. Urotoxicity may mandate interruption of treatment. Cases of urotoxicity with fatal outcomes have been reported.

Urotoxicity can occur with short-term and long-term use of cyclophosphamide. Hemorrhagic cystitis after single doses of cyclophosphamide has been reported. Cystectomy may become necessary due to fibrosis, bleeding, or secondary malignancy. Past or concomitant radiation or busulfan treatment may increase the risk for cyclophosphamide-induced hemorrhagic cystitis. Cystitis is, in general, initially abacterial. Secondary bacterial colonisation may follow.

Before starting treatment, it is necessary to exclude or correct any urinary tract obstructions. See section 4.3.Urinary sediment should be checked regularly for the presence of erythrocytes and other signs of uro/nephrotoxicity. Adequate treatment with mesna and/or strong hydration to force diuresis can markedly reduce the frequency and severity of bladder toxicity. It is important to ensure that patients empty the bladder at regular intervals. Haematuria usually resolves in a few days after cyclophosphamide treatment is stopped, but it may persist. Severe hemorrhagic cystitis usually requires a discontinuation of the treatment with cyclophosphamide.

Cyclophosphamide has also been associated with nephrotoxicity, including renal tubular necrosis.

Hyponatremia associated with increased total body water, acute water intoxication, and a syndrome resembling SIADH (syndrome of inappropriate secretion of antidiuretic hormone) have been reported in association with cyclophosphamide administration. Fatal outcomes have been reported.

Cardiotoxicity, Use in Patients with Cardiac Disease

Myocarditis and myopericarditis, which may be accompanied by significant pericardial effusion and cardiac tamponade, have been reported with cyclophosphamide therapy and have led to severe, sometimes fatal congestive heart failure. Histopathologic examination has primarily shown hemorrhagic myocarditis. Haemopericardium has been reported secondary to hemorrhagic myocarditis and myocardial necrosis. Acute cardiac toxicity has been reported with single doses as low as 20 mg/kg of cyclophosphamide.

Following exposure to treatment regimens that included cyclophosphamide, supraventricular arrhythmias (including atrial fibrillation and flutter) as well as ventricular arrhythmias (including severe QT prolongation associated with ventricular tachyarrhythmia) have been reported in patients with and without other signs of cardiotoxicity.

The risk of cyclophosphamide cardiotoxicity as a result of treatment with cyclophosphamide may, for example, be increased following high doses of cyclophosphamide, in patients with advanced age, and in patients with previous radiation treatment of the cardiac region and/or previous or concomitant treatment with other cardiotoxic agents. See section 4.5.

Particular caution is required in patients with risk factors for cardiotoxicity and in patients with a pre-existing cardiac disease.

Pulmonary Toxicity

Pneumonitis and pulmonary fibrosis have been reported during and following treatment with cyclophosphamide. Pulmonary veno-occlusive disease and other forms of pulmonary toxicity have also been reported. Pulmonary toxicity leading to respiratory failure has been reported. While the incidence of cyclophosphamide-associated pulmonary toxicity is low, prognosis for affected patients is poor. Late onset of pneumonitis (greater than 6 months after start of cyclophosphamide) appears to be associated with a particularly high mortality. Pneumonitis may develop even years after treatment with cyclophosphamide. Acute pulmonary toxicity has been reported after a single cyclophosphamide dose.

Secondary Malignancies

As with all cytotoxic therapy, treatment with cyclophosphamide involves the risk of secondary tumours and their precursors as sequelae.

The risk of urinary tract cancer as well as the risk of myelodysplastic alterations, partly progressing to acute leukemias, is increased. Other malignancies reported after use of cyclophosphamide or regimens with cyclophosphamide include lymphomas, thyroid cancer, and sarcomas.

In some cases, the second malignancy developed several years after cyclophosphamide treatment had been discontinued. Malignancy has also been reported after in utero exposure.

The risk of bladder cancer can be markedly reduced by hemorrhagic cystitis prophylaxis.

Veno-occlusive Liver Disease

Veno-occlusive liver disease (VOLD) has been reported in patients receiving cyclophosphamide, mainly in patients receiving a cytoreductive regimen in preparation for bone marrow transplantation in combination with whole-body irradiation, busulfan, or other agents (see section 4.5). After cytoreductive therapy, the clinical syndrome typically develops 1 to 2 weeks after transplantation and is characterized by sudden weight gain, painful hepatomegaly, ascites, and hyperbilirubinemia/jaundice. However, VOLD has also been reported to develop gradually in patients receiving long-term low-dose immunosuppressive doses of cyclophosphamide.

As a complication of VOLD, hepatorenal syndrome and multiorgan failure may develop. Fatal outcome of cyclophosphamide-associated VOLD has been reported. Risk factors predisposing a patient to the development of VOLD include pre-existing disturbances of hepatic function, previous radiation therapy of the abdomen, and a low performance score.

VOLD incidence has been reported to reduce, if a time interval of at least 24 hours is observed between the last administration of busulfan and the first administration of cyclophosphamide (see section 4.2 and 4.5).

Genotoxicity

Cyclophosphamide is genotoxic and mutagenic, both in somatic and in male and female germ cells. Therefore, women should not become pregnant and men should not father a child during therapy with cyclophosphamide.

Women should not become pregnant during the treatment and for a period of 12 months following discontinuation of the therapy.

Men should not father a child during the treatment and for a period of 6 months following discontinuation of the therapy.

Animal data indicate that exposure of oocytes during follicular development may result in a decreased rate of implantations and viable pregnancies, and in an increased risk of malformations. This effect should be considered in case of intended fertilisation or pregnancy after discontinuation of cyclophosphamide therapy. The exact duration of follicular development in humans is not known, but may be longer than 12 months. Sexually active women and men should use effective methods of contraception during these periods of time (see section 4.6).

Fertility

Cyclophosphamide interferes with oogenesis and spermatogenesis. It may cause sterility in both sexes. Men treated with cyclophosphamide should be informed about sperm preservation prior to treatment (see section 4.6).

Impairment of Wound Healing

Cyclophosphamide may interfere with normal wound healing.

PRECAUTIONS

Alopecia

Alopecia has been reported and may occur more commonly with increasing doses. Alopecia may progress to baldness. The hair can be expected to grow back after treatment with the drug or even during continued drug treatment, though it may be different in texture or colour.

Nausea and Vomiting

Administration of cyclophosphamide may cause nausea and vomiting. Current guidelines on the use of anti-emetics for prevention and amelioration of nausea and vomiting should be considered.

Alcohol consumption may increase cyclophosphamide-induced vomiting and nausea.

Stomatitis

Administration of cyclophosphamide may cause stomatitis (oral mucositis). Current guidelines on measures for prevention and amelioration of stomatitis should be considered.

Paravenous Administration

The cytostatic effect of cyclophosphamide occurs after its activation, which takes place mainly in the liver. Therefore, the risk of tissue injury from accidental paravenous administration is low.

In case of accidental paravenous administration of cyclophosphamide, the infusion should be stopped immediately, the extravascular cyclophosphamide solution should be aspirated with the cannula in place, and other measures should be instituted as appropriate. The area should subsequently be rinsed with physiological saline solution, and the arm or leg should rest.

Use in Patients with Renal Impairment

In patients with renal impairment, particularly in patients with severe renal impairment, decreased renal excretion may result in increased plasma levels of cyclophosphamide and its metabolites. This may result in increased toxicity and should be considered when determining the dosage in such patients. See section 4.2.

