CLINICAL STUDIES SECTION.


14 CLINICAL STUDIES. 14.1 Ovarian Cancer. The efficacy of gemcitabine for injection was evaluated in randomized trial (Study 1) conducted in women with advanced ovarian cancer that had relapsed at least months after first-line platinum-based therapy. Patients were randomized to receive either gemcitabine for injection 1000 mg/m2 on Days and of each 21-day cycle with carboplatin AUC on Day after gemcitabine for injection administration (n=178) or carboplatin AUC on Day of each 21-day cycle (n=178). The major efficacy outcome measure was progression free survival (PFS). total of 356 patients were enrolled. Demographics and baseline characteristics are shown in Table 16. Efficacy results are presented in Table 17 and Figure 1. The addition of gemcitabine for injection to carboplatin resulted in statistically significant improvements in PFS and overall response rate. Approximately 75% of patients in each arm received additional chemotherapy for disease progression; 13 of 120 patients in the carboplatin alone arm received gemcitabine for injection for treatment of disease progression. There was no significant difference in overall survival between the treatment arms. Table 16: Baseline Demographics and Clinical Characteristics for Study a patients on gemcitabine for injection with carboplatin arm and patients on carboplatin arm had no baseline Eastern Cooperative Oncology Group (ECOG) performance status. 2 patients on gemcitabine for injection with carboplatin arm and patient on carboplatin arm had platinum-free interval <6 months. Gemcitabine For Injection/Carboplatin(N=178)Carboplatin(N=178)Median age, years 59 58 Range 36 to 78 21 to 81 Baseline ECOG performance status 0-1a 94% 95% Disease Status Evaluable 8% 3% Bidimensionally measurable 92% 96% Platinum-free intervalb 6-12 months 40% 40% >12 months 59% 60% First-line therapy Platinum-taxane combination 70% 71% Platinum-non-taxane combination 29% 28% Platinum monotherapy 1% 1% Table 17: Efficacy Results in Study a CI=confidence interval. Log rank, unadjusted. Chi square. CR=Complete response. PR with PRNM=Partial response with partial response, non-measurable disease. Independently reviewed cohort gemcitabine for injection/carboplatin (n=121), carboplatin (n=101); independent reviewers unable to measure disease detected by sonography or physical exam. Efficacy ParameterGemcitabine For Injection/Carboplatin(N=178)Carboplatin(N=178)Progression-Free SurvivalMedian (95% CIa) in months 8.6 (8.0, 9.7) 5.8 (5.2, 7.1) Hazard Ratio (95% CI) 0.72 (0.57, 0.90) p-valueb p=0.0038 Overall Survival Median (95% CI) in months 18.0 (16.2, 20.3) 17.3 (15.2, 19.3) Hazard Ratio (95% CI) 0.98 (0.78, 1.24) p-valueb p=0.8977 Overall Response Rate by Investigator Review47.2% 30.9% p-valuec p=0.0016 CRd 14.6% 6.2% PR with PRNMe 32.6% 24.7% Overall Response Ratef by Independent Review46.3% 35.6% p-valuec p=0.11 CRd 9.1% 4.0% PR with PRNMe 37.2% 31.7% Figure 1: Kaplan-Meier Curves for Progression Free Survival in Study 1. Figure 1. 14.2 Breast Cancer. The efficacy of gemcitabine for injection was evaluated in multinational, randomized, open-label trial (Study 2) conducted in women receiving initial treatment for metastatic breast cancer and who have received prior adjuvant/neoadjuvant anthracycline chemotherapy unless clinically contraindicated. Patients were randomized to receive either gemcitabine for injection 1250 mg/m2 on Days and of each 21-day cycle with paclitaxel 175 mg/m2 administered on Day before gemcitabine for injection administration (n=267) or paclitaxel 175 mg/m2 on Day of each 21-day cycle (n=262). The major efficacy outcome measure was time to documented disease progression. total of 529 patients were enrolled. Demographic and baseline characteristics were similar between treatment arms (Table 18). Efficacy results are presented in Table 19 and Figure 2. The addition of gemcitabine for injection to paclitaxel resulted in statistically significant improvement in time to documented disease progression and overall response rate compared to paclitaxel alone. There was no significant difference in overall survival. Table 18: Baseline Demographics and Clinical Characteristics for Study a Karnofsky Performance Status. Gemcitabine For Injection/Paclitaxel(N=267)Paclitaxel(N=262)Median age (years) 53 52 Range 26 to 83 26 to 75 Metastatic disease 97% 97% Baseline KPSa >=90 70% 74% Number of tumor sites 1-2 57% 59% >=3 43% 41% Visceral disease 73% 73% Prior anthracycline 97% 96% Table 19: Efficacy Results in Study a These represent reconciliation of investigator and Independent Review Committee assessments according to predefined algorithm. Based on the ITT population. Efficacy ParameterGemcitabine For Injection/Paclitaxel(N=267)Paclitaxel(N=262)Time to Documented Disease ProgressionaMedian (95% CI) in months 5.2 (4.2, 5.6) 2.9 (2.6, 3.7) Hazard Ratio (95% CI) 0.650 (0.524, 0.805) p-value p<0.0001 Overall Survivalb Median (95% CI) in months 18.6 (16.5, 20.7) 15.8 (14.1, 17.3) Hazard Ratio (95% CI) 0.86 (0.71, 1.04) p-value Not Significant Overall Response Rate40.8% 22.1% (95% CI) (34.9, 46.7) (17.1, 27.2) p-value p<0.0001 Figure 2: Kaplan-Meier Curves for Time to Documented Disease Progression in Study 2. Figure 2. 14.3 Non-Small Cell Lung Cancer. The efficacy of gemcitabine for injection was evaluated in two randomized, multicenter trials.. Study 3: 28-Day ScheduleA multinational, randomized trial (Study 3) compared gemcitabine for injection with cisplatin to cisplatin alone in the treatment of patients with inoperable Stage IIIA, IIIB, or IV NSCLC who had not received prior chemotherapy. Patients were randomized to receive either gemcitabine for injection 1000 mg/m2 on Days 1, 8, and 15 of each 28-day cycle with cisplatin 100 mg/m2 on Day after gemcitabine for injection administration (N=260) or cisplatin 100 mg/m2 on Day of each 28-day cycle (N=262). The major efficacy outcome measure was overall survival.A total of 522 patients were enrolled. Demographics and baseline characteristics (Table 20) were similar between arms with the exception of histologic subtype of NSCLC, with 48% of patients on the cisplatin arm and 37% of patients on the gemcitabine for injection with cisplatin arm having adenocarcinoma.Efficacy results are presented in Table 21 and Figure 3.. Study 4: 21-Day ScheduleA randomized (1:1), multicenter trial (Study 4) was conducted in patients with Stage IIIB or IV NSCLC. Patients were randomized to receive either gemcitabine for injection 1250 mg/m2 on Days and of each 21-day cycle with cisplatin 100 mg/m2 on Day after gemcitabine for injection administration or etoposide 100 mg/m2 intravenously on Days 1, 2, and with cisplatin 100 mg/m2 on Day of each 21 -day cycle. The major efficacy outcome measure was response rate. total of 135 patients were enrolled. Demographics and baseline characteristics are summarized in Table 20. Efficacy results are presented in Table 21. There was no significant difference in survival between the two treatment arms. The median survival was 8.7 months for the gemcitabine for injection with cisplatin arm versus months for the etoposide with cisplatin arm. Median time to disease progression for the gemcitabine for injection with cisplatin arm was months compared to 4.1 months on the etoposide with cisplatin arm (Log rank p=0.015, two-sided). The objective response rate for the gemcitabine for injection with cisplatin arm was 33% compared to 14% on the etoposide with cisplatin arm (Fishers Exact p=0.01, two-sided). Table 20: Baseline Demographics and Clinical Characteristics for Studies and a N/A Not applicable. Karnofsky Performance Status. Trial28-day Schedule (Study 3)21-day Schedule (Study 4)Gemcitabine For Injection/ Cisplatin(N=260)Cisplatin(N=262)Gemcitabine For Injection/ Cisplatin(N=69)Etoposide/ Cisplatin(N=66) Male 70% 71% 93% 92% Median age, years 62 63 58 60 Range 36 to 88 35 to 79 33 to 76 35 to 75 Stage IIIA 7% 7% N/Aa N/Aa Stage IIIB 26% 23% 48% 52% Stage IV 67% 70% 52% 49% Baseline KPSb 70 to 80 41% 44% 45% 52% Baseline KPSb 90 to 100 57% 55% 55% 49% Table 21: Efficacy Results for Studies and a CI=confidence intervals. p-value two-sided Fishers Exact test for difference in binomial proportions; log rank test for time-to-event analyses. Trial28-day Schedule (Study 3)21-day Schedule (Study 4)Efficacy ParameterGemcitabine For Injection/ Cisplatin(N=260)Cisplatin(N=262)Gemcitabine For Injection/ Cisplatin(N=69)Etoposide/ Cisplatin(N=66)Survival Median (95% CIa) in months 9.0 (8.2, 11.0) 7.6 (6.6, 8.8) 8.7 (7.8, 10.1) 7.0 (6.0, 9.7) p-valuef p=0.008 p=0.18 Time to Disease Progression Median (95% CIa) in months 5.2 (4.2, 5.7) 3.7 (3.0, 4.3) 5.0 (4.2, 6.4) 4.1 (2.4, 4.5) p-valueb p=0.009 p=0.05 Tumor Response26% 10% 33% 14% p-valueb p<0.0001 p=0.01 Figure 3: Kaplan-Meier Curves for Overall Survival in Study 3. Figure 3. 14.4 Pancreatic Cancer. The efficacy of gemcitabine for injection was evaluated in two trials (Studies and 6), randomized, single-blind, two-arm, active-controlled trial (Study 5) conducted in patients with locally advanced or metastatic pancreatic cancer who had received no prior chemotherapy and in single-arm, open-label, multicenter trial (Study 6) conducted in patients with locally advanced or metastatic pancreatic cancer previously treated with fluorouracil or fluorouracil-containing regimen. In Study 5, patients were randomized to receive either gemcitabine for injection 1000 mg/m2 intravenously over 30 minutes once weekly for weeks followed by one-week rest, then once weekly for consecutive weeks every 28-days in subsequent cycles (n=63) or fluorouracil 600 mg/m2 intravenously over 30 minutes once weekly (n=63). In Study 6, all patients received gemcitabine for injection 1000 mg/m2 intravenously over 30 minutes once weekly for weeks followed by one-week rest, then once weekly for consecutive weeks every 28-days in subsequent cycles. The major efficacy outcome measure in both trials was clinical benefit response. patient was considered to have had clinical benefit response if either of the following occurred: The patient achieved >=50% reduction in pain intensity (Memorial Pain Assessment Card) or analgesic consumption, or 20-point or greater improvement in performance status (Karnofsky Performance Status) for period of at least consecutive weeks, without showing any sustained worsening in any of the other parameters. Sustained worsening was defined as consecutive weeks with either any increase in pain intensity or analgesic consumption or 20-point decrease in performance status occurring during the first 12 weeks of therapy.OR The patient was stable on all of the aforementioned parameters and showed marked, sustained weight gain (>=7% increase maintained for >=4 weeks) not due to fluid accumulation. Study enrolled 126 patients. Demographics and baseline characteristics were similar between the arms (Table 22). The efficacy results are shown in Table 23 and Figure 4. Patients treated with gemcitabine for injection had statistically significant increases in clinical benefit response, survival, and time to disease progression compared to those randomized to receive fluorouracil. No confirmed objective tumor responses were observed in either treatment arm. Table 22: Baseline Demographics and Clinical Characteristics for Study a Karnofsky Performance Status. Gemcitabine For Injection(N=63)Fluorouracil(N=63) Male 54% 54% Median age, years 62 61 Range 37 to 79 36 to 77 Stage IV disease 71% 76% Baseline KPSa <=70 70% 68% Table 23: Efficacy Results in Study a p-value for clinical benefit response calculated using the two-sided test for difference in binomial proportions. All other p-values are calculated using log rank test. Efficacy ParameterGemcitabine For Injection(N=63)Fluorouracil(N=63)Clinical Benefit Response22.2% 4.8% p-valuea p=0.004 Overall Survival Median (95% CI) in months 5.7 (4.7, 6.9) 4.2 (3.1, 5.1) p-valuea p=0.0009 Time to Disease Progression Median (95% CI) in months 2.1 (1.9, 3.4) 0.9 (0.9, 1.1) p-valuea p=0.0013 Figure 4: Kaplan-Meier Curves for Overall Survival in Study 5. The patient achieved >=50% reduction in pain intensity (Memorial Pain Assessment Card) or analgesic consumption, or 20-point or greater improvement in performance status (Karnofsky Performance Status) for period of at least consecutive weeks, without showing any sustained worsening in any of the other parameters. Sustained worsening was defined as consecutive weeks with either any increase in pain intensity or analgesic consumption or 20-point decrease in performance status occurring during the first 12 weeks of therapy.OR The patient was stable on all of the aforementioned parameters and showed marked, sustained weight gain (>=7% increase maintained for >=4 weeks) not due to fluid accumulation. Figure 4.

