eumocystis jiroveci pneumonia in patients with hiv infection was associated with increased rates of treatment failure and morbidity in a placebo-controlled study [see warnings and precautions ( 5.3 )] .

sk of progression of neurologic manifestations despite hematologic remission. ( 1 ) limitations of use levoleucovorin for injection is not indicated for pernicious anemia and megaloblastic anemia secondary to the lack of vitamin b 12 , because of the risk of progression of neurologic manifestations despite hematologic remission.

ies of fluorouracil [see drug interactions ( 7 )] . gastrointestinal toxicities, including stomatitis and diarrhea, occur more commonly and may be of greater severity and of prolonged duration. deaths from severe enterocolitis, diarrhea, and dehydration have occurred in elderly patients receiving weekly d,l- leucovorin and fluorouracil. monitor patients for gastrointestinal toxicities. do not initiate or continue therapy with levoleucovorin and fluorouracil in patients with symptoms of gastrointestinal toxicity until those symptoms have resolved. monitor patients with diarrhea until resolved, as rapid deterioration leading to death can occur. 5.3 drug interaction with trimethoprim-sulfamethoxazole the concomitant use of d,l- leucovorin with trimethoprim-sulfamethoxazole for the acute treatment of pneumocystis jiroveci pneumonia in patients with hiv infection was associated with increased rates of treatment failure and morbidity [see drug interactions ( 7 )] .