Use in Patients with Hepatic Impairment

Severe hepatic impairment may be associated with a decreased effect of cyclophosphamide. This may negatively alter the effectiveness of cyclophosphamide treatment and should be considered when selecting the dose and interpreting response to the dose selected. See section 4.2. Due to the porphyrogenic effect of Cycolphosphamide patients with acute porphyria should be treated with caution.

Use in Adrenalectomised Patients

Patients with adrenal insufficiency may require an increase in corticoid substitution dose when exposed to stress from toxicity due to cytostatics, including cyclophosphamide.

Use in Patients with Diabetes Mellitus

Caution is also advised in is patients with diabetes mellitus, since cyclophosphamide may interact with insulin and other hypoglycaemic agents (also see section 4.5).

Use in Patients who have recently undergone surgery

In general, cytostatics (among which agents cyclophosphamide) should not be administered to patients who had a surgery less than 10 days ago.

4.5 Interaction with other medicinal products and other forms of interaction

Cyclophosphamide is inactive, but is metabolised in the liver, mainly by CYP2A6, 2B6, 2C9, 2C19 and 3A4, into two active metabolites.

Planned co-administration or sequential administration of other substances or treatments with cyclophosphamide that could increase the likelihood or severity of toxic effects (by means of pharmacodynamic or pharmacokinetic interactions) requires careful individual assessment of the expected benefit and the risks.

Patients receiving such combinations must be monitored closely for signs of toxicity to permit timely intervention. Patients being treated with cyclophosphamide and agents that reduce its activation should be monitored for a potential reduction of therapeutic effectiveness and the need for dose adjustment.

Interactions negatively affecting the pharmacokinetics of cyclophosphamide and its metabolites

  • Reduced activation of cyclophosphamide may alter the effectiveness of cyclophosphamide treatment. Substances that delay activation of cyclophosphamide include:

– Aprepitant

– Bupropion

– Busulfan: decreased elimination of cyclophosphamide and prolonged half-life has been reported in patients who received high-dose cyclophosphamide less than 24 hours after high-dose busulfan. Increased incidence of hepatic veno-occlusive disease and mucositis has been reported with concomitant administration (see section 4.2 and 4.4).

– Ciprofloxacin: when administered prior to treatment with cyclophosphamide (used for conditioning prior to bone marrow transplant), ciprofloxacin may cause regression of the underlying disease.

– Chloramphenicol

– Azole-antimycotics (Fluconazole, Itraconazole): Azole-antimycotics are known to inhibit cytochrome P450 enzymes. Increased amounts of toxic degradation products of cyclophosphamide have been reported in combination with Itraconazole.

– CYP2B6 and CYP3A4 inhibitors (Nevirapin, Ritonavir): co-administration may reduce the efficacy of cyclophosphamide

– Prasugrel

– Sulfonamides, e.g. sulfadiazine, sulfamethoxazoel and sulfapyridine

– Thiotepa: a strong inhibition of cyclophosphamide bioactivation by thiotepa in high-dose chemotherapy regimens has been reported when thiotepa was administered 1 hour prior to cyclophosphamide.

– Ondansetron: There have been reports of a pharmacokinetic interaction between ondansetron and high-dose cyclophosphamide resulting in decreased cyclophosphamide AUC.

– Grapefruit (fruit or juice), Rifampicin, St. Johns worth: Co-administration with CYP3A4 Inhibitors or Inducers can reduce the efficacy or increase the toxicity of cyclophosphamide.

  • An increase of the concentration of cytotoxic metabolites may occur with:

– Allopurinol: an increase of bone marrow suppression was reported

– Azathioprine: increased risk of hepatotoxicity (liver necrosis)

– Chloral hydrate

– Cimetidine

– Disulfiram

– Glyceraldehyde

– Protease inhibitors: concomitant use of protease inhibitors may increase the concentration of cytotoxic metabolites. Use of protease inhibitor-based regimens was found to be associated with a higher incidence of infections and neutropenia in patients receiving cyclophosphamide, doxorubicin, and etoposide (CDE) than use of an NNRTI-based regimen. Increased incidence of mucositis is reported in combined therapy of cyclophosphamide (CDE) and saquinavir

– Inducers of human hepatic and extrahepatic microsomal enzymes (e.g., cytochrome P450 enzymes): The potential for hepatic and extrahepatic microsomal enzyme induction must be considered in case of prior or concomitant treatment with substances known to induce an increased activity of such enzymes such as rifampin, phenobarbital, carbamazepine, phenytoin, St. John’s wort, benzodiazepines and corticosteroids.

– Dabrafenib

Pharmacodynamic Interactions and Interactions of Unknown Mechanism Affecting the Use of Cyclophosphamide

Combined or sequential use of cyclophosphamide and other agents with similar toxicities can cause combined (increased) toxic effects.

  • Increased hematotoxicity and/or immunosuppression may result from a combined effect of cyclophosphamideand, for example

– ACE inhibitors: ACE inhibitors can cause leukopenia.

– Natalizumab

– Paclitaxel: Increased hematotoxicity has been reported when cyclophosphamide was administered after paclitaxel infusion.

– Thiazide diuretics (e.g. hydrochlorthiazide): An increase of bone marrow suppression was reported.

– Zidovudine

– Clozapine

  • Increased cardiotoxicity may result from a combined effect of cyclophosphamide and, for example

– Anthracyclines

– Mitomycin

– Cytarabine

– Pentostatin

– Radiation therapy of the cardiac region or a whole-body irradiation in combination with high doses of cyclophosphamide

– Trastuzumab

  • Increased pulmonary toxicity may result from a combined effect of cyclophosphamide and, for example

– Amiodarone

– G-CSF, GM-CSF (granulocyte colony-stimulating factor, granulocyte macrophage colony-stimulating factor): reports suggest an increased risk of pulmonary toxicity in patients treated with cytotoxic chemotherapy that includes cyclophosphamide and G-CSF or GMCSF.

  • Increased nephrotoxicity may result from a combined effect of cyclophosphamide and, for example

– Amphotericin B

– Indomethacin: acute water intoxication has been reported with concomitant use of indomethacin.

Other interactions

  • Alcohol

A reduced antitumor activity was observed in tumour-bearing animals during ethanol (alcohol) consumption and concomitant oral low-dose cyclophosphamide medication. In some patients, alcohol may increase cyclophosphamide-induced vomiting and nausea.

  • Etanercept

In patients with Wegener’s granulomatosis, the addition of etanercept to standard treatment, including cyclophosphamide, was associated with a higher incidence of non-cutaneous solid malignancies.

  • Metronidazole

Acute encephalopathy has been reported in a patient receiving cyclophosphamide and metronidazole. Causal association is unclear.

In an animal study, the combination of cyclophosphamide with metronidazole was associated with increased cyclophosphamide toxicity.

  • Tamoxifen

Concomitant use of tamoxifen and chemotherapy may increase the risk of thromboembolic complications.

Interactions Affecting the Pharmacokinetics and/or Actions of Other Drugs

  • Bupropion

Cyclophosphamide metabolism by CYP2B6 may inhibit bupropion metabolism.

  • Coumarins

Both increased and decreased warfarin effects have been reported in patients receiving warfarin and cyclophosphamide.

  • Cyclosporine

Lower serum concentrations of cyclosporine have been observed in patients receiving a combination of cyclophosphamide and cyclosporine than in patients receiving only cyclosporine. This interaction may result in an increased incidence of graft versus host disease (GVHD).

