Consumer medicine information

Cipla Bleomycin 15K

Bleomycin sulfate

BRAND INFORMATION

Brand name

Cipla Bleomycin 15K Powder for injection

Active ingredient

Bleomycin sulfate

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Cipla Bleomycin 15K.

What is in this leaflet

This leaflet answers some common questions about CIPLA BLEOMYCIN 15K for Injection. It does not contain all the available information.

It does not take the place of talking to your doctor and pharmacist.

All medicines have risks and benefits. Your doctor has weighed the risks of you taking CIPLA BLEOMYCIN 15K for Injection against the benefits they expect it will have for you.

If you have any concerns about taking this medicine, ask your doctor or pharmacist.

Keep this leaflet with the medicine.

You may need to read it again.

What CIPLA BLEOMYCIN 15K for Injection is used for

CIPLA BLEOMYCIN 15K belongs to a group of medicines known as antineoplastic or cytotoxic agents. You may hear it referred to as chemotherapy medicine.

CIPLA BLEOMYCIN 15K is classified as an antitumour antibiotic. It interferes with the growth of cancer cells, which are eventually destroyed.

Your doctor may have prescribed CIPLA BLEOMYCIN 15K for another reason.

Ask your doctor if you have any questions about why CIPLA BLEOMYCIN 15K has been prescribed for you.

This medicine is available only with a doctor’s prescription.

CIPLA BLEOMYCIN 15K is not recommended for use in children, as there have not been enough studies of its effects in children.

Before you are given CIPLA BLEOMYCIN 15K

When you must not be given it

You must not be given CIPLA BLEOMYCIN 15K for Injection if you are allergic to any of the ingredients listed at the end of this leaflet.

Symptoms of an allergic reaction to CIPLA BLEOMYCIN 15K may include:

  • shortness of breath, wheezing or difficulty breathing
  • swelling of the face, lips, tongue or other parts of the body
  • rash, itching or hives on the skin

You should not be given CIPLA BLEOMYCIN 15K if you have any of the following conditions:

  • low white blood cell (WBC) count
  • problems with blood clotting
  • severe lung problems, a lung infection or reduced lung function.

Tell your doctor if you have an infection or high temperature.

Your doctor may decide to delay your treatment until the infection has gone. A mild illness, such as a cold, is not usually a reason to delay treatment.

If you are not sure whether you should start treatment with CIPLA BLEOMYCIN 15K, talk to your doctor.

Before you are given it

Tell your doctor or pharmacist if you have allergies to:

  • any other medicines
  • any other substances, such as foods, preservatives or dyes.

Tell your doctor or pharmacist if you are pregnant or intend to become pregnant.

Your doctor or pharmacist will discuss the possible risks and benefits of treatment with CIPLA BLEOMYCIN 15K during pregnancy.

CIPLA BLEOMYCIN 15K may cause birth defects of either the male or the female is receiving it at the time of conception or if it is used during pregnancy.

You should use some form of birth control while you are receiving CIPLA BLEOMYCIN 15K and for at least 12 weeks after stopping. Your doctor will discuss this with you.

Tell your doctor if you are breastfeeding or plan to breast-feed.

Like most antineoplastic medicines, CIPLA BLEOMYCIN 15K is not recommended while you are breastfeeding.

Tell your doctor or pharmacist if you have had any medical conditions, especially the following:

  • kidney disease
  • liver disease
  • lung disease.

Tell your doctor if you smoke. There is a greater chance of CIPLA BLEOMYCIN 15K affecting your lungs if you smoke.

Tell your doctor if you have had radiation therapy for cancer.

There is a greater chance of CIPLA BLEOMYCIN 15K affecting your lungs if you have had radiation therapy, especially to the chest.

If you have been told by your doctor or pharmacist about any of the above, tell them before you start treatment with CIPLA BLEOMYCIN 15K.

Taking other medicines

Tell your doctor if you are taking any other medicines, including medicines that you buy without a prescription from your pharmacy, supermarket or health food shop.

Some medicines may interfere with CIPLA BLEOMYCIN 15K. These include:-

  • digoxin, a medicine used to treat heart failure
  • phenytoin, a medicine used to treat epilepsy, fits and seizures
  • cisplatin, a medicine used to treat some types of cancer
  • oxygen therapy, which may be given to you during surgery,
  • other medicines used to treat cancer, radiation therapy or any other treatment which lowers your immune system
  • any medicine which suppresses your immune immune system eg azathioprine
  • general anaesthetics
  • granulocyte colony stimulating factor ( such as filgrastim and lenograstim).

These medicines may be affected by CIPLA BLEOMYCIN 15K, or may affect how well it works. You may need to take different amounts of your medicine, or you may need to take different medicines. Some of these medicines and CIPLA BLEOMYCIN 15K may interfere with each other even if they are not given at the same time. Your doctor or pharmacist will advise you.

