英文药名: Nipent(Pentostatin for powder solution infusion) 中文药名: 喷司他丁冻干粉/溶液输注 生产厂家：Hospira UK Ltd 药品说明 中文别名：脱氧肋间型霉素，脱氧考福霉素，2-脱氧咖啡霉素，喷妥司汀 外文名：Pentostatin,Nipent,Deoxyco-formycin,2-Deoxycoformycin. 外文缩写：2’-dcF,DCF。 药理作用： 本品是从链霉素菌中分离得的抗生素，从结构上是次黄嘌呤增加一个碳成7元环与咪唑骈合。DCF是嘌呤衍生物强力的腺苷脱氨酶（ADA）的抑制剂，是一种较新的抗代谢类药物。急性淋巴细胞白血病与髓细胞性白血病患者的淋巴母细胞和髓母细胞中ADA的活性增高。本品在体外与ADA有较高的亲和力，并能抑制动物和人慢性髓细胞白血病患者髓细胞中此酶的活性，随着ADA的活性被抑制，细胞的脱氧腺苷三磷酸（dATP）水平增高，dATP通过抑制核糖核苷酸还原酶而阻断DNA的生物合成，抑制细胞繁殖，淋巴样细胞最为敏感。还能抑制RNA合成和增强有对DNA的损伤。本品且能增强其他受腺苷脱氨酶代谢的抗肿瘤药物的作用，同时本品还具有免疫抑制作用。 体内过程： 静脉注射本品0.25-1mg/kg，约14小时后血药平均浓度为2-6umol/L;本品能通过血脑屏障，静脉注射后2~4小时脑脊液中药物浓度为血药浓度的10%~12%。其血浆消除半衰期为3-9.6小时，静脉注射本品5-30mg/m2后，第1日尿中可回收剂量的50%~82%。 临床应用： 对急性及慢性淋巴细胞白血病、非霍奇金淋巴瘤、皮肤T细胞淋巴瘤及毛细胞白血病有效；对抗干扰素的病人使用本品仍非常有效。 （1）行细胞白血病患者无论有无脾切除或以往是否接受a-干扰素治疗，使用本品后完全缓解率(CR)达33%~92%。几首所有患者经本品治疗2个疗程后，可见外周血细胞计数改善，最明显的改善平均在治疗4个月左右。所有CR的患者平均6年保持稳定，不需再治疗。 （2）对B细胞性慢性淋巴细胞白细胞病地完全缓解率仅为4%，部分缓解率为15%~27%。 （3）对幼淋巴细胞白细胞病的完全缓解率为10%，部分缓解率为58%。 （4）对复发性急性淋巴母细胞白血病儿童患者的完全缓解率可达10%。 （5）对皮肤T细胞淋巴瘤（CTCL）的总缓解率（CR+PR）为17%~40%；对其他非霍奇鑫淋巴瘤的CR为0%~20%，PR为10%~30%。 用法用量： 静脉注射：每日5mg/m2，连用3日，每4周重复；或每次4mg/m2，每2周1次。 不良反应： （1）骨髓抑制：为剂量限制性毒性，主要为白细胞与淋巴细胞减少，16%~25%是严重缺乏。 （2）胃肠道反应：恶心，呕吐（36%~87%）。 （3）肾脏毒性：可出现高尿酸血症。 （4）中枢神经毒性：疲倦、头痛，不适，抑郁，甚至昏睡、昏迷。 （5）其他反应：发生机会20%~58%，结膜炎，肺毒性，肝功能损害，关节痛，肌痛，皮疹，带状疱疹等。 禁忌证： 哺乳妇女须慎用。 注意事项： （1）本品与干扰素无交叉耐药性，但两者同用是否能提高疗效尚无定论。 （2）使用本品期间应定期检查血像，若发生严重毒副作用，则应停药并对症处理。 （3）本品避免与氟达拉滨同用，剂量应在推荐的范围内。 贮藏： 室温凉暗处保存。 制剂规格：[注：本品英国产品，采购者在线咨询] 注射剂：10mg/支 生产厂家：[英国]Hospira UK Ltd Nipent 10mg powder for solution for injection, powder for solution for infusion 1. Name of the medicinal product NIPENT 10 mg powder for solution for injection, powder for solution for infusion. 2. Qualitative and quantitative composition One vial contains 10 mg Pentostatin. When reconstituted (see Section 6.6), the resulting solution contains pentostatin 2 mg/ml. For a full list of excipients, see section 6.1. 3. Pharmaceutical form Powder for solution for injection, powder for solution for infusion. The vials contain a solid white to off-white cake or powder. The pH of reconstituted solution is 7.0 – 8.2. 4. Clinical particulars 4.1 Therapeutic indications Pentostatin is indicated as single agent therapy in the treatment of adult patients with hairy cell leukaemia. 4.2 Posology and method of administration Pentostatin is indicated for adult patients. Administration to Patient It is recommended that patients receive hydration with 500 to 1,000 ml of 5% glucose only or 5% glucose in 0.18% or 0.9% saline or glucose 3.3% in 0.3% saline or 2.5% glucose in 0.45% saline or equivalent before pentostatin administration. An additional 500 ml of 5% glucose only or 5% glucose in 0.18% or 0.9% saline or 2.5% glucose in 0.45% saline or equivalent should be administered after pentostatin is given. The recommended dosage of pentostatin for the treatment of hairy cell leukaemia is 4 mg/m2 in a single administration every other week. Pentostatin may be given intravenously by bolus injection or diluted in a larger volume and given over 20 to 30 minutes. (See Special precautions for disposal and other handling under Section 6.6.) Higher doses are not recommended. No extravasation injuries were reported in clinical studies. The optimal duration of treatment has not been determined. In the absence of major toxicity and with observed continuing improvement, the patient should be treated until a complete response has been achieved. Although not established as required, the administration of two additional doses has been recommended following the achievement of a complete response. All patients receiving pentostatin at 6 months should be assessed for response to treatment. If the patient has not achieved a complete or partial response, treatment with pentostatin should be discontinued. If the patient has achieved a partial response, pentostatin treatment