  • Depolarising muscle relaxants

Cyclophosphamide treatment causes a marked and persistent inhibition of cholinesterase activity. Prolonged apnoea may occur with concurrent depolarizing muscle relaxants (e.g. succinylcholine, suxamethonium) as a result of a decreased pseudocholinesterase level. If a patient has been treated with cyclophosphamide within 10 days of general anaesthesia, the anaesthesiologist should be alerted.

  • Digoxin, β- acetyldigoxin

Impaired absorption of digoxin and β-acetyldigoxin tablets have been reported during a concomitant cytotoxic treatment

  • Vaccines

The immunosuppressive effects of cyclophosphamide can be expected to reduce the response to vaccination. Use of live vaccines may lead to vaccine-induced infection.

  • Verapamil

Impaired intestinal absorption of orally administered verapamil has been reported.

  • Sulfonylurea derivatives

Blood sugar levels may drop, if cyclophosphamide and sulfonylurea derivatives are used concomitantly.

4.6 Fertility, pregnancy and lactation

Women of childbearing potential

Girls treated with cyclophosphamide during pre-pubescence generally develop secondary sexual characteristics normally and have regular menses.

Girls treated with cyclophosphamide during pre-pubescence subsequently have conceived.

Girls treated with cyclophosphamide who have retained ovarian function after completing treatment are at increased risk of developing premature menopause (cessation of menses before age of 40 years).

Contraception in males and females

Women should not become pregnant during the treatment and for a period of 12 months following discontinuation of the therapy.

Men should not father a child during the treatment and for a period of 6 months following discontinuation of the therapy.

Sexually active women and men should use effective methods of contraception during these periods of time.

Pregnancy

There are very limited data from the use of cyclophosphamide in pregnant women. There are reports of serious multiple congenital aberrations after use during the first trimester.

Animal studies have shown teratogenicity and other reproduction toxicity (see section 5.3).

Considering the data from human case reports, animal studies and the mechanism of action of cyclophosphamide, its use during pregnancy, in particular during the first trimester, is not recommended.

In each individual case the potential benefit of the treatment should be weighed against the potential risk for the foetus.

Breastfeeding

Cyclophosphamide is excreted into the breast milk and can cause neutropenia, thrombocytopenia, low haemoglobin, and diarrhoea in children. Cyclophosphamide is contraindicated during breastfeeding (see section 4.3).

Fertility

Cyclophosphamide interferes with oogenesis and spermatogenesis. It may cause sterility in both sexes. In women cyclophosphamide may cause transient or permanent amenorrhea, and in boys treated with cyclophosphamide during pre-pubescence, oligospermia or azoospermia. Men treated with cyclophosphamide may develop oligospermia or azoospermia. Prior to treatment of men with cyclophosphamide, they should be informed of the possibility to store and keep viable sperm collected before treatment.

4.7 Effects on ability to drive and use machines

Patients undergoing treatment with cyclophosphamide may experience undesirable effects (including nausea, vomiting, dizziness, blurred vision, visual impairment) which could affect the ability to drive or use machines. The decision to drive or operate machinery should be made on an individual basis.

4.8 Undesirable effects

The frequency of adverse reactions reported in the table below are derived from clinical trials and from post marketing experience and are defined using the following convention: very common (>1/10), common (> 1/100 to <1/10), uncommon (> 1/1,000 to <1/100), rare (> 1/10,000 to <1/1,000), very rare (< 1/10,000) not known.

Organ System Class (SOC) Recommended MedDRA term Frequency
Infections and infestations Infections 1

Pneumonia2

Sepsis1

Common

Uncommon

Uncommon

Neoplasms, benign and malignant and unspecified (including cysts and polyps) Acute leukaemia3

Myelodysplastic syndrome

Secondary malignancies

Bladder cancer

Ureteric cancer

Tumour lysis syndrome

Non-Hodgkin’s lymphoma

Sarcoma

Renal cell carcinoma

Renal pelvis cancer

Thyroid cancer

Rare

Rare

Rare

Rare

Rare

Very rare

Not known

Not known

Not known

Not known

Not known

Blood and lymphatic system disorders Myelosuppression4

Leukopenia

Neutropenia

Febrile neutropenia

Thrombocytopenia

Anaemia

Disseminated intravascular coagulation

Haemolytic uremic syndrome

Agranulocytosis

Lymphopenia

Haemoglobin decreased

Very common

Very common

Very common

Common

Uncommon

Uncommon

Very rare

Very rare

Not known

Not known

Not known

Immune system disorders Immunosuppression

Anaphylactic/Anaphylactoid reaction

Hypersensitivity reaction

Anaphylactic shock

Very common

Uncommon

Uncommon

Very rare

Endocrine disorders SIADH (syndrome of inappropriate antidiuretic hormone secretion) Rare
Metabolism and nutrition disorders Anorexia

Dehydration

Hyponatremia

Blood glucose increased

Blood glucose decreased

Uncommon

Rare

Very rare

Not known

Not known

Psychiatric disorders Confusional state Very rare
Nervous system disorders Peripheral neuropathy

Polyneuropathy

Neuralgia

Convulsion

Dizziness

Dysgeusia

Hypogeusia

Paresthesia

Neurotoxicity5

Reversible posterior leukoencephalopathy Syndrome6

Encephalopathy

Uncommon

Uncommon

Uncommon

Rare

Rare

Very rare

Very rare

Very rare

Not known

Not known

Not known

Eye disorders Blurred vision

Visual impairment

Conjunctivitis

Eye oedema 7

Lacrimation increased

Rare

Rare

Very rare

Very rare

Not known

Ear and labyrinth disorders Deafness

Tinnitus

Uncommon

Not known

Cardiac disorders Cardiomyopathy

Myocarditis

Heart failure 8

Tachycardia

Ventricular arrhythmia

Supraventricular arrhythmia

Ventricular fibrillation

Angina

Myocardial infarction

Pericarditis

Atrial fibrillation

Ventricular tachycardia

Cardiogenic shock

Pericardial effusion

Bradycardia

Palpitations

Electrocardiogram QT prolonged

Uncommon

Uncommon

Uncommon

Uncommon

Rare

Rare

Very rare

Very rare

Very rare

Very rare

Very rare

Not known

Not known

Not known

Not known

Not known

Not known

Vascular disorders Flushing

Haemorrhage

Thromboembolism

Hypertension

Hypotension

Pulmonary embolism

Venous thrombosis

Vasculitis

Peripheral ischemia

Uncommon

Rare

Very rare

Very rare

Very rare

Not known

Not known

Not known

Not known

Respiratory, thoracic and mediastinal disorders 89 Acute respiratory distress syndrome (ARDS)