combination with fluorouracil the following regimens have been used for the treatment of colorectal cancer: levoleucovorin for injection 100 mg/m 2 by intravenous injection over a minimum of 3 minutes, followed by fluorouracil 370 mg/m 2 once daily for 5 consecutive days. ( 2.5 ) levoleucovorin for injection 10 mg/m 2 by intravenous injection followed by fluorouracil 425 mg/m 2 once daily for 5 consecutive days. ( 2.5 ) administer fluorouracil and levoleucovorin for injection separately to avoid the formation of precipitate. the above five-day courses may be repeated every 4 weeks for 2 courses, then every 4 to 5 weeks, if the patient has recovered from toxicity from the prior course. do not adjust levoleucovorin for injection dosage for toxicity. ( 2.5 ) 2.1 important use information levoleucovorin for injection is indicated for intravenous administration only. do not administer intrathecally . 2.2 co-administration of levoleucovorin for injection with other agents due to the risk of precipitation, do not co-administer levoleucovorin for injection with other agents in the same admixture. 2.3 recommended dosage for rescue after high-dose methotrexate therapy the recommended dosage for levoleucovorin for injection is based on a methotrexate dose of 12 grams/m 2 administered by intravenous infusion over 4 hours. twenty-four hours after starting the methotrexate infusion, initiate levoleucovorin for injection at a dose of 7.5 mg (approximately 5 mg/m 2 ) as an intravenous infusion every 6 hours. monitor serum creatinine and methotrexate levels at least once daily. continue levoleucovorin for injection administration, hydration, and urinary alkalinization (ph of 7 or greater) until the methotrexate level is below 5 x 10 -8 m (0.05 micromolar). adjust the levoleucovorin for injection dose or extend the duration as recommended in table 1 . table 1 recommended dosage for levoleucovorin for injection based on serum methotrexate and creatinine levels * these patients are likely to develop reversible renal failure. in addition to appropriate levoleucovorin for injection therapy, continue hydration and urinary alkalinization and monitor fluid and electrolyte status, until the serum methotrexate level has fallen to below 0.05 micromolar and the renal failure has resolved. clinical situation laboratory findings recommendation normal methotrexate elimination serum methotrexate level approximately 10 micromolar at 24 hours after administration, 1 micromolar at 48 hours, and less than 0.2 micromolar at 72 hours. administer 7.5 mg by intravenous infusion every 6 hours for 60 hours (10 doses starting at 24 hours after start of methotrexate infusion). delayed late methotrexate elimination serum methotrexate level remaining above 0.2 micromolar at 72 hours, and more than 0.05 micromolar at 96 hours after administration. continue 7.5 mg by intravenous infusion every 6 hours until methotrexate level is less than 0.05 micromolar. delayed early methotrexate elimination and/or evidence of acute renal injury* serum methotrexate level of 50 micromolar or more at 24 hours, or 5 micromolar or more at 48 hours after administration or 100% or greater increase in serum creatinine level at 24 hours after methotrexate administration (e.g., an increase from 0.5 mg/dl to a level of 1 mg/dl or more). administer 75 mg by intravenous infusion every 3 hours until methotrexate level is less than 1 micromolar; then 7.5 mg by intravenous infusion every 3 hours until methotrexate level is less than 0.05 micromolar. impaired methotrexate elimination or renal impairment decreased methotrexate elimination or renal impairment which are clinically important but less severe than the abnormalities described in table 1 can occur following methotrexate administration. if toxicity associated with methotrexate is observed, in subsequent courses extend levoleucovorin for injection rescue for an additional 24 hours (total of 14 doses over 84 hours). third-space fluid collection and other causes of delayed methotrexate elimination accumulation in a third space fluid collection (i.e., ascites, pleural effusion), renal insufficiency, or inadequate hydration can delay methotrexate elimination. under such circumstances, higher doses of levoleucovorin for injection or prolonged administration may be indicated. 2.4 recommended dosage for overdosage of folic acid antagonists or impaired methotrexate elimination start levoleucovorin for injection as soon as possible after an overdosage of methotrexate or within 24 hours of methotrexate administration when methotrexate elimination is impaired. as the time interval between methotrexate administration and levoleucovorin for injection increases, the effectiveness of levoleucovorin for injection to diminish methotrexate toxicity may decrease. administer levoleucovorin for injection 7.5 mg (approximately 5 mg/m 2 ) by intravenous infusion every 6 hours until the serum methotrexate level is less than 5 x 10 -8 m (0.05 micromolar). monitor serum creatinine and methotrexate levels at least every 24 hours. increase the dosage of levoleucovorin for injection to 50 mg/m 2 intravenously every 3 hours and continue levoleucovorin for injection at this dosage until the methotrexate level is less than 5 x 10 -8 m for the following: if serum creatinine at 24-hours increases 50% or more compared to baseline if the methotrexate level at 24-hours is greater than 5 x 10 -6 m if the methotrexate level at 48-hours is greater than 9 x 10 -7 m, continue concomitant hydration (3 l per day) and urinary alkalinization with sodium bicarbonate. adjust the sodium bicarbonate dose to maintain urine ph at 7 or greater. 2.5 dosage in combination with fluorouracil for metastatic colorectal cancer the following regimens have been used for the treatment of colorectal cancer: levoleucovorin for injection 100 mg/m 2 by intravenous injection over a minimum of 3 minutes, followed by fluorouracil at 370 mg/m 2 by intravenous injection, once daily for 5 consecutive days. levoleucovorin for injection 10 mg/m 2 by intravenous injection, followed by fluorouracil 425 mg/m 2 by intravenous injection, once daily for 5 consecutive days. administer fluorouracil and levoleucovorin for injection separately to avoid the formation of a precipitate. this five-day course may be repeated every 4 weeks for 2 courses, then every 4 to 5 weeks, if the patient has recovered from the toxicity from the prior course. do not adjust levoleucovorin for injection dosage for toxicity. refer to fluorouracil prescribing information for information on fluorouracil dosage and dosage modifications for adverse reactions. 2.6 preparation for administration levoleucovorin for injection prior to intravenous injection, reconstitute the 50 mg vial of levoleucovorin for injection with 5.3 ml of 0.9% sodium chloride injection, usp to yield a levoleucovorin concentration of 10 mg per ml. reconstitution with sodium chloride solutions with preservatives (e.g. benzyl alcohol) has not been studied. the use of solutions other than 0.9% sodium chloride injection, usp is not recommended. the reconstituted 10 mg per ml levoleucovorin contains no preservative. observe strict aseptic technique during reconstitution of the drug product. discard unused portion. saline reconstituted levoleucovorin solutions may be further diluted, immediately, to concentrations of 0.5 mg/ml to 5 mg/ml in 0.9% sodium chloride injection, usp or 5% dextrose injection, usp. do not store the reconstituted product or reconstituted product diluted using 0.9% sodium chloride injection, usp for more than 12 hours at room temperature. do not store reconstituted product diluted using 5% dextrose injection, usp for more than 4 hours at room temperature. visually inspect the reconstituted solution for particulate matter and discoloration prior to administration. do not use if cloudiness or precipitate is observed. do not intravenously inject more than 16 ml of reconstituted solutions (160 mg of levoleucovorin) per minute, because of the calcium content of the levoleucovorin solution.