CONTRAINDICATIONS SECTION.


4 CONTRAINDICATIONS. Gemcitabine for injection is contraindicated in patients with known hypersensitivity to gemcitabine. Reactions include anaphylaxis [see Adverse Reactions (6.1)]. Patients with known hypersensitivity to gemcitabine. (4).

ADVERSE REACTIONS SECTION.


6 ADVERSE REACTIONS. The following clinically significant adverse reactions are described elsewhere in the labeling: Hypersensitivity [see Contraindications (4)] Schedule-Dependent Toxicity [see Warnings and Precautions (5.1)] Myelosuppression [see Warnings and Precautions (5.2)] Pulmonary Toxicity and Respiratory Failure [see Warnings and Precautions (5.3)] Hemolytic Uremic Syndrome [see Warnings and Precautions (5.4)] Hepatic Toxicity [see Warnings and Precautions (5.5)] Exacerbation of Radiation Therapy Toxicity [see Warnings and Precautions (5.7)] Capillary Leak Syndrome [see Warnings and Precautions (5.8)] Posterior Reversible Encephalopathy Syndrome [see Warnings and Precautions (5.9)] Hypersensitivity [see Contraindications (4)] Schedule-Dependent Toxicity [see Warnings and Precautions (5.1)] Myelosuppression [see Warnings and Precautions (5.2)] Pulmonary Toxicity and Respiratory Failure [see Warnings and Precautions (5.3)] Hemolytic Uremic Syndrome [see Warnings and Precautions (5.4)] Hepatic Toxicity [see Warnings and Precautions (5.5)] Exacerbation of Radiation Therapy Toxicity [see Warnings and Precautions (5.7)] Capillary Leak Syndrome [see Warnings and Precautions (5.8)] Posterior Reversible Encephalopathy Syndrome [see Warnings and Precautions (5.9)] The most common adverse reactions for the single agent (>=20%) are nausea/vomiting, anemia, increased aspartate aminotransferase (AST), increased alanine aminotransferase (ALT), neutropenia, increased alkaline phosphatase, proteinuria, fever, hematuria, rash, thrombocytopenia, dyspnea, and edema. (6.1) To report SUSPECTED ADVERSE REACTIONS, contact Dr. Reddys Laboratories Inc., at 1-888-375-3784 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.. 6.1 Clinical Trials Experience. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.. Single AgentThe data described below reflect exposure to gemcitabine for injection as single agent administered at doses between 800 mg/m2 to 1250 mg/m2 intravenously over 30 minutes once weekly in 979 patients with various malignancies. The most common (>=20%) adverse reactions of single agent gemcitabine for injection are nausea/vomiting, anemia, increased alanine aminotransferase (ALT), increased aspartate aminotransferase (AST), neutropenia, increased alkaline phosphatase, proteinuria, fever, hematuria, rash, thrombocytopenia, dyspnea, and edema. The most common (>=5%) Grade or adverse reactions were neutropenia, nausea/vomiting, increased ALT, increased alkaline phosphatase, anemia, increased AST, and thrombocytopenia. Approximately 10% of the 979 patients discontinued gemcitabine for injection due to adverse reactions. Adverse reactions resulting in discontinuation of gemcitabine for injection in 2% of 979 patients were cardiovascular adverse reactions (myocardial infarction, cerebrovascular accident, arrhythmia, and hypertension) and adverse reactions resulting in discontinuation of gemcitabine for injection in <1% of 979 patients were anemia, thrombocytopenia, hepatic dysfunction, renal dysfunction, nausea/vomiting, fever, rash, dyspnea, hemorrhage, infection, stomatitis, somnolence, flu-like syndrome, and edema. Tables and present the incidence of selected adverse reactions and laboratory abnormalities reported in patients with various malignancies receiving single agent gemcitabine for injection across clinical trials. Additional clinically significant adverse reactions are provided following Table 6. Table 5: Selected Adverse Reactions Occurring in >=10% of Patients Receiving Single Agent Gemcitabine For Injectiona Grade based on criteria from the World Health Organization (WHO). For approximately 60% of patients, non-laboratory adverse reactions were graded only if assessed to be possibly drug-related. N=699-974; all patients with laboratory or non-laboratory data. Adverse ReactionsbGemcitabine For InjectioncAll Grades(%)Grade 3(%)Grade 4(%)Nausea and Vomiting 69 13 Fever 41 0 Rash 30 <1 Dyspnea 23 <1 Diarrhea 19 0 Hemorrhage 17 <1 <1 Infection 16 <1 Alopecia 15 <1 Stomatitis 11 <1 Somnolence 11 <1 <1 Paresthesias 10 <1 Table 6: Selected Laboratory Abnormalities Occurring in Patients Receiving Single Agent Gemcitabine For Injectiona Grade based on criteria from the WHO. Regardless of causality. N=699-974; all patients with laboratory or non-laboratory data. Laboratory AbnormalitybGemcitabine For InjectioncAll Grades(%)Grade 3(%)Grade 4(%)Hematologic Anemia 68 1 Neutropenia 63 19 Thrombocytopenia 24 1 Hepatic Increased ALT 68 2 Increased AST 67 2 Increased Alkaline Phosphatase 55 2 Hyperbilirubinemia 13 <1 Renal Proteinuria 45 <1 Hematuria 35 <1 Increased BUN 16 0 Increased Creatinine <1 Additional adverse reactions include the following: Transfusion requirements: Red blood cell transfusions (19%); platelet transfusions (<1%) Edema: Edema (13%), peripheral edema (20%), generalized edema (<1%) Flu-like symptoms: Fever, asthenia, anorexia, headache, cough, chills, myalgia, asthenia insomnia, rhinitis, sweating, and/or malaise (19%) Infection: Sepsis (<1%) Extravasation: Injection-site reactions (4%) Allergic: Bronchospasm (<2%); anaphylactoid reactions Transfusion requirements: Red blood cell transfusions (19%); platelet transfusions (<1%) Edema: Edema (13%), peripheral edema (20%), generalized edema (<1%) Flu-like symptoms: Fever, asthenia, anorexia, headache, cough, chills, myalgia, asthenia insomnia, rhinitis, sweating, and/or malaise (19%) Infection: Sepsis (<1%) Extravasation: Injection-site reactions (4%) Allergic: Bronchospasm (<2%); anaphylactoid reactions Ovarian CancerTables and present the incidence of selected adverse reactions and laboratory abnormalities, occurring in >=10% of gemcitabine for injection-treated patients and at higher incidence in the gemcitabine for injection with carboplatin arm, reported in randomized trial (Study 1) of gemcitabine for injection with carboplatin (n=175) compared to carboplatin alone (n=174) for the second-line treatment of ovarian cancer in women with disease that had relapsed more than months following first-line platinum-based chemotherapy [see Clinical Studies (14.1)]. Additional clinically significant adverse reactions, occurring in <10% of patients, are provided following Table 8. The proportion of patients with dose adjustments for carboplatin (1.8% versus 3.8%), doses of carboplatin omitted (0.2% versus 0) and discontinuing treatment for adverse reactions (11% versus 10%), were similar between arms. Dose adjustment for gemcitabine for injection occurred in 10% of patients and gemcitabine for injection dose was omitted in 14% of patients in the gemcitabine for injection/carboplatin arm. Table 7: Adverse Reactions Occurring in >10% of Patients Receiving Gemcitabine with Carboplatin and at Higher Incidence than in Patients Receiving Single Agent Carboplatin [Between Arm Difference of >=5% (All Grades) or >=2% (Grades 3-4)] in Study 1a Grade based on National Cancer Institute CTC Version 2.0. Regardless of causality. Adverse ReactionsbGemcitabine for Injection/Carboplatin(N=175)Carboplatin(N=174)All Grades(%)Grade 3(%)Grade 4(%)All Grades(%)Grade 3(%)Grade 4(%)Nausea 69 0 61 0 Alopecia 49 0 17 0 Vomiting 46 0 36 <1 Constipation 42 1 37 0 Fatigue 40 <1 32 0 Diarrhea 25 0 14 <1 Stomatitis/Pharyngitis 22 <1 13 0 Table 8: Laboratory Abnormalities Occurring in Patients Receiving Gemcitabine with Carboplatin and at Higher Incidence than in Patients Receiving Single Agent Carboplatin [Between Arm Difference of >=5% (All Grades) or >=2% (Grades 3-4)] in Study 1a Grade based on National Cancer Institute CTC Version 2.0. Regardless of causality. Percent of patients receiving transfusions. Transfusions are not CTC-graded events. Blood transfusions included both packed red blood cells and whole blood. Laboratory AbnormalitybGemcitabine for Injection/Carboplatin(N=175)Carboplatin(N=174)All Grades(%)Grade 3(%)Grade 4(%)All Grades(%)Grade 3(%)Grade 4(%)Hematologic Neutropenia 90 42 29 58 11 Anemia 86 22 75 2 Thrombocytopenia 78 30 57 10 RBC Transfusionsc 38 - 15 - Platelet Transfusionsc - 3 - Hematopoietic growth factors were administered more frequently in the gemcitabine for injection-containing arm: leukocyte growth factor (24% and 10%) and erythropoiesis-stimulating agent (7% and 3.9%). The following clinically relevant Grade and adverse reactions occurred more frequently in the gemcitabine for injection with carboplatin arm: dyspnea (3.4% versus 2.9%), febrile neutropenia (1.1% versus 0), hemorrhagic event (2.3% versus 1.1 %), motor neuropathy (1.1% versus 0.6%), and rash/desquamation (0.6% versus 0). Breast CancerTables and 10 present the incidence of selected adverse reactions and laboratory abnormalities, occurring in >=10% of gemcitabine for injection-treated patients and at higher incidence in the gemcitabine for injection with paclitaxel arm, reported in randomized trial (Study 2) of gemcitabine for injection with paclitaxel (n=262) compared to paclitaxel alone (n=259) for the first-line treatment of metastatic breast cancer (MBC) in women who received anthracycline-containing chemotherapy in the adjuvant/neo-adjuvant setting or for whom anthracyclines were contraindicated [see Clinical Studies (14.2)]. Additional clinically significant adverse reactions, occurring in <10% of patients, are provided following Table 10. The requirement for dose reduction of paclitaxel were higher for patients in the gemcitabine for injection/paclitaxel arm (5% versus 2%). The number of paclitaxel doses omitted (<1%), the proportion of patients discontinuing treatment for adverse reactions (7% versus 5%) and the number of treatment-related deaths (1 patient in each arm) were similar between the two arms. Table 9: Selected Adverse Reactions