should be continued in an effort to achieve a complete response. At any time after a complete response is achieved, two additional doses of pentostatin are recommended. Pentostatin treatment should then be stopped. If the best response to treatment at the end of 12 months is a partial response, it is recommended that treatment with pentostatin be stopped. Withholding or discontinuation of individual doses may be needed when severe adverse reactions occur. Drug treatment should be withheld in patients with severe rash, and withheld or discontinued in patients showing evidence of nervous system toxicity. Pentostatin treatment should be withheld in patients with active infection occurring during the treatment but may be resumed when the infection is controlled. Dosage in Patients with Cytopenias No dosage reduction is recommended at the start of therapy with pentostatin in patients with anaemia, neutropenia, or thrombocytopenia. In addition, dosage reductions are not recommended during treatment in patients with anaemia and thrombocytopenia. Pentostatin should be temporarily withheld if the absolute neutrophil count during treatment falls below 200 cells/mm3 in a patient who had an initial neutrophil count greater than 500 cells/mm3 and may be resumed when the count returns to predose levels. Renal Insufficiency There is limited experience in patients with impaired renal function (creatinine clearance (Clcr) <60 ml/min) (see section 5.2). Creatinine clearance should be determined prior to each administration of NIPENT. Liver Impairment Because of limited experience treating patients with abnormal liver function, treatment of such patients should be done with caution. Administration to Elderly Patients The recommended dosage of pentostatin for the treatment of hairy cell leukaemia in the elderly is 4 mg/m2 in a single administration every other week. Clinical trials have included patients over 65 years old and no adverse reactions specific to this age group have been reported. Paediatric Use Hairy cell leukaemia is a disease affecting adults, most commonly in the sixth decade of life. Safety and effectiveness of Nipent in children have not been established. 4.3 Contraindications Pentostatin is contraindicated in patients who have demonstrated hypersensitivity to the active ingredient or to any of the excipients. Pentostatin is contraindicated in patients with impaired renal function (Creatinine clearance < 60 ml/min). Pentostatin is contraindicated in patients with active infection. 4.4 Special warnings and precautions for use Warnings Pentostatin should be administered under the supervision of a physician qualified and experienced in the use of cancer chemotherapeutic agents. The use of doses higher than those specified (see Section 4.2) is not recommended. Dose-limiting severe renal, liver, pulmonary, and CNS toxicities occurred in Phase 1 studies that used pentostatin at a higher dose (20-50 mg/m2/course) than recommended. In a clinical investigation in patients with refractory chronic lymphocytic leukaemia using pentostatin at the recommended dose in combination with fludarabine phosphate, four of six patients entered on the study had severe or fatal pulmonary toxicity. The use of pentostatin in combination with fludarabine phosphate is not recommended. Biochemical studies have demonstrated that pentostatin enhances the effects of vidarabine, a purine nucleoside with antiviral activity. The combined use of vidarabine and pentostatin may result in an increase in adverse reactions associated with each drug. The therapeutic benefit of the drug combination has not been established. Patients with hairy cell leukaemia may experience myelosuppression primarily during the first few courses of treatment. Patients with infections prior to pentostatin treatment have