drug and may not reflect the rates observed in practice. high-dose methotrexate therapy table 2 presents the frequency of adverse reactions which occurred during the administration of 58 courses of high-dose methotrexate 12 grams/m 2 followed by levoleucovorin rescue for osteosarcoma in 16 patients aged 6 to 21 years. most patients received levoleucovorin 7.5 mg every 6 hours for 60 hours or longer, beginning 24 hours after completion of methotrexate administration. table 2 adverse reactions with high-dose methotrexate therapy adverse reactions levoleucovorin for injection n = 16 all grades (%) grades 3-4 (%) gastrointestinal stomatitis 38 6 vomiting 38 0 nausea 19 0 diarrhea 6 0 dyspepsia 6 0 typhlitis 6 6 respiratory dyspnea 6 0 skin and appendages dermatitis 6 0 other confusion 6 0 neuropathy 6 0 renal function abnormal 6 0 taste perversion 6 0 combination with fluorouracil in colorectal cancer table 3 presents the frequency of adverse reaction which occurred in 2 arms of a randomized controlled trial conducted by the north central cancer treatment group (ncctg) in patients with metastatic colorectal cancer. the trial failed to show superior overall survival with fluorouracil + levoleucovorin compared to fluorouracil + d,l -leucovorin. patients were randomized to fluorouracil 370 mg/m 2 intravenously and levoleucovorin 100 mg/m 2 intravenously, both daily for 5 days, or to fluorouracil 370 mg/m 2 intravenously and d,l -leucovorin 200 mg/m 2 intravenously, both daily for 5 days. treatment was repeated week 4 and week 8, and then every 5 weeks until disease progression or unacceptable toxicity. table 3 adverse reactions occurring in ≥ 10% of patients in either arm 1 includes abdominal pain, upper abdominal pain, lower abdominal pain, and abdominal tenderness adverse reaction levoleucovorin/fluorouracil n=318 d,l -leucovorin/fluorouracil n=307 grades 1-4 (%) grades 3-4 (%) grades 1-4 (%) grades 3-4 (%) gastrointestinal disorders stomatitis 72 12 72 14 diarrhea 70 19 65 17 nausea 62 8 61 8 vomiting 40 5 37 6 abdominal pain 1 14 3 19 3 general disorders asthenia/fatigue/malaise 29 5 32 11 skin disorders dermatitis 29 1 28 1 alopecia 26 0.3 28 1 metabolism and nutrition anorexia/decreased appetite 24 4 25 2 6.2 postmarketing experience the following adverse reaction have been identified during postapproval use of levoleucovorin products. because these reactions are reported from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. dermatologic: pruritus, rash respiratory: dyspnea other: temperature change, rigors, allergic reactions

eumocystis jiroveci pneumonia in patients with hiv infection was associated with increased rates of treatment failure and morbidity in a placebo-controlled study [see warnings and precautions ( 5.3 )] .

pediatric patients for rescue after high-dose methotrexate therapy in osteosarcoma and diminishing the toxicity associated with overdosage of folic acid antagonists or impaired methotrexate elimination. use of levoleucovorin in pediatric patients is supported by open-label clinical trial data in 16 pediatric patients 6 years of age and older, with additional supporting evidence from literature [see clinical studies ( 14.1 )]. the safety and effectiveness of levoleucovorin have not been established for the treatment of pediatric patients with advanced metastatic colorectal cancer. 8.5 geriatric use clinical studies of levoleucovorin in the treatment of osteosarcoma did not include patients aged 65 and over to determine whether they respond differently from younger patients. in the ncctg clinical trial of levoleucovorin in combination with fluorouracil for the treatment of metastatic colorectal cancer, no overall differences in safety or effectiveness were observed between patients age 65 years and older and younger patients.

