Cerebyx (Fosphenytoin Sodium)

CEREBYX®

Parke-Davis

Fosphenytoin Sodium

Antiepileptic

Action And Clinical Pharmacology: Introduction: Following parenteral administration of fosphenytoin, fosphenytoin is converted to the anticonvulsant phenytoin. For every mmol of fosphenytoin administered, 1 mmol of phenytoin is produced. The pharmacological and toxicological effects of fosphenytoin include those of phenytoin. However, the hydrolysis of fosphenytoin to phenytoin yields 2 metabolites, phosphate and formaldehyde. Formaldehyde is subsequently converted to formate, which is in turn metabolized via a folate dependent mechanism. Although phosphate and formaldehyde (formate) have potentially important biological effects, these effects typically occur at concentrations considerably in excess of those obtained when fosphenytoin is administered under conditions of use recommended in this labeling.

Mechanism of Action: Fosphenytoin is a prodrug of phenytoin and accordingly, its anticonvulsant effects are attributable to phenytoin.

After i.v. administration to mice, fosphenytoin blocked the tonic phase of maximal electroshock seizures at doses equivalent to those effective for phenytoin. In addition to its ability to suppress maximal electroshock seizures in mice and rats, phenytoin exhibits anticonvulsant activity against kindled seizures in rats, audiogenic seizures in mice, and seizures produced by electrical stimulation of the brainstem in rats. The cellular mechanisms of phenytoin thought to be responsible for its anticonvulsant actions include modulation of voltage-dependent sodium channels of neurons, inhibition of calcium flux across neuronal membranes, modulation of voltage-dependent calcium channels of neurons, and enhancement of the sodium-potassium ATPase activity of neurons and glial cells. The modulation of sodium channels may be a primary anticonvulsant mechanism because this property is shared with several other anticonvulsants in addition to phenytoin.

Pharmacokinetics and Drug Metabolism: Fosphenytoin: Absorption/Bioavailability: I.V.: When fosphenytoin is administered by i.v. infusion, maximum plasma fosphenytoin concentrations are achieved at the end of the infusion. Fosphenytoin has a half-life of approximately 15 minutes.

I.M.: Fosphenytoin is completely bioavailable following i.m. administration of fosphenytoin. Peak concentrations occur at approximately 30 minutes postdose. Plasma fosphenytoin concentrations following i.m. administration are lower but more sustained than those following i.v. administration due to the time required for absorption of fosphenytoin from the injection site.

Distribution: Fosphenytoin is extensively bound (95 to 99%) to human plasma proteins, primarily albumin. Binding to plasma proteins is saturable with the result that the percent bound decreases as total fosphenytoin concentrations increase. Fosphenytoin displaces phenytoin from protein binding sites. The volume of distribution of fosphenytoin increases with fosphenytoin dose and rate, and ranges from 4.3 to 10.8 L.

Metabolism and Elimination: The conversion half-life of fosphenytoin to phenytoin is approximately 15 minutes. The mechanism of fosphenytoin conversion has not been determined, but phosphatases probably play a major role. Fosphenytoin is not excreted in urine. Each mmol of fosphenytoin is metabolized to 1 mmol of phenytoin, phosphate, and formate (see Introduction and Precautions, Phosphate Load for Renally Impaired Patients).

Phenytoin (after Fosphenytoin Administration): In general, i.m. administration of fosphenytoin generates systemic phenytoin concentrations that are similar enough to oral phenytoin sodium to allow essentially interchangeable use.

The pharmacokinetics of fosphenytoin following i.v. administration of fosphenytoin, however, are complex, and when used in an emergency setting (e.g., status epilepticus), differences in rate of availability of phenytoin could be critical. Studies have therefore empirically determined an infusion rate for fosphenytoin that gives a rate and extent of phenytoin systemic availability similar to that of a 50 mg/min phenytoin sodium infusion.

A dose of 15 to 20 mg PE/kg of fosphenytoin infused at 100 to 150 mg PE/min yields plasma free phenytoin concentrations over time that approximate those achieved when an equivalent dose of phenytoin sodium (e.g., parenteral phenytoin sodium) is administered at 50 mg/min (see Dosage and Warnings).

Following administration of single i.v. fosphenytoin doses of 400 to 1 200 mg PE, mean maximum total phenytoin concentrations increase in proportion to dose, but do not change appreciably with changes in infusion rate. In contrast, mean maximum unbound phenytoin concentrations increase with both dose and rate.