in some cases developed worsening of their condition leading to death; whereas others have achieved complete response. Patients with infection should be treated only when the potential benefit of treatment justifies the potential risk to the patient. Efforts should be made to control the infection before treatment is initiated or resumed. In patients with progressive hairy cell leukaemia, the initial courses of pentostatin treatment were associated with worsening of neutropaenia. Therefore, frequent monitoring of complete blood counts during this time is necessary. If severe neutropenia continues beyond the initial cycles, patient should be evaluated for disease status, including a bone marrow examination. Pentostatin might have harmful effects on the genotype. Therefore, it is recommended that men undergoing treatment with pentostatin should not father a child during treatment up to 6 months thereafter. Contraception is to be guaranteed for women of childbearing age. Should a pregnancy occur during treatment, the possibility of a genetic consultation is to be considered. Bone Marrow Transplant Regimen with high dose cyclophosphamide Acute pulmonary oedema and hypotension leading to death, have been reported in the literature in patients treated with pentostatin in combination with carmustine, etoposide and high dose cyclophosphamide as part of an ablative regimen for bone marrow transplant. The combination of pentostatin and high dose cyclophosphamide is not recommended. Elevations in liver function tests occurred during treatment with pentostatin and were generally reversible. Renal toxicity was observed at higher doses in early studies; however, in patients treated at the recommended dose, elevations in serum creatinine were usually minor and reversible. There were some patients who began treatment with normal renal function who had evidence of mild to moderate toxicity at a final assessment. (See Administration to Patient [4.2].) Rashes, occasionally severe, were commonly reported and may worsen with continued treatment. Withholding of treatment may be required. (See Administration to Patient [4.2].) Extra care should be taken in treating patients beginning therapy with poor performance. Precautions Therapy with pentostatin requires regular patient observation and monitoring of haematologic parameters and blood chemistry values. If severe adverse reactions occur, the drug should be withheld (see Administration to Patient [4.2]) and appropriate corrective measures should be taken according to the clinical judgement of the physician. Pentostatin treatment should be withheld or discontinued in patients showing evidence of nervous system toxicity. Prior to initiating therapy with pentostatin, renal function should be assessed with a serum creatinine and/or a creatinine clearance assay. (See Pharmacokinetic Properties [5.2], Administration to Patient [4.2].) Complete blood counts, serum creatinine, and BUN should be performed before each dose of pentostatin and at appropriate periods during therapy. Severe neutropenia has been observed following the early courses of treatment with pentostatin and therefore frequent monitoring of complete blood counts is recommended during this time. If haematologic parameters do not improve with subsequent courses, patients should be evaluated for disease status, including a bone marrow examination. Periodic monitoring of the peripheral blood for hairy cells should be performed to assess the response to treatment. In addition, bone marrow aspirates and biopsies may be required at 2 to 3 month intervals to assess the response to treatment. 