WARNINGS
Included as part of the PRECAUTIONS section.
PRECAUTIONS
Myelosuppression
FOLOTYN can cause myelosuppression, manifested by thrombocytopenia, neutropenia, and/or anemia.
Administer vitamin B12 and instruct patients to take folic acid to reduce the risk of treatment-related myelosuppression [see DOSAGE AND ADMINISTRATION].
Monitor complete blood counts and omit and/or reduce the dose based on ANC and platelet count prior to each dose [see DOSAGE AND ADMINISTRATION].
Mucositis
FOLOTYN can cause mucositis [see ADVERSE REACTIONS].
Administer vitamin B12 and instruct patients to take folic acid to reduce the risk of mucositis [see DOSAGE AND ADMINISTRATION]. Monitor for mucositis weekly and omit and/or reduce the dose for grade 2 or higher mucositis [see DOSAGE AND ADMINISTRATION].
Dermatologic Reactions
FOLOTYN can cause severe dermatologic reactions, which may result in death. These dermatologic reactions have been reported in clinical studies (2.1% of 663 patients) and post marketing experience, and have included skin exfoliation, ulceration, and toxic epidermal necrolysis (TEN) [see ADVERSE REACTIONS]. They may be progressive and increase in severity with further treatment and may involve skin and subcutaneous sites of known lymphoma.
Monitor closely for dermatologic reactions. Withhold or discontinue FOLOTYN based on severity [see DOSAGE AND ADMINISTRATION].
Tumor Lysis Syndrome
FOLOTYN can cause tumor lysis syndrome (TLS). Monitor patients who are at increased risk of TLS and treat promptly.
Hepatic Toxicity
FOLOTYN can cause hepatic toxicity and liver function test abnormalities [see ADVERSE REACTIONS]. Persistent liver function test abnormalities may be indicators of hepatic toxicity and require dose modification or discontinuation.
Monitor liver function tests. Omit dose until recovery, adjust or discontinue therapy based on the severity of the hepatic toxicity [see DOSAGE AND ADMINISTRATION].
Risk Of Increased Toxicity With Renal Impairment
Patients with severe renal impairment (eGFR 15 to < 30 mL/min/1.73 m² based on MDRD) may be at greater risk for increased exposure and adverse reactions. Reduce FOLOTYN dosage in patients with severe renal impairment [see DOSAGE AND ADMINISTRATION].
Serious adverse reactions, including TEN and mucositis, were reported in patients with end stage renal disease (ESRD) undergoing dialysis who were administered FOLOTYN. Avoid FOLOTYN in patients with ESRD with or without dialysis. If the potential benefit of administration justifies the potential risk, monitor renal function and reduce the FOLOTYN dose based on adverse reactions [see DOSAGE AND ADMINISTRATION].
Embryo-Fetal Toxicity
Based on findings in animals and its mechanism of action, FOLOTYN can cause fetal harm when administered to a pregnant woman. FOLOTYN was embryotoxic and fetotoxic in rats and rabbits. Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment with FOLOTYN and for 6 months after the last dose. Advise males with female partners of reproductive potential to use effective contraception during treatment with FOLOTYN and for 3 months after the last dose [see Use In Specific Populations].
Patient Counseling Information
Advise the patient to read the FDA-approved patient labeling (PATIENT INFORMATION).
Folic Acid And Vitamin B12 Supplementation
Advise patients treated with FOLOTYN to take folic acid and vitamin B12 to reduce the risk of possible side effects [see DOSAGE AND ADMINISTRATION].
Myelosuppression
Inform patients of the risk of myelosuppression and to immediately contact their healthcare provider should any signs of infection develop, including fever. Inform patients to contact their healthcare provider if bleeding or symptoms of anemiaoccur [see WARNINGS AND PRECAUTIONS].
Mucositis
Inform patients of the signs and symptoms of mucositis. Instruct patients on ways to reduce the risk of its development, and on ways to maintain nutrition and control discomfort from mucositis if it occurs [see WARNINGS AND PRECAUTIONS].
Dermatologic Reactions
Advise patients about the risks for and the signs and symptoms of dermatologic reactions. Instruct patients to immediately notify their healthcare provider if any skin reactions occur [see WARNINGS AND PRECAUTIONS].
Tumor Lysis Syndrome
Inform patients about the risk of and the signs and symptoms of tumor lysis syndrome. Patients should be instructed to notify their healthcare provider if they experience these symptoms [see WARNINGS AND PRECAUTIONS].
Concomitant Medications
Patients should be instructed to inform their healthcare provider if they are taking any concomitant medications including prescription drugs (such as trimethoprim/sulfamethoxazole and probenecid) and nonprescription drugs (such as nonsteroidal anti-inflammatory drugs) [see DRUG INTERACTIONS].