Do not have any vaccinations (immunisations) without your doctor’s approval while you are being treated with CIPLA BLEOMYCIN 15K, and for about one month after you stop treatment with it.

CIPLA BLEOMYCIN 15K may lower your body’s resistance to infection and there is a chance that you may get the infection the immunisation is meant to prevent. In addition, other people close to you (such as other persons living in your household), should not take oral polio vaccine (sabin) since there is a chance they could pass the polio virus on to you.

Your doctor and pharmacist may have more information of medicines to be careful with or avoid while you are being given the CIPLA BLEOMYCIN 15K.

How CIPLA BLEOMYCIN 15K is given

How much is given

Your doctor will decide what dose of CIPLA BLEOMYCIN 15K you will receive. This depends on your condition and other factors, such as your weight and height, kidney function and other chemotherapy medicines you are being given.

CIPLA BLEOMYCIN 15K may be given alone or in combination with other drugs.

Several courses of CIPLA BLEOMYCIN 15K therapy may be needed, depending on your response to treatment.

Additional treatment may not be repeated until your blood cell numbers return to acceptable levels and any unwanted side effects have been controlled.

Ask your doctor if you want to know more about the dose of CIPLA BLEOMYCIN 15K you receive.

How it is given

CIPLA BLEOMYCIN 15K should only be given by a doctor or nurse.

CIPLA BLEOMYCIN 15K can be given in a number of different ways: -

  • an injection under the skin
  • an injection into a muscle
  • an injection into a vain
  • an injection into an artery

The first time you are given CIPLA BLEOMYCIN 15K, you will normally receive a small test dose to check that you are not allergic to CIPLA BLEOMYCIN 15K. If no reaction occurs, the full dose will be given.

How long it is given

A course of CIPLA BLEOMYCIN 15K may consist of a dose once or twice weekly, or it may be given as a daily dose for 7 consecutive days. This is called one cycle of chemotherapy. Your doctor will decide how many of these cycles you will need.

Overdose

As CIPLA BLEOMYCIN 15K will be given to you under the supervision of your doctor, it is very unlikely that you will receive too much. However, if you experience severe side effects tell your doctor immediately or go to the Accident and Emergency department of your nearest hospital.

You may need urgent medical attention.

Symptoms of a CIPLA BLEOMYCIN 15K overdose include the side effects listed below in the ‘ Side Effects’ section, but are usually of a more sever nature.

While you are using CIPLA BLEOMYCIN 15K for Injection

Tell your doctor, nurse or pharmacist if you have any concerns before, during or after administration or CIPLA BLEOMYCIN 15K.

Things you must do

Be sure to keep all your doctor’s appointments so your progress can be checked.

Your doctor may want to do some blood and other tests form time to time to check on your progress and detect any unwanted side effects.

Keep follow up appointments with your doctor.

It is important to have your follow-up doses of CIPLA BLEOMYCIN 15K at the appropriate times to get the best effects from your treatments.

Tell any other doctors, dentists, and pharmacists who are treating you that you are being given CIPLA BLEOMYCIN 15K. If you are about to be started on any new medicine, tell your doctor, dentist or pharmacist that you are being given CIPLA BLEOMYCIN 15K.

If you plan to have surgery that needs a general anaesthetic, tell your doctor or dentist that you are being given CIPLA BLEOMYCIN 15K.

If you become pregnant while you are being treated with CIPLA BLEOMYCIN 15K, tell your doctor immediately.

CIPLA BLEOMYCIN 15K can lower the number of white blood cells and platelets in your blood. This means that you have an increased chance of getting an infection or bleeding. The following precautions should be taken to reduce your risk of infection or bleeding:

  • Avoid people with infections. Check with your doctor immediately if you think you may be getting an infection, or if you get a fever, chills, cough, hoarse throat, lower back or side pain, or find it painful or difficult to urinate;
  • Be careful when using a toothbrush, dental floss or toothpick. Your doctor, dentist, nurse or pharmacist may recommend other ways to clean your teeth and gums. Check with your doctor before having any dental work done;
  • Be careful not to cut yourself when you are using sharp objects such as a razor or nail cutter.
  • Avoid contact sports or other situations where bruising or injury may occur.

While you are being given CIPLA BLEOMYCIN 15K

Your doctor should order regularly tests to check the number of blood cells in your blood. The results of these tests will be used to determine the amount of CIPLA BLEOMYCIN 15K you will be given for your next dose.

While you are being given CIPLA BLEOMYCIN 15K your doctor should order regular tests to check how well your kidneys are working. Your doctors should also order periodic tests to estimate how well your liver is working during treatment with CIPLA BLEOMYCIN 15K.