Absorption/Bioavailability: Fosphenytoin is completely converted to phenytoin following i.v. administration, with a half-life of approximately 15 minutes. Fosphenytoin is also completely converted to phenytoin following i.m. administration and plasma total phenytoin concentrations peak in approximately 3 hours.

Distribution: Phenytoin is highly bound to plasma proteins, primarily albumin, although to a lesser extent than fosphenytoin. In the absence of fosphenytoin, approximately 12% of total plasma phenytoin is unbound over the clinically relevant concentration range. However, fosphenytoin displaces phenytoin from plasma protein binding sites. This increases the fraction of phenytoin unbound (up to 30% unbound) during the period required for conversion of fosphenytoin to phenytoin (approximately 0.5 to 1 hour postinfusion).

Metabolism and Elimination: Phenytoin derived from administration of fosphenytoin is extensively metabolized in the liver and excreted in urine primarily as 5-(p-hydroxy-phenyl)-5-phenylhydantoin and its glucuronide; little unchanged phenytoin (1 to 5% of the fosphenytoin dose) is recovered in urine. Phenytoin hepatic metabolism is saturable, and following administration of single i.v. fosphenytoin doses of 400 to 1 200 mg PE, total and unbound phenytoin AUC values increase disproportionately with dose. Mean total phenytoin half-life values (12 to 28.9 hours) following fosphenytoin administration at these doses are similar to those after equal doses of parenteral Dilantin and tend to be greater at higher plasma phenytoin concentrations.

Special Populations: Patients with Renal or Hepatic Disease: Due to an increased fraction of unbound phenytoin in patients with renal or hepatic disease, or in those with hypoalbuminemia, the interpretation of total phenytoin plasma concentrations should be made with caution (see Dosage). Unbound phenytoin concentrations may be more useful in these patient populations. After i.v. administration of fosphenytoin to patients with renal and/or hepatic disease, or in those with hypoalbuminemia, fosphenytoin clearance to phenytoin may be increased without a similar increase in phenytoin clearance. This has the potential to increase the frequency and severity of adverse events (see Precautions).

Age: The effect of age was evaluated in patients 5 to 98 years of age. Patient age had no significant impact on fosphenytoin pharmacokinetics. Phenytoin clearance tends to decrease with increasing age (20% less in patients over 70 years of age relative to that in patients 20 to 30 years of age). Phenytoin dosing requirements vary between patients and must be individualized (see Dosage).

Gender and Race: Gender and race have no significant impact on fosphenytoin or phenytoin pharmacokinetics.

Clinical Studies: Infusion tolerance was evaluated in clinical studies. One double-blind study assessed infusion-site tolerance of equivalent loading doses (15 to 20 mg PE/kg) of fosphenytoin infused at 150 mg PE/min or phenytoin infused at 50 mg/min. The study demonstrated better local tolerance (pain and burning at the infusion site), fewer disruptions of the infusion, and a shorter infusion period for fosphenytoin-treated patients (see Table I).

Fosphenytoin-treated patients, however, experienced more systemic sensory disturbances (see Precautions, Sensory Disturbances). Infusion disruptions in fosphenytoin-treated patients were primarily due to systemic burning, pruritus, and/or paresthesia while those in phenytoin-treated patients were primarily due to pain and burning at the infusion site (see Table I).

In a double-blind study investigating temporary substitution of fosphenytoin for oral phenytoin, i.m. fosphenytoin was as well-tolerated as i.m. placebo. I.M. Fosphenytoin resulted in a slight increase in transient, mild to moderate local itching (23% of patients versus 11% of i.m. placebo-treated patients at any time during the study). This study also demonstrated that equimolar doses of i.m. fosphenytoin may be substituted for oral phenytoin sodium with no dosage adjustments needed when initiating i.m. or returning to oral therapy. In contrast, switching between i.m. and oral phenytoin requires dosage adjustments because of slow and erratic phenytoin absorption from muscle.

Indications And Clinical Uses: For short-term parenteral administration when other means of phenytoin administration are unavailable, inappropriate or deemed less advantageous. The safety and effectiveness of fosphenytoin in this use has not been systematically evaluated for more than 5 days.

Fosphenytoin can be used for the control of generalized convulsive status epilepticus and prevention and treatment of seizures occurring during neurosurgery. It can also be substituted, short-term, for oral phenytoin.

Contra-Indications: Patients who have demonstrated hypersensitivity to fosphenytoin or its ingredients, or phenytoin or other hydantoins.

