Cidofovir warnings and precautions

# Warnings And Precautions

## Warnings

### nephrotoxicity
Dose-dependent nephrotoxicity is the major dose-limiting toxicity related to VISTIDE administration. Cases of acute renal failure resulting in dialysis and/or contributing to death have occurred with as few as one or two doses of VISTIDE. Renal function (serum creatinine and urine protein) must be monitored within 48 hours prior to each dose of VISTIDE. Dose adjustment or discontinuation is required for changes in renal function (serum creatinine and/or urine protein) while on therapy. Proteinuria, as measured by urinalysis in a clinical laboratory, may be an early indicator of VISTIDE-related nephrotoxicity. Continued administration of VISTIDE may lead to additional proximal tubular cell injury, which may result in glycosuria, decreases in serum phosphate, uric acid, and bicarbonate, elevations in serum creatinine, and/or acute renal failure, in some cases, resulting in the need for dialysis. Patients with these adverse events occurring concurrently and meeting a criteria of Fanconi's syndrome have been reported. Renal function that did not return to baseline after drug discontinuation has been observed in clinical studies of VISTIDE.
Intravenous normal saline hydration and oral probenecid must accompany each VISTIDE infusion. probenecid is known to interact with the metabolism or renal tubular excretion of many drugs (seePRECAUTIONS). The safety of VISTIDE has not been evaluated in patients receiving other known potentially nephrotoxic agents, such as intravenous aminoglycosides (e.g., tobramycin, gentamicin, and amikacin), amphotericin B, foscarnet, intravenous pentamidine, vancomycin, and non-steroidal anti-inflammatory agents (see DOSAGE AND ADMINISTRATION).

### Preexisting Renal Impairment
Initiation of therapy with VISTIDE is contraindicated in patients with a baseline serum creatinine > 1.5 mg/dL, a creatinine clearance  55 mL/min, or a urine protein  100 mg/dL (equivalent to  2+ Proteinuria).

### Hematological Toxicity
Neutropenia may occur during VISTIDE therapy. Neutrophil count should be monitored while receiving VISTIDE therapy.
Decreased Intraocular Pressure/Ocular Hypotony
Decreased intraocular pressure may occur during VISTIDE therapy, and in some instances has been associated with decreased visual acuity. Intraocular pressure should be monitored during VISTIDE therapy.

### Metabolic Acidosis
Decreased serum bicarbonate associated with proximal tubule injury and renal wasting syndrome (including Fanconi's syndrome) have been reported in patients receiving VISTIDE (see ADVERSE REACTIONS). Cases of metabolic acidosis in association with liver dysfunction and pancreatitis resulting in death have been reported in patients receiving VISTIDE.

## PRECAUTIONS

### General
Due to the potential for increased nephrotoxicity, doses greater than the recommended dose must not be administered and the frequency or rate of administration must not be exceeded (see DOSAGE AND ADMINISTRATION).
VISTIDE is formulated for intravenous infusion only and must not be administered by intraocular injection. Administration of VISTIDE by infusion must be accompanied by oral probenecid and intravenous saline prehydration (see DOSAGE AND ADMINISTRATION).

### Uveitis/Iritis
Uveitis or Iritis was reported in clinical trials and during postmarketing in patients receiving VISTIDE therapy. Treatment with topical corticosteroids with or without topical cycloplegic agents should be considered. Patients should be monitored for signs and symptoms of Uveitis/Iritis during VISTIDE therapy.

### Information for Patients
Patients should be advised that VISTIDE is not a cure for CMV retinitis, and that they may continue to experience progression of retinitis during and following treatment. Patients receiving VISTIDE should be advised to have regular follow-up ophthalmologic examinations. Patients may also experience other manifestations of CMV disease despite VISTIDE therapy.
HIV-infected patients may continue taking antiretroviral therapy, but those taking zidovudine should be advised to temporarily discontinue zidovudine administration or decrease their zidovudine dose by 50%, on days of VISTIDE administration only, because probenecid reduces metabolic clearance of zidovudine.
Patients should be informed of the major toxicity of VISTIDE, namely renal impairment, and that dose modification, including reduction, interruption, and possibly discontinuation, may be required. Close monitoring of renal function (routine urinalysis and serum creatinine) while on therapy should be emphasized.
The importance of completing a full course of probenecid with each VISTIDE dose should be emphasized. Patients should be warned of potential adverse events caused by probenecid (e.g., headache, nausea, vomiting, and hypersensitivity reactions). Hypersensitivity/allergic reactions may include rash, fever, chills and anaphylaxis. Administration of probenecid after a meal or use of antiemetics may decrease the nausea. Prophylactic or therapeutic antihistamines and/or acetaminophen can be used to ameliorate hypersensitivity reactions.
Patients should be advised that cidofovir causes tumors, primarily mammary adenocarcinomas, in rats. VISTIDE should be considered a potential carcinogen in humans (See Carcinogenesis, Mutagenesis, & Impairment of Fertility). Women should be advised of the limited enrollment of women in clinical trials of VISTIDE.
Patients should be advised that VISTIDE caused reduced testes weight and hypospermia in animals. Such changes may occur in humans and cause infertility. Women of childbearing potential should be advised that cidofovir is embryotoxic in animals and should not be used during pregnancy. Women of childbearing potential should be advised to use effective contraception during and for 1 month following treatment with VISTIDE. Men should be advised to practice barrier contraceptive methods during and for 3 months after treatment with VISTIDE. =