4.5 Interaction with other medicinal products and other forms of interaction Allopurinol Allopurinol and pentostatin are both associated with skin rashes. Based on clinical studies in 25 refractory patients who received both pentostatin and allopurinol, the combined use of pentostatin and allopurinol did not appear to produce a higher incidence of skin rashes than observed with pentostatin alone. There has been a report of one patient who received both drugs and experienced a hypersensitivity vasculitis that resulted in death. It was unclear whether this adverse event and subsequent death resulted from the drug combination. Vidarabine Biochemical studies have demonstrated that pentostatin enhances the effects of vidarabine, a purine nucleoside with antiviral activity. The combined use of vidarabine and pentostatin may result in an increase in adverse reactions associated with each drug. The therapeutic benefit of the drug combination has not been established. Fludarabine The combined use of pentostatin and fludarabine phosphate is not recommended because it has been associated with an increased risk of fatal pulmonary toxicity. (See Section 4.4, Warnings.) Bone Marrow Transplant Regimen with high dose cyclophosphamide Acute pulmonary oedema and hypotension leading to death, have been reported in the literature in patients treated with pentostatin in combination with carmustine, etoposide and high dose cyclophosphamide as part of an ablative regimen for bone marrow transplant. The combination of pentostatin and high dose cyclophosphamide is not recommended. 4.6 Pregnancy and lactation Women of childbearing potential receiving pentostatin should be advised not to become pregnant. No fertility studies have been conducted in animals. Incompletely reversible seminiferous tubular atrophy and degeneration in rats and in dogs may be indicative of potential effects on male fertility. The possible adverse effects on human fertility have not been determined. There are no data from the use of pentostatin in pregnant patients. Studies in animals have shown reproductive toxicity. Pentostatin has been shown to be teratogenic in rodent studies. Pentostatin is not recommended in pregnancy and women of child bearing potential not using effective contraception. If the patient becomes pregnant while receiving this drug, the patient should be apprised of the potential hazards to the foetus. It is not known whether pentostatin is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions from pentostatin in nursing infants, nursing is not recommended. 4.7 Effects on ability to drive and use machines Pentostatin has a minor or moderate influence on the ability to drive and use machines. Patients should be advised to use caution in driving or using machinery following drug administration. 4.8 Undesirable effects Pentostatin is lymphotoxic. Aside from myelosuppression, pentostatin is immunosuppressive in particular by suppression of the CD4+ lymphocyte subset. CD4+ counts smaller than 200 per µl are usually seen during treatment with pentostatin and CD4+ count suppression can outlast the end of treatment by more than 6 months. With the exception of frequent herpes zoster infections the clinical consequences of the suppression of CD4+ counts in hairy cell leukaemia are not well understood yet. Long term consequences are not predictable, but currently there is no evidence for higher frequency of secondary malignancies. The following adverse events were reported during clinical studies in patients with hairy cell leukaemia who were refractory to alpha-interferon or were treated as front-line therapy. Most patients experienced an adverse event. The most commonly reported reactions were nausea and/or vomiting or leucopenia, each occurring in about 60% of patients. Fever, rash and fatigue were reported in about 40% of patients. Most adverse events were either mild or moderate diminished in frequency with continued therapy. Twelve percent of patients withdrew from treatment