CIPLA BLEOMYCIN 15K is known to affect the way the lungs work in some patients. This may be serious, therefore your doctor should arrange frequent tests to check how well your lungs are working. Your doctor may also arrange weekly chest X-rays while you are being treated with CIPLA BLEOMYCIN 15K. These should continue for up to 4 weeks after completion of treatment with CIPLA BLEOMYCIN 15K.

CIPLA BLEOMYCIN 15K and its breakdown products may be excreted in body fluids and waste, including blood, urine, faeces, vomitus and semen.

In general, precautions to protect other people should be taken while you are receiving chemotherapy and for one week after the treatment period.

  • Flush the toilet twice to dispose of any body fluids and waste.
  • Wear gloves to clean any spill of body fluid or waste. Use paper towels or old rags, a strong solution of non-bleaching detergent and large amounts of water to mop up the spills. Discard the towels or rags into a separate waste bag and dispose of fluids in the toilet.
  • Wash linen or clothing that is heavily contaminated body fluids or waste separately from other items.
    Use a strong solution of non-bleaching detergent and large amounts of water.
  • Place soiled disposable nappies and other pads in a plastic bag; seal and dispose into the garbage.
  • For sexual intercourse, use a barrier method such as a condom.

Things to be careful of

Be careful driving or operating machinery until you know how CIPLA BLEOMYCIN 15K affects you.

As with some other medicines, CIPLA BLEOMYCIN 15K may cause dizziness, light-headedness and tiredness in some people. Make sure you know how you react to CIPLA BLEOMYCIN 15K before you drive a car, operate machinery, or do anything else that could be dangerous if you are dizzy or light headed. If this occurs do not drive. If you drink alcohol, dizziness or light-headedness may be worse.

Side effects

Tell your doctor, pharmacist or nurse as soon as possible if you do not feel well while you are being give CIPLA BLEOMYCIN 15K.

Like other medicines that treat cancer, CIPLA BLEOMYCIN 15K may have unwanted side effects, some of which may be serious. You may need medical treatment if you get some of these side effects.

If you are over 65 years of age you may have an increased chance of getting side effects.

Ask your doctor or pharmacist to answer any questions you may have.

Tell your doctor or nurse if you notice any of the following and they worry you:

  • Nausea, vomiting or loss of appetite
  • Tiredness or weakness
  • Headaches
  • Pain and inflammation at the injection site
  • Rash and other skin conditions such as itchiness, tenderness, altered pain sensation and altered skin colour
  • Conjunctivitis (infection/inflammation of the eye)
  • Soreness or ulceration of the mouth.

These are more common side effects of CIPLA BLEOMYCIN 15K.

Tell your doctor or nurse immediately, or go to the Accident and Emergency department of your nearest hospital if you notice any of the following:

  • Cough and shortness of breath
  • Fever and chills
  • Signs of allergic reactions such as those listed at the start of this leaflet
  • Disorientation or personality changes
  • Severe nausea and vomiting
  • Severe abdominal pain
  • Chest pain
  • Severe headache
  • Severe mouth ulceration and/or anal ulceration
  • Unusual bleeding or bruising (including blood in your stools or urine)
  • Painful or difficult urination
  • Blurred vision or eye pain
  • Yellowing of the skin or eyes
  • Fits (seizures)

These are very serious side effects. You may need urgent medical attention or hospitalisation.

Temporary loss of hair, particularly that o the scalp is a less common side effect of CIPLA BLEOMYCIN 15K occurs in a small number of patients. The severity of hair loss will depend on the dose of CIPLA BLEOMYCIN 15K given. It is more common when other anti-cancer medicines are used together with CIPLA BLEOMYCIN 15K.

Other side effects not listed above may occur in some patients. Tell your doctor or pharmacist if you feel unwell.

Do not be alarmed by this list of possible side effects You may not experience any of them.

The effects of CIPLA BLEOMYCIN 15K may take some time to occur and therefore the side effects may be delayed. It is possible that the unwanted side effects may not occur until months after CIPLA BLEOMYCIN 15K is given.

Therefore, even after you have finished receiving your treatment you should tell your doctor immediately if you notice any of the side effects listed above.

After you have been given CIPLA BLEOMYCIN 15K for Injection

Storage

CIPLA BLEOMYCIN 15K for Injection will be stored in the pharmacy or on the ward. The injection is kept in a cool dry place, protected from light, where the temperature stays at between 2 - 8ºC. (Refrigerate. Do not freeze).

Product description

What it looks like

CIPLA BLEOMYCIN 15K for Injection is sterile freeze-dried white to off white powder. It must be dissolved in Water for Injections, 0.9% Sodium Chloride solution or Bacteriostatic water for Injection before use.

Ingredients

Active ingredients:

  • Bleomycin Sulfate 15,000IU (15 units USP) per vial

There are no other ingredients.

CIPLA BLEOMYCIN 15K glass vials are available in packs sizes of 1’s and 10’s.