Because of the effect of parenteral phenytoin on ventricular automaticity, fosphenytoin is contraindicated in patients with sinus bradycardia, sino-atrial block, second-and third-degree AV block, and Adams-Stokes syndrome.

Manufacturers’ Warnings In Clinical States: Doses of fosphenytoin are expressed as their phenytoin sodium equivalents in this monograph (PE=phenytoin sodium equivalent).

Do not, therefore, make any adjustment in the recommended doses when substituting fosphenytoin for phenytoin sodium or vice versa.

The following warnings are based on experience with fosphenytoin or phenytoin.

Status Epilepticus Dosing Regimen: Do not administer fosphenytoin at a rate greater than 150 mg PE/min.

The dose of i.v. fosphenytoin (15 to 20 mg PE/kg) that is used to treat status epilepticus is administered at a maximum rate of 150 mg PE/min. The typical fosphenytoin infusion administered to a 50 kg patient would take between 5 and 7 minutes. Note that the delivery of an identical molar dose of phenytoin using parenteral Dilantin or generic phenytoin sodium injection cannot be accomplished in less than 15 to 20 minutes because of the untoward cardiovascular effects that accompany the direct i.v. administration of phenytoin at rates greater than 50 mg/min. If rapid phenytoin loading is a primary goal, i.v. administration of fosphenytoin is preferred because the time to achieve therapeutic plasma phenytoin concentrations is greater following i.m. than that following i.v. administration (see Dosage).

Withdrawal Precipitated Seizure, Status Epilepticus: Antiepileptic drugs should not be abruptly discontinued because of the possibility of increased seizure frequency, including status epilepticus. When, in the judgment of the clinician, the need for dosage reduction, discontinuation, or substitution of alternative antiepileptic medication arises, this should be done gradually. However, in the event of an allergic or hypersensitivity reaction, rapid substitution of alternative therapy may be necessary. In this case, alternative therapy should be an antiepileptic drug not belonging to the hydantoin chemical class.

Cardiovascular Depression: Hypotension may occur, especially after i.v. administration at high doses and high rates of administration. Following administration of phenytoin, severe cardiovascular reactions and fatalities have been reported with atrial and ventricular conduction depression and ventricular fibrillation. Severe complications are most commonly encountered in elderly or gravely ill patients. Therefore, careful cardiac monitoring is needed when administering i.v. loading doses of fosphenytoin. Reduction in rate of administration or discontinuation of dosing may be needed.

Fosphenytoin should be used with caution in patients with hypotension and severe myocardial insufficiency.

Rash: Fosphenytoin should be discontinued if a skin rash appears. If the rash is exfoliative, purpuric, or bullous, or if lupus erythematosus, Stevens-Johnson syndrome, or toxic epidermal necrolysis is suspected, use of this drug should not be resumed and alternative therapy should be considered. If the rash is of a milder type (measles-like or scarlatiniform), therapy may be resumed after the rash has completely disappeared. If the rash recurs upon reinstitution of therapy, further fosphenytoin or phenytoin administration is contraindicated.

Hepatic Injury: Cases of acute hepatotoxicity, including infrequent cases of acute hepatic failure, have been reported with phenytoin. These incidents have been associated with a hypersensitivity syndrome characterized by fever, skin eruptions, and lymphadenopathy, and usually occur within the first 2 months of treatment. Other common manifestations include jaundice, hepatomegaly, elevated serum transaminase levels, leukocytosis, and eosinophilia. The clinical course of acute phenytoin hepatotoxicity ranges from prompt recovery to fatal outcomes. In patients with acute hepatotoxicity, fosphenytoin should be immediately discontinued and not readministered.

Hemopoietic System: Hemopoietic complications, some fatal, have occasionally been reported in association with administration of phenytoin. These have included thrombocytopenia, leukopenia, granulocytopenia, agranulocytosis, and pancytopenia with or without bone marrow suppression.

There have been a number of reports that have suggested a relationship between phenytoin and the development of lymphadenopathy (local or generalized), including benign lymph node hyperplasia, pseudolymphoma, lymphoma, and Hodgkin’s disease. Although a cause and effect relationship has not been established, the occurrence of lymphadenopathy indicates the need to differentiate such a condition from other types of lymph node pathology. Lymph node involvement may occur with or without symptoms and signs resembling serum sickness, e.g., fever, rash, and liver involvement. In all cases of lymphadenopathy, follow-up observation for an extended period is indicated and every effort should be made to achieve seizure control using alternative antiepileptic drugs.

Alcohol Use: Acute alcohol intake may increase plasma phenytoin concentrations while chronic alcohol use may decrease plasma concentrations.