due to an adverse event. Many hairy cell leukaemia patients experience adverse events while under therapy with pentostatin. Given the natural history of the disease and the pharmacological properties of the drug it may be difficult in certain cases to discriminate between drug-related and disease-related adverse events. No extravasation injuries were reported in clinical studies. The following adverse reactions have been reported during clinical studies in patients with HCL or during post-authorization use of pentostatin, either as single agent or in combinations with various agents for unapproved indications. They have been listed as Very common (>10%), Common (1-10%), Uncommon (0.1-1%) or Rare (0.01-0.1%) Body System Frequency Adverse Reaction Infections and Infestations Very common (>10%) Upper respiratory infection, Rhinitis, Pharyngitis, Viral infection Common1 (1-10%) Herpes Zoster, Infection (unspecified), Sinusitis, Cellulitis, Bacterial infection, Pneumonia, Conjunctivitis, Furunculosis, Herpes simplex, Bronchitis, Sepsis, Urinary tract infection, Abscess skin, Oral Candidiasis, Mycotic skin infection, Peri-anal abscess, E. Coli pneumonia, Fungal pneumonia, Septic shock, Staphylococcal infection, Urosepis, Osteomyelitis Uncommon2 (0.1-1%) Acute gastroenteritis, Pulmonary Aspergillosis, Clostridium Difficile colitis, Cystitis, Cytomegalovirus infection Rare2 (0.01-0.1%) Oesophageal candidiasis Neoplasms benign, malignant and unspecified (incl cysts and polyps) Common1 (1-10%) Neoplasms, Skin carcinoma Uncommon2 (0.1-1%) Tumor lysis syndrome Blood and Lymphatic System Disorders Very common (>10%) Leucopenia, thrombocytopenia, Anaemia, Blood disorder, Eosinophilia, Hypochromic anaemia, Pancytopenia Common1 (1-10%) Agranulocytosis, Acute leukaemia, Febrile neutropenia, Ecchymosis, Lymphadenopathy, Splenomegaly Uncommon2 (0.1-1%) Pure red cell aplasia, Autoimmune haemolytic anaemia, Anaemia-Haemolytic, Aplastic anaemia haemolytic uremic syndrome, Idiopathic thrombocytopenia purpura, Thrombotic thrombocytopenia purpura. Rare2 (0.01-0.1%) Autoimmune thrombocytopenia Immune System Disorders Very common (>10%) Allergic reaction Common1 (1-10%) Graft versus Host Disease3 Uncommon2 (0.1-1%) Graft failure Rare2 (0.01-0.1%) Anaphylaxis Metabolism and Nutrition Disorders Common1 (1-10%) Dehydration, Gout, Electrolyte imbalance, Hypercalcaemia, Hyponatraemia, Hyperglycaemia, Weight increased, Weight decreased, LDH increased Uncommon2 (0.1-1%) Hyperkalaemia, Hypokalaemia, Oxygen saturation decreased Rare2 (0.01-0.1%) Fluid overload, Hypocalcaemia Psychiatric disorders Common1 (1-10%) Anxiety, Depression, Nervousness, Abnormal dreams, Decrease/loss libido, Emotional lability, Hallucination, Hostility, Neurosis, Thinking abnormal, Depersonalisation Nervous System Disorders Very common (>10%) Headache, Neurotoxicity Common1 (1-10%) Confusion, Dizziness, Insomnia, Paraesthesia, Somnolence, Amnesia, Ataxia, Convulsions, Dysarthria, Dysgeusia, Encephalitis, Hyperkinesia, Meningism, Neuralgia, Neuritis, Neuropathy, Paralysis, Syncope, Twitching, Tremor, Vertigo, Hypaesthesia Rare2 (0.01-0.1%) Dementia Alzheimer's (suspected), Grand mal convulsion, Migraine, Parkinson's disease (aggravated), Petit mal epilepsy Eye Disorders Common1 (1-10%) Dry eyes, Lacrimal disorder, Photophobia, Retinopathy, Vision abnormal, Fixed pupil, Lacrimation increased, Eye pain Rare2 (0.01-0.1%) Blepharitis Very rare Unilateral uveitis with vision loss Ear and Labyrinth Disorders: Common1 (1-10%) Deafness, Ear pain, Labyrinthitis, Tinnitus Cardiac Disorders Common1 (1-10%) Angina pectoris, Arrhythmia, A-V block, Bradycardia, Extrasystoles ventricular, Heart arrest, Heart failure, Pericardial effusion, Sinus arrest, Tachycardia, Atrial fibrillation, Cardiac failure congestive, Flushing, Abnormal