Occurring in Patients Receiving Gemcitabine with Paclitaxel and at Higher Incidence than in Patients Receiving Single Agent Paclitaxel [Between Arm Difference of >=5% (All Grades) or >=2% (Grades 3-4)] in Study 2a Grade based on National Cancer Institute CTC Version 2.0. Non-laboratory events were graded only if assessed to be possibly drug-related. Adverse ReactionsbGemcitabine for Injection/Paclitaxel(N=262)Paclitaxel(N=259)All Grades(%)Grade 3(%)Grade 4(%)All Grades(%)Grade 3(%)Grade 4(%)Alopecia 90 14 92 19 Neuropathy-Sensory 64 <1 58 0 Nausea 50 0 31 0 Fatigue 40 <1 28 <1 Vomiting 29 0 15 0 Diarrhea 20 0 13 0 Anorexia 17 0 12 <1 Neuropathy-Motor 15 <1 10 <1 Stomatitis/Pharyngitis 13 <1 <1 Fever 13 <1 3 0 Rash/Desquamation 11 <1 <1 0 Febrile Neutropenia 5 <1 1 Table 10: Selected Laboratory Abnormalities Occurring in >10% of Patients Receiving Gemcitabine with Paclitaxel and at Higher Incidence than Patients Receiving Single Agent Paclitaxel [Between Arm Difference of >=5% (All Grades) or >=2% (Grades 3-4)] in Study 2a Grade based on National Cancer Institute CTC Version 2.0. Regardless of causality. Laboratory AbnormalitybGemcitabine for Injection/Paclitaxel(N=262)Paclitaxel(N=259)All Grades(%)Grade 3(%)Grade 4(%)All Grades(%)Grade 3(%)Grade 4(%)Hematologic Anemia 69 1 51 <1 Neutropenia 69 31 17 31 7 Thrombocytopenia 26 <1 <1 <1 Hepatobiliary Increased ALT 18 <1 <1 Increased AST 16 0 <1 Clinically relevant Grade or dyspnea occurred with higher incidence in the gemcitabine for injection with paclitaxel arm compared with the paclitaxel arm (1.9% versus 0). Non-Small Cell Lung CancerTables 11 and 12 present the incidence of selected adverse reactions and laboratory abnormalities occurring in >=10% of gemcitabine for injection-treated patients and at higher incidence in the gemcitabine for injection with cisplatin arm, reported in randomized trial (Study 3) of gemcitabine for injection with cisplatin (n=260) administered in 28-day cycles as compared to cisplatin alone (n=262) in patients receiving first-line treatment for locally advanced or metastatic NSCLC [see Clinical Studies (14.3)]. Patients randomized to gemcitabine for injection with cisplatin received median of cycles of treatment and those randomized to cisplatin alone received median of cycles of treatment. In this trial, the requirement for dose adjustments (>90% versus 16%), discontinuation of treatment for adverse reactions (15% versus 8%), and the proportion of patients hospitalized (36% versus 23%) were all higher for patients receiving gemcitabine for injection with cisplatin compared to those receiving cisplatin alone. The incidence of febrile neutropenia (3% versus <1%), sepsis (4% versus 1%), Grade cardiac dysrhythmias (3% versus <1%) were all higher in the gemcitabine for injection with cisplatin arm compared to the cisplatin alone arm. The two-drug combination was more myelosuppressive with (1.5%) possibly treatment-related deaths, including resulting from myelosuppression with infection and one case of renal failure associated with pancytopenia and infection. No deaths due to treatment were reported on the cisplatin arm. Table 11: Selected Adverse Reactions Occurring in >=10% of Patients Receiving Gemcitabine with Cisplatin and at Higher Incidence than in Patients Receiving Single Agent Cisplatin [Between Arm Difference of >=5% (All Grades) or >=2% (Grades 3-4)] in Study 3a Grade based on National Cancer Institute Common Toxicity Criteria (CTC). Non-laboratory events were graded only if assessed to be possibly drug-related. N=217-253; all gemcitabine for injection/cisplatin patients with laboratory or non-laboratory data N=213-248; all cisplatin patients with laboratory or non-laboratory data Adverse ReactionsbGemcitabine For Injection/CisplatincCisplatindAll Grades(%)Grade 3(%)Grade 4(%)All Grades(%)Grade 3(%)Grade 4(%)Nausea 93 25 87 20 <1 Vomiting 78 11 12 71 10 Alopecia 53 0 33 0 Neuro Motor 35 12 15 0 Diarrhea 24 2 13 0 Neuro Sensory 23 0 18 0 Infection 18 2 12 0 Fever 16 0 0 Neuro Cortical 16 1 1 Neuro Mood 16 0 10 0 Local 15 0 0 Neuro Headache 14 0 0 Stomatitis 14 0 0 Hemorrhage 14 0 0 Hypotension 12 0 1 Rash 11 0 0 Table 12: Selected Laboratory Abnormalities Occurring in >10% of Patients Receiving Gemcitabine with Cisplatin and at Higher Incidence than in Patients Receiving Single Agent Cisplatin [Between Arm Difference of >=5% (All Grades) or >=2% (Grades 3-4)] in Study 3a Grade based on National Cancer Institute CTC. Regardless of causality. N=217-253; all gemcitabine for injection/cisplatin patients with laboratory or non-laboratory data N=213-248; all cisplatin patients with laboratory or non-laboratory data Percent of patients receiving transfusions. Percent transfusions are not CTC-graded events. Laboratory AbnormalitybGemcitabine For Injection/Cisplatinc Cisplatind All Grades(%)Grade 3(%)Grade 4(%)All Grades(%)Grade 3(%)Grade 4(%)Hematologic Anemia 89 22 67 1 Thrombocytopenia 85 25 25 13 1 Neutropenia 79 22 35 20 1 Lymphopenia 75 25 18 51 12 RBC Transfusionse 39 - 13 - Platelet Transfusionse 21 - <1 - Hepatic Increased Transaminases 22 1 10 0 Increased Alkaline Phosphatase 19 0 13 0 Renal Increased Creatinine38 <1 31 <1 Proteinuria 23 0 18 0 Hematuria 15 0 13 0 Other Laboratory Hyperglycemia 30 0 23 0 Hypomagnesemia 30 3 17 0 Hypocalcemia 18 0 0 <1 Tables 13 and 14 present the incidence of selected adverse reactions and laboratory abnormalities occurring in >=10% of gemcitabine for injection-treated patients and at higher incidence in the gemcitabine for injection with cisplatin arm, reported in randomized trial (Study 4) of gemcitabine for injection with cisplatin (n=69) administered in 21-day cycles as compared to etoposide with cisplatin (n=66) in patients receiving first-line treatment for locally advanced or metastatic NSCLC [see Clinical Studies (14.3)]. Additional clinically significant adverse reactions are provided following Table 14. Patients in the gemcitabine for injection/cisplatin (GC) arm received median of cycles and those in the etoposide/cisplatin (EC) arm received median of cycles. The majority of patients receiving more than one cycle of treatment required dose adjustments; 81% in the GC arm and 68% in the EC arm. The incidence of hospitalizations for adverse reactions was 22% in the GC arm and 27% in the EC arm. The proportion of patients who discontinued treatment for adverse reactions was higher in the GC arm (14% versus 8%). The proportion of patients who were hospitalized for febrile neutropenia was lower in the GC arm (7% versus 12%). There was one death attributed to treatment, patient with febrile neutropenia and renal failure, which occurred in the GC arm. Table 13: Selected Adverse Reactions in Patients Receiving Gemcitabine with Cisplatin in Study 4a Grade based on criteria from the WHO. Non-laboratory events were graded only if assessed to be possibly drug-related. Pain data were not collected. N=67-69; all gemcitabine for injection/cisplatin patients with laboratory or non-laboratory data. N=57-63; all Etoposide/cisplatin patients with laboratory or non-laboratory data. Flu-like syndrome and edema were not graded. Adverse ReactionsbGemcitabine For Injection/CisplatincEtoposide/CisplatindAll Grades(%)Grade 3(%)Grade 4(%)All Grades(%)Grade 3(%)Grade 4(%)Nausea and Vomiting 96 35 86 19 Alopecia 77 13 92 51 Paresthesias 38 0 16 0 Infection 28 1 21 0 Stomatitis 20 0 18 0 Diarrhea 14 1 13 2 Edemae 12 - - Rash 10 0 0 Hemorrhage 0 3 3 Fever 0 3 0 Somnolence 0 3 0 Flu-like Syndromee - 0 - Dyspnea 0 3 0 Table 14: Selected Laboratory Abnormalities Occurring in Patients Receiving Gemcitabine with Cisplatin in Study 4a Grade based on criteria from the WHO. Regardless of causality. N=67-69; all gemcitabine for injection/cisplatin patients with laboratory or non-laboratory data. N=57-63; all Etoposide/cisplatin patients with laboratory or non-laboratory data. WHO grading scale not applicable to proportion of patients with transfusions. Laboratory AbnormalitybGemcitabine For Injection/CisplatincEtoposide/CisplatindAll Grades(%)Grade 3(%)Grade 4(%)All Grades(%)Grade 3(%)Grade 4(%)Hematologic Anemia 88 22 77 13 Neutropenia 88 36 28 87 20 56 Thrombocytopenia 81 39 16 45 5 RBC Transfusionsc 29 - 21 - Platelet Transfusionse - 8 - Hepatic Increased Alkaline Phosphatase 16 0 11 0 Increased ALT 0 12 0 Increased AST 0 11 0 Renal Hematuria 22 0 10 0 Proteinuria 12 0 0 Increased BUN 0 4 0 Increased Creatinine 0 2 0 6.2 Postmarketing Experience. The following adverse reactions have been identified during post approval use of gemcitabine for injection. Because these reactions are reported voluntarily from population of uncertain size, it is not always possible to reliably estimate their frequency or establish causal relationship to drug exposure. Blood and lymphatic system disorders: Thrombotic microangiopathy (TMA)Cardiovascular: Congestive heart failure, myocardial infarction, arrhythmias, supraventricular arrhythmias Vascular: Peripheral vasculitis, gangrene, capillary leak syndrome Skin: Cellulitis, pseudocellulitis, severe skin reactions, including desquamation and bullous skin eruptions Hepatic: Hepatic failure, hepatic veno-occlusive disease Pulmonary: Interstitial pneumonitis, pulmonary fibrosis, pulmonary edema, adult respiratory distress syndrome (ARDS) ), pulmonary eosinophilia Nervous System: Posterior reversible encephalopathy syndrome (PRES) Blood and lymphatic system disorders: Thrombotic microangiopathy (TMA). Cardiovascular: Congestive heart failure, myocardial infarction, arrhythmias, supraventricular arrhythmias Vascular: Peripheral vasculitis, gangrene, capillary leak syndrome Skin: Cellulitis, pseudocellulitis, severe skin reactions, including desquamation and bullous skin eruptions Hepatic: Hepatic failure, hepatic veno-occlusive disease Pulmonary: Interstitial pneumonitis, pulmonary fibrosis, pulmonary edema, adult respiratory distress syndrome (ARDS) ), pulmonary eosinophilia Nervous System: Posterior reversible encephalopathy syndrome (PRES).