CIPLA BLEOMYCIN 15K for Injection does not contain lactose, sucrose, gluten, tartrazine or any other azo dyes.

Sponsor

Cipla Australia Pty Ltd
Level 1, 132 – 136 Albert Rd,
South Melbourne VIC 3205

AUST R 220440

Date of preparation of this leaflet January 2016

BRAND INFORMATION

Brand name

Cipla Bleomycin 15K Powder for injection

Active ingredient

Bleomycin sulfate

Schedule

S4

 

Name of the medicine

Bleomycin sulfate.

Excipients.

Hydrochloric acid and sodium hydroxide, both for pH adjustment.

Description

Bleomycin Sulfate Powder for Injection contains bleomycin sulfate 15,000 IU per vial.
The CAS number of bleomycin sulfate is 9041-93-4.
Molecular formula. Bleomycin A2: C55H81N16O21S3.½SO4H2SO4. Bleomycin B2: C55H81N19O21S2.1½ H2SO4. M.W. Bleomycin A2: 1,545.6. Bleomycin B2: 1,555.6.
Bleomycin sulfate is a white or yellowish white or cream coloured amorphous hygroscopic powder. It is very soluble in water, slightly soluble in dehydrated alcohol, and practically insoluble in acetone and ether.
It is a purified mixture of glycopeptides produced by a fermentation process employing the actinomycetes Streptoverticillium species. The bleomycin mixture contains predominantly the A2 and B2 peptides. When reconstituted in water for injections, the pH of the solution is approximately 5. Each vial contains 55 to 70% of bleomycin A2 and 25 to 32% of bleomycin B2.
Bleomycin injection contains the excipients: hydrochloric acid and sodium hydroxide, both for pH adjustment.

Pharmacology

Although the precise mechanism of action of bleomycin is not fully known, it is thought that the primary action is to produce single and double strand breaks in DNA, leading to inhibition of cell division and growth, and inhibition of DNA synthesis in the cells. Bleomycin is probably most effective against cells in the M and G2 (premitotic) phase of the cell cycle. Bleomycin has not been shown to have an immunosuppressive effect in vitro and shows no significant inhibition of immune response in patients treated with the drug. Bleomycin inactivating enzyme has been detected in both normal and malignant cells and is particularly prominent in liver. The enzyme is not found in lung or skin, two normal tissues sensitive to bleomycin action.

Pharmacokinetics.

Absorption.

Bleomycin is well absorbed in animals upon parenteral administration. Intramuscular injection of 15 units in humans resulted in a maximum serum concentration of 1 mU/mL 30 minutes after administration. Intravenous injection of 15 units in humans resulted in a maximum serum concentration of 3.3 mU/mL.

Distribution.

In mice, bleomycin diffusing from the blood produces high concentrations in the skin, lungs, kidneys, peritoneum, lymphatic system and susceptible tumour tissue if present. Bleomycin crosses the placenta, but does not cross the blood brain barrier. Equilibrium dialysis and gel permeation experiments suggest that less than 1.0% of the drug is protein bound after incubation with normal human serum in vitro.

Metabolism.

The majority of a bleomycin dose is not readily metabolised. The highest rate of metabolism occurs in the liver and gastrointestinal tract. A lower rate of metabolism also occurs in skin, lungs, kidneys, muscle and serum. The products of bleomycin metabolism are not known.

Excretion.

Bleomycin is primarily excreted in the urine. After intravenous injection an average of 40% of the administered dose is recovered unchanged in the urine within 24 hours. After intramuscular injection 20% is recovered in the urine after six hours. The plasma half-lives have varied from 15 to 60 minutes in patients with normal renal function following intravenous administration. The serum half-life is prolonged in patients with renal dysfunction. In one patient with severe renal dysfunction the biological half-life was 21 hours when the creatinine clearance was 10.7 mL/minute, and 13 hours when the creatinine clearance was 15.2 mL/minute. There were undetectable serum levels of bleomycin 72 hours after the intravenous dose.

Indications

Palliation and treatment adjuvant to surgery and radiation therapy of the following neoplasms:
Squamous cell carcinoma of the skin, head and neck, and oesophagus (primary indication).
Squamous cell carcinoma of the larynx, penis and uterine cervix.
Squamous cell carcinoma of the bronchus (response infrequent).
Choriocarcinoma and embryonal cell carcinoma of the testis.
Advanced Hodgkin's disease and other lymphomas.
Mycosis fungoides.

Note.

Use of bleomycin after radiation therapy is less successful than use before radiation therapy. Bleomycin is bone marrow sparing and may be used when other cytotoxic agents are contraindicated.

Contraindications

Known allergy or idiosyncrasy to the drug.
Acute pulmonary infection or greatly reduced lung function.
A repeat course of therapy is contraindicated in any patient who has shown any signs of pneumonitis or decreased pulmonary function (see Precautions).

