Vincristine liposome

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# Black Box Warning

# Overview
Vincristine liposome is an mitotic inhibitor that is FDA approved for the treatment of adult patients with Philadelphia chromosome-negative (Ph-) acute lymphoblastic leukemia (ALL) in second or greater relapse or whose disease has progressed following two or more anti-leukemia therapies. There is a Black Box Warning for this drug as shown here.  Common adverse reactions include constipation , nausea , pyrexia , fatigue , peripheral neuropathy , febrile neutropenia , diarrhea , anemia , decreased appetite, and insomnia.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)
- Vincristine Sulfate  is indicated for the treatment of adult patients with Philadelphia chromosome-negative (Ph-) acute lymphoblastic leukemia (ALL) in second or greater relapse or whose disease has progressed following two or more anti-leukemia therapies. This indication is based on overall response rate. Clinical benefit such as improvement in overall survival has not been verified.
- For Intravenous Use Only. Fatal if Given by Other Routes.
- Vincristine Sulfate  (Vincristine Sulfate LIPOSOME injection) has different dosage recommendations than Vincristine Sulfate injection. Verify drug name and dose prior to preparation and administration to avoid overdosage.
- The recommended dose of Vincristine Sulfate  is 2.25 mg/m2 intravenously over 1 hour once every 7 days.
- Vincristine Sulfate  is liposome-encapsulated vincristine.
- Vincristine Sulfate  is contraindicated in patients with demyelinating conditions including Charcot-Marie-Tooth syndrome. Patients with preexisting severe neuropathy should be treated with Vincristine Sulfate  only after careful risk-benefit assessment .
- Vincristine Sulfate  Kit
- Water bath
- Calibrated thermometer (0C to 100C)
- Calibrated electronic timer
- Sterile venting needle or other suitable device equipped with a sterile 0.2 micron filter
- 1 mL or 3 mL sterile syringe with needle, and
- 5 mL sterile syringe with needle.
- The manufacturer will provide the water bath, calibrated thermometer, and calibrated electronic timer to the medical facility at the initial order of Vincristine Sulfate  and will replace them every 2 years.
- Procedures for handling and disposal of anticancer drugs should be followed .
- Call  if you have questions about the preparation of Vincristine Sulfate . Vincristine Sulfate  takes approximately 60 to 90 minutes to prepare. The preparer should have dedicated uninterrupted time to prepare Vincristine Sulfate  due to the extensive monitoring of temperature and time required for the preparation.
- Aseptic technique must be strictly observed since no preservative or bacteriostatic agent is present in Vincristine Sulfate . The preparation steps of Vincristine Sulfate  that involve mixing the Sodium Phosphate Injection, Sphingomyelin/Cholesterol Liposome Injection, and Vincristine Sulfate Injection must be done in abiological safety cabinet or by established pharmacy safety procedures for the preparation of sterile injectable formulations and hazardous drugs. However, the preparation steps that involve placement of the vial in the water bath must be done outside of the sterile area.
- Do not use with in-line filters. Do not mix with other drugs.
- Fill a water bath with water to a level of at least 8 cm (3.2 inches) measured from the bottom and maintain this minimum water level throughout the procedure. The *water bath must remain outside of the sterile area.
- Place a calibrated thermometer in the water bath to monitor water temperature and leave it in the water bath until the procedure has been completed.
- Preheat water bath to 63C to 67C. Maintain this water temperature until completion of the procedure using the calibrated thermometer.