Pregnancy : Clinical: Risks to Mother: An increase in seizure frequency may occur during pregnancy because of altered phenytoin pharmacokinetics. Periodic measurement of plasma phenytoin concentrations may be valuable in the management of pregnant women as a guide to appropriate adjustment of dosage (see Precautions, Laboratory Tests). However, postpartum restoration of the original dosage will probably be indicated.

Risks to the Fetus: If this drug is used during pregnancy, or if the patient becomes pregnant while taking the drug, the patient should be apprised of the potential harm to the fetus.

Prenatal exposure to phenytoin may increase the risks for congenital malformations and other adverse developmental outcomes. Increased frequencies of major malformations (such as orofacial clefts and cardiac defects), minor anomalies (dysmorphic facial features, nail and digit hypoplasia), growth abnormalities (including microcephaly), and mental deficiency have been reported among children born to epileptic women who took phenytoin alone or in combination with other antiepileptic drugs during pregnancy. There have also been several reported cases of malignancies, including neuroblastoma, in children whose mothers received phenytoin during pregnancy. The overall incidence of malformations for children of epileptic women treated with antiepileptic drugs (phenytoin and/or others) during pregnancy is about 10%, or 2- to 3-fold that in the general population. However, the relative contribution of antiepileptic drugs and other factors associated with epilepsy to this increased risk are uncertain and in most cases it has not been possible to attribute specific developmental abnormalities to particular antiepileptic drugs.

Patients should consult with their physicians to weigh the risks and benefits of phenytoin during pregnancy and to select the regimen which would provide the least risk to mother and fetus.

Postpartum Period: A potentially life-threatening bleeding disorder related to decreased levels of vitamin K-dependent clotting factors may occur in newborns exposed to phenytoin in utero. This drug-induced condition can be prevented with vitamin K administration to the mother before delivery and to the neonate after birth.

Precautions: General (Fosphenytoin Specific): Sensory Disturbances: Severe burning, itching, and/or paresthesia were reported by 7 of 16 normal volunteers administered i.v. fosphenytoin at a dose of 1 200 mg PE at the maximum rate of administration (150 mg PE/min). The severe sensory disturbance lasted from 3 to 50 minutes in 6 of these subjects and for 14 hours in the seventh subject. In some cases, milder sensory disturbances persisted for as long as 24 hours. The location of the discomfort varied among subjects with the groin mentioned most frequently as an area of discomfort. In a separate cohort of 16 normal volunteers (taken from 2 other studies) who were administered i.v. fosphenytoin at a dose of 1 200 mg PE at the maximum rate of administration (150 mg PE/min), none experienced severe disturbances, but most experienced mild to moderate itching or tingling.

Patients administered fosphenytoin at doses of 20 mg PE/kg at 150 mg PE/min are expected to experience discomfort of some degree. The occurrence and intensity of the discomfort can be lessened by slowing or temporarily stopping the infusion.

The effect of continuing infusion unaltered in the presence of these sensations is unknown. No permanent sequelae have been reported thus far. The pharmacologic basis for these positive sensory phenomena is unknown, but other phosphate ester drugs, which deliver smaller phosphate loads, have been associated with burning, itching, and/or tingling predominantly in the groin area.

Phosphate Load: The phosphate load provided by fosphenytoin (0.0037 mmol phosphate/mg PE fosphenytoin) should be considered when treating patients who require phosphate restriction, such as those with severe renal impairment.

I.V. Loading in Renal and/or Hepatic Disease or in Those With Hypoalbuminemia: After i.v. administration to patients with renal and/or hepatic disease, or in those with hypoalbuminemia, fosphenytoin clearance to phenytoin may be increased without a similar increase in phenytoin clearance. This has the potential to increase the frequency and severity of adverse events (see Pharmacology, Special Populations and Dosage, Dosing in Special Populations).

General (Phenytoin Associated): Fosphenytoin is not indicated for the treatment of absence seizures.

A small percentage of individuals who have been treated with phenytoin have been shown to metabolize the drug slowly. Slow metabolism may be due to limited enzyme availability and lack of induction; it appears to be genetically determined.

Phenytoin and other hydantoins are contraindicated in patients who have experienced phenytoin hypersensitivity. Additionally, caution should be exercised if using structurally similar (e.g., barbiturates, succinimides, oxazolidinediones, and other related compounds) in these same patients.

Phenytoin has been infrequently associated with the exacerbation of porphyria. Caution should be exercised when fosphenytoin is used in patients with this disease.