Precautions

It is recommended that bleomycin be administered under the supervision of a qualified doctor experienced in the use of cancer chemotherapeutic agents. Appropriate management of therapy and complications is possible only when adequate diagnostic and treatment facilities are readily available. Patients receiving bleomycin must be observed carefully and frequently during and after therapy.
After injection, bleomycin is readily absorbed and distributed in the body, particularly in the skin, lungs and any susceptible tumour tissue, leading to possible skin and pulmonary toxicity, as well as antitumour activity.

Pulmonary toxicity.

No single predictive monitoring test for bleomycin induced pulmonary toxicity has been identified. Frequent physical examinations should be undertaken. Cough, basal rales and pleuritic chest pain are frequent first signs of toxicity. Dyspnoea is usually the first symptom. If pulmonary changes are noted, treatment should be discontinued until it can be determined whether the cause is drug related. Pulmonary function tests (especially total lung volume (TLV) and forced vital capacity (FVC)) may be of value in detecting early lung changes, although these are not always predictive of subsequent toxicity. It has been suggested that bleomycin shouldbe discontinued if FVC decreases rapidly. Baseline and subsequent monthly evaluation of carbon monoxide diffusion capacity (DLCO) are also recommended, and bleomycin should be discontinued when the DLCO is less than 30 to 35% of the pretreatment value.
The most commonly recommended method of monitoring the onset of pulmonary toxicity is weekly chest X-rays, which should be continued up to four weeks after completion of treatment. However, high resolution computer tomography is a more sensitive method of detection.
Other proposed methods of monitoring pulmonary toxicity include 99mTechnetium scans and measurement of erythrocyte sedimentation rate (ESR), which has been found to increase prior to the development of symptomatic toxicity. However, the usefulness of these methods as predictors of development of toxicity have not been proven in clinical practice.

Anaesthesia.

Because of bleomycin's effects on lung tissue, patients who have received the drug are at increased risk of developing pulmonary toxicity when oxygen is administered during surgery. Long exposure to very high concentrations of oxygen is a known cause of lung damage, but after administration of bleomycin, lung damage can occur at oxygen concentrations lower than those usually considered safe.
Therefore, to minimise the risk in patients undergoing surgery who have received bleomycin, the following is recommended:
FI O2 (fraction of inspired oxygen) concentration should be maintained at approximately that of room air (25%) during surgery and the postoperative period;
fluid replacement should be carefully monitored, with emphasis on administration of colloid rather than crystalloid.

Pneumonitis.

Pneumonitis due to bleomycin has been treated with corticosteroids in an effort to prevent progression to pulmonary fibrosis. Infectious pneumonitis should receive appropriate antibiotic therapy.

Lung cancer.

Bleomycin should be used with extreme caution in patients with lung cancer as these patients show an increased incidence of pulmonary toxicity.

Compromised pulmonary function due to disease other than malignancy.

Bleomycin should be used with extreme caution in patients with compromised pulmonary function as pulmonary toxicity may be particularly dangerous in these patients (see Contraindications).

Previous cytotoxic or radiation therapy (especially chest irradiation); smokers.

Bleomycin should be used with caution in patients who have had previous cytotoxic drug therapy or radiation therapy (especially chest irradiation), and in patients who smoke, since the risk of pulmonary toxicity may be increased in these patients.

Cisplatin.

Cisplatin induced renal function impairment may result in delayed clearance and bleomycin toxicity even at low doses. An increased incidence of bleomycin induced pulmonary toxicity has been observed when these two agents are administered as part of an antineoplastic treatment regimen. Dosage reduction may be required (see Interactions with Other Medicines).

Granulocyte colony stimulating factor.

It has been suggested that concomitant administration of granulocyte colony stimulating factor (G-CSF) and bleomycin may increase the risk of bleomycin induced pulmonary toxicity, especially at higher doses, although this has not been confirmed in clinical trials. If G-CSF is added to bleomycin containing treatment regimens, patients should be closely observed for signs of pulmonary toxicity (see Interactions with Other Medicines).

Combination therapy.

Pulmonary toxicity may be observed at lower doses of bleomycin when bleomycin is administered as part of a multidrug treatment regimen. Patients should be closely monitored for signs of pulmonary toxicity (see Interactions with Other Medicines).

Use in the elderly.

Patients over 70 years of age should be closely observed for signs of pulmonary toxicity due to bleomycin therapy (see Adverse Effects).

Cumulative dose.

Pulmonary toxicity is more common in patients receiving a total dose of more than 400,000 IU.

Renal or hepatic toxicity.

Renal or hepatic toxicity, beginning as a deterioration in renal or liver function tests, have been reported infrequently. These toxicities may occur, however, at any time after initiation of therapy.

Use in renally impaired patients.