ereby enhancing the inhibition of thymidylate synthase. 12.3 pharmacokinetics the pharmacokinetics of levoleucovorin after intravenous administration of a 15 mg dose was studied in healthy subjects. the mean maximum serum total tetrahydrofolate (total-thf) concentrations was 1722 ng/ml (cv 39%) and the mean maximum serum (6s)-5-methyl-5,6,7,8-tetrahydrofolate concentrations was 275 ng/ml (cv 18%) observed around 0.9 hours post injection. distribution exploratory studies show that small quantities of systemically administered leucovorin enter the cerebrospinal fluid (csf), primarily as its major metabolite 5-methyltetrahydrofolate (5-mthfa). in humans, the csf levels of 5-mthfa remain 1-3 orders of magnitude lower than the usual methotrexate concentrations following intrathecal administration. elimination the mean terminal half-life was 5.1 hours for total-thf and 6.8 hours for (6s)-5-methyl-5,6,7,8-tetrahydrofolate. drug interaction studies the mean dose-normalized steady-state plasma concentrations for both levoleucovorin and 5-methyl-thf were comparable whether fluorouracil (370 mg/m 2 /day as an intravenous bolus) was given in combination with levoleucovorin (250 mg/m 2 and 1000 mg/m 2 as a continuous intravenous infusion for 5.5 days) or with d,l -leucovorin (500 mg/m 2 as a continuous intravenous infusion for 5.5 days).

were comparable whether fluorouracil (370 mg/m 2 /day as an intravenous bolus) was given in combination with levoleucovorin (250 mg/m 2 and 1000 mg/m 2 as a continuous intravenous infusion for 5.5 days) or with d,l -leucovorin (500 mg/m 2 as a continuous intravenous infusion for 5.5 days).

eucovorin rescue following high-dose methotrexate was based on the adverse reaction profile [see adverse reactions ( 6.1 )]. 14.2 metastatic colorectal cancer in a randomized clinical study conducted by mayo clinic and the north central cancer treatment group (ncctg) in patients with metastatic colorectal cancer comparing d,l -leucovorin 200 mg/m 2 and fluorouracil 370 mg/m 2 versus d,l -leucovorin 20 mg/m 2 and fluorouracil 425 mg/m 2 versus fluorouracil 500 mg/m 2 , with all drugs administered by intravenous infusion daily for 5 days every 28 to 35 days, response rates were 26% (p=0.04 versus fluorouracil alone), 43% (p=0.001 versus fluorouracil alone) and 10%, respectively. respective median survival times were 12.2 months (p=0.037), 12 months (p=0.050), and 7.7 months. the low dose d,l -leucovorin regimen was associated with a statistically significant improvement in weight gain of more than 5%, relief of symptoms, and improvement in performance status. the high dose d,l -leucovorin regimen was associated with a statistically significant improvement in performance status and trended toward improvement in weight gain and in relief of symptoms but these were not statistically significant. in a second randomized clinical study conducted by mayo clinic and ncctg, the fluorouracil alone arm was replaced by a regimen of sequentially administered methotrexate, fluorouracil, and d,l -leucovorin. response rates with d,l -leucovorin 200 mg/m 2 and fluorouracil 370 mg/m 2 versus d,l -leucovorin 20 mg/m 2 and fluorouracil 425 mg/m 2 versus sequential methotrexate and fluorouracil and d,l -leucovorin were respectively 31% (p≤0.01), 42% (p≤0.01), and 14%. respective median survival times were 12.7 months (p≤0.04), 12.7 months (p≤0.01), and 8.4 months. there was no statistically significant difference in weight gain of more than 5% or in improvement in performance status was seen between the treatment arms. a randomized controlled trial conducted by ncctg in patients with metastatic colorectal cancer failed to show superiority of a regimen of fluorouracil + levoleucovorin to fluorouracil + d,l -leucovorin in overall survival. patients were randomized to fluorouracil 370 mg/m 2 intravenously and levoleucovorin 100 mg/m 2 intravenously, both daily for 5 days, or to fluorouracil 370 mg/m 2 intravenously and d,l -leucovorin 200 mg/m 2 intravenously, both daily for 5 days. treatment was repeated week 4 and week 8, and then every 5 weeks until disease progression or unacceptable toxicity.