Daptomycin warnings

# Anaphylaxis/Hypersensitivity Reactions
Anaphylaxis/hypersensitivity reactions have been reported with the use of antibacterial agents, including CUBICIN, and may be life-threatening.  If an allergic reaction to CUBICIN occurs, discontinue the drug and institute appropriate therapy .

# Myopathy and Rhabdomyolysis
Myopathy, defined as muscle aching or muscle weakness in conjunction with increases in creatine phosphokinase (CPK) values to greater than 10 times the upper limit of normal (ULN), has been reported with the use of CUBICIN.  Rhabdomyolysis, with or without acute renal failure, has been reported .
Patients receiving CUBICIN should be monitored for the development of muscle pain or weakness, particularly of the distal extremities.  In patients who receive CUBICIN, CPK levels should be monitored weekly, and more frequently in patients who received recent prior or concomitant therapy with an HMG-CoA reductase inhibitor or in whom elevations in CPK occur during treatment with CUBICIN.
In patients with renal impairment, both renal function and CPK should be monitored more frequently than once weekly .
In Phase 1 studies and Phase 2 clinical trials, CPK elevations appeared to be more frequent when CUBICIN was dosed more than once daily.  Therefore, CUBICIN should not be dosed more frequently than once a day.
CUBICIN should be discontinued in patients with unexplained signs and symptoms of myopathy in conjunction with CPK elevations to levels >1,000 U/L (~5 ULN), and in patients without reported symptoms who have marked elevations in CPK, with levels >2,000 U/L (10 ULN).  In addition, consideration should be given to suspending agents associated with rhabdomyolysis, such as HMG-CoA reductase inhibitors, temporarily in patients receiving CUBICIN .

# Eosinophilic Pneumonia
Eosinophilic pneumonia has been reported in patients receiving CUBICIN .  In reported cases associated with CUBICIN, patients developed fever, dyspnea with hypoxic respiratory insufficiency, and diffuse pulmonary infiltrates.  In general, patients developed eosinophilic pneumonia 2 to 4 weeks after starting CUBICIN and improved when CUBICIN was discontinued and steroid therapy was initiated.  Recurrence of eosinophilic pneumonia upon re-exposure has been reported.  Patients who develop these signs and symptoms while receiving CUBICIN should undergo prompt medical evaluation, and CUBICIN should be discontinued immediately.  Treatment with systemic steroids is recommended.

# Peripheral Neuropathy
Cases of peripheral neuropathy have been reported during the CUBICIN postmarketing experience .  Therefore, physicians should be alert to signs and symptoms of peripheral neuropathy in patients receiving CUBICIN.

# Clostridium difficileAssociated Diarrhea
Clostridium difficileassociated diarrhea (CDAD) has been reported with the use of nearly all systemic antibacterial agents, including CUBICIN, and may range in severity from mild diarrhea to fatal colitis .  Treatment with antibacterial agents alters the normal flora of the colon, leading to overgrowth of C. difficile.
C. difficile produces toxins A and B, which contribute to the development of CDAD.  Hypertoxin-producing strains of C. difficile cause increased morbidity and mortality, since these infections can be refractory to antimicrobial therapy and may require colectomy.  CDAD must be considered in all patients who present with diarrhea following antibacterial use.  Careful medical history is necessary because CDAD has been reported to occur more than 2 months after the administration of antibacterial agents.
If CDAD is suspected or confirmed, ongoing antibacterial use not directed against C. difficile may need to be discontinued.  Appropriate fluid and electrolyte management, protein supplementation, antibacterial treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated.

# Persisting or Relapsing S. aureus Bacteremia/Endocarditis
Patients with persisting or relapsing S. aureus bacteremia/endocarditis or poor clinical response should have repeat blood cultures.  If a blood culture is positive for S. aureus, minimum inhibitory concentration (MIC) susceptibility testing of the isolate should be performed using a standardized procedure, and diagnostic evaluation of the patient should be performed to rule out sequestered foci of infection.  Appropriate surgical intervention (e.g., debridement, removal of prosthetic devices, valve replacement surgery) and/or consideration of a change in antibacterial regimen may be required.
Failure of treatment due to persisting or relapsing S. aureus bacteremia/endocarditis may be due to reduced daptomycin susceptibility (as evidenced by increasing MIC of the S. aureus isolate) .

# Decreased Efficacy in Patients with Moderate Baseline Renal Impairment
Limited data are available from the two Phase 3 complicated skin and skin structure infection (cSSSI) trials regarding clinical efficacy of CUBICIN treatment in patients with creatinine clearance (CLCR) <50 mL/min; only 31/534 (6%) patients treated with CUBICIN in the intent-to-treat (ITT) population had a baseline CLCR <50 mL/min.  Table 2 shows the number of patients by renal function and treatment group who were clinical successes in the Phase 3 cSSSI trials.
In a subgroup analysis of the ITT population in the Phase 3 S. aureus bacteremia/endocarditis trial, clinical success rates, as determined by a treatment-blinded Adjudication Committee , in the CUBICIN-treated patients were lower in patients with baseline CLCR <50 mL/min (seeTable 3).  A decrease of the magnitude shown in Table 3 was not observed in comparator-treated patients.
Consider these data when selecting antibacterial therapy for use in patients with baseline moderate to severe renal impairment.

# 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 .

# Non-Susceptible Microorganisms
The use of antibacterials may promote the overgrowth of non-susceptible microorganisms.  If superinfection occurs during therapy, appropriate measures should be taken.
Prescribing CUBICIN in the absence of a proven or strongly suspected bacterial infection is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.