Bleomycin should be used with extreme caution in patients with severely impaired renal function (see Dosage and Administration, Impaired renal function).

Idiosyncratic reactions.

Idiosyncratic reactions similar to anaphylaxis have been reported in 1% of patients treated with bleomycin (5% of lymphoma patients). Since these usually occur after the first or second dose, careful monitoring is essential after these doses.

Lymphoma patients.

All lymphoma patients should receive test doses of bleomycin before initiating full dose therapy. (See Adverse Effects.)

Carcinogenesis, mutagenesis, impairment of fertility.

Bleomycin is mutagenic in both in vitro and in vivo test systems. It is not known whether bleomycin is carcinogenic in humans. However, an increased incidence of nodular hyperplasia was noted in F344/N male rats with lung cancer induced by nitrosamines, after bleomycin treatment. In another study where bleomycin was administered subcutaneously to rats at a dose of 0.35 mg/kg weekly (or about 30% the recommended human dose), necropsy findings included dose related injection site fibrosarcomas and various renal tumours. The effects of bleomycin on fertility are not known.

Use in pregnancy.

(Category D)
Category D: (Drugs which have caused, are suspected to have caused or may be expected to cause, an increased incidence of human fetal malformations or irreversible damage. These drugs may also have adverse pharmacological effects.)
Bleomycin has caused, is suspected to have caused or may be expected to cause an increased incidence of human fetal malformations or irreversible damage. It may also have adverse pharmacological effects.

Use in lactation.

It is not known whether bleomycin is excreted in breast milk. Due to the potential for serious adverse effects in infants, it is recommended that breastfeeding is discontinued prior to administration of bleomycin sulfate to the mother.

Interactions

Pharmacodynamic interactions.

Anaesthetics, general and oxygen.

Use in patients previously treated with bleomycin may result in rapid pulmonary deterioration, since bleomycin causes sensitisation of lung tissue to oxygen.

Radiation therapy.

Radiation therapy, especially to the chest area, either prior to, during or after bleomycin therapy may result in increased bleomycin toxicity. Dosage adjustment may be necessary.

Antineoplastic agents.

Concurrent use may result in increased bleomycin toxicity, or in occurrence of pulmonary toxicity at lower doses of bleomycin (see Precautions).

Combination therapy.

Pulmonary toxicity may be observed at lower doses of bleomycin when bleomycin is administered as part of a multidrug treatment regimen. Patients should be closely monitored for signs of pulmonary toxicity (see Precautions).

Granulocyte colony stimulating factor.

It has been suggested that concomitant administration of G-CSF and bleomycin may increase the risk of bleomycin induced pulmonary toxicity, especially at higher doses, although this has not been confirmed in clinical trials. If G-CSF is added to bleomycin containing treatment regimens, patients should be closely observed for signs of pulmonary toxicity (see Precautions).

Pharmacokinetic interactions.

Cisplatin.

Cisplatin induced renal function impairment may result in delayed clearance and bleomycin toxicity even at low doses. An increased incidence of bleomycin induced pulmonary toxicity has been observed when these two agents are administered as part of an antineoplastic treatment regimen. Dosage reduction may be required (see Precautions).

Digoxin.

Serum levels of digoxin may be reduced and its actions may be decreased. It is thought that drug induced alterations of the intestinal mucosa may be involved in the reduced gastrointestinal absorption.

Phenytoin.

Serum concentrations of phenytoin may be decreased due to decreased absorption or increased metabolism of phenytoin.

Effects on laboratory tests.

No information available.

Adverse Effects

Severe or life-threatening reactions.

Pulmonary toxicity.

The most serious toxicity of bleomycin is a subacute or chronic pneumonitis that progresses to interstitial fibrosis and may be fatal. This occurs in approximately 10% of treated patients, about 1% of whom have died of pulmonary fibrosis. Pulmonary toxicity is both age and dose related, being more common in patients over 70 years of age and in those receiving over 400,000 IU total dose. This toxicity, however, is unpredictable and has been seen occasionally in young patients receiving low doses. Also, when used in combination with other antineoplastic agents, pulmonary toxicities may occur at lower doses.
This toxicity is frequently seen in those with underlying lung disease such as emphysema and in those previously treated with pulmonary or mediastinal irradiation.
The identification of patients with pulmonary toxicity due to bleomycin has been extremely difficult. The clinical symptoms and X-ray findings of bleomycin pulmonary toxicity are not easily distinguished from other syndromes commonly observed in cancer patients, including progressive metastatic tumour (especially lymphangitic tumour), infectious processes such as Pneumocystis carinii or cytomegalovirus, or radiation injury.
The first symptoms to appear are dyspnoea, with cough and low grade fever, commonly occurring four to ten weeks after initiation of therapy, although the time of onset of pulmonary toxicity may vary from during therapy to up to six months after the cessation of therapy.
The microscopic tissue changes due to bleomycin toxicity are frequently present as bronchiolar squamous metaplasia, reactive macrophages, atypical alveolar epithelial cells, fibrinous oedema and interstitial fibrosis. The acute stage may involve capillary changes and subsequent fibrinous exudation into alveoli producing a change similar to hyaline membrane formation and progressing to a diffuse interstitial fibrosis resembling the Hamman-Rich syndrome.
These microscopic findings are nonspecific and are similar to the changes produced in radiation pneumonitis, pneumocystic pneumonitis, and at times reaction to long standing malignant pulmonary disease.
Pulmonary function tests have revealed some alteration in the pulmonary status such as decreased total lung volume and decreased vital capacity, but these tests have proved to be of limited value in predicting pulmonary fibrosis. It has been suggested that bleomycin should be discontinued if forced vital capacity decreases rapidly.
Pulmonary toxicity is seen more commonly in smokers.