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.


13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. Long-term animal studies to evaluate the carcinogenic potential of gemcitabine for injection have not been conducted. Gemcitabine was mutagenic in an in vitro mouse lymphoma (L5178Y) assay and was clastogenic in an in vivo mouse micronucleus assay. Gemcitabine intraperitoneal doses of 0.5 mg/kg/day [about 1/700 the 1000 mg/m2 clinical dose based on body surface area (BSA)] in male mice resulted in moderate to severe hypospermatogenesis, decreased fertility, and decreased implantations. In female mice, fertility was not affected but maternal toxicities were observed at 1.5 mg/kg/day administered intravenously (about 1/200 the 1000 mg/m2 clinical dose based on BSA) and fetotoxicity or embryolethality was observed at 0.25 mg/kg/day administered intravenously (about 1/1300 the 1000 mg/m2 clinical dose based on BSA).

CLINICAL PHARMACOLOGY SECTION.


12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. Gemcitabine kills cells undergoing DNA synthesis and blocks the progression of cells through the G1/S-phase boundary. Gemcitabine is metabolized by nucleoside kinases to diphosphate (dFdCDP) and triphosphate (dFdCTP) nucleosides. Gemcitabine diphosphate inhibits ribonucleotide reductase, an enzyme responsible for catalyzing the reactions that generate deoxynucleoside triphosphates for DNA synthesis, resulting in reductions in deoxynucleotide concentrations, including dCTP. Gemcitabine triphosphate competes with dCTP for incorporation into DNA. The reduction in the intracellular concentration of dCTP by the action of the diphosphate enhances the incorporation of gemcitabine triphosphate into DNA (self-potentiation). After the gemcitabine nucleotide is incorporated into DNA, only one additional nucleotide is added to the growing DNA strands, which eventually results in the initiation of apoptotic cell death.. 12.3 Pharmacokinetics. The pharmacokinetics of gemcitabine were examined in 353 patients with various solid tumors. Pharmacokinetic parameters were derived using data from patients treated for varying durations of therapy given weekly with periodic rest weeks and using both short infusions (<70 minutes) and long infusions (70 to 285 minutes). The total gemcitabine for injection dose varied from 500 mg/m2 to 3600 mg/m2.. DistributionThe volume of distribution was increased with infusion length. Volume of distribution of gemcitabine was 50 L/m2 following infusions lasting <70 minutes. For long infusions, the volume of distribution rose to 370 L/m2.Gemcitabine pharmacokinetics are linear and are described by 2-compartment model. Population pharmacokinetic analyses of combined single and multiple dose studies showed that the volume of distribution of gemcitabine was significantly influenced by duration of infusion and sex. Gemcitabine plasma protein binding is negligible.. Elimination. MetabolismThe active metabolite, gemcitabine triphosphate, can be extracted from peripheral blood mononuclear cells. The half-life of the terminal phase for gemcitabine triphosphate from mononuclear cells ranges from 1.7 to 19.4 hours.. ExcretionGemcitabine disposition was studied in patients who received single 1000 mg/m2 of radiolabeled drug as 30-minute infusion. Within one week, 92% to 98% of the dose was recovered, almost entirely in the urine. Gemcitabine (<10%) and the inactive uracil metabolite, 2-deoxy-2,2-difluorouridine (dFdU) accounted for 99% of the excreted dose. The metabolite dFdU is also found in plasma.. Specific Populations. Geriatric PatientsClearance of gemcitabine was affected by age. The lower clearance in geriatric patients results in higher concentrations of gemcitabine for any given dose. Differences in either clearance or volume of distribution based on patient characteristics or the duration of infusion result in changes in half-life and plasma concentrations. Table 15 shows plasma clearance and half-life of gemcitabine following short infusions for typical patients by age and sex. Table 15: Gemcitabine Clearance and Half-Life for the Typical Patient Half-life for patients receiving <70 minute infusion. AgeClearance Men(L/hr/m2)Clearance Women(L/hr/m2)Half-Lifea Men(min)Half-Lifea Women(min)29 92.2 69.4 42 49 45 75.7 57.0 48 57 65 55.1 41.5 61 73 79 40.7 30.7 79 94 Gemcitabine half-life for short infusions ranged from 42 to 94 minutes and for long infusions varied from 245 to 638 minutes, depending on age and sex, reflecting greatly increased volume of distribution with longer infusions. Male and Female PatientsFemales have lower clearance and longer half-lives than male patients as described in Table 15.. Patients with Renal ImpairmentNo clinical studies have been conducted with gemcitabine in patients with decreased renal function.. Patients with Hepatic ImpairmentNo clinical studies have been conducted with gemcitabine in patients with decreased hepatic function.. Drug Interaction StudiesWhen gemcitabine for injection (1250 mg/m2 on Days and 8) and cisplatin (75 mg/m2 on Day 1) were administered in patients with NSCLC, the clearance of gemcitabine on Day was 128 L/hr/m2 and on Day was 107 L/hr/m2. Data from patients with NSCLC demonstrate that gemcitabine for injection and carboplatin given in combination does not alter the pharmacokinetics of gemcitabine or carboplatin compared to administration of either single agent; however, due to wide confidence intervals and small sample size, interpatient variability may be observed.Data from metastatic breast cancer patients shows that gemcitabine for injection has little or no effect on the pharmacokinetics (clearance and half-life) of paclitaxel and paclitaxel has little or no effect on the pharmacokinetics of gemcitabine.

DESCRIPTION SECTION.