- Visually inspect each vial in the Vincristine Sulfate  Kit for particulate matter and discoloration prior to preparation, whenever solution and container permit. Do not use if a precipitate or foreign matter is present.
- Remove all the caps on the vials and swab the vials with sterile alcohol pads.
- Vent the Sodium Phosphate Injection vial with a sterile venting needle equipped with a sterile 0.2 micron filter or other suitable venting device in the biological safety cabinet. Always position venting needle point well above liquid level before adding Sphingomyelin/Cholesterol Liposome Injection and Vincristine Sulfate Injection.
- Withdraw 1 mL of Sphingomyelin/Cholesterol Liposome Injection.
- Inject 1 mL of Sphingomyelin/Cholesterol Liposome Injection into the Sodium Phosphate Injection vial.
- Withdraw 5 mL of Vincristine Sulfate Injection.
- Inject 5 mL of Vincristine Sulfate Injection into the Sodium Phosphate Injection vial.
- Remove the venting needle and gently invert the Sodium Phosphate Injection vial 5 times to mix. DO NOT SHAKE.
- Fit Flotation Ring around the neck of the Sodium Phosphate Injection vial.
- Confirm that the water bath temperature is at 63C to 67C using the calibrated thermometer. Remove the Sodium Phosphate Injection vial containing Vincristine Sulfate Injection, Sphingomyelin/Cholesterol Liposome Injection, and Sodium Phosphate Injection from the biological safety cabinet and place into the water bath for 10 minutes using the calibrated electronic timer. Monitor the temperature to ensure the temperature is maintained at 63C to 67C.
- IMMEDIATELY after placing the Sodium Phosphate Injection vial into the water bath, record the constitution start time and water temperature on the Vincristine Sulfate  Overlabel.
- At the end of the 10 minutes, confirm that the water temperature is 63C to 67C using the calibrated thermometer. Remove the vial from the water bath (use tongs to prevent burns) and remove the Flotation Ring.
- Record the final constitution time and the water temperature on the Vincristine Sulfate  Overlabel.
- Dry the exterior of the Sodium Phosphate Injection vial with a clean paper towel, affix Vincristine Sulfate  (Vincristine Sulfate LIPOSOME injection) Overlabel, and gently invert 5 times to mix. DO NOT SHAKE.
- Permit the constituted vial contents to equilibrate for at least 30 minutes to controlled room temperature (15C to 30C, 59F to 86F).
- Vincristine Sulfate  (Vincristine Sulfate LIPOSOME injection) contains 5 mg/31 mL (0.16 mg/mL) Vincristine Sulfate. ONCE PREPARED, STORE AT CONTROLLED ROOM TEMPERATURE (15C to 30C, 59F to 86F) FOR NO MORE THAN 12 HOURS.
- Swab the top of the vial now containing Vincristine Sulfate  with a sterile alcohol pad and return the vial back into the biological safety cabinet.
- Calculate the patient's Vincristine Sulfate  dose based on the patient's actual body surface area (BSA) and remove the volume corresponding to the patient's Vincristine Sulfate  dose from an infusion bag containing 100 mL of 5% Dextrose Injection or 0.9% Sodium Chloride Injection.
- Inject the dose of Vincristine Sulfate  into the infusion bag to result in a final volume of 100 mL.
- Complete the information required on the Infusion Bag Label and apply to the infusion bag.
- Finish administration of the diluted product within 12 hours of the initiation of Vincristine Sulfate  preparation.
- Empty, clean, and dry the water bath after each use.
- Deviations in temperature, time, and preparation procedures may fail to ensure proper encapsulation of Vincristine Sulfate into the liposomes. In the event that the preparation deviates from the instructions in the above steps, the components of the kit should be discarded and a new kit should be used to prepare the dose.
- Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Do not use if a precipitate or foreign matter is present.