Chronic pulmonary interstitial fibrosis,

Pulmonary oedema

Bronchospasm

Dyspnoea

Hypoxia

Cough

Nasal congestion

Oropharyngeal pain

Rhino rhea

Sneezing

Pulmonary veno-occlusive disease

Obliterative bronchiolitis

Alveolitis allergic

Pneumonitis

Pleural effusion

Very rare

Very rare

Very rare

Very rare

Very rare

Very rare

Very rare

Not known

Not known

Not known

Not known

Not known

Not known

Not known

Not known

Not known

Gastrointestinal disorders Mucosal inflammation

Enterocolitis haemorrhagic

Acute pancreatitis

Ascites

Stomatitis

Diarrhoea

Vomiting

Constipation

Nausea

Abdominal pain

Parotid gland inflammation

Gastrointestinal haemorrhage

Cecitis

Colitis

Enteritis

Common

Very rare

Very rare

Very rare

Very rare

Very rare

Very rare

Very rare

Very rare

Not known

Not known

Not known

Not known

Not known

Not known

Hepatobiliary disorders Hepatic function abnormal

Hepatitis

Veno-occlusive liver disease

Hepatomegaly

Jaundice

Cholestatic hepatitis

Hepatotoxicity 10

Common

Rare

Very rare

Very rare

Very rare

Not known

Not known

Skin and subcutaneous tissue disorders Alopecia 11

Rash

Dermatitis

Nail discolouration

Skin discolouration 12

Stevens-Johnson syndrome

Toxic epidermal necrolysis

Radiation erythaema

Pruritus (including itching due to inflammation)

Erythaema multiforme

Palmar-plantar erythrodysesthesia syndrome (hand-foot syndrome)

Urticaria

Erythaema

Facial swelling

Hyperhidrosis

Very common

Rare

Rare

Rare

Rare

Very rare

Very rare

Very rare

Very rare

Not known

Not known

Not known

Not known

Not known

Not known

Musculoskeletal and connective tissue disorders Rhabdomyolysis

Cramps

Scleroderma

Muscle spasms

Myalgia

Arthralgia

Very rare

Very rare

Not known

Not known

Not known

Not known

Renal and urinary tract disorders Cystitis

Microhaematuria

Haemorrhagic cystitis

Macrohematuria

Suburethral haemorrhage

Bladder wall oedema

Bladder fibrosis and sclerosis

Renal impairment

Blood creatinine increased

Renal tubular necrosis

Renal tubular disorder

Nephropathy toxic

Hemorrhagic ureteritis

Bladder contracture

Nephrogenic diabetes insipidus

Atypical urinary bladder epithelial cells

Blood urea nitrogen increased

Very common

Very common

Common

Common

Very rare

Very rare

Very rare

Very rare

Very rare

Very rare

Not known

Not known

Not known

Not known

Not known

Not known

Not known

Pregnancy, puerperium and perinatal conditions Premature labour Not known
Reproductive system and breast disorders Impairment of spermatogenesis

Ovulation disorder (rarely irreversible)

Amenorrhea 13

Azoospermia/asperima 13

Oligospermia 13

Infertility

Ovarian Failure

Oligomenorrhoe

Testicular atrophy

Common

Uncommon

Rare

Rare

Rare

Not known

Not known

Not known

Not known

Congenital, familial and genetic disorders Intra-uterine death

Foetal malformation

Foetal growth retardation

Foetal damage

Carcinogenic effect on offspring

Not known

Not known

Not known

Not known

Not known

General disorders and administrative site conditions Fever

Chills

Asthenia

Malaise

Chest pain

Headache

Multiorgan failure

Injection/infusion site reactions

(thrombosis, necrosis, phlebitis, inflammation, pain, swelling, erythaema)

Very common

Common

Common

Common

Rare

Very rare

Very rare

Very rare

Investigations Blood lactate dehydrogenase increased

C-reactive protein increased

ECG changes

Decreased LVEF

Weight gain

Lower levels of female sex hormones

Blood oestrogen level decreased

Blood gonadotropin level increased

Uncommon

Uncommon

Uncommon

Uncommon

Very rare

Uncommon

Not known

Not known

1 An increased risk for and severity of pneumonias (including fatal outcomes), other bacterial, fungal, viral, protozoal, and parasitic infections; reactivation of latent infections, including viral hepatitis, tuberculosis, JC virus with progressive multifocal leukoencephalopathy (including fatal outcomes), pneumocystis jiroveci, herpes zoster, strongyloides, sepsis and septic shock (including fatal outcomes).

2 including fatal outcomes

3 including acute myeloid leukemia, acute promyelocytic leukemia

4 manifested as Bone marrow failure, Pancytopenia, Neutropaenia, Agranulocytosis, Granulocytopenia,Thrombocytopaenia (complicated by bleeding), Leukopenia, Anaemia

5 manifested as myelopathy, peripheral neuropathy, polyneuropathy,neuralgia, dysesthesia, hypoesthesia, paresthesia, tremor, dysgeusia, hypogeusia,parosmia.

6 manifested as headache, altered mental functioning, seizures and abnormal vision from blurriness to vision loss

7 Observed in connection with an allergic reaction

8 Including fatal outcomes

9 While the incidence of cyclophosphamide-associated pulmonary toxicity is low, prognosis for affected patients is poor.

10 Hepatic failure, Hepatic encephalopathy, Ascites, Hepatomegaly, Jaundice, Blood bilirubin increased, Hepatic enzymes increased (ASAT, ALAT, ALP, gamma-GT)

11 May progress to baldness

12 Of the palms and heels

13 Persistent

Remark:

Certain complication such as thromboembolisms, disseminated intravascular coagulation, and haemolytic uremic syndrome may occur as a result of the underlying disorders, but the frequency of these complications may increase due to chemotherapy with Cyclophosphamide.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product.

4.9 Overdose

Serious consequences of overdosage include manifestations of dose dependent toxicities such as myelosuppression, urotoxicity, cardiotoxicity (including cardiac failure), veno occlusive hepatic disease, and stomatitis. See section 4.4.

Patients who received an overdose should be closely monitored for the development of toxicities, and hematotoxicity in particular.

There is no specific antidote for an overdosage of cyclophosphamide.

Cyclophosphamide and its metabolites are dialyzable. Therefore, rapid haemodialysis is indicated when treating any suicidal or accidental overdose or intoxication.

Overdosage should be managed with supportive measures, including appropriate, state-of-the-art treatment for any concurrent infection, myelosuppression, or other toxicity, should it occur.

Cystitis prophylaxis with mesna can help to prevent or reduce urotoxic effects in case of cyclophosphamide overdosage.

  1. Pharmacological properties

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Antineoplastic and Immunomodulating Agents; Antineoplastic agents. Alkylating agents. Nitrogen mustard analogues

Cyclophosphamide has been demonstrated to have a cytostatic effect in many tumour types.

Cyclophosphamide engages probably to the S-or G2-phase of the cell cycle.

It remains to be shown whether the cytostatic effect is entirely dependent on the alkylation of DNA or other mechanisms such as inhibition of chromatin transformation processes or inhibition of DNA polymerases play a role. The metabolite acrolein has no antineoplastic activity, but is responsible for the adverse urotoxic effect.

The immunosuppressive effect of cyclophosphamide is based on the fact that cyclophosphamide has an inhibitory effect on B-cells, CD4 + T-cells and to a lesser extent on CD8 +-T-cells. In addition, it is assumed that cyclophosphamide has an inhibitory effect on the suppressor that regulate the IgG2 class of antibodies.

Cross-resistance, especially with structurally related cytotoxic agents, e.g. ifosfamide, as well as other alkylating agents, cannot be excluded.

5.2 Pharmacokinetic properties

Cyclophosphamide is administered as an inactive prodrug that is activated in the liver.

Absorption

Cyclophosphamide is quickly and almost completely absorbed from parenteral sites.

Distribution

Less than 20% of cyclophosphamide is bound to plasma proteins. The protein binding of the metabolites of cyclophosphamide is higher but less than 70%. To what extent the active metabolites protein bound, is not known.