11 DESCRIPTION. Gemcitabine is nucleoside metabolic inhibitor. Gemcitabine hydrochloride is 2-deoxy-2,2-difluorocytidine monohydrochloride (-isomer) with the following structural formula: The empirical formula for gemcitabine hydrochloride is C9H11F2N3O4 HCl. It has molecular weight of 299.66 g/mol. Gemcitabine HCl, USP is white to off-white solid. It is soluble in water, slightly soluble in methanol, and practically insoluble in ethanol and polar organic solvents.Gemcitabine for injection, USP is white to off-white lyophilized powder and available as 200 mg and g sterile single-dose vials for intravenous use only. Each 200 mg vial contains 200 mg gemcitabine hydrochloride (expressed as free base), 200 mg mannitol and 20.73 mg of sodium acetate trihydrate (equivalent to 12.5 mg of sodium acetate anhydrous). Each g vial contains g gemcitabine hydrochloride (expressed as free base), g mannitol, and 103.5 mg of sodium acetate trihydrate (equivalent to 62.5 mg of sodium acetate anhydrous). Hydrochloric acid and/or sodium hydroxide may have been added for pH adjustment.. Structural Formula.

DOSAGE & ADMINISTRATION SECTION.


2 DOSAGE AND ADMINISTRATION. Gemcitabine for injection is for intravenous use only. Ovarian Cancer: 1000 mg/m2 over 30 minutes on Days and of each 21-day cycle. (2.1) Breast Cancer: 1250 mg/m2 over 30 minutes on Days and of each 21-day cycle. (2.2) Non-Small Cell Lung Cancer: 1000 mg/m2 over 30 minutes on Days 1, 8, and 15 of each 28-day cycle or 1250 mg/m2 over 30 minutes on Days and of each 21-day cycle. (2.3) Pancreatic Cancer: 1000 mg/m2 over 30 minutes once weekly for the first weeks, then one week rest, then once weekly for weeks of each 28-day cycle. (2.4) Ovarian Cancer: 1000 mg/m2 over 30 minutes on Days and of each 21-day cycle. (2.1) Breast Cancer: 1250 mg/m2 over 30 minutes on Days and of each 21-day cycle. (2.2) Non-Small Cell Lung Cancer: 1000 mg/m2 over 30 minutes on Days 1, 8, and 15 of each 28-day cycle or 1250 mg/m2 over 30 minutes on Days and of each 21-day cycle. (2.3) Pancreatic Cancer: 1000 mg/m2 over 30 minutes once weekly for the first weeks, then one week rest, then once weekly for weeks of each 28-day cycle. (2.4) 2.1 Ovarian Cancer. Recommended Dose and ScheduleThe recommended dosage of gemcitabine for injection is 1000 mg/m2 intravenously over 30 minutes on Days and of each 21-day cycle in combination with carboplatin AUC administered intravenously on Day after gemcitabine for injection administration. Refer to carboplatin prescribing information for additional information.. Dosage ModificationsRecommended gemcitabine for injection dosage modifications for myelosuppression are described in Tables and [see Warnings and Precautions (5.2)]. Refer to the recommended dosage modifications for non-hematologic adverse reactions [see Dosage and Administration (2.5)]. Table 1: Recommended Dosage Modifications for Gemcitabine For Injection for Myelosuppression on Day of Treatment in Ovarian Cancer Treatment DayAbsolute Neutrophil Count(x 106/L)Platelet Count(x 106/L)Dosage ModificationDay 1Greater than or equal to 1500 And Greater than or equal to 100,000 None Less than 1500 Or Less than 100,000 Delay Treatment Cycle Day 8Greater than or equal to 1500 And Greater than or equal to 100,000 None 1000 to 1499 Or 75,000 to 99,999 50% of full dose Less than 1000 Or Less than 75,000 Hold Table 2: Recommended Dosage Modifications for Gemcitabine For Injection for Myelosuppression in Previous Cycle in Ovarian Cancer OccurrenceMyelosuppression During Treatment CycleDosage ModificationInitial OccurrenceAbsolute neutrophil count less than 500 106/L for more than days or Absolute neutrophil count less than 100 106/L for more than days or Febrile neutropenia or Platelets less than 25,000 106/L or Cycle delay for more than one week due to toxicity Permanently reduce gemcitabine for injection to 800 mg/m2 on Days and Subsequent OccurrenceIf any of the above toxicities occur after the initial dose reduction: Permanently reduce gemcitabine for injection to 800 mg/m2 on Day only Absolute neutrophil count less than 500 106/L for more than days or Absolute neutrophil count less than 100 106/L for more than days or Febrile neutropenia or Platelets less than 25,000 106/L or Cycle delay for more than one week due to toxicity 2.2 Breast Cancer. Recommended Dose and ScheduleThe recommended dosage of gemcitabine for injection is 1250 mg/m2 intravenously over 30 minutes on Days and of each 21-day cycle in combination with paclitaxel 175 mg/m2 administered as 3-hour intravenous infusion on Day before gemcitabine for injection administration. Refer to paclitaxel prescribing information for additional information.. Dosage ModificationsRecommended gemcitabine for injection dosage modifications for myelosuppression are described in Table [see Warnings and Precautions (5.2)]. Refer to the recommended dosage modifications for non-hematologic adverse reactions [see Dosage and Administration (2.5)]. Table 3: Recommended Dosage Modifications for Gemcitabine For Injection for Myelosuppression on Day of Treatment in Breast Cancer Treatment DayAbsolute Neutrophil Count(x 106/L)Platelet Count(x 106/L)Dosage ModificationDay 1Greater than or equal to 1500 And Greater than or equal to 100,000 None Less than 1500 Or Less than 100,000 Hold Day 8Greater than or equal to 1200 And Greater than 75,000 None 1000 to 1199 Or 50,000 to 75,000 75% of full dose 700 to 999 And Greater than or equal to 50,000 50% of full dose Less than 700 Or Less than 50,000 Hold 2.3 Non-Small Cell Lung Cancer. Recommended Dose and Schedule. 28-day scheduleThe recommended dosage of gemcitabine for injection is 1000 mg/m2 intravenously over 30 minutes on Days 1, 8, and 15 of each 28-day cycle in combination with cisplatin 100 mg/m2 administered intravenously on Day after gemcitabine for injection administration.. 21-day scheduleThe recommended dosage of gemcitabine for injection is 1250 mg/m2 intravenously over 30 minutes on Days and of each 21-day cycle in combination with cisplatin 100 mg/m2 administered intravenously on Day after gemcitabine for injection administration.Refer to cisplatin prescribing information for additional information.. Dosage ModificationsRecommended dosage modifications for gemcitabine for injection myelosuppression are described in Table [see Warnings and Precautions (5.2)]. Refer to the recommended dosage modifications for non-hematologic adverse reactions [see Dosage and Administration (2.5)].. 2.4 Pancreatic Cancer. Recommended Dose and ScheduleThe recommended dosage of gemcitabine for injection is 1000 mg/m2 intravenously over 30 minutes. The recommended treatment schedule is as follows:Weeks to 8: weekly dosing for the first weeks followed by one week rest.After week 8: weekly dosing on Days 1, 8, and 15 of each 28-day cycle.. Weeks to 8: weekly dosing for the first weeks followed by one week rest.. After week 8: weekly dosing on Days 1, 8, and 15 of each 28-day cycle.. Dosage ModificationsRecommended dosage modifications for gemcitabine for injection for myelosuppression are described in Table [see Warnings and Precautions (5.2)]. Refer to the recommended dosage modifications for non-hematologic adverse reactions [see Dosage and Administration (2.5)]. Table 4: Recommended Dosage Modifications for Gemcitabine For Injection for Myelosuppression in Pancreatic Cancer and Non-Small Cell Lung Cancer Absolute Neutrophil Count(x 106/L)Platelet Count(x 106/L)Dosage ModificationGreater than or equal to 1000 And Greater than or equal to 100,000 None 500 to 999 Or 50,000 to 99,999 75% of full dose Less than 500 Or Less than 50,000 Hold 2.5 Dosage Modifications for Non-Hematologic Adverse Reactions. Permanently discontinue gemcitabine for injection for any of the following:Unexplained dyspnea or evidence of severe pulmonary toxicity [see Warnings and Precautions (5.3)] Hemolytic-uremic syndrome (HUS) or severe renal impairment [see Warnings and Precautions (5.4)] Severe hepatic toxicity [see Warnings and Precautions (5.5)] Capillary leak syndrome (CLS) [see Warnings and Precautions (5.8)] Posterior reversible encephalopathy syndrome (PRES) [see Warnings and Precautions (5.9)] Withhold gemcitabine for injection or reduce dose by 50% for other Grade or non-hematological adverse reactions until resolved. No dose modifications are recommended for alopecia, nausea, or vomiting.. Unexplained dyspnea or evidence of severe pulmonary toxicity [see Warnings and Precautions (5.3)] Hemolytic-uremic syndrome (HUS) or severe renal impairment [see Warnings and Precautions (5.4)] Severe hepatic toxicity [see Warnings and Precautions (5.5)] Capillary leak syndrome (CLS) [see Warnings and Precautions (5.8)] Posterior reversible encephalopathy syndrome (PRES) [see Warnings and Precautions (5.9)] 2.6 Preparation. Gemcitabine for injection vials contain no antimicrobial preservatives and are intended for single use only. Gemcitabine for injection is cytotoxic drug. Follow applicable special handling and disposal procedures.1 Exercise caution and wear gloves when preparing gemcitabine for injection solutions. Immediately wash the skin thoroughly or rinse the mucosa with copious amounts of water if gemcitabine for injection contacts the skin or mucus membranes. Death has occurred in animal studies due to dermal absorption. Reconstitute the 200 mg vial with mL and the g vial with 25 mL of 0.9% Sodium Chloride Injection, USP to yield gemcitabine for injection concentration of 38 mg/mL. Reconstituted gemcitabine for injection is clear, colorless to light straw-colored solution. Visually inspect reconstituted product for particulate matter and discoloration. Discard if particulate matter or discoloration is observed. Withdraw the calculated dose from the vial and discard any unused portion. Prior to administration, dilute the reconstituted solution with 0.9% Sodium Chloride Injection, USP to minimum final concentration of at least 0.1 mg/mL. Store gemcitabine solutions (reconstituted and diluted) at controlled room temperature of 20C to 25C (68F to 77F). Do not refrigerate as crystallization can occur. Discard gemcitabine solutions if not used within 24 hours after reconstitution. No incompatibilities have been observed with infusion bottles or polyvinyl chloride bags and administration sets. Gemcitabine for injection vials contain no antimicrobial preservatives and are intended for single use only. Gemcitabine for injection is cytotoxic drug. Follow applicable special handling and disposal procedures.1 Exercise caution and wear gloves when preparing gemcitabine for injection solutions. Immediately wash the skin thoroughly or rinse the mucosa with copious amounts of water if gemcitabine for injection contacts the skin or mucus membranes. Death has occurred in animal studies due to dermal absorption. Reconstitute the 200 mg vial with mL and the g vial with 25 mL of 0.9% Sodium Chloride Injection, USP to yield gemcitabine for injection concentration of 38 mg/mL. Reconstituted gemcitabine for injection is clear, colorless to light straw-colored solution. Visually inspect reconstituted product for particulate matter and discoloration. Discard if particulate matter or discoloration is observed. Withdraw the calculated dose from the vial and discard any unused portion. Prior to administration, dilute the reconstituted solution with 0.9% Sodium Chloride Injection, USP to minimum final concentration of at least 0.1 mg/mL. Store gemcitabine solutions (reconstituted and diluted) at controlled room temperature of 20C to 25C (68F to 77F). Do not refrigerate as crystallization can occur. Discard gemcitabine solutions if not used within 24 hours after reconstitution. No incompatibilities have been observed with infusion bottles or polyvinyl chloride bags and administration sets.