Idiosyncratic effects.

Hypersensitivity reactions consisting of hypotension, fever, chills, mental confusion and wheezing have occurred in approximately 1% of patients receiving bleomycin.
This idiosyncratic reaction occurs mainly in lymphoma patients (5%), may be immediate or delayed for several hours, and usually occurs after the first or second dose. The reaction has resulted in death. Treatment of anaphylactoid reactions is supportive and symptomatic and may include volume expansion, vasopressor therapy, antihistamines and corticosteroids.

Cardiovascular.

Vascular toxicities coincident with the use of bleomycin in combination with other antineoplastic agents have been reported rarely. The events are clinically heterogeneous and may include myocardial infarction, cerebrovascular accident, thrombotic microangiopathy (haemolytic uraemic syndrome) or cerebrovascular arteritis. Acute chest pain syndrome, acute pericarditis, fulminant fatal hyperpyrexia and fulminant, fatal angioedema have been reported.

More common reactions.

Body as a whole.

Fever, chills and headache frequently follow parenteral administration of bleomycin (20 to 50%). These reactions have been reported to occur most frequently with large single doses and occur within a few hours of administration lasting 4 to 12 hours. Usually, febrile reactions become less frequent with continued use of the drug but may occur sporadically and reoccur later in the treatment course.

Gastrointestinal.

Anorexia, nausea and vomiting (20 to 50%) (anorexia and weight loss may persist after discontinuing therapy), tiredness.

Mucocutaneous (50%).

Hypoaesthesia which may progress to hyperaesthesia, urticaria, erythematous swelling, tenderness, pruritus, hyperpigmentation (particularly in those areas subject to friction or pressure and in skin folds, nail cuticles, scars, and intramuscular injection sites), patchy hyperkeratosis, alopecia, ichthyosis, rash, striae, vesiculation, peeling, and bleeding, stomatitis, ulcerations of the tongue and lips. This toxicity is usually evident within one to three weeks following initiation of therapy and appears to be reversible and dose related, usually after 150,000 to 200,000 IU of bleomycin has been administered and, in general, is related to total cumulative dose. In 0.2% of patients it was necessary to discontinue treatment because of this toxicity.
When bleomycin is administered intra-arterially, dermal lesions are most common in the region supplied by the artery used. The incidence of mucocutaneous adverse events is increased when bleomycin sulfate is given in combination with radiotherapy to head and neck.

Less common reactions.

Body as a whole.

Idiosyncratic reactions occurring in 1% of patients (5% of lymphoma patients) (see Severe or life-threatening reactions).

Cardiovascular.

Diverse vascular toxicities (see Severe or life-threatening reactions), hypotension (more common after intrapleural administration), sudden onset of an acute chest pain syndrome, suggestive of pleuropericarditis (although each patient must be individually evaluated, further courses of bleomycin do not appear to be contraindicated), ocular haemorrhage.
There are isolated reports of Raynaud's phenomenon occurring in patients treated with a combination of bleomycin and vinblastine with or without cisplatin or, in a few cases, with bleomycin as a single agent. It is currently unknown if the cause of the Raynaud's phenomenon in these cases is the disease, underlying vascular compromise, bleomycin, vinblastine, cisplatin induced hypomagnesaemia or a combination of any or all of these.

Central nervous system.

CNS toxicity is rare, but monitoring is advised. Disorientation and aggressive behaviour have been reported.

Haematological.

Thrombocytopenia, leucopenia, slight depression of haemoglobin levels. Bleomycin does not frequently produce serious bone marrow toxicity.

Hepatic.

Liver toxicity beginning as deterioration in liver function tests has been reported infrequently.

Injection site.

Pain at injection site, phlebitis, other local reactions.

Renal.

Renal toxicity beginning as deterioration in renal function tests has been reported infrequently. Haematuria and cystitis have been reported.

Respiratory.

Pulmonary toxicity (10%) (see Severe or life-threatening reactions).