electrocardiogram. Uncommon2 (0.1-1%) Cardiomyopathy, Myocardial infarction Rare2 (0.01-0.1%) Pericarditis; Decreased ejection fraction Vascular Disorders Common1 (1-10%) Haemorrhage, Hypotension, Hypertension, Deep thrombophlebitis, Phlebitis, Vasculitis Uncommon2 (0.1-1%) Capillary leak syndrome Rare2 (0.01-0.1%) Shock Respiratory, Thoracic and Mediastinal Disorders Very common (>10%) Coughing, Lung disorder Common1 (1-10%) Asthma, Dyspnoea, Laryngeal oedema, Lung oedema, Pulmonary embolism, Epistaxis Uncommon2 (0.1-1%) Adult respiratory distress syndrome, Acute respiratory failure, Bronchospasm, Pleural effusion, Pneumothorax, Respiratory tract haemorrhage, Wheezing Rare2 (0.01-0.1%) Alveolitis, Alveolitis fibrosing, Cryptogenic organizing pneumonia, Diffuse alveolar damage, Obstructive airway disease, Pulmonary alveolar haemorrhage Gastrointestinal Disorders Very common (>10%) Nausea and/or vomiting; Diarrhoea, Abdominal pain, Anorexia, Rectal disorder, Rectal haemorrhage Common1 (1-10%) Dental Disorder, Dyspepsia, Gingivitis, Stomatitis, Constipation, Dysphagia, Flatulence, Glossitis, Ileus, Dry mouth Uncommon2 (0.1-1%) Acute enteritis Hepato-biliary disorders Very common (>10%) LFT increased, jaundice, hyperbilirubinaemia, ALT increased, AST increased Skin and Subcutaneous Tissue Disorders Very common (>10%) Rash, Pruritus, Sweating, Skin disorder, Maculopapular rash Common1 (1-10%) Dry skin, Urticaria, Acne, Alopecia, Eczema, Petechial Rash, Photosensitivity reaction, Exfoliative dermatitis, Skin discoloration, Dermatitis bullous, Seborrhoea Uncommon2 (0.1-1%) Angioneurotic oedema Rare Pemphigus, Stevens-Johnsons's syndrome Musculoskeletal and Connective Tissue Disorders Very common (>10%) Myalgia, Bone disorder, Arthropathy Common1 (1-10%) Arthralgia, Arthritis Uncommon2 (0.1-1%) Pain in extremities Renal and Urinary Disorders Very common (10%) Genito-urinary disorder, BUN increased Common1 (1-10%) Creatinine increased, Renal impairment, Nephropathy, Renal failure, Nephrolithiasis, Acute renal failure, Dysuria, Urinary retention Uncommon2 (0.1-1%) Cystitis haemorrhagic Reproductive system and breast disorders: Common1 (1-10%) Amenorrhoea, Breast mass, Erectile dysfunction General Disorders and Administration Site Conditions Very common (>10%) Fever, fatigue, chills, asthenia, pain Common1 (1-10%) Chest pain, Death, Face oedema, Peripheral oedema, Flu-like symptoms, Hangover, Back pain, Malaise Uncommon2 (0.1-1%) Mucositis, Multiorgan failure Rare2 (0.01-0.1%) Systemic inflammatory response syndrome, Lower extremity tenderness 1Includes all events which occurred in less than 3% of NIPENT-treated patients during the initial phase of the SWOG study: 2Based on 1549 patients included in post-marketing studies through Oct 10, 2005. 3Reported only in GVHD studies. 4.9 Overdose No specific antidote for pentostatin overdose is known. Pentostatin administered at higher doses (20-50 mg/m2/course) than recommended was associated with deaths due to severe renal, hepatic, pulmonary, and CNS toxicity. In case of overdose, management would include general supportive measures through any period of toxicity that occurs. 5. Pharmacological properties 5.1 Pharmacodynamic properties LO1X X08 Pharmacotherapeutic Group Pentostatin is an adenosine deaminase (ADA) inhibitor. Mechanism of Action Pentostatin is a potent transition state inhibitor of the enzyme adenosine deaminase. The greatest activity of ADA is found in cells of the lymphoid system with T-cells having higher activity than B- cells and T-cell malignancies higher ADA activity than B-cell malignancies. Pentostatin inhibition of ADA, as well as direct inhibition of RNA synthesis and increased DNA damage, may contribute to the overall cytotoxic effect of pentostatin. The precise mechanism of pentostatin's antitumour effect, however, in hairy cell leukaemia is not known. Pentostatin has been shown to have activity against a variety of lymphoid malignancies, but is most active against indolent cancers with lower ADA concentration, such as hairy cell leukaemia. 