Cyclophosphamide is about in the cerebrospinal fluid and the mother’s milk. Cyclophosphamide and metabolites can pass through the placenta.

Metabolism

Cyclophosphamide is activated in the liver to the active metabolites 4-hydroxy-cyclophosphamide and aldofosfamide (tautomeric form of 4-hydroxy-cyclophosphamide) through phase I metabolism by cytochrome P450 (CYP) enzymes. Different CYP isozymes contribute to the bioactivation of cyclophosphamide, including CYP2A6, 2B6, 2C9, 2C19 and 3A4, 2B6 in which the exhibits highest 4-hydroxylase activity. Detoxification is done mainly through glutathione-S-transferases (GSTA1, GSTP1) and alcohol dehydrogenase (ALDH1, ALDH3). Two to four hours after administration of cyclophosphamide, the plasma concentrations of the active metabolites are maximal, after which a rapid decrease of plasma concentrations takes place.

Elimination

The plasma half-life of cyclophosphamide is about 4 to 8 hours in adults and children. The plasma half-lives of the active metabolites are not known.

Following high-dose IV administration within the framework of allogeneic bone marrow transplantation, the plasma concentration of pure cyclophosphamide follows linear first- order kinetics. Compared with conventional cyclophosphamide therapy, there is an increase in inactive metabolites, indicating saturation of activating enzyme systems, but not of the stages of metabolism leading to inactive metabolites. During the course of high-dose cyclophosphamide therapy over several days, there is a decrease in the areas under the plasma concentration-time curve of the parent compound, probably due to auto-induction of microsomal metabolism activity.

Cyclophosphamide and its metabolites are primarily excreted by the kidneys.

5.3 Preclinical safety data

Acute toxicity

The acute toxicity of cyclophosphamide is relatively low. This was demonstrated in studies on mice, guinea pigs, rabbits and dogs.

Chronic toxicity

Chronic administration of toxic doses led to hepatic lesions manifested as fatty degeneration followed by necrosis. The intestinal mucosa was not affected. The threshold for hepatotoxic effects was 100 mg/kg in the rabbit and 10 mg/kg in the dog

Mutagenicity and carcinogenicity

The mutagenic effects of cyclophosphamide have been demonstrated in various in-vitro and in-vivo tests. Chromosome aberrations following administration of cyclophosphamide have also been observed in humans. The carcinogenic effects of cyclophosphamide have been demonstrated in animal studies on rats and mice.

Teratogenicity

The teratogenic effects of cyclophosphamide have been demonstrated in various animals (mice, rats, rabbits, rhesus monkeys and dogs). Cyclophosphamide can cause skeletal, tissue as well as other malformations.

  1. Pharmaceutical particulars

6.1 List of excipients

None

6.2 Incompatibilities

Not applicable

6.3 Shelf life

2 years

Chemical and physical in-use stability has been demonstrated for 24 hours at 2°C – 8°C for the reconstituted solution.

From a microbiological point of view, the reconstituted solution should be used immediately, unless reconstitution has taken place in controlled and validated aseptic conditions. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2°C- 8°C.

6.4 Special precautions for storage

Do not store above 25°C.

For storage conditions after reconstitution of the medicinal product, see section 6.3.

6.5 Nature and contents of container

Cyclophosphamide, Powder for Solution for Injection or Infusion, is available in the following pack sizes:

1, 5 or 10 clear colourless 100 ml Type I-glass vials containing 200 mg cyclophosphamide sealed with bromobutyl rubber stopper, and secured with a flip-off seal with a sea green PP button

Not all pack sizes may be marketed.

Vials are packed with or without a protective plastic overwrap (Onco-Safe). “Onco-Safe” does not come into contact with the medicinal product and provides additional transport protection, which increases the safety for the medical and pharmaceutical personnel.

6.6 Special precautions for disposal and other handling

For each 100 mg of cyclophosphamide, 5 ml of solvent must be added for reconstitution.

The choice of diluent for reconstituting Cyclophosphamide containing cyclophosphamide depends on the route of administration to be used.

Direct injection:

If the solution is to be used for direct injection, Cyclophosphamide (containing cyclophosphamide) is reconstituted by adding 0.9% sterile sodium chloride solution.

Infusion:

If the solution is to be used for IV infusion, Cyclophosphamide (containing cyclophosphamide) is reconstituted by adding sterile water for injection or 0.9% sterile sodium chloride solution.

The following quantities of water for injections or sodium chloride 0.9 % are added to the vials containing Cyclophosphamide, Powder for Solution for Injection or Infusion

Vial of 500 mg: 25 ml

Vial of 200 mg: 50 ml

Vial of 2000 mg: 100 ml

Injecting the solvent into the vial for injection creates an abnormally high pressure, which disappears as soon as the second sterile needle has been inserted in the rubber stop of the vial for injection. The powder easily dissolves when the vial for injection is shaken vigorously to produce a clear solution. If the powder does not immediately dissolve, continue to shake the vial vigorously for up to several minutes until complete dissolution of the powder. The solution must be administered as soon as possible following its reconstitution.

After reconstitution the solution is clear and colourless to light yellow. Please check the vial before further use. Only clear solutions must be used.

Cyclophosphamide, Powder for Solution for Injection or Infusion reconstituted in water for injection has an osmolality of 92 mOsm/kg.

Cyclophosphamide, Powder for Solution for Injection or Infusion reconstituted in 0.9% sodium chloride has an osmolality of 353 mOsm/kg and a pH of 4.6

Intravenous use

Intravenous administration should preferably be conducted as an infusion.

Infusion:

Reconstituted Cyclophosphamide should be further diluted in 5% dextrose or 0.9% sodium chloride injection prior to infusion.

Direct injection:

Please note that only Cyclophosphamide reconstituted in 0.9% sterile sodium chloride solution is suitable for bolus injection.

Cyclophosphamide (containing cyclophosphamide) reconstituted in water is hypotonic and should not be injected directly.

The rules and regulations for handling cytostatics in general must be observed when reconstituting or handling Cyclophosphamide. Reconstitution must, to the extent possible, be performed in a laminar air flow safety cabinet. The person handling the product must wear a protective mask and protective gloves. In case of spills, the area must be thoroughly rinsed with water. If Cyclophosphamide, Powder for Solution for Injection or Infusion is stored (e.g. during transport) at the temperature exceeding the maximum temperature, cyclophosphamide may melt. Vials for injections containing melted cyclophosphamide can be visually recognised. Cyclophosphamide is a white powder. Melted cyclophosphamide is a clear or yellowish viscous liquid (usually found as droplets in the affected vials.). Vials for injections containing melted cyclophosphamide may no longer be used.

7. Manufactured in India By:
TAJ PHARMACEUTICALS LIMITED
at SURVEY NO.188/1 TO 189/1,190/1 TO 4,
ATHIYAWAD, DABHEL, DAMAN- 396210 (INDIA)

Cyclophosphamide 200 mg Powder for Injection USP Taj Pharma

Package leaflet: Information for the patient

 Read all of this leaflet carefully before you are given this medicine because it contains important information for you.