## Off-Label Use and Dosage (Adult)

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

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Vincristine Sulfate  in adult patients.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
There is limited information regarding FDA-Labeled Use of Vincristine Sulfate  in pediatric patients.

## Off-Label Use and Dosage (Pediatric)

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

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Vincristine Sulfate  in pediatric patients.

# Contraindications
- Vincristine Sulfate  is contraindicated in patients with demyelinating conditions including Charcot-Marie-Tooth syndrome.
- Vincristine Sulfate  is contraindicated in patients with hypersensitivity to Vincristine Sulfate or any of the other components of Vincristine Sulfate  (Vincristine Sulfate LIPOSOME injection).
- Vincristine Sulfate  is contraindicated for intrathecal administration.

# Warnings
- Fatal if Given by Other Routes. Death has occurred with intrathecal use.
- Only administer through a secure and free-flowing venous access line. If extravasation is suspected, discontinue infusion immediately and consider local treatment measures.
- Sensory and motor neuropathies are common and are cumulative. Monitor patients for symptoms of neuropathy, such as hypoesthesia, hyperesthesia, paresthesia, hyporeflexia, areflexia, neuralgia, jaw pain, decreased vibratory sense, cranial neuropathy, ileus, burning sensation, arthralgia, myalgia, muscle spasm, or weakness, both before and during treatment. Orthostatic hypotension may occur. The risk of neurologic toxicity is greater if Vincristine Sulfate  is administered to patients with preexisting neuromuscular disorders or when other drugs with risk of neurologic toxicity are being given. In the studies of relapsed and/or refractory adult ALL patients, Grade  3 neuropathy events occurred in 32.5% of patients. Worsening neuropathy requires dose delay, reduction, or discontinuation of Vincristine Sulfate  .
- Monitor complete blood counts prior to each dose of Vincristine Sulfate . If Grade 3 or 4 neutropenia, thrombocytopenia, or anemia develops, consider Vincristine Sulfate  dose modification or reduction as well as supportive care measures.
- Tumor lysis syndrome (TLS) may occur in patients with ALL receiving Vincristine Sulfate . Anticipate, monitor for, and manage.
- Ileus, bowel obstruction, and colonic pseudo-obstruction have occurred. Vincristine Sulfate  can cause constipation . Institute a prophylactic bowel regimen to mitigate potential constipation, bowel obstruction, and/or paralytic ileus, considering adequate dietary fiber intake, hydration, and routine use of stool softeners, such as docusate. Additional treatments, such as senna, bisacodyl, milk of magnesia, magnesium citrate, and lactulose may be considered.
- Vincristine Sulfate  can cause severe fatigue. Vincristine Sulfate  dose delay, reduction, or discontinuation may be necessary.
- Fatal liver toxicity and elevated levels of aspartate aminotransferase have occurred. Elevated levels of aspartate aminotransferase of Grade 3 occurred in 6-11% of patients in clinical trials. Monitor hepatic function tests. Reduce or interrupt Vincristine Sulfate  for hepatic toxicity.
- Vincristine Sulfate  can cause fetal harm when administered to a pregnant woman. Vincristine Sulfate liposome injection was teratogenic or caused embryo-fetal death in animals. Women of childbearing potential should avoid becoming pregnant while being treated with Vincristine Sulfate . There are no adequate and well-controlled studies of Vincristine Sulfate  in pregnant women and there were no reports of pregnancy in any of the clinical studies in the Vincristine Sulfate  clinical development program. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to a fetus

# Adverse Reactions

## Clinical Trials Experience
- The following adverse reactions are also discussed in other sections of the labeling:
- For intravenous use only
- Extravasation tissue injury
- Peripheral Neuropathy
- Myelosuppression
- Tumor lysis syndrome
- Constipation and bowel obstruction
- Fatigue
- Hepatic toxicity
- Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.
- Integrated Summary of Safety in Relapsed and/or Refractory Ph- Adult Acute Lymphoblastic Leukemia
- Vincristine Sulfate , at a dose of 2.25 mg/m2 weekly, was studied in a total of 83 patients in two trials: study 1 and study 2. Adverse reactions were observed in 100% of patients. The most common adverse reactions (>30%) were constipation (57%), nausea (52%), pyrexia (43%), fatigue (41%), peripheral neuropathy (39%), febrile neutropenia (38%), diarrhea (37%), anemia (34%), decreased appetite (33%), and insomnia (32%).
- Adverse reactions of Grade 3 or greater were reported in 96% of patients. Adverse reactions of Grade 3 or greater and occurring in  5% of patients are summarized in Table2
- A total of 75.9% of patients experienced serious adverse events (SAEs) during the studies. The most commonly reported SAEs included febrile neutropenia (20.5%), pyrexia (13.3%), hypotension (7.2%), respiratory distress (6.0%), and cardiac arrest (6.0%).
- Dose reduction, delay, or omission occurred in 53% of patients during the treatment.
- Twenty-eight percent of patients experienced adverse reactions leading to treatment discontinuation. The most common adverse reactions that caused treatment discontinuation were peripheral neuropathy (10%), leukemia-related (7%), and tumor lysis syndrome (2%).
- Adverse reactions related to neuropathy and leading to treatment discontinuation were decreased vibratory sense, facial palsy, hyporeflexia, constipation, asthenia, fatigue, and musculoskeletal pain, each reported in at least 1 patient.
- Deaths occurred in 23% of patients in study 1. The non-leukemia related causes of deaths were brain infarct (1), intracerebral hemorrhage (2), liver failure (1), multi system organ failure (2), pneumonia and septic shock (3), respiratory failure (4), pulmonary hemorrhage (1), and sudden cardiac death (1).