Hyperglycemia, resulting from phenytoin’s inhibitory effect on insulin release, has been reported. Phenytoin may also raise serum glucose concentrations in diabetic patients. Plasma concentrations of phenytoin sustained above the optimal range may produce confusional states referred to as “delirium”, “psychosis”, or “encephalopathy”, or rarely, irreversible cerebellar dysfunction. Accordingly, at the first sign of acute toxicity, determination of plasma phenytoin concentrations is recommended (see Precautions, Laboratory Tests). Fosphenytoin dose reduction is indicated if phenytoin concentrations are excessive; if symptoms persist, administration of fosphenytoin should be discontinued.

The liver is the primary site of biotransformation of phenytoin; patients with impaired liver function, elderly patients, or those who are gravely ill may show early signs of toxicity. Phenytoin and other hydantoins are not indicated for seizures due to hypoglycemic or other metabolic causes. Appropriate diagnostic procedures should be performed as indicated.

Phenytoin has the potential to lower serum folate levels.

Laboratory Tests: Phenytoin doses are usually selected to attain therapeutic plasma total phenytoin concentrations of 40 to 80 µmol/L (10 to 20 µg/mL), (unbound phenytoin concentrations of 4 to 8 µmol/L (1 to 2 µg/mL)). Following fosphenytoin administration, it is recommended that phenytoin concentrations not be monitored until conversion to phenytoin is essentially complete. This occurs within approximately 2 hours after the end of i.v. infusion and 4 hours after i.m. injection.

Prior to complete conversion, commonly used immunoanalytical techniques, such as TDx/TDxFLx (fluorescence polarization) and Emit 2 000 (enzyme multiplied), may significantly overestimate plasma phenytoin concentrations because of cross-reactivity with fosphenytoin. The TDx/TDxFLx assay is not recommended while unconverted fosphenytoin is present in plasma, due to an unacceptable margin of error (overestimation) in the phenytoin measurement. The difference between predicted and actual phenytoin concentrations at 4 hours postdose is £20 µmol/L (5 µg/mL). The error is dependent on plasma phenytoin and fosphenytoin concentration (influenced by fosphenytoin dose, route and rate of administration, and time of sampling relative to dosing), and analytical method. Chromatographic assay methods accurately quantitate phenytoin concentrations in biological fluids in the presence of fosphenytoin. Prior to complete conversion, blood samples for phenytoin monitoring should be collected in tubes containing EDTA as an anticoagulant to minimize ex vivo conversion of fosphenytoin to phenytoin. However, even with specific assay methods, phenytoin concentrations measured before conversion of fosphenytoin is complete will not reflect phenytoin concentrations ultimately achieved.

Drug Interactions: No drugs are known to interfere with the conversion of fosphenytoin to phenytoin. Conversion could be affected by alterations in the level of phosphatase activity, but given the abundance and wide distribution of phosphatases in the body it is unlikely that drugs would affect this activity enough to affect conversion of fosphenytoin to phenytoin. Drugs highly bound to albumin could increase the unbound fraction of fosphenytoin. Although, it is unknown whether this could result in clinically significant effects, caution is advised when administering fosphenytoin with other drugs that significantly bind to serum albumin.

The most significant drug interactions following administration of fosphenytoin are expected to occur with drugs that interact with phenytoin. Phenytoin is extensively bound to plasma proteins and is prone to competitive displacement. Phenytoin is metabolized by hepatic cytochrome P450 enzymes and is particularly susceptible to inhibitory drug interactions because it is subject to saturable metabolism. Inhibition of metabolism may produce significant increases in circulating phenytoin concentrations and enhance the risk of drug toxicity. Phenytoin is a potent inducer of hepatic drug-metabolizing enzymes.

The most commonly occurring drug interactions are listed below.

Drugs that may increase plasma phenytoin concentrations include: acute alcohol intake, amiodarone, chloramphenicol, chlordiazepoxide, cimetidine, diazepam, dicumarol, disulfiram, estrogens, ethosuximide, fluoxetine, H2-antagonists, halothane, isoniazid, methylphenidate, phenothiazines, phenylbutazone, salicylates, succinimides, sulfonamides, tolbutamide, trazodone.

Drugs that may decrease plasma phenytoin concentrations include: carbamazepine, chronic alcohol abuse, reserpine, vigabatrin.

Drugs that may either increase or decrease plasma phenytoin concentrations include: phenobarbital, valproic acid, and sodium valproate. Similarly, the effects of phenytoin on phenobarbital, valproic acid and sodium plasma valproate concentrations are unpredictable.