5.2 Pharmacokinetic properties In man, pentostatin pharmacokinetics are linear with plasma concentrations increasing proportionately with dose. Following a single dose of 4 mg/m2 of pentostatin infused over 5 minutes, the distribution half-life was 11 minutes and the mean terminal half-life was 5.7 hours, with a range of 2.6 to 10 hours; the mean plasma clearance was 68 ml/min/m2, and approximately 90% of the dose was excreted in the urine as unchanged pentostatin and/or metabolites as measured by adenosine deaminase inhibitory activity. The plasma protein binding of pentostatin is low, approximately 4%. A positive correlation was observed between pentostatin clearance and creatinine clearance (CrCl) in patients with creatinine clearance values ranging from 60 ml/min to 130 ml/min. Pentostatin half-life in patients with renal impairment (CrCl <50 ml/min, n = 2) was 18 hours, which was much longer than that observed in patients with normal renal function (CrCl >60 ml/min, n = 14), about 6 hours. Results from a published study in 13 patients with impaired renal function suggested dosage adjustment of NIPENT based on creatinine clearance (Clcr) values. Dosage was adjusted to 75% at a Clcr of 40-59 ml/min (3 mg/m2) and to 50% at a Clcr of 35-39 ml/min (2 mg/m2). There are insufficient data to recommend a starting or a subsequent dose for patients with creatinine clearance < 35 ml/min. A tissue distribution and whole-body autoradiography study in the rat revealed that radioactivity concentrations were highest in the kidneys with very little central nervous system penetration. Pentostatin penetrates the blood-brain barrier leading to measurable concentrations in the cerebrospinal fluid (CSF). 5.3 Preclinical safety data Adverse reactions not observed in clinical studies, but seen in animals at exposure levels similar to clinical exposure levels and with possible relevance to clinical use were as follows: Acute Toxicity The combined-sex intravenous LD10, LD50 and LD90 values in mice given formulated pentostatin were 129, 300 and 697 mg/kg (387, 900, and 2091 mg/m2), respectively. Signs of acute toxicity in rodents and dogs were hypoactivity, dehydration, and emaciation. Lymphoid tissue was a principal target of pentostatin in rats and dogs; thymic atrophy and liver damage occurred in mice. There were no gonadal effects in rodents or dogs. Multidose Toxicity Five daily dose IV combined-sex LD10, LD50 and LD90 values in mice administered bulk pentostatin were 4.9, 6.4, and 8.3 mg/kg (14.8, 19.1, and 24.8 mg/m2), respectively. Regardless of route or duration of treatment, lymphoid tissue was the primary target of pentostatin in all species examined in toxicology studies. This is consistent with pentostatin's antineoplastic activity in hairy cell leukaemia. Effects of lymphoid tissue may be related to adenosine deaminase inhibition, the major pharmacologic action of pentostatin. Increased serum hepatic enzymes and liver changes in rodents and dogs indicate that the liver is also a target organ at high doses. Testicular changes in rats and dogs may be indicative of potential effects on male fertility. Effects on lymphoid tissue, liver, and testes did not resolve completely during observation periods after drug withdrawal. Target organ effects occurring only in rats included alveolar duct metaplasia and/or goblet cell hyperplasia of the bronchioles, lymphoplasmacytic thyroiditis, and an increased incidence of spontaneous glomerulonephritis. Published studies, not conducted by the sponsor, indicate that pentostatin has