  • Keep this leaflet. You may need to read it
  • If you have any further questions, ask your doctor, pharmacist or
  • If you get any side effects, talk to your doctor, pharmacist or This includes any possible side effects not listed in this leaflet. See section 4.
What is in this leaflet
  1. What is and what it is used for
  2. What you need to know before you are given
  3. How to use
  4. Possible side effects
  5. How to store
  6. Contents of the pack and other information
1.  What is and what it is used for

Contains an active substance called cyclophosphamide. Cyclophosphamide is a cytotoxic medicine or anti-cancer medicine. It works by killing cancer cells, this is sometimes called ‘chemotherapy’.

Cyclophosphamide is often used alone or together with other anti-cancer drugs or radiotherapy in the treatment of various cancers. These include:

  • certain types of cancer of the white blood cells (acute lymphoblastic leukemia, chronic lymphocytic leukemia);
  • different forms of lymphomas that affect the immune system (Hodgkin’s disease, non-Hodgkin’s lymphoma and multiple myeloma);
  • ovarian cancer and breast cancer
  • Ewing’s sarcoma (a form of bone cancer)
  • small cell lung cancer;
  • in the treatment of advanced or metastatic tumor of the central nervous (neuroblastoma);

Furthermore, cyclophosphamide is used in preparation for bone marrow transplantation to treat certain types of cancer of the white blood cells (acute lymphoblastic leukemia, chronic myeloid leukemia and acute myeloid leukemia)

Occasionally, some doctors may prescribe cyclophosphamide for other conditions not related to cancer:

  • life threatening autoimmune diseases: severe progressive forms of lupus nephritis (inflammation of the kidney caused by a disease of the immune system) and Wegener’s granulomatosis (a rare form of vasculitis).
2.  What you need to know before you are given You will not be given :
  • if you are allergic to cyclophosphamide or any of its metabolites. An allergic reaction can include shortness of breath, wheezing, rash, itching or swelling of the face and
  • if you currently have any
  • if your bone marrow is not working properly (especially if you have previously had chemotherapy or radiotherapy). You will have blood tests to check how well your bone marrow is
  • if you have a urinary tract infection, which can be recognised as pain when passing urine (cystitis)
  • you have ever had kidney or bladder problems as a result of previous chemotherapy or radiotherapy if you have a condition which decreases your ability to urinate (urinary outflow obstruction).
  • if you are breast-feeding
Warnings and precautions

Talk to your doctor before being given if you:

·      have low blood cell counts
  • have severe infections
  • have liver or kidney problems. Your doctor will check how well your liver and kidneys are working by doing a blood test have had your adrenal glands removed
  • are already having, or have recently had, radiotherapy or chemotherapy;have heart problems or have had radiotherapy in the area of your heart have diabetes
  • have poor general health or are frail are elderly
  • have had surgery less than 10 days

Potentially life threatening allergic reactions (anaphylactic reaction) may occur during treatment with cyclophosphamide.

Cyclophosphamide can have effects on your blood and immune system.

Blood cells are made in your bone marrow. Three different types of blood cell are made:

  • red blood cells, which carry oxygen around your body,
  • white blood cells, which fight infection, and
  • platelets, which help your blood to

After receiving Cyclophosphamide, your blood count of the three types of cells will drop. This is an unavoidable side effect of Cyclophosphamide . Your blood count will reach its lowest level about 5 to 10 days after you start receiving Cyclophosphamide and will stay low until a few days after you finish the course of treatment. Most people recover to a normal blood count within 21 to 28 days. If you have had a lot of chemotherapy in the past, it may take a little longer to return to normal.

You may be more likely to get infections when your blood count drops. Try to avoid close contact with people who have coughs, colds and other infections. Your doctor will treat you with appropriate medicine if they think you have, or are at risk of an infection.

Your doctor will check that the number of red blood cells, white blood cells and platelets is high enough before and during your treatment with Cyclophosphamide . They may need to reduce the amount of medicine you are given or delay your next dose.

Cyclophosphamide can effect with normal wound healing. Keep any cuts clean and dry and check that they are healing normally. It is important to keep your gums healthy, as mouth ulcers and infections can occur. Ask your doctor about it if you are unsure.

Cyclophosphamide can damage the lining of your bladder, causing bleeding into your urine and pain on urination. Your doctor knows this can happen and, if necessary, he or she will give you a medicine called Mesna which will protect your bladder. Mesna can either be given to you as a short injection, or mixed into the drip solution with your Cyclophosphamide, or as tablets. More information on Mesna can be found in the Patient Information Leaflet for Mesna Injection and Mesna tablets.

Most people being given Cyclophosphamide with Mesna do not develop any problems with their bladder, but your doctor may want to test your urine for the presence of blood using a ‘dipstick’ or microscope.If you notice that you have blood in your urine, you must tell your doctor straight.

Cancer medicines and radiation therapy can increase the risk of you developing other cancers; this can be a number of years after your treatment has stopped. Cyclophosphamide has an increased risk of causing cancer in the area of your bladder.

Cyclophosphamide can cause damage to your heart or affect the rhythm of its beating. This increases with higher doses of cyclophosphamide, if you are being treated with radiation or other chemotherapy medicines or if you are elderly. Your doctor will monitor your heart closely during treatment.

Cyclophosphamide can cause lung problems such as inflammation or scarring in your lungs. This can occur more than six months after your treatment. If you start having difficulty breathing, tell your doctor straight away.

Cyclophosphamide can have life threatening effects on your liver.

If you have sudden weight gain, liver pain and yellowing of the skin or whites of the eyes (jaundice) tell your doctor straight away.

Hair thinning or baldness can occur. Your hair should grow back normally though it may be different in texture or colour.

Cyclophosphamide can make you feel sick or be sick. This can last for about 24 hours after taking Cyclophosphamide. You may need to be given medicines to stop feeling or being sick. Ask your doctor about this.

Other medicines and

Tell your doctor if you are taking, have recently taken or might take any other medicines. In particular, tell them about the following medicines or treatments as they may not work well with Cyclophosphamide:

The following medicines can reduce how effective Cyclophosphamide is:

·      aprepitant (used to prevent being sick)
  • bupropion (an anti-depressant)
  • busulfan, thiotepa (used to treat cancer)
  • ciprofloxacin, chloramphenicol (used to treat bacterial infections)
  • fluconazole, itraconazole (used to treat fungal infections)
  • Prasugrel (used to thin the blood)
  • Sulfonamides, such as sulfadiazine, sulfasalazine, sulfamethoxazole (used to treat bacterial infections
  • ondansetron (used to prevent being sick)

The following medicines can increase the toxicity of Cyclophosphamide:

·      allopurinol (used to treat gout)
  • azathioprine (used to reduce the activity of the immune system)
  • chloral hydrate (used to treat insomnia)
  • cimetidine (used to reduce stomach acid)
  • disulfiram (used to treat alcoholism)
  • glyceraldehyde (used to treat warts)
  • protease inhibitors (used to treat viruses)
  • medicines that increase liver enzymes such as: rifampicin (used to treat bacterial infections), carbamazepine, phenobarbital, phenytoin (used to treat epilepsy), John’s wort (a herbal remedy for mild depression), Corticosteroids (used to treat inflammation)
  • dabrafenib (anti cancer drug)

Medicines that can increase the toxic effects of Cyclophosphamide on your blood cells and immunity:

  • ACE inhibitors (used to treat high blood pressure).
  • natalizumab (used to treat multiple sclerosis)
  • paclitaxel (used to treat cancer)
  • thiazide diuretics such as hydrochlorothiazide or chlortalidone (used to treat high blood pressure or water retention)
  • zidovudine (used to treat viruses).
  • Clozapine (used to treat symptoms of some psychiatric disorders)

Medicines that can increase the toxic effects of Cyclophosphamide on your heart:

  • anthracyclines such as bleomycin, doxorubicin, epirubicin,
  • mitomycin (used to treat cancer)
  • cytarabine , pentostatin, trastuzumab (used to treat cancer)
  • radiation in the area of your heart

Medicines that can increase the toxic effects of Cyclophosphamide on your lungs

  • amiodarone (used to treat irregular heart beat)
  • G-CSF, GM-CSF hormones (used to increase white blood cell numbers after chemotherapy)

Medicines that can increase the toxic effects of Cyclophosphamide on your kidneys

  • amphotericin B (used to treat fungal infections)
  • Indomethacin (used to treat pain and inflammation)

Other medicines that can affect or be affected by Cyclophosphamide includes.

