Daptomycin precautions

## DRUG INTERACTIONS
HMG-CoA Reductase Inhibitors
In healthy subjects, concomitant administration of CUBICIN and simvastatin had no effect on plasma trough concentrations of simvastatin, and there were no reports of skeletal myopathy .
However, inhibitors of HMG-CoA reductase may cause myopathy, which is manifested as muscle pain or weakness associated with elevated levels of creatine phosphokinase (CPK).  In the Phase 3 S. aureus bacteremia/endocarditis trial, some patients who received prior or concomitant treatment with an HMG-CoA reductase inhibitor developed elevated CPK .  Experience with the coadministration of HMG-CoA reductase inhibitors and CUBICIN in patients is limited; therefore, consideration should be given to suspending use of HMG-CoA reductase inhibitors temporarily in patients receiving CUBICIN.
Drug-Laboratory Test Interactions
Clinically relevant plasma concentrations of daptomycin have been observed to cause a significant concentration-dependent false prolongation of prothrombin time (PT) and elevation of International Normalized Ratio (INR) when certain recombinant thromboplastin reagents are utilized for the assay.  The possibility of an erroneously elevated PT/INR result due to interaction with a recombinant thromboplastin reagent may be minimized by drawing specimens for PT or INR testing near the time of trough plasma concentrations of daptomycin.  However, sufficient daptomycin concentrations may be present at trough to cause interaction.
If confronted with an abnormally high PT/INR result in a patient being treated with CUBICIN, it is recommended that clinicians:
Repeat the assessment of PT/INR, requesting that the specimen be drawn just prior to the next CUBICIN dose (i.e., at trough concentration).  If the PT/INR value obtained at trough remains substantially elevated above what would otherwise be expected, consider evaluating PT/INR utilizing an alternative method.
Evaluate for other causes of abnormally elevated PT/INR results.

## Carcinogenesis, Mutagenesis, Impairment of Fertility
Long-term carcinogenicity studies in animals have not been conducted to evaluate the carcinogenic potential of CUBICIN.  However, neither mutagenic nor clastogenic potential was found in a battery of genotoxicity tests, including the Ames assay, a mammalian cell gene mutation assay, a test for chromosomal aberrations in Chinese hamster ovary cells, an in vivo micronucleus assay, an in vitro DNA repair assay, and an in vivo sister chromatid exchange assay in Chinese hamsters.
Daptomycin did not affect the fertility or reproductive performance of male and female rats when administered intravenously at doses up to 150 mg/kg/day, which is approximately 9 times the estimated human exposure level based upon AUCs.

# USE IN SPECIFIC POPULATIONS

## Pregnancy
Teratogenic Effects: Pregnancy Category B
There are no adequate and well-controlled trials of CUBICIN in pregnant women.  Embryofetal development studies performed in rats and rabbits at doses of up to 75 mg/kg (2 and 4 times the 6 mg/kg human dose, respectively, on a body surface area basis) revealed no evidence of harm to the fetus due to daptomycin.  Because animal reproduction studies are not always predictive of human response, CUBICIN should be used during pregnancy only if the potential benefit outweighs the possible risk.
Nursing Mothers
Daptomycin is present in human milk but is poorly bioavailable orally.  In a single case study, CUBICIN was administered daily for 28 days to a nursing mother at an IV dose of 6.7 mg/kg/day, and samples of the patient's breast milk were collected over a 24-hour period on day 27.  The highest measured concentration of daptomycin in the breast milk was 0.045 mcg/mL1.  The calculated maximum daily CUBICIN dose to the infant (assuming mean milk consumption of 150 mL/kg/day) was 0.1% of the maternal dose of 6.7 mg/kg/day.  Caution should be exercised when CUBICIN is administered to a nursing woman.

## Pediatric Use
Safety and effectiveness of CUBICIN in patients under the age of 18 years have not been established .

## Geriatric Use
Of the 534 patients treated with CUBICIN in Phase 3 controlled clinical trials of complicated skin and skin structure infections (cSSSI), 27% were 65 years of age or older and 12% were 75 years of age or older.  Of the 120 patients treated with CUBICIN in the Phase 3 controlled clinical trial of S. aureusbacteremia/endocarditis, 25% were 65 years of age or older and 16% were 75 years of age or older.  In Phase 3 clinical trials of cSSSI and S. aureusbacteremia/endocarditis, clinical success rates were lower in patients 65 years of age than in patients <65 years of age.  In addition, treatment-emergent adverse events were more common in patients 65 years of age than in patients <65 years of age.
The exposure of daptomycin was higher in healthy elderly subjects than in healthy young subjects.  However, no adjustment of CUBICIN dosage is warranted for elderly patients with creatinine clearance (CLCR) 30 mL/min .

## Patients with Renal Impairment
Daptomycin is eliminated primarily by the kidneys; therefore, a modification of CUBICIN dosage interval is recommended for patients with CLCR <30 mL/min, including patients receiving hemodialysis or continuous ambulatory peritoneal dialysis (CAPD).  In patients with renal impairment, both renal function and creatine phosphokinase (CPK) should be monitored more frequently than once weekly .