Although not a true drug interaction, tricyclic antidepressants may precipitate seizures in susceptible patients and fosphenytoin dosage may need to be adjusted.

Drugs whose efficacy is impaired by phenytoin include: anticoagulants, corticosteroids, coumarin, digitoxin, doxycycline, estrogens, furosemide, oral contraceptives, rifampin, quinidine, theophylline, vitamin D.

Coadministration of phenytoin with lamotrigine doubles the plasma clearance and reduces the elimination half-life of lamotrigine by 50%. This clinically important interaction requires dosage adjustment.

Monitoring of plasma phenytoin concentrations may be helpful when possible drug interactions are suspected (see Laboratory Tests).

Drug/Laboratory Test Interactions : Phenytoin may decrease serum concentrations of T4. It may also produce artifactually low results in dexamethasone or metyrapone tests. Phenytoin may cause increased serum concentrations of glucose, alkaline phosphatase, and gamma glutamyl transpeptidase (GGT).

Care should be taken when using immunoanalytical methods to measure plasma phenytoin concentrations following fosphenytoin administration (see Laboratory Tests).

Lactation: It is not known whether fosphenytoin is excreted in human milk.

Following administration of Dilantin, phenytoin appears to be excreted in low concentrations in human milk. Therefore, breast-feeding is not recommended for women receiving fosphenytoin.

Children: The safety of fosphenytoin in pediatric patients has not been established. Only limited pharmacokinetic data are available in children (N=8; age 5 to 10 years). In these patients with status epilepticus who received loading doses of fosphenytoin, the plasma fosphenytoin, total phenytoin, and unbound phenytoin concentration-time profiles did not signal any major differences from those in adult patients with status epilepticus receiving comparable doses.

Geriatrics: No systematic studies in geriatric patients have been conducted. Phenytoin clearance tends to decrease with increasing age (see Pharmacology, Special Populations).

Adverse Reactions: The more important adverse clinical events caused by the i.v. use of fosphenytoin or phenytoin are cardiovascular collapse and/or CNS depression. Hypotension can occur when either drug is administered rapidly by the i.v. route. The rate of administration is very important; for fosphenytoin, it should not exceed 150 mg PE/min.

The adverse clinical events most commonly observed with the use of fosphenytoin in clinical trials were nystagmus, dizziness, pruritus, paresthesia, headache, somnolence, and ataxia. With 2 exceptions, these events are commonly associated with the administration of i.v phenytoin. Paresthesia and pruritus, however, were seen much more often following fosphenytoin administration and occurred more often with i.v. fosphenytoin administration than with i.m fosphenytoin administration. These events were dose and rate related; most alert patients (41 of 64; 64%) administered doses of ³15 mg PE/kg at 150 mg PE/min experienced discomfort of some degree. These sensations, generally described as itching, burning, or tingling, were usually not at the infusion site. The location of the discomfort varied with the groin mentioned most frequently as a site of involvement. The paresthesia and pruritus were transient events that occurred within several minutes of the start of infusion and generally resolved within 10 minutes after completion of fosphenytoin infusion. Some patients experienced symptoms for hours. These events did not increase in severity with repeated administration. Concurrent adverse events or clinical laboratory change suggesting an allergic process were not seen (see Precautions, Sensory Disturbances).

Approximately 2% of the 859 individuals who received fosphenytoin in premarketing clinical trials discontinued treatment because of an adverse event. The adverse events most commonly associated with withdrawal were pruritus (0.5%), hypotension (0.3%), and bradycardia (0.2%).

Dose and Rate Dependency of Adverse Events Following I.V. Fosphenytoin: The incidence of adverse events tended to increase as both dose and infusion rate increased. In particular, at doses of ³15 mg PE/kg and rates ³150 mg PE/min, transient pruritus, tinnitus, nystagmus, somnolence, and ataxia occurred 2 to 3 times more often than at lower doses or rates.

Incidence in Controlled Clinical Trials: All adverse events were recorded during the trials by the clinical investigators using terminology of their own choosing. Similar types of events were grouped into standardized categories using modified fosphenytoin dictionary terminology. These categories are used in the tables and listings below with the frequencies representing the proportion of individuals exposed to fosphenytoin or comparative therapy. The prescriber should be aware that these figures cannot be used to predict the frequency of adverse events in the course of usual medical practice where patient characteristics and other factors may differ from those prevailing during clinical studies. Similarly, the cited frequencies cannot be directly compared with figures obtained from other clinical investigations involving different treatments, uses or investigators. An inspection of these frequencies, however, does provide the prescribing physician with one basis to estimate the relative contribution of drug and nondrug factors to the adverse event incidences in the population studied.