## Postmarketing Experience
There is limited information regarding Postmarketing Experience of Vincristine Sulfate  in the drug label.

# Drug Interactions
- No formal drug interaction studies have been conducted with Vincristine Sulfate . Vincristine Sulfate  is expected to interact with drugs known to interact with non-liposomal Vincristine Sulfate.
- Simultaneous oral or intravenous administration of phenytoin and antineoplastic chemotherapy combinations that included non-liposomal Vincristine Sulfate have been reported to reduce blood levels of phenytoin and to increase seizure activity.
- Vincristine Sulfate, the active agent in Vincristine Sulfate , is a substrate for cytochrome P450 3A isozymes (CYP3A); therefore, the concomitant use of strong CYP3A inhibitors should be avoided(e.g., ketoconazole, itraconazole, voriconazole, posaconazole, clarithromycin, atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin). Similarly, the concomitant use of strong CYP3A inducers should be avoided (e.g., dexamethasone, phenytoin, carbamazepine, rifampin, rifabutin, rifapentine, phenobarbital, St. John's Wort).
- Vincristine Sulfate, the active agent in Vincristine Sulfate , is also a substrate for P-glycoprotein (P-gp). The effect of concomitant use of potent P-gp inhibitors or inducers has not been investigated; it is likely that these agents will alter the pharmacokinetics or pharmacodynamics of Vincristine Sulfate . Therefore the concomitant use of potent P-gp inhibitors or inducers should be avoided.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): D
- Based on its mechanism of action and findings from animal studies, Vincristine Sulfate  can cause fetal harm when administered to 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 a fetus. In an embryofetal developmental study, pregnant rats were administered Vincristine Sulfate liposome injection intravenously during the period of organogenesis at Vincristine Sulfate doses of 0.022 to 0.09 mg/kg/day. Drug-related adverse effects included fetal malformations (skeletal and visceral), decreases in fetal weights, increased numbers of early resorptions and post-implantation losses, and decreased maternal body weights Malformations were observed at doses  0.044 mg/kg/day in animals at systemic exposures approximately 20-40% of those reported in patients at the recommended dose.
Pregnancy Category (AUS): 
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Vincristine Sulfate  in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Vincristine Sulfate  during labor and delivery.

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

### Pediatric Use
- The safety and effectiveness of Vincristine Sulfate  in pediatric patients have not been established.

### Geriatic Use
- Safety and effectiveness in elderly individuals have not been established. In general, dose selection for an elderly patient should be cautious, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy.

### Gender
There is no FDA guidance on the use of Vincristine Sulfate  with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Vincristine Sulfate  with respect to specific racial populations.

### Renal Impairment
- The influence of renal impairment on the safety, efficacy, and pharmacokinetics of Vincristine Sulfate  has not been evaluated.