immunosuppressive properties in mice and rats given multiple doses. Mutagenesis Pentostatin was not mutagenic in Salmonella typhimurium at concentrations up to 10000 µg/plate or in V79 Chinese hamster lung cells at concentrations up to 3000 µg/ml, in the presence or absence of metabolic activation. Pentostatin was not clastogenic in V79 Chinese hamster lung cells in vitro at concentrations up to 3000 µg/ml. However, pentostatin did increase the frequency of micronucleus formation in mice administered single intravenous injections of formulated pentostatin at 60, 360, and 720 mg/m2. The relevance of the positive mouse micronucleus test for man is not known. Carcinogenicity The carcinogenic potential of pentostatin has not been evaluated. The possibility that Nipent causes tumours cannot be ruled out. Pentostatin has been shown to be teratogenic from studies perfomed in rats and mice. Following systemic administration in rats, foetal abnormalities were observed. 6. Pharmaceutical particulars 6.1 List of excipients Mannitol Sodium hydroxide or Hydrochloric acid (for pH adjustment) 6.2 Incompatibilities Acidic solutions should be avoided (the pH of the reconstituted powder is 7.0 to 8.2). 6.3 Shelf life 3 years The reconstituted solution for injection or reconstituted and further diluted solution for infusion should be used within 8 hours and should not be stored above 25°C. Immediate administration after reconstitution is recommended. 6.4 Special precautions for storage Store in a refrigerator (2°C – 8°C) For storage conditions of the reconstituted medicinal product, see Section 6.3. 6.5 Nature and contents of container NIPENT is supplied in single-dose, 10-mg vials packaged in individual cartons (packs of 1 vial). Vials are made from Type I glass and siliconised stoppers. 6.6 Special precautions for disposal and other handling Any unused product or waste material should be disposed of in accordance with local requirements. Prescribers should refer to national or recognised guidelines on handling cytotoxic agents. Procedures for proper handling and disposal of anticancer drugs should be followed. 1. Reconstitution of Nipent should only be carried out by trained personnel in a cytotoxic-designated area. 2. Adequate protective gloves should be worn. 3. The cytotoxic preparation should not be handled by pregnant staff. 4. Adequate care and precautions should be taken in the disposal of items syringes, needles etc. used to reconstitute cytotoxic drugs. 5. Contaminated surfaces should be washed with copious amounts of water. 6. Any remaining solution should be discarded. Transfer 5 ml of Sterile Water for Injection to the vial containing NIPENT and mix thoroughly to obtain complete dissolution. The solution should be colourless to pale yellow and yield 2 mg/ml pentostatin. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration. NIPENT may be given intravenously by bolus injection or diluted in a larger volume (25 to 50 ml) with 5% Dextrose Injection (5% glucose solution) or 0.9% Sodium Chloride Injection (0.9% saline solution). Dilution of the entire contents of a reconstituted vial with 25 ml or 50 ml provides a pentostatin concentration of 0.33 mg/ml or 0.18 mg/ml, respectively, for the diluted solutions. NIPENT solution when diluted for infusion with 5% Dextrose Injection (5% glucose solution) or 0.9% Sodium Chloride Injection (0.9% saline solution) does not interact with PVC infusion containers or administration sets at concentrations of 0.18 mg/ml to 0.33 mg/ml. 7. Marketing authorisation holder Hospira UK Limited Queensway Royal Leamington Spa Warwickshire CV31 3RW United Kingdom 8. Marketing authorisation number(s) PL 04515/0222 9. Date of first authorisation/renewal of the authorisation 30th January 2009 10. Date of revision of the text 17th August 2012