Embryo-Fetal Toxicity
Advise pregnant women and females of reproductive potential of the potential risk to a fetus. Advise females or reproductive potential to inform their healthcare provider of a known or suspected pregnancy [see WARNINGS AND PRECAUTIONS and Use In Specific Populations].
Advise females patients of reproductive potential to use effective contraception during treatment with FOLOTYN and for 6 months after the final dose [see Use In Specific Populations].
Advise males with female partners of reproductive potential to use effective contraception during treatment with FOLOTYN and for at least 3 months after the final dose [see Use In Specific Populations]
Lactation
Advise females women not to breastfeed during treatment with FOLOTYN and for 1 week after the final dose [see Use In Specific Populations].
Nonclinical Toxicology
Carcinogenesis, Mutagenesis, Impairment Of Fertility
Carcinogenesis
Carcinogenicity studies have not been performed with pralatrexate.
Mutagenesis
Pralatrexate did not cause mutations in the Ames test or the Chinese hamster ovary cell chromosome aberration assay. Nevertheless, these tests do not reliably predict genotoxicity for this class of compounds. Pralatrexate did not cause mutations in the mouse micronucleus assay.
Impairment Of Fertility
No fertility studies have been performed.
Use In Specific Populations
Pregnancy
Risk Summary
Based on findings from animal studies and its mechanism of action [see CLINICAL PHARMACOLOGY], FOLOTYN can cause fetal harm when administered to a pregnant woman. There are insufficient data on FOLOTYN use in pregnant women to evaluate for a drug-associated risk. FOLOTYN was embryotoxic and fetotoxic in rats and rabbits when administered during organogenesis at doses about 1.2% (0.012 times) of the clinical dose on a mg/m² basis. Advise pregnant women of the potential risk to a fetus.
The estimated background risk of major birth defects and miscarriage for the indicated population(s) is unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.
Data
Animal Data
Pralatrexate was embryotoxic and fetotoxic in rats at intravenous doses of 0.06 mg/kg/day (0.36 mg/m²/day or about 1.2% of the clinical dose on a mg/m² basis) given on gestation days 7 through 20. Treatment with pralatrexate caused a dose-dependent decrease in fetal viability manifested as an increase in late, early, and total resorptions. There was also a dose-dependent increase in post-implantation loss. In rabbits, intravenous doses of 0.03 mg/kg/day (0.36 mg/m²/day) or greater given on gestation days 8 through 21 also caused abortion and fetal lethality. This toxicity manifested as early and total resorptions, post-implantation loss, and a decrease in the total number of live fetuses.
Lactation
Risk Summary
There is no data on the presence of pralatrexate in human milk or its effects on the breastfed child or milk production. Because of the potential for serious adverse reactions in a breastfed child, advise women not to breastfeed during treatment with FOLOTYN and for 1 week after the last dose.
Females And Males Of Reproductive Potential
FOLOTYN can cause fetal harm when administered to a pregnant woman [see Use In Specific Populations].
Pregnancy Testing
Verify pregnancy status in females of reproductive potential prior to initiation of FOLOTYN.
Contraception
Females
Advise females of reproductive potential to use effective contraception during treatment with FOLOTYN and for 6 months following the last dose.
Males
Advise males with female partners of reproductive potential to use effective contraception during treatment with FOLOTYN and for 3 months following the last dose.
Pediatric Use
The safety and effectiveness of FOLOTYN in pediatric patients have not been established.
Geriatric Use
In the Study PDX-008, 36% of patients (n = 40) were 65 years of age and over. No overall differences in efficacy and safety were observed in patients based on age (< 65 years compared with ≥ 65 years). Due to the contribution of renal excretion to overall clearance of pralatrexate (approximately 34%), age-related decline in renal function may lead to a reduction in clearance and a commensurate increase in plasma exposure. In general, dose selection for an elderly patient should be cautious, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. Since elderly patients may be at higher risk, monitor more closely. Omit dose and subsequently adjust or discontinue therapy for adverse reactions [see DOSAGE AND ADMINISTRATION].
Renal Impairment
No dosage modification is recommended for patients with mild or moderate renal impairment (eGFR 30 to 59 mL/min/1.73 m² based on MDRD). For patients with severe renal impairment (eGFR 15 to 29 mL/min/1.73 m²), reduce the recommended dose of FOLOTYN [see DOSAGE AND ADMINISTRATION].
Serious adverse drug reactions, including TEN and mucositis, have been reported in patients with ESRD undergoing dialysis. Avoid the use of FOLOTYN in patients with ESRD with or without dialysis. If the potential benefit of administration justifies the potential risk, monitor renal function and reduce the FOLOTYN dose based on adverse reactions [see DOSAGE AND ADMINISTRATION, WARNINGS AND PRECAUTIONS].