### Hepatic Impairment
- Non-liposomal Vincristine Sulfate is excreted primarily by the liver. The influence of severe hepatic impairment on the safety and efficacy of Vincristine Sulfate  has not been evaluated.
- The pharmacokinetics of Vincristine Sulfate  was evaluated in patients with moderate hepatic dysfunction (Child-Pugh B) secondary to melanoma liver metastases. The dose-adjusted maximum plasma concentration (Cmax) and area under the concentration-time curve (AUC) of Vincristine Sulfate  in patients with moderate hepatic impairment was comparable to the Cmax and AUC of patients with ALL who had otherwise normal hepatic function.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Vincristine Sulfate  in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Vincristine Sulfate  in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Intravenous

### Monitoring
There is limited information regarding Monitoring of Vincristine Sulfate  in the drug label.

# IV Compatibility
There is limited information regarding IV Compatibility of Vincristine Sulfate  in the drug label.

# Overdosage
- When Vincristine Sulfate  (Vincristine Sulfate LIPOSOME injection) was administered at a dose of 2.4 mg/m2, severe toxicities including motor neuropathy of Grade 3, grand mal seizure of Grade 4, and elevated aspartate aminotransferase and hyperbilirubinemia of Grade 4 were reported in 1 patient each. There is no known antidote for overdosage

# Pharmacology
There is limited information regarding Vincristine liposome Pharmacology in the drug label.

## Mechanism of Action
- Vincristine Sulfate  is a sphingomyelin/cholesterol liposome-encapsulated formulation of Vincristine Sulfate. Non-liposomal Vincristine Sulfate binds to tubulin, altering the tubulin polymerization equilibrium, resulting in altered microtubule structure and function. Non-liposomal Vincristine Sulfate stabilizes the spindle apparatus, preventing chromosome segregation, triggering metaphase arrest and inhibition of mitosis.

## Structure
- Vincristine Sulfate  (Vincristine Sulfate LIPOSOME injection) is vincristine encapsulated in sphingomyelin/cholesterol liposomes for intravenous administration.
- The active ingredient in Vincristine Sulfate  is Vincristine Sulfate. Vincristine Sulfate is a vinca alkaloid isolated as a 1:1 sulfate salt from the periwinkle plant (Catharanthus roseus). It is a hygroscopic, white to slightly yellowish crystalline powder that is soluble in water. It has a molecular weight of 923.04 (salt form) / 824.98 (base form) and a molecular formula of C46H56N4O10 - H2SO4. The chemical name for Vincristine Sulfate is 22-oxovincaleukoblastine and it has the following chemical structure:
- Vincristine is encapsulated in a Sphingomyelin/Cholesterol liposome. The lipid components in the liposome are sphingomyelin and cholesterol at a molar ratio of approximately 60:40 (mol:mol).
- After preparation, each vial of Vincristine Sulfate  contains 5 mg Vincristine Sulfate, 500 mg mannitol, 73.5 mg sphingomyelin, 29.5 mg cholesterol, 36 mg sodium citrate, 38 mg citric acid, 355 mg sodium phosphate, and 225 mg sodium chloride.
- Vincristine Sulfate  (Vincristine Sulfate LIPOSOME injection) appears as a white to off-white, translucent suspension, essentially free of visible foreign matter and aggregates, comprised of sphingomyelin/cholesterol liposomes, with an approximate liposome mean diameter of 100 nm. Greater than 95% of the drug is encapsulated in the liposomes.
- The Vincristine Sulfate  Kit component vials for the preparation of Vincristine Sulfate  (Vincristine Sulfate LIPOSOME injection) include:
- Vincristine Sulfate Injection, USP (5 mg/5 mL). Each Vincristine Sulfate Injection vial consists of 5 mg/5 mL Vincristine Sulfate (which is equivalent to 4.5 mg/5 mL vincristine free base) and 500 mg/5 mL mannitol.
- Sphingomyelin/Cholesterol Liposome Injection (103 mg/mL). Each Sphingomyelin/Cholesterol Liposome Injection vial consists of 73.5 mg/mL sphingomyelin, 29.5 mg/mL cholesterol, 33.6 mg/mL citric acid, 35.4 mg/mL sodium citrate, and not more than 0.1% ethanol.
- Sodium Phosphate Injection (355 mg/25 mL). Each Sodium Phosphate Injection vial consists of 355 mg/25 mL dibasic sodium phosphate and 225 mg/25 mL sodium chloride.