DOSAGE FORMS & STRENGTHS SECTION.


3 DOSAGE FORMS AND STRENGTHS. For injection: Gemcitabine For Injection USP, 200 mg is white to off-white, lyophilized powder available in sterile single-dose vial containing 200 mg gemcitabine. Gemcitabine For Injection USP, g is white to off-white, lyophilized powder available in sterile single-dose vial containing g gemcitabine.. For injection: 200 mg or gram lyophilized powder in single-dose vials for reconstitution. (3).

FEMALES & MALES OF REPRODUCTIVE POTENTIAL SECTION.


8.3 Females and Males of Reproductive Potential. Pregnancy TestingVerify pregnancy status in females of reproductive potential prior to initiating gemcitabine for injection [see Use in Specific Populations (8.1)].. ContraceptionGemcitabine for injection can cause fetal harm when administered to pregnant woman [see Use in Specific Populations (8.1)]. FemalesBecause of the potential for genotoxicity, advise females of reproductive potential to use effective contraception during treatment with gemcitabine for injection and for months after the final dose of gemcitabine for injection.. MalesBecause of the potential for genotoxicity, advise males with female partners of reproductive potential to use effective contraception during treatment with gemcitabine for injection and for months after the final dose [see Nonclinical Toxicology (13.1)]. Infertility. MalesBased on animal studies, gemcitabine for injection may impair fertility in males of reproductive potential [see Nonclinical Toxicology (13.1)]. It is not known whether these effects on fertility are reversible.

GERIATRIC USE SECTION.


8.5 Geriatric Use. In clinical studies which enrolled 979 patients with various malignancies who received single agent gemcitabine for injection, no overall differences in safety were observed between patients aged 65 and older and younger patients, with the exception of higher rate of Grade 3-4 thrombocytopenia in older patients as compared to younger patients. In randomized trial in women with ovarian cancer (Study 1), 175 women received gemcitabine for injection with carboplatin, of which 29% were age 65 years or older. Similar effectiveness was observed between older and younger women. There was significantly higher Grade 3-4 neutropenia in women 65 years of age or older [see Dosage and Administration (2.1)]. Gemcitabine for injection clearance is affected by age; however, there are no recommended dose adjustments based on patients age [see Clinical Pharmacology (12.3)].

HOW SUPPLIED SECTION.


16 HOW SUPPLIED/STORAGE AND HANDLING. Gemcitabine for injection, USP is white to off-white lyophilized powder available in sterile single-dose vials individually packaged in carton containing 200 mg or g gemcitabine:200 mg vial: NDC 55111-686-071 vial: NDC 55111-687-25 Gemcitabine for injection, USP is cytotoxic drug. Follow applicable special handling and disposal procedures.1 Store at 20C to 25C (68F to 77F) [see USP Controlled Room Temperature].. 200 mg vial: NDC 55111-686-07. g vial: NDC 55111-687-25.

INDICATIONS & USAGE SECTION.


1 INDICATIONS AND USAGE. Gemcitabine for injection is nucleoside metabolic inhibitor indicated: in combination with carboplatin, for the treatment of advanced ovarian cancer that has relapsed at least months after completion of platinum-based therapy. (1.1) in combination with paclitaxel, for first-line treatment of metastatic breast cancer after failure of prior anthracycline-containing adjuvant chemotherapy, unless anthracyclines were clinically contraindicated. (1.2) in combination with cisplatin, for the treatment of non-small cell lung cancer. (1.3) as single agent for the treatment of pancreatic cancer. (1.4) in combination with carboplatin, for the treatment of advanced ovarian cancer that has relapsed at least months after completion of platinum-based therapy. (1.1) in combination with paclitaxel, for first-line treatment of metastatic breast cancer after failure of prior anthracycline-containing adjuvant chemotherapy, unless anthracyclines were clinically contraindicated. (1.2) in combination with cisplatin, for the treatment of non-small cell lung cancer. (1.3) as single agent for the treatment of pancreatic cancer. (1.4) 1.1 Ovarian Cancer. Gemcitabine for injection in combination with carboplatin is indicated for the treatment of patients with advanced ovarian cancer that has relapsed at least months after completion of platinum-based therapy. 1.2 Breast Cancer. Gemcitabine for injection in combination with paclitaxel is indicated for the first-line treatment of patients with metastatic breast cancer after failure of prior anthracycline-containing adjuvant chemotherapy, unless anthracyclines were clinically contraindicated. 1.3 Non-Small Cell Lung Cancer. Gemcitabine for injection in combination with cisplatin is indicated for the first-line treatment of patients with inoperable, locally advanced (Stage IIIA or IIIB) or metastatic (Stage IV) non-small cell lung cancer (NSCLC). 1.4 Pancreatic Cancer. Gemcitabine for injection is indicated as first-line treatment for patients with locally advanced (nonresectable Stage II or Stage III) or metastatic (Stage IV) adenocarcinoma of the pancreas. Gemcitabine for injection is indicated for patients previously treated with fluorouracil.

INFORMATION FOR PATIENTS SECTION.


17 PATIENT COUNSELING INFORMATION. MyelosuppressionAdvise patients of the risks of myelosuppression. Instruct patients to immediately contact their healthcare provider should any signs or symptoms of infection, including fever, or if bleeding or signs of anemia, occur [see Warnings and Precautions (5.2)].. Pulmonary ToxicityAdvise patients of the risks of pulmonary toxicity, including respiratory failure and death. Instruct patients to immediately contact their healthcare provider for development of shortness of breath, wheezing, or cough [see Warnings and Precautions (5.3)].. Hemolytic-Uremic Syndrome and Renal FailureAdvise patients of the risks of hemolytic-uremic syndrome and associated renal failure. Instruct patients to immediately contact their healthcare provider for changes in the color or volume of urine output or for increased bruising or bleeding [see Warnings and Precautions (5.4)].. Hepatic ToxicityAdvise patients of the risks of hepatic toxicity including liver failure and death. Instruct patients to immediately contact their healthcare provider for signs of jaundice or for pain/tenderness in the right upper abdominal quadrant [see Warnings and Precautions (5.5)].. Embryo-Fetal ToxicityAdvise females and males of reproductive potential that gemcitabine for injection can cause fetal harm. Advise females of reproductive potential to use effective contraception during treatment with gemcitabine for injection and for months after the final dose. Advise male patients with female partners of reproductive potential to use effective contraception during treatment with gemcitabine for injection and for months after the final dose [see Warnings and Precaution (5.6), Use in Specific Populations (8.1, 8.3)].. LactationAdvise women not to breastfeed during treatment with gemcitabine for injection and for at least one week after the last dose [see Use in Specific Populations (8.2)].. InfertilityAdvise males of reproductive potential of the potential for reduced fertility with gemcitabine for injection [see Use in Specific Populations (8.3), Nonclinical Toxicology (13.1)]. Rx OnlyManufactured By: Dr. Reddys Laboratories Limited Visakhapatnam-530 046, INDIARevised: 0719.

LACTATION SECTION.


8.2 Lactation. Risk SummaryThere is no information regarding the presence of gemcitabine for injection or its metabolites in human milk, or their effects on the breastfed infant or on milk production. Due to the potential for serious adverse reactions in breastfed infants from gemcitabine for injection, advise women not to breastfeed during treatment with gemcitabine for injection and for at least one week following the last dose.

MECHANISM OF ACTION SECTION.


12.1 Mechanism of Action. Gemcitabine kills cells undergoing DNA synthesis and blocks the progression of cells through the G1/S-phase boundary. Gemcitabine is metabolized by nucleoside kinases to diphosphate (dFdCDP) and triphosphate (dFdCTP) nucleosides. Gemcitabine diphosphate inhibits ribonucleotide reductase, an enzyme responsible for catalyzing the reactions that generate deoxynucleoside triphosphates for DNA synthesis, resulting in reductions in deoxynucleotide concentrations, including dCTP. Gemcitabine triphosphate competes with dCTP for incorporation into DNA. The reduction in the intracellular concentration of dCTP by the action of the diphosphate enhances the incorporation of gemcitabine triphosphate into DNA (self-potentiation). After the gemcitabine nucleotide is incorporated into DNA, only one additional nucleotide is added to the growing DNA strands, which eventually results in the initiation of apoptotic cell death.

NONCLINICAL TOXICOLOGY SECTION.


13 NONCLINICAL TOXICOLOGY. 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. Long-term animal studies to evaluate the carcinogenic potential of gemcitabine for injection have not been conducted. Gemcitabine was mutagenic in an in vitro mouse lymphoma (L5178Y) assay and was clastogenic in an in vivo mouse micronucleus assay. Gemcitabine intraperitoneal doses of 0.5 mg/kg/day [about 1/700 the 1000 mg/m2 clinical dose based on body surface area (BSA)] in male mice resulted in moderate to severe hypospermatogenesis, decreased fertility, and decreased implantations. In female mice, fertility was not affected but maternal toxicities were observed at 1.5 mg/kg/day administered intravenously (about 1/200 the 1000 mg/m2 clinical dose based on BSA) and fetotoxicity or embryolethality was observed at 0.25 mg/kg/day administered intravenously (about 1/1300 the 1000 mg/m2 clinical dose based on BSA).

