nces of pericarditis-myocarditis, not dose-related, have been reported. in adults, at cumulative doses exceeding 550 mg/m 2 , there is an increased incidence of drug-induced congestive heart failure. based on prior clinical experience with doxorubicin, this limit appears lower, namely 400 mg/m 2 , in patients who received radiation therapy that encompassed the heart. in infants and children, there appears to be a greater susceptibility to anthracycline-induced cardiotoxicity compared to that in adults, which is more clearly dose-related. anthracycline therapy (including daunorubicin) in pediatric patients has been reported to produce impaired left ventricular systolic performance, reduced contractility, congestive heart failure or death. these conditions may occur months to years following cessation of chemotherapy. this appears to be dose-dependent and aggravated by thoracic irradiation. long-term periodic evaluation of cardiac function in such patients should, thus, be performed. in both children and adults, the total dose of daunorubicin hydrochloride administered should also take into account any previous or concomitant therapy with other potentially cardiotoxic agents or related compounds such as doxorubicin. there is no absolutely reliable method of predicting the patients in whom acute congestive heart failure will develop as a result of the cardiac toxic effect of daunorubicin hydrochloride. however, certain changes in the electrocardiogram and a decrease in the systolic ejection fraction from pre-treatment baseline may help to recognize those patients at greatest risk to develop congestive heart failure. on the basis of the electrocardiogram, a decrease equal to or greater than 30% in limb lead qrs voltage has been associated with a significant risk of drug-induced cardiomyopathy. therefore, an electrocardiogram and/or determination of systolic ejection fraction should be performed before each course of daunorubicin hydrochloride. in the event that one or the other of these predictive parameters should occur, the benefit of continued therapy must be weighed against the risk of producing cardiac damage. early clinical diagnosis of drug-induced congestive heart failure appears to be essential for successful treatment. evaluation of hepatic and renal function significant hepatic or renal impairment can enhance the toxicity of the recommended doses of daunorubicin hydrochloride; therefore, prior to administration, evaluation of hepatic function and renal function using conventional clinical laboratory tests is recommended (see dosage and administration section). pregnancy daunorubicin hydrochloride may cause fetal harm when administered to a pregnant woman. an increased incidence of fetal abnormalities (parieto-occipital cranioschisis, umbilical hernias, or rachischisis) and abortions was reported in rabbits at doses of 0.05 mg/kg/day or approximately 1/100th of the highest recommended human dose on a body surface area basis. rats showed an increased incidence of esophageal, cardiovascular and urogenital abnormalities as well as rib fusions at doses of 4 mg/kg/day or approximately 1/2 the human dose on a body surface area basis. decreases in fetal birth weight and post-delivery growth rate were observed in mice. there are no adequate and well-controlled studies in pregnant women. 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 the fetus. women of childbearing potential should be advised to avoid becoming pregnant. secondary leukemias there have been reports of secondary leukemias in patients exposed to topoisomerase ii inhibitors when used in combination with other antineoplastic agents or radiation therapy. extravasation at injection site extravasation of daunorubicin hydrochloride at the site of intravenous administration can cause severe local tissue necrosis. (see adverse reactions section)

icin hydrochloride 45 mg/m 2 /day iv on days 1, 2, and 3 of the first course and on days 1, 2 of subsequent courses and cytosine arabinoside 100 mg/m 2 /day iv infusion daily for 7 days for the first course and for 5 days for subsequent courses. for patients 60 years of age and above, daunorubicin hydrochloride 30 mg/m 2 /day iv on days 1, 2, and 3 of the first course and on days 1, 2 of subsequent courses and cytosine arabinoside 100 mg/m 2 /day iv infusion daily for 7 days for the first course and for 5 days for subsequent courses. this daunorubicin hydrochloride dose-reduction is based on a single study and may not be appropriate if optimal supportive care is available. the attainment of a normal-appearing bone marrow may require up to three courses of induction therapy. evaluation of the bone marrow following recovery from the previous course of induction therapy determines whether a further course of induction treatment is required. representative dose schedule and combination for the approved indication of remission induction in pediatric acute lymphocytic leukemia in combination daunorubicin hydrochloride 25 mg/m 2 iv on day 1 every week, vincristine 1.5 mg/m 2 iv on day 1 every week, prednisone 40 mg/m 2 po daily. generally, a complete remission will be obtained within four such courses of therapy; however, if after four courses the patient is in partial remission, an additional one or, if necessary, two courses may be given in an effort to obtain a complete remission. in children less than 2 years of age or below 0.5 m 2 body surface area, it has been recommended that the daunorubicin hydrochloride dosage calculation should be based on weight (1 mg/kg) instead of body surface area. representative dose schedules and combination for the approved indication of remission induction in adult acute lymphocytic leukemia in combination daunorubicin hydrochloride 45 mg/m 2 /day iv on days 1, 2, and 3 and vincristine 2 mg iv on days 1, 8, and 15; prednisone 40 mg/m 2 /day po on days 1 through 22, then tapered between days 22 to 29; l-asparaginase 500 iu/kg/day x 10 days iv on days 22 through 32. the sterile vial contents provide 20 mg of daunorubicin, with 5 mg of daunorubicin per ml. the desired dose is withdrawn into a syringe containing 10 ml to 15 ml of 0.9% sodium chloride injection, usp and then injected into the tubing or sidearm in a rapidly flowing iv infusion of 5% dextrose injection, usp or 0.9% sodium chloride injection, usp. daunorubicin hydrochloride should not be administered mixed with other drugs or heparin. storage and handling store unopened vials in refrigerator, 2° to 8°c (36° to 46°f). store prepared solution for infusion at room temperature, 15° to 30°c (59° to 86°f) for up to 24 hours. contains no preservative. discard unused portion. protect from light . if daunorubicin hydrochloride contacts the skin or mucosae, the area should be washed thoroughly with soap and water. procedures for proper handling and disposal of anticancer drugs should be considered. several guidelines on this subject have been published. 1-7 there is no general agreement that all of the procedures recommended in the guidelines are necessary or appropriate.