## Pharmacodynamics
There is limited information regarding Pharmacodynamics of Vincristine Sulfate  in the drug label.

## Pharmacokinetics
- The plasma pharmacokinetics of Vincristine Sulfate  was investigated in 13 adult patients with relapsed ALL who received a Vincristine Sulfate  dose of 2.25 mg/m2 administered as a 1-hour intravenous infusion. The calculated pharmacokinetic parameters for total plasma Vincristine Sulfate are given in TABLE 3. The Vincristine Sulfate levels reported in TABLE 3 reflect liposome-encapsulated drug that may not be immediately bioavailable and may not be directly comparable to plasma levels of Vincristine Sulfate after administration of non-liposomal Vincristine Sulfate, which is immediately bioavailable.
- The plasma clearance (CL) of Vincristine Sulfate  is slow, 345 mL/h, at a dose of 2.25 mg/m2. This is in comparison to the rapid clearance of non-liposomal Vincristine Sulfate at 189 mL/min/m2 (11,340 mL/h). The slow clearance of Vincristine Sulfate  contributes to a much higher AUC for Vincristine Sulfate  relative to non-liposomal Vincristine Sulfate.
- Following intravenous administration of Vincristine Sulfate , urinary excretion was a minor route of elimination for Vincristine Sulfate and its metabolite. Less than 8% of the administered Vincristine Sulfate  dose was eliminated in urine over a 96-hour observation period, which is similar to the urinary excretion of non-liposomal Vincristine Sulfate. Following non-liposomal Vincristine Sulfate infusion, the main route of Vincristine Sulfate excretion was the fecal route, accounting for 69% of the administered dose over 72 hours.

## Nonclinical Toxicology
- No carcinogenicity studies have been conducted with Vincristine Sulfate  or non-liposomal Vincristine Sulfate. Based on the mechanism of action and genotoxicity findings in nonclinical studies conducted with non-liposomal Vincristine Sulfate, Vincristine Sulfate  may be carcinogenic.
- No genotoxicity studies have been conducted with Vincristine Sulfate . Non-liposomal vincristine was genotoxic in some in vitro and in vivo studies.
- The single- and repeat-dose animal toxicology study results indicate that Vincristine Sulfate  can impair male fertility, consistent with the literature on non-liposomal Vincristine Sulfate. Administration of vincristine liposome injection causes testicular degeneration and atrophy, and epididymal aspermia in rats.
- Gonadal dysfunction has been reported in both male and female post-pubertal patients who received multi-agent chemotherapy including non-liposomal Vincristine Sulfate. The degree to which testicular or ovarian functions are affected is age-, dose-, and agent-dependent. Recovery may occur in some but not all patients.
- In a repeat-dose comparative toxicology study in rats, Vincristine Sulfate liposome injection or non-liposomal Vincristine Sulfate was administered to animals intravenously once per week for 6 weeks. Clinical signs of toxicity consistent with neurotoxicity were greater with Vincristine Sulfate liposome injection than with non-liposomal Vincristine Sulfate at equal Vincristine Sulfate doses of 2 mg/m2/week and included uncoordinated movements, weakness, reduced muscle tone, and limited usage of the limbs. Neurological testing indicated drug-induced peripheral neurotoxicity with both drugs. Based on the histopathology examination after 6 weekly doses, Vincristine Sulfate liposome injection induced greater peripheral neurotoxicity (nerve fiber degeneration) and secondary skeletal muscle atrophy than the equal dose of non-liposomal Vincristine Sulfate. In a separate tissue distribution study in rats, administration of 2 mg/m2 of intravenous liposomal or non-liposomal Vincristine Sulfate showed greater accumulation of Vincristine Sulfate in sciatic and tibial nerves (as well as the lymph nodes, spleen, and bone marrow) of the animals following Vincristine Sulfate liposome injection.