Dosage and Administration

Bleomycin may be given by the intramuscular, intravenous, subcutaneous or intra-arterial routes.

Note.

Because of the possibility of an anaphylactoid reaction, lymphoma patients should receive test doses of between 1 and 5 units, for the first two treatments. If no acute allergic reaction occurs within four to six hours, the balance of the dose may be given. Thereafter the regular dosage schedule may be followed, if no reaction occurs.

Use in adults.

Initial treatment (intramuscular, intravenous or subcutaneous administration).

Total doses of over 300,000 IU should be given with great caution.
10,000 to 20,000 IU/m2 of body surface area given weekly or twice weekly.
Alternatively, give 15,000 IU daily for seven days followed by three weeks off treatment and repeat twice so that a total dose of approximately 300,000 IU is administered.
Improvement of lymphomas and testicular tumours is prompt, i.e. within two weeks while response by squamous cell cancers may take as long as three weeks.
A therapeutic response should be observed as the total dose approaches 150,000 IU, if this is not seen, consideration should be given to other therapy.

Note.

When bleomycin is used in combination with other antineoplastic agents, pulmonary toxicities may occur at lower doses (see Precautions, Pulmonary toxicity and Interactions with Other Medicines).

Intra-arterial administration.

Intra-arterial infusion/ perfusion is employed when increased drug concentrations at the cancer site are desired. The suggested dosage schedule is 30,000 to 60,000 IU once or twice a week until the total recommended dose of 300,000 IU is reached.

Repeat treatment.

In patients for whom a course of bleomycin treatment provides an initial but incomplete response, a repeat course is suggested. Patients who show superficial improvement after one course, e.g. in cases of squamous cell carcinoma, may benefit from a second course of treatment to prevent recurrence.
A repeat course may be commenced after a minimum of three to four weeks following completion of the first course, providing no sign of pulmonary toxicity has been observed (see Contraindications). A total dose of 150,000 IU for repeat treatment is recommended.

Use in children.

No information available.

Use in the elderly.

Adult dose should be used with caution, particularly in patients over 70 years (see Adverse Effects, Pulmonary toxicity).

Impaired hepatic function.

Use adult dose with caution.

Impaired renal function.

As bleomycin is mostly excreted unchanged and as there is a high correlation between renal bleomycin clearance and creatinine clearance, impairment of function may require reduction in dosage and careful monitoring for toxicity. Dosage reductions of 40 to 75% have been recommended for patients with creatinine clearance values of less than or equal to 40 mL/minute.

Reconstitution.

Intramuscular, subcutaneous injection.

For intramuscular or subcutaneous injection, dissolve the contents of the vial in 1 to 5 mL of sterile water for injection or sodium chloride intravenous infusion 0.9%.

Intravenous, intra-arterial injection.

For intravenous or intra-arterial injection, dissolve the contents of the vial in 5 to 10 mL of diluent and administer slowly over a period of 10 minutes.
Suitable diluents are water for injections, bacteriostatic water for injection and sodium chloride intravenous infusion 0.9%. Although glucose intravenous infusion 5% has been used in the past, recent data suggests that it is not the diluent of choice, as over the concentration range of 300 to 15,000 IU/mL the content of bleomycin A2 + B2 was consistently lower when glucose intravenous infusion 5% was used.
Reconstituted solutions containing bleomycin 150 to 15,000 IU/mL prepared using the recommended diluents remain stable for periods of at least 24 hours when stored in the dark, at temperatures of 2 to 8°C. Solutions of bleomycin sulfate in sodium chloride intravenous 0.9% stored in the dark at 2 to 8°C for ten days were chemically stable. However, in order to reduce the possibility of microbiological contamination, reconstituted injections should be used as soon as practicable after preparation. If storage of the reconstituted solution is necessary, store at 2 to 8°C for no more than 24 hours. Any unused portions must be discarded in compliance with acceptable procedures for the disposal of anticancer medicines.

Overdosage

Symptoms.

There has been no reported case of overdosage. The acute reaction would probably include hypotension, fever, rapid pulse and general symptoms of shock.

Treatment.

There is no specific antidote for bleomycin overdosage. Treatment should be symptomatic and supportive. In the event of respiratory complications treatment with a corticosteroid may be beneficial and the administration of a broad spectrum antibiotic is advisable.
Bleomycin is probably not dialysable.
In case of overdose, immediately contact the Poisons Information Centre for advice. (In Australia, call 131 126.)

Presentation

A sterile freeze dried powder for reconstitution. White to off white crystalline powder, very hygroscopic. Clear, colourless solution on reconstitution, equiv. 15,000 IU bleomycin activity.
Cipla Bleomycin 15K glass vials are available in pack sizes of 1's and 10's.
AUST R 220440.

Storage

Store at 2-8°C. (Refrigerate. Do not freeze.)

Poison Schedule

S4.