itial phase and 18.5 hours in the terminal phase. by 1 hour after drug administration, the predominant plasma species is daunorubicinol, an active metabolite, which disappears with a half-life of 26.7 hours. distribution daunorubicin hydrochloride is rapidly and widely distributed in tissues, with highest levels in the spleen, kidneys, liver, lungs, and heart. the drug binds to many cellular components, particularly nucleic acids. there is no evidence that daunorubicin crosses the blood-brain barrier, but the drug apparently crosses the placenta. metabolism and elimination daunorubicin hydrochloride is extensively metabolized in the liver and other tissues, mainly by cytoplasmic aldo-keto reductases, producing daunorubicinol, the major metabolite which has antineoplastic activity. approximately 40% of the drug in the plasma is present as daunorubicinol within 30 minutes and 60% in 4 hours after a dose of daunorubicin. further metabolism via reduction cleavage of the glycosidic bond, 4-o demethylation, and conjugation with both sulfate and glucuronide have been demonstrated. simple glycosidic cleavage of daunorubicin or daunorubicinol is not a significant metabolic pathway in man. twenty-five percent of an administered dose of daunorubicin hydrochloride is eliminated in an active form by urinary excretion and an estimated 40% by biliary excretion. special populations pediatric patients although appropriate studies with daunorubicin hydrochloride have not been performed in the pediatric population, cardiotoxicity may be more frequent and occur at lower cumulative doses in children. geriatric patients although appropriate studies with daunorubicin hydrochloride have not been performed in the geriatric population, cardiotoxicity may be more frequent in the elderly. caution should also be used in patients who have inadequate bone marrow reserves due to old age. in addition, elderly patients are more likely to have age-related renal function impairment, which may require reduction of dosage in patients receiving daunorubicin hydrochloride. renal and hepatic impairment doses of daunorubicin hydrochloride should be reduced in patients with hepatic and renal impairment. patients with serum bilirubin concentrations of 1.2 to 3 mg/dl should receive 75% of the usual daily dose and patients with serum bilirubin concentrations greater than 3 mg/dl should receive 50% of the usual daily dose. patients with serum creatinine concentrations of greater than 3 mg/dl should receive 50% of the usual daily dose. (see warnings , evaluation of hepatic and renal function ). clinical studies in the treatment of adult acute nonlymphocytic leukemia, daunorubicin hydrochloride, used as a single agent, has produced complete remission rates of 40 to 50%, and in combination with cytarabine, has produced complete remission rates of 53 to 65%. the addition of daunorubicin hydrochloride to the two-drug induction regimen of vincristine-prednisone in the treatment of childhood acute lymphocytic leukemia does not increase the rate of complete remission. in children receiving identical cns prophylaxis and maintenance therapy (without consolidation), there is prolongation of complete remission duration (statistically significant, p<0.02) in those children induced with the three drug (daunorubicin-vincristine-prednisone) regimen as compared to two drugs. there is no evidence of any impact of daunorubicin hydrochloride on the duration of complete remission when a consolidation (intensification) phase is employed as part of a total treatment program. in adult acute lymphocytic leukemia, in contrast to childhood acute lymphocytic leukemia, daunorubicin hydrochloride during induction significantly increases the rate of complete remission, but not remission duration, compared to that obtained with vincristine, prednisone, and l-asparaginase alone. the use of daunorubicin hydrochloride in combination with vincristine, prednisone, and l-asparaginase has produced complete remission rates of 83% in contrast to a 47% remission in patients not receiving daunorubicin hydrochloride.

ermatocyte series in the seminiferous tubules with complete aspermatogenesis.

ytic leukemia, in contrast to childhood acute lymphocytic leukemia, daunorubicin hydrochloride during induction significantly increases the rate of complete remission, but not remission duration, compared to that obtained with vincristine, prednisone, and l-asparaginase alone. the use of daunorubicin hydrochloride in combination with vincristine, prednisone, and l-asparaginase has produced complete remission rates of 83% in contrast to a 47% remission in patients not receiving daunorubicin hydrochloride.