# Clinical Studies
- Vincristine Sulfate  was studied in an international, open-label, multi-center, single-arm trial (Study 1). Eligible patients were 18 years of age or older with Philadelphia chromosome negative ALL in second or greater relapse or whose disease progressed after two or greater treatment lines of anti-leukemia therapy. Patients had to have achieved a complete remission (CR) to at least one prior anti-leukemia chemotherapy, defined by a leukemia-free interval of equal or more than 90 days. Patients were not eligible for immediate hematopoietic stem cell transplantation (HSCT) at the time of screening and enrollment.
- Patients received intravenous Vincristine Sulfate  monotherapy at 2.25 mg/m2 over 60 minutes every 7 days. Concomitant corticosteroids were not permitted beyond Day 5.
- The treated population included 65 patients who received at least 1 dose of Vincristine Sulfate . All of the treated patients had received prior Vincristine Sulfate and 80% had evidence of residual neuropathy at study baseline. Among treated patients, 51% were male, 86% were white, 45% were under 30 years of age, 11% were age 65 or older, 48% had undergone prior HSCT, 51% had received 3 or more prior therapies, and 45% were refractory to their immediate prior therapy. Disease characteristics were 85% precursor B-cell ALL and 15% precursor T-cell ALL. In addition, 22 of 65 (34%) treated patients did not receive asparaginase products prior to enrollment. Efficacy results are shown in TABLE 4.

# How Supplied
- The Vincristine Sulfate  Kit (NDC # 20536-322-01) contains:
- Vial containing Vincristine Sulfate Injection, USP 5 mg/5 mL (1 mg/mL)  NDC # 20536-323-01
- Vial containing Sphingomyelin/Cholesterol Liposome Injection 103 mg/mL  NDC # 20536-324-01
- Vial containing Sodium Phosphate Injection 355 mg/25 mL (14.2 mg/mL)  NDC # 20536-325-01
- Flotation Ring
- Overlabel for Sodium Phosphate Injection vial containing constituted Vincristine Sulfate  (Vincristine Sulfate LIPOSOME injection), 5 mg/31 mL (0.16 mg/mL)
- Infusion Bag Label

## Storage
- Store the Vincristine Sulfate  Kit in the refrigerator at 2C to 8C  Do Not Freeze

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
- Physicians are advised to discuss the following with patients prior to treatment with Vincristine Sulfate :
- Extravasation Tissue Injury: Advise patients to report immediately any burning or local irritation during or after the infusion .
- Ability to Drive or Operate Machinery or Impairment of Mental Ability: Vincristine Sulfate  may cause fatigue and symptoms of peripheral neuropathy. Advise patients not to drive or operate machinery if they experience any of these symptoms .
- Gastrointestinal/Constipation: Patients receiving Vincristine Sulfate  may experience constipation. Advise patients how to avoid constipation by a diet high in bulk fiber, fruits and vegetables, and adequate fluid intake as well as use of a stool softener, such as docusate. Instruct patients to seek medical advice if they experience symptoms of constipation such bowel movement infrequency, abdominal pain, bloating, diarrhea, nausea, or vomiting .
- Pregnancy/Nursing: Advise patients to use effective contraceptive measures to prevent pregnancy during treatment with Vincristine Sulfate  . Instruct patients to report pregnancy to their physicians immediately. Advise patients that they should not receive Vincristine Sulfate  while pregnant or breastfeeding. If a patient wishes to re-start breastfeeding after treatment, she should be advised to discuss the appropriate timing with her physician .
- Concomitant Medications: Advise patients to speak with their physicians about any other medication they are currently taking .
- Peripheral Neuropathy: Advise patients to contact their physicians if they experience new or worsening symptoms of peripheral neuropathy such as tingling, numbness, pain, a burning feeling in the feet or hands, or weakness in the feet or hands .
- Other: Instruct patients to notify their physicians if they experience fever, productive cough, or decreased appetite

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

# Brand Names
- Marqibo

# Look-Alike Drug Names
There is limited information regarding Vincristine liposome Look-Alike Drug Names in the drug label.

# Drug Shortage Status

# Price