  • metronidazole (used to treat bacterial or protozoal infections)
  • tamoxifen (used to treat breast cancer)
  • bupropion (used to help stop smoking)
  • coumarins such as warfarin (used to thin the blood)
  • cyclosporine (used to reduce the activity of the immune system)
  • succinylcholine (used to relax muscles during medical procedures)
  • digoxin, ß-acetyldigoxin (used to treat heart conditions)
  • vaccines
  • verapamil (used to treat high blood pressure, angina or irregular heart beat)
  • Sulfonylurea derivatives (blood sugar levels may drop, if cyclophosphamide and sulfonylurea derivatives are used concomitantly)
 with food, drink and alcohol

Drinking alcohol can increase the nausea and vomiting caused by Cyclophosphamide.

Grapefruit (fruit or juice) should not be consumed while taking Cyclophosphamide. It can interfere with the usual effect of your medicine and may alter the effectiveness of Cyclophosphamide. Pregnancy, breast-feeding and fertility

If you are pregnant or breast-feeding, think you may be pregnant or are planning to have a baby, ask your doctor for advice before taking this medicine.

Pregnancy

Cyclophosphamide can cause miscarriage or damage your unborn baby.

If you are a woman, you should not get pregnant during treatment with cyclophsphamide or up to 12 months after treatment.

If you are a man, you should take adequate precautions, including use of an effective contraceptive to ensure that you do not father a child during your treatment with cyclophosphamide or up to 6 months after treatment.

Lactation

Do not breast-feed while being treated with Cyclophosphamide. Ask your doctor for advice.

Fertility

Cyclophosphamide can affect your ability to have children in the future. Talk to your doctor about cryo-preservation (freezing) of sperm or eggs prior to treatment because of the possibility of irreversible infertility due to therapy with cyclophosphamide. If you are considering becoming parents after the treatment please discuss this with your doctor.

Driving and using machines

Some of the side effects of treatment with Cyclophosphamide might affect your ability to drive and use machines safely. Your doctor will decide if it is safe for you to do so.

3.  How to use

Method of administration

For intravenous use will be given to you by a a doctor or nurse experienced in the used of cancer chemotherapy is given as an injection and will normally be added to a large bag of fluid and will be slowly injected (infused) directly into your vein. The vein can be in your arm, the back of your hand or a large vein under your collar bone.

Depending on your dose, it will usually take between 30-120 minutes to be given as an infusion. Cyclophosphamide is often given in combination with other anti-cancer medicines or radiotherapy.

The recommended dose

  • Your doctor will decide how much of the medicine you need and when you should be given it.
  • The amount of cyclophosphamide you will be given depends on:
    • the type of illness you have;
    • how big you are (a combination of your height and weight);
    • your general health;
    • whether you are being given other anti-cancer medicines or having

It is advisable to get cyclophosphamide administered in the morning. Before, during and after the administration, it is important that you get adequate amounts of fluid, to avoid potential adverse effects on the urinary tract.

If you notice is working too strong or too weak, talk to your doctor or pharmacist.

Your doctor may need to change the amount of medicine you are given and monitor you more closely if you:

  • have problems with your liver or kidneys;
  • you are
Use in children and adolescent

Cyclophosphamide is also indicated in children. The safety profile of cyclophosphamide in children is similar to that of adults.

If you use more than you should

As cyclophosphamide is given to you under the supervision of your doctor, it is very unlikely that you will receive too much. However, if you experience any side effects after being given cyclophosphamide, tell your doctor immediately or go to Accident and Emergency at your nearest hospital. You may need urgent medical attention.

Symptoms of a cyclophosphamide overdose include the side effects listed below in the ‘Side Effects’ section, but are usually of a more severe nature.

If you have any further questions on the use of this medicine, ask your doctor, pharmacist or nurse.

  1. Possible side effects

Like all medicines, Cyclophosphamide can cause side effects, although not everybody gets them.

Tell your doctor immediately if you experience:

  • Allergic reactions. Signs of these would be shortness of breath, wheezing, increased heart rate, decreased blood pressure (extreme tiredness), rash, itching or swelling of the face and Severe allergic reactions could lead to difficulty in breathing or shock, with a possible fatal outcome (anaphylactic shock, anaphylactic/ anaphylactoid reaction).
  • getting bruises without knocking yourself, or bleeding from your This may be a sign that the platelet levels in your blood are getting too low
  • Severe infection or fever,ulcers in the mouth, coughing, breathlessness, signs of sepsis like fever, rapid breathing, elevated heart rate, confusion and This may be a sign of a lowering of your white blood cell count and antibiotics may be needed to fight infections.
  • being very pale, lethargic and tired. This may be a sign of low red blood cells (anaemia). Usually, no treatment is required, your body will eventually replace the red blood If you are very anaemic, you may need a blood transfusion
  • having blood in your urine, pain while passing urine, or passing less urine
  • severe pain in the chest
  • symptoms like weakness, vision loss, impaired speech, loss of sense of touch

Cyclophosphamide can also cause the following side-effects:

Very common: may affect more than 1 in 10 people

  • Decrease in the number of blood cells (myelosuppression)
  • Decrease in white blood cells which are important in fighting infection (leucopenia, neutropenia)
  • Loss of hair (alopecia)
  • Burning sensations during urination and frequent need to urinate (cystitis).
  • Appearance of blood in the urine (microhaematuria)
  • Fever
  • Suppression of the immune system
Common: may affect up to 1 in 10 people
  • Infections
  • inflammation of mucous membranes (mucositis)
  • blood in the urine and painful voiding (haemorrhagic cystitis)
  • Appearance of blood in the urine (macrohaematuria)
  • abnormal liver function
  • infertility in men
  • chills
  • feeling of weakness
  • generally feeling unwell
  • Decrease in white blood cells and fever (febrile neutropenia)
Uncommon: may affect up to 1 in 100 people
  • Anaemia (a low red blood cell count) that can leave you feeling tired and drowsy
  • have easy bruising caused by thrombocytopenia (low platelet count)
  • Inflammation of the lung (pneumonia)
  • Sepsis
  • Allergic reactions
  • infertility in women (rarely irreversible)
  • chest pain
  • fast heart beat
  • heart problems
  • changes in the results of some blood tests
  • redness of the skin (flush)
  • damage to the nerves which can cause numbness, pin, and weakness (neuropathy)
  • pain in the distribution of a nerve (neuralgia)
  • anorexia
  • deafness
Rare: may affect up to 1 in 1,000 people
  • increased risk of cancer of the white blood cells (acute leukaemia)and some other cancers (bladder cancer, ureter cancer)
  • ineffective production of the myeloid class of blood cells (myelodysplastic syndrome)
  • increase in the release of antidiuretic hormone from the pituitary gland (syndrome of inappropriate antidiuretic hormone secretion). This affects the kidneys causing the low levels of sodium in your blood (hyponatremia) and water retention resulting in swelling of the brain due to too much water in your Signs of this can be headache, changes in personality or behaviour, confusion, drowsiness.
  • changes in heart beat
  • inflammation of the liver
  • rash
  • inflammation of the skin
  • Lack of menstruation (periods)
  • Lack of spermia
  • Dizziness
  • Visual impairment, blurred vision
  • changes in the color of your nails and skin
  • dehydration
  • convulsion
  • bleedings
Very rare: may affect up to 1 in 10,000 people
  • breakup of red blood cells and kidney failure (Hemolytic uremic syndrome)
  • blood clots form throughout the body’s small blood vessels (Disseminated intravascular coagulation)
  • shock
  • complications that can occur after cancer treatment caused by break-down products of dying cancer cells (tumor lysis syndrome)
  • low levels of sodium in your blood (hyponatremia)
  • high blood pressure (hypertension)
  • low blood pressure (hypotension)
  • angina
  • heart attack
  • occlusion of a blood vessel due to a blood clot in the circulatory system, (thromboemboembolism),
  • injury of the lung (acute respiratory distress syndrome)
  • scarring of the lungs which causes shortness of breath (chronic pulmonary interstitial fibrosis)
  • difficulty breathing with wheezing or coughing (bronchospasm)
  • breathlessness (dyspnoea)
  • a condition in which the body or a region of the body is deprived of adequate oxygen supply (hypoxia)
  • cough
  • soreness or ulcers in the mouth (stomatitis)
  • feeling sick (nausea) being sick (vomiting) or diarrhea
  • constipation
  • inflammation of the intestine
  • inflammation of the pancreas
  • blood clot in the liver (veno-occlusive liver disease)
  • enlargement of the liver (hepatomegaly)
  • yellow eyes or skin
  • severe hypersensitivity reactions with (high) fever, red spots on the skin, joint pain and / or eye infection (Stevens-Johnson syndrome)
  • severe sudden (hypersensitive) reaction with fever and blisters on the skin / peeling of the skin (toxic epidermal necrolysis)
  • Radiation erythaema
  • itching
  • impairment of the sense of taste (dysgeusia, hypogeusia)
  • sensation of tingling, tickling, prickling, pricking, or burning (paraesthesia)
  • impairment of the sense of smell (parosmia)
  • abnormal muscle breakdown which can lead to kidney problems (rhabdomyolysis)
  • cramps
  • problems with your bladder
  • kidney problems, including kidney
  • Headache
  • Multi organ failure
  • Injection/infusion site reactions
  • Weight gain
  • Confusion
  • Conjunctivitis, eye oedema
  • acute kidney failure with decreased number of red blood cells and platelets (Haemolytic uraemic syndrome)
  • respiratory failure due to fluid accumulation in the lung (pulmonary oedema)
  • accumulation of fluid in the abdominal cavity (ascites)
Not known: frequency cannot be estimated from the available data
  • Different kinds of cancer g. blood cancer (Non-Hodgkin’s lymphoma), kidney cancer, thyroid cancer
  • Sarcoma
  • Different kind of blood disorders (Agranulocytosis, Lymphopenia, Haemoglobin decreased)
  • occlusion of a blood vessel due to a blood clot in the circulatory system, (thromboembolic events), including the possibility of occlusion of the lung vessels (pulmonary embolism)
  • lacrimation increased
  • tinnitus
  • blockage of the nasal passages (nasal congestion)
  • Oropharyngeal pain
  • Rhino rhea
  • Sneezing
  • Pulmonary veno-occlusive disease
  • Obliterative bronchiolitis
  • Alveolitis allergic
  • Pneumonitis
  • Pleural effusion
  • abdominal pain
  • bleeding in stomach or guts
  • intestinal problems/bleeding
  • liver impairment
  • rash, skin reddening, blistering of lips, eyes or mouth, skin peeling (erythema multiforme, urticaria, erythema)
  • hand-foot syndrome
  • facial swelling
  • increased sweating
  • hardening of skin (scleroderma)
  • muscle spasm and pain
  • joint pain
  • inflammation, scarring and contraction of your bladder
  • damage or death of the foetus
  • changes in the results of some blood tests (glucose level, hormone levels)
  • disorder of the brain (encephalopathy), neurotoxicity manifested as a syndrome characterized by headache, confusion, seizures and visual loss (posterior reversible encephalopathy syndrome), abnormal sensation (dysesthesia, hypoesthesia, ), tremor, impairment of the sense of taste (dysgeusia, hypogeusia), impairment of the sense of smell (parosmia)Different kind of heart disorders (Ventricular tachycardia, Cardiogenic shock, Pericardial effusion, Bradycardia, Palpitations, Electrocardiogram QT prolonged)
  • Infertility in women and men
  • Changes in the frequency of menstruation
  • Intra-uterine death
  • Foetal malformation
  • Foetal growth retardation
  • Carcinogenic effect on offspring
  • Salivary gland inflammation (usually in cheek area; parotid gland inflammation)
If any of the side effects gets serious, or if you notice any side effects not listed in this leaflet, please tell your doctor or pharmacist.
Reporting of side effects

If you get any side effects, talk to your doctor. This includes any possible side effects not listed in this leaflet.

5.  How to store

Keep this medicine out of the sight and reach of children.

Do not use this medicine after the expiry date which is stated on the label after EXP The expiry date refers to the last day of that month.

Do not store above 25°C.

After reconstitution for intravenous administration

Chemical and physical in-use stability has been demonstrated for 24 hours at 2°C-8°C.

From a microbiological point of view, the reconstituted solution should be used immediately, unless reconstitution has taken place in controlled and validated aseptic conditions. If not used immediately, in-use storage times and conditions before use are the responsibility of the user and would normally not be longer than 24 hours at 2 – 8°C.

Do not throw away any medicines via wastewater. Ask your pharmacist how to throw away medicines you no longer use. These measures will help protect the environment.
6.  Contents of the pack and other information

What  contains

  • The active substance is cyclophosphamide 200mg
What  looks like and contents of the pack

 200mg powder for solution for injection/infusion is packed in boxes containing 1,5 or 10 clear-colourless Type I-glass 100 ml vials with bromobutyl rubber stopper, and flip-off seal.

Vials are packed with or without a protective plastic overwrap (Onco-Safe). “Onco-Safe” does not come into contact with the medicinal product and provides additional transport protection, which increases the safety for the medical and pharmaceutical personnel.

7. Manufactured in India By:
TAJ PHARMACEUTICALS LIMITED
at SURVEY NO.188/1 TO 189/1,190/1 TO 4,
ATHIYAWAD, DABHEL, DAMAN- 396210 (INDIA).

Related Products

Taj Generics (Taj Pharma) provides a wide range of products to the Indian market, including an extensive range of generics and specialty products; Our products cover a vast array of therapeutic categories, and we offer an extensive range of dosage forms and delivery systems including oral solids, controlled-release, steriles, injectables, topicals, liquids, transdermals, semi-solids and high-potency products. Our Generics portfolio offers over 1500 products in the major therapeutic areas of gastro-intestinal, cardiovascular, pain management, oncology, anti-infectives, paediatrics and dermatology.