OVERDOSAGE SECTION.


10 OVERDOSAGE. There is no known antidote for overdoses of gemcitabine. Myelosuppression, paresthesias, and severe rash were the principal toxicities seen when single dose as high as 5700 mg/m2 was administered by intravenous infusion over 30 minutes every weeks to several patients in dose-escalation study. In the event of suspected overdose, monitor with appropriate blood counts and provide supportive therapy, as necessary.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.


PACKAGE CARTON Gemcitabine For Injection 200 mg carton 1ctSterile Single-Dose Vial Discard Unused Portion NDC 55111-686-07Gemcitabine For Injection, USP200 mg/vial Rx only For Intravenous Use Only gemcitabine for injection 200 mg carton 1ct.

PEDIATRIC USE SECTION.


8.4 Pediatric Use. The safety and effectiveness of gemcitabine for injection have not been established in pediatric patients.The safety and pharmacokinetics of gemcitabine were evaluated in trial in pediatric patients with refractory leukemia. The maximum tolerated dose was 10 mg/m2/min for 360 minutes weekly for three weeks followed by one-week rest period.The safety and activity of gemcitabine for injection were evaluated in trial of pediatric patients with relapsed acute lymphoblastic leukemia (22 patients) and acute myelogenous leukemia (10 patients) at dose of 10 mg/m2/min administered over 360 minutes weekly for three weeks followed by one-week rest period. Patients with M1 or M2 bone marrow on Day 28 who did not experience unacceptable toxicity were eligible to receive maximum of one additional four-week course. Toxicities observed included myelosuppression, febrile neutropenia, increased serum transaminases, nausea, and rash/desquamation. No meaningful clinical activity was observed in this trial.

PHARMACOKINETICS SECTION.


12.3 Pharmacokinetics. The pharmacokinetics of gemcitabine were examined in 353 patients with various solid tumors. Pharmacokinetic parameters were derived using data from patients treated for varying durations of therapy given weekly with periodic rest weeks and using both short infusions (<70 minutes) and long infusions (70 to 285 minutes). The total gemcitabine for injection dose varied from 500 mg/m2 to 3600 mg/m2.. DistributionThe volume of distribution was increased with infusion length. Volume of distribution of gemcitabine was 50 L/m2 following infusions lasting <70 minutes. For long infusions, the volume of distribution rose to 370 L/m2.Gemcitabine pharmacokinetics are linear and are described by 2-compartment model. Population pharmacokinetic analyses of combined single and multiple dose studies showed that the volume of distribution of gemcitabine was significantly influenced by duration of infusion and sex. Gemcitabine plasma protein binding is negligible.. Elimination. MetabolismThe active metabolite, gemcitabine triphosphate, can be extracted from peripheral blood mononuclear cells. The half-life of the terminal phase for gemcitabine triphosphate from mononuclear cells ranges from 1.7 to 19.4 hours.. ExcretionGemcitabine disposition was studied in patients who received single 1000 mg/m2 of radiolabeled drug as 30-minute infusion. Within one week, 92% to 98% of the dose was recovered, almost entirely in the urine. Gemcitabine (<10%) and the inactive uracil metabolite, 2-deoxy-2,2-difluorouridine (dFdU) accounted for 99% of the excreted dose. The metabolite dFdU is also found in plasma.. Specific Populations. Geriatric PatientsClearance of gemcitabine was affected by age. The lower clearance in geriatric patients results in higher concentrations of gemcitabine for any given dose. Differences in either clearance or volume of distribution based on patient characteristics or the duration of infusion result in changes in half-life and plasma concentrations. Table 15 shows plasma clearance and half-life of gemcitabine following short infusions for typical patients by age and sex. Table 15: Gemcitabine Clearance and Half-Life for the Typical Patient Half-life for patients receiving <70 minute infusion. AgeClearance Men(L/hr/m2)Clearance Women(L/hr/m2)Half-Lifea Men(min)Half-Lifea Women(min)29 92.2 69.4 42 49 45 75.7 57.0 48 57 65 55.1 41.5 61 73 79 40.7 30.7 79 94 Gemcitabine half-life for short infusions ranged from 42 to 94 minutes and for long infusions varied from 245 to 638 minutes, depending on age and sex, reflecting greatly increased volume of distribution with longer infusions. Male and Female PatientsFemales have lower clearance and longer half-lives than male patients as described in Table 15.. Patients with Renal ImpairmentNo clinical studies have been conducted with gemcitabine in patients with decreased renal function.. Patients with Hepatic ImpairmentNo clinical studies have been conducted with gemcitabine in patients with decreased hepatic function.. Drug Interaction StudiesWhen gemcitabine for injection (1250 mg/m2 on Days and 8) and cisplatin (75 mg/m2 on Day 1) were administered in patients with NSCLC, the clearance of gemcitabine on Day was 128 L/hr/m2 and on Day was 107 L/hr/m2. Data from patients with NSCLC demonstrate that gemcitabine for injection and carboplatin given in combination does not alter the pharmacokinetics of gemcitabine or carboplatin compared to administration of either single agent; however, due to wide confidence intervals and small sample size, interpatient variability may be observed.Data from metastatic breast cancer patients shows that gemcitabine for injection has little or no effect on the pharmacokinetics (clearance and half-life) of paclitaxel and paclitaxel has little or no effect on the pharmacokinetics of gemcitabine.

PREGNANCY SECTION.


8.1 Pregnancy. Risk SummaryBased on animal data and its mechanism of action, gemcitabine for injection can cause fetal harm when administered to pregnant woman [see Clinical Pharmacology (12.1)]. There are no available data on the use of gemcitabine for injection in pregnant women. In animal reproduction studies, gemcitabine was teratogenic, embryotoxic, and fetotoxic in mice and rabbits (see Data). Advise pregnant women of the potential risk to fetus [see Use in Special Populations (8.3)]. In the U.S. general population, the estimated background risk of major birth defects and miscarriages in clinically recognized pregnancies is 2-4% and 15-20% respectively. Data. Animal DataGemcitabine is embryotoxic in mice. Daily dosing of gemcitabine to pregnant mice increased the incidence of fetal malformation (cleft palate, incomplete ossification) at doses of 1.5 mg/kg/day [approximately 0.005 times the 1000 mg/m2 clinical dose based on body surface area (BSA)]. Gemcitabine was embryotoxic and fetotoxic in rabbits. Daily dosing of gemcitabine to pregnant rabbits resulted in fetotoxicity (decreased fetal viability, reduced litter sizes, and developmental delays) and increased the incidence of fetal malformations (fused pulmonary artery, absence of gall bladder) at doses of 0.1 mg/kg/day (approximately 0.002 times the 1000 mg/m2 clinical dose based on BSA).

RECENT MAJOR CHANGES SECTION.


Warnings and Precautions, Hemolytic Uremic Syndrome (5.4) 5/2019.

REFERENCES SECTION.


15 REFERENCES. OSHA Hazardous Drugs. OSHA. http://www.osha.gov/SLTC/hazardousdrugs/index.html OSHA Hazardous Drugs. OSHA. http://www.osha.gov/SLTC/hazardousdrugs/index.html.

SPL UNCLASSIFIED SECTION.


1.1 Ovarian Cancer. Gemcitabine for injection in combination with carboplatin is indicated for the treatment of patients with advanced ovarian cancer that has relapsed at least months after completion of platinum-based therapy.

USE IN SPECIFIC POPULATIONS SECTION.


8 USE IN SPECIFIC POPULATIONS. Lactation: Advise not to breastfeed. (8.2). 8.1 Pregnancy. Risk SummaryBased on animal data and its mechanism of action, gemcitabine for injection can cause fetal harm when administered to pregnant woman [see Clinical Pharmacology (12.1)]. There are no available data on the use of gemcitabine for injection in pregnant women. In animal reproduction studies, gemcitabine was teratogenic, embryotoxic, and fetotoxic in mice and rabbits (see Data). Advise pregnant women of the potential risk to fetus [see Use in Special Populations (8.3)]. In the U.S. general population, the estimated background risk of major birth defects and miscarriages in clinically recognized pregnancies is 2-4% and 15-20% respectively. Data. Animal DataGemcitabine is embryotoxic in mice. Daily dosing of gemcitabine to pregnant mice increased the incidence of fetal malformation (cleft palate, incomplete ossification) at doses of 1.5 mg/kg/day [approximately 0.005 times the 1000 mg/m2 clinical dose based on body surface area (BSA)]. Gemcitabine was embryotoxic and fetotoxic in rabbits. Daily dosing of gemcitabine to pregnant rabbits resulted in fetotoxicity (decreased fetal viability, reduced litter sizes, and developmental delays) and increased the incidence of fetal malformations (fused pulmonary artery, absence of gall bladder) at doses of 0.1 mg/kg/day (approximately 0.002 times the 1000 mg/m2 clinical dose based on BSA).. 8.2 Lactation. Risk SummaryThere is no information regarding the presence of gemcitabine for injection or its metabolites in human milk, or their effects on the breastfed infant or on milk production. Due to the potential for serious adverse reactions in breastfed infants from gemcitabine for injection, advise women not to breastfeed during treatment with gemcitabine for injection and for at least one week following the last dose.. 8.3 Females and Males of Reproductive Potential. Pregnancy TestingVerify pregnancy status in females of reproductive potential prior to initiating gemcitabine for injection [see Use in Specific Populations (8.1)].. ContraceptionGemcitabine for injection can cause fetal harm when administered to pregnant woman [see Use in Specific Populations (8.1)]. FemalesBecause of the potential for genotoxicity, advise females of reproductive potential to use effective contraception during treatment with gemcitabine for injection and for months after the final dose of gemcitabine for injection.. MalesBecause of the potential for genotoxicity, advise males with female partners of reproductive potential to use effective contraception during treatment with gemcitabine for injection and for months after the final dose [see Nonclinical Toxicology (13.1)]. Infertility. MalesBased on animal studies, gemcitabine for injection may impair fertility in males of reproductive potential [see Nonclinical Toxicology (13.1)]. It is not known whether these effects on fertility are reversible.. 8.4 Pediatric Use. The safety and effectiveness of gemcitabine for injection have not been established in pediatric patients.The safety and pharmacokinetics of gemcitabine were evaluated in trial in pediatric patients with refractory leukemia. The maximum tolerated dose was 10 mg/m2/min for 360 minutes weekly for three weeks followed by one-week rest period.The safety and activity of gemcitabine for injection were evaluated in trial of pediatric patients with relapsed acute lymphoblastic leukemia (22 patients) and acute myelogenous leukemia (10 patients) at dose of 10 mg/m2/min administered over 360 minutes weekly for three weeks followed by one-week rest period. Patients with M1 or M2 bone marrow on Day 28 who did not experience unacceptable toxicity were eligible to receive maximum of one additional four-week course. Toxicities observed included myelosuppression, febrile neutropenia, increased serum transaminases, nausea, and rash/desquamation. No meaningful clinical activity was observed in this trial.. 8.5 Geriatric Use. In clinical studies which enrolled 979 patients with various malignancies who received single agent gemcitabine for injection, no overall differences in safety were observed between patients aged 65 and older and younger patients, with the exception of higher rate of Grade 3-4 thrombocytopenia in older patients as compared to younger patients. In randomized trial in women with ovarian cancer (Study 1), 175 women received gemcitabine for injection with carboplatin, of which 29% were age 65 years or older. Similar effectiveness was observed between older and younger women. There was significantly higher Grade 3-4 neutropenia in women 65 years of age or older [see Dosage and Administration (2.1)]. Gemcitabine for injection clearance is affected by age; however, there are no recommended dose adjustments based on patients age [see Clinical Pharmacology (12.3)]. 8.6 Gender. Gemcitabine for injection clearance is decreased in females [see Clinical Pharmacology (12.3)]. In single agent studies of gemcitabine for injection, women, especially older women, were more likely not to proceed to subsequent cycle and to experience Grade 3-4 neutropenia and thrombocytopenia [see Dosage and Administration (2.1, 2.2. 2.3, 2.4)].