Incidence in Controlled Clinical Trials – I.V. Administration To Patients With Epilepsy or Neurosurgical Patients: Table II lists treatment-emergent adverse events that occurred in at least 2% of patients treated with i.v. fosphenytoin at the maximum dose and rate in a randomized, double-blind, controlled clinical trial where the rates for phenytoin and fosphenytoin administration would have resulted in equivalent systemic exposure to phenytoin.

Incidence in Controlled Trials – I.M. Administration to Patients With Epilepsy: Table III lists treatment-emergent adverse events that occurred in at least 2% of fosphenytoin-treated patients in a double-blind, randomized, controlled clinical trial of adult epilepsy patients receiving either i.m. fosphenytoin substituted for oral Dilantin or continuing oral Dilantin. Both treatments were administered for 5 days.

Adverse Events During All Clinical Trials: Fosphenytoin has been administered to 859 individuals during all clinical trials. All adverse events seen at least twice are listed in the following, except those already included in previous tables and listings. Events are further classified within body system categories and enumerated in order of decreasing frequency using the following definitions: frequent adverse events are defined as those occurring in greater than 1/100 individuals; infrequent adverse events are those occurring in 1/100 to 1/1 000 individuals.

Body As a Whole: Frequent: fever, injection-site reaction, infection, chills, face edema, injection-site pain. Infrequent: sepsis, injection-site inflammation, injection-site edema, injection-site hemorrhage, flu syndrome, malaise, generalized edema, shock, photosensitivity reaction, cachexia, cryptococcosis.

Cardiovascular: Frequent: hypertension. Infrequent: cardiac arrest, migraine, syncope, cerebral hemorrhage, palpitation, sinus bradycardia, atrial flutter, bundle branch block, cardiomegaly, cerebral infarct, postural hypotension, pulmonary embolus, QT interval prolongation, thrombophlebitis, ventricular extrasystoles, congestive heart failure.

Digestive: Frequent: constipation. Infrequent: dyspepsia, diarrhea, anorexia, gastrointestinal hemorrhage, increased salivation, liver function tests abnormal, tenesmus, tongue edema, dysphagia, flatulence, gastritis, ileus.

Endocrine: Infrequent: diabetes insipidus.

Hematologic and Lymphatic: Infrequent: thrombocytopenia, anemia, leukocytosis, cyanosis, hypochromic anemia, leukopenia, lymphadenopathy, petechia.

Metabolic and Nutritional: Frequent: hypokalemia. Infrequent: hyperglycemia, hypophosphatemia, alkalosis, acidosis, dehydration, hyperkalemia, ketosis.

Musculoskeletal: Frequent: myasthenia. Infrequent: myopathy, leg cramps, arthralgia, myalgia.

Nervous: Frequent: reflexes increased, speech disorder, dysarthria, intracranial hypertension, thinking abnormal, nervousness, hypaesthesia. Infrequent: confusion, twitching, Babinski sign positive, circumoral paresthesia, hemiplegia, hypotonia, convulsion, extrapyramidal syndrome, insomnia, meningitis, depersonalization, CNS depression, depression, hypokinesia, hyperkinesia, brain edema, paralysis, psychosis, aphasia, emotional lability, coma, hyperesthesia, myoclonus, personality disorder, acute brain syndrome, encephalitis, subdural hematoma, encephalopathy, hostility, akathisia, amnesia, neurosis.

Respiratory: Frequent: pneumonia. Infrequent: pharyngitis, sinusitis, hyperventilation, rhinitis, apnea, aspiration pneumonia, asthma, dyspnea, atelectasis, cough increased, sputum increased, epistaxis, hypoxia, pneumothorax, hemoptysis, bronchitis.

Skin and Appendages: Frequent: rash. Infrequent: maculopapular rash, urticaria, sweating, skin discoloration, contact dermatitis, pustular rash, skin nodule.

Special Senses: Frequent: taste perversion. Infrequent: deafness, visual field defect, eye pain, conjunctivitis, photophobia, hyperacusis, mydriasis, parosmia, ear pain, taste loss.

Urogenital: Infrequent: urinary retention, oliguria, dysuria, vaginitis, albuminuria, genital edema, kidney failure, polyuria, urethral pain, urinary incontinence, vaginal moniliasis.