WARNINGS AND PRECAUTIONS SECTION.


5 WARNINGS AND PRECAUTIONS. Schedule-Dependent Toxicity: Increased toxicity with infusion time greater than 60 minutes or dosing more frequently than once weekly. (5.1) Myelosuppression: Monitor for myelosuppression prior to each cycle and reduce or withhold dose for severe myelosuppression. (5.2, 5.7) Pulmonary Toxicity and Respiratory Failure: Discontinue gemcitabine for injection for unexplained dyspnea or other evidence of severe pulmonary toxicity. (5.3) Hemolytic-Uremic Syndrome (HUS): Monitor renal function prior to initiation and during treatment. Discontinue gemcitabine for injection for HUS or severe renal impairment. (5.4) Hepatic Toxicity: Monitor hepatic function prior to initiation and during treatment. Discontinue gemcitabine for injection for severe hepatic toxicity. (5.5) Embryo-Fetal Toxicity: Can cause fetal harm. Advise females and males of reproductive potential to use effective contraception. (5.6, 8.1) Exacerbation of Radiation Therapy Toxicity: May cause severe and life-threatening toxicity when administered during or within days of radiation therapy. (5.7) Capillary Leak Syndrome: Discontinue gemcitabine for injection. (5.8) Posterior Reversible Encephalopathy Syndrome (PRES): Discontinue gemcitabine for injection. (5.9) Schedule-Dependent Toxicity: Increased toxicity with infusion time greater than 60 minutes or dosing more frequently than once weekly. (5.1) Myelosuppression: Monitor for myelosuppression prior to each cycle and reduce or withhold dose for severe myelosuppression. (5.2, 5.7) Pulmonary Toxicity and Respiratory Failure: Discontinue gemcitabine for injection for unexplained dyspnea or other evidence of severe pulmonary toxicity. (5.3) Hemolytic-Uremic Syndrome (HUS): Monitor renal function prior to initiation and during treatment. Discontinue gemcitabine for injection for HUS or severe renal impairment. (5.4) Hepatic Toxicity: Monitor hepatic function prior to initiation and during treatment. Discontinue gemcitabine for injection for severe hepatic toxicity. (5.5) Embryo-Fetal Toxicity: Can cause fetal harm. Advise females and males of reproductive potential to use effective contraception. (5.6, 8.1) Exacerbation of Radiation Therapy Toxicity: May cause severe and life-threatening toxicity when administered during or within days of radiation therapy. (5.7) Capillary Leak Syndrome: Discontinue gemcitabine for injection. (5.8) Posterior Reversible Encephalopathy Syndrome (PRES): Discontinue gemcitabine for injection. (5.9) 5.1 Schedule-Dependent Toxicity. In clinical trials evaluating the maximum tolerated dose of gemcitabine for injection, prolongation of the infusion time beyond 60 minutes or more frequent than weekly dosing resulted in an increased incidence of clinically significant hypotension, severe flu-like symptoms, myelosuppression, and asthenia. The half-life of gemcitabine for injection is influenced by the length of the infusion [see Clinical Pharmacology (12.3)]. Refer to the recommended gemcitabine for injection dosage [see Dosage and Administration (2.1, 2.2, 2.3, 2.4)].. 5.2 Myelosuppression. Myelosuppression manifested by neutropenia, thrombocytopenia, and anemia occurs with gemcitabine for injection as single agent and the risks are increased when gemcitabine for injection is combined with other cytotoxic drugs. In clinical trials, Grade 3-4 neutropenia, anemia, and thrombocytopenia occurred in 25%, 8%, and 5%, respectively of the 979 patients who received single agent gemcitabine for injection. The frequencies of Grade 3-4 neutropenia, anemia, and thrombocytopenia varied from 48% to 71%, 8% to 28%, and 5% to 55%, respectively, in patients receiving gemcitabine for injection in combination with another drug [see Adverse Reactions (6.1)].Prior to each dose of gemcitabine for injection, obtain complete blood count (CBC) with differential and platelet count. Modify the dosage as recommended [see Dosage and Administration (2.1, 2.2, 2.3, 2.4)].. 5.3 Pulmonary Toxicity and Respiratory Failure. Pulmonary toxicity, including interstitial pneumonitis, pulmonary fibrosis, pulmonary edema, and adult respiratory distress syndrome (ARDS), has been reported. In some cases, these pulmonary events can lead to fatal respiratory failure despite the discontinuation of therapy. The onset of pulmonary symptoms may occur up to weeks after the last dose of gemcitabine for injection [see Adverse Reactions (6.1, 6.2)].Permanently discontinue gemcitabine for injection in patients who develop unexplained dyspnea, with or without bronchospasm, or evidence of severe pulmonary toxicity.. 5.4 Hemolytic Uremic Syndrome. Hemolytic uremic syndrome (HUS), including fatalities from renal failure or the requirement for dialysis, can occur with gemcitabine for injection. In clinical trials, HUS occurred in 0.25% of 2429 patients. Most fatal cases of renal failure were due to HUS [see Adverse Reactions (6.1)]. Serious cases of thrombotic microangiopathy other than HUS have been reported with gemcitabine for injection [see Adverse Reactions (6.2)]. Assess renal function prior to initiation of gemcitabine for injection and periodically during treatment. Consider the diagnosis of HUS in patients who develop anemia with evidence of microangiopathic hemolysis; increased bilirubin or LDH; reticulocytosis; severe thrombocytopenia; or renal failure (increased serum creatinine or BUN). Permanently discontinue gemcitabine for injection in patients with HUS or severe renal impairment. Renal failure may not be reversible even with the discontinuation of therapy. 5.5 Hepatic Toxicity. Drug-induced liver injury, including liver failure and death, has been reported in patients receiving gemcitabine for injection alone or with other potentially hepatotoxic drugs [see Adverse Reactions (6.1, 6.2)]. Administration of gemcitabine for injection in patients with concurrent liver metastases or pre-existing medical history of hepatitis, alcoholism, or liver cirrhosis can lead to exacerbation of the underlying hepatic insufficiency. Assess hepatic function prior to initiation of gemcitabine for injection and periodically during treatment. Permanently discontinue gemcitabine for injection in patients who develop severe hepatic toxicity. 5.6 Embryo-Fetal Toxicity. Based on animal data and its mechanism of action, gemcitabine for injection can cause fetal harm when administered to pregnant woman. Gemcitabine was teratogenic, embryotoxic, and fetotoxic in mice and rabbits. Advise pregnant women of the potential risk to fetus. Advise females of reproductive potential to use effective contraception during treatment with gemcitabine for injection and for months after the final dose. Advise male patients with female partners of reproductive potential to use effective contraception during treatment with gemcitabine for injection and for months following the final dose [see Use in Specific Populations (8.1, 8.3)]. 5.7 Exacerbation of Radiation Therapy Toxicity. Gemcitabine for injection is not recommended for use in combination with radiation therapy. Concurrent (given together or <=7 days apart)Life-threatening mucositis, especially esophagitis and pneumonitis occurred in trial in which gemcitabine for injection was administered at dose of 1000 mg/m2 to patients with non-small cell lung cancer for up to consecutive weeks concurrently with thoracic radiation.. Non-concurrent (given >7 days apart)Excessive toxicity has not been observed when gemcitabine for injection is administered more than days before or after radiation. Radiation recall has been reported in patients who received gemcitabine for injection after prior radiation. 5.8 Capillary Leak Syndrome. Capillary leak syndrome (CLS) with severe consequences has been reported in patients receiving gemcitabine for injection as single agent or in combination with other chemotherapeutic agents [see Adverse Reactions (6.2)]. Permanently discontinue gemcitabine for injection if CLS develops during therapy.. 5.9 Posterior Reversible Encephalopathy Syndrome. Posterior reversible encephalopathy syndrome (PRES) has been reported in patients receiving gemcitabine for injection as single agent or in combination with other chemotherapeutic agents [see Adverse Reactions (6.2)]. PRES can present with headache, seizure, lethargy, hypertension, confusion, blindness, and other visual and neurologic disturbances. Confirm the diagnosis of PRES with magnetic resonance imaging (MRI). Permanently discontinue gemcitabine for injection if PRES develops during therapy.