Symptoms And Treatment Of Overdose: There is no experience with fosphenytoin overdosage in humans. The median lethal dose of fosphenytoin given i.v. in mice and rats was 156 mg PE/kg and approximately 250 mg PE/kg, or about 0.6 and 2 times, respectively, the maximum human loading dose on a mg/mbasis. Signs of acute toxicity in animals included ataxia, labored breathing, ptosis, and hypoactivity.Symptoms: Because fosphenytoin is a prodrug of phenytoin, the following information may be helpful. Initial symptoms of acute phenytoin toxicity are nystagmus, ataxia and dysarthria. Other signs include tremor, hyperreflexia, lethargy, slurred speech, nausea, vomiting, coma and hypotension. Depression of respiratory and circulatory systems leads to death. There are marked variations among individuals with respect to plasma phenytoin concentrations where toxicity occurs. Lateral gaze nystagmus usually appears at 80 µmol/L (20 µg/mL), ataxia at 119 µmol/L (30 µg/mL), and dysarthria and lethargy appear when the plasma concentration is over 159 µmol/L (40 µg/mL). However, phenytoin concentrations as high as 198 µmol/L (50 µg/mL) have been reported without evidence of toxicity. As much as 25 times the therapeutic phenytoin dose has been taken, resulting in plasma phenytoin concentrations over 396 µmol/L (100 µg/mL), with complete recovery.

Treatment: Treatment is nonspecific since there is no known antidote to fosphenytoin or phenytoin overdosage. The adequacy of the respiratory and circulatory systems should be carefully observed, and appropriate supportive measures employed. Hemodialysis can be considered since phenytoin is not completely bound to plasma proteins. Total exchange transfusion has been used in the treatment of severe intoxication in children. In acute overdosage the possibility of other CNS depressants, including alcohol, should be borne in mind.

Formate and phosphate are metabolites of fosphenytoin and therefore may contribute to signs of toxicity following overdosage. Signs of formate toxicity are similar to those of methanol toxicity and are associated with severe anion-gap metabolic acidosis. Large amounts of phosphate, delivered rapidly, could potentially cause hypocalcemia with paresthesia, muscle spasms, and seizures. Ionized free calcium levels can be measured and, if low, used to guide treatment.

Dosage And Administration: The dose, concentration in dosing solutions, and infusion rate of i.v. fosphenytoin is expressed as phenytoin sodium equivalents (PE) to avoid the need to perform molecular weight-based adjustments when converting between fosphenytoin and phenytoin sodium doses. Fosphenytoin should always be prescribed and dispensed in phenytoin sodium equivalent units (PE). Fosphenytoin has important differences in administration from those for parenteral phenytoin sodium (see below).

Phenytoin doses are usually selected to attain therapeutic plasma total phenytoin concentrations of 40 to 80 µmol/L (10 to 20 µg/mL), (unbound phenytoin concentrations of 4 to 8 µmol/L (1 to 2 µg/mL)). Following fosphenytoin administration, it is recommended that phenytoin concentrations not be monitored until conversion to phenytoin is essentially complete. This occurs within approximately 2 hours after the end of i.v. infusion and 4 hours after i.m. injection.

Prior to complete conversion, commonly used immunoanalytical techniques, such as TDx/TDxFLx (fluorescence polarization) and Emit 2 000 (enzyme multiplied), may significantly overestimate plasma phenytoin concentrations because of cross-reactivity with fosphenytoin. The TDx/TDxFLx assay is not recommended due to an unacceptable margin of error. The difference between predicted and actual phenytoin concentrations at 4 hours postdose is £20 µmol/L (5 µg/mL). The error is dependent on plasma phenytoin and fosphenytoin concentration (influenced by fosphenytoin dose, route and rate of administration, and time of sampling relative to dosing), and analytical method. Chromatographic assay methods accurately quantitate phenytoin concentrations in biological fluids in the presence of fosphenytoin. Prior to complete conversion, blood samples for phenytoin monitoring should be collected in tubes containing EDTA as an anticoagulant to minimize ex vivo conversion of fosphenytoin to phenytoin. However, even with specific assay methods, phenytoin concentrations measured before conversion of fosphenytoin is complete will not reflect phenytoin concentrations ultimately achieved. Products with particulate matter or discoloration should not be used. Prior to i.v infusion, dilute fosphenytoin in 5% dextrose or 0.9% saline solution for injection to a concentration ranging from 1.5 to 25 mg PE/mL.

Status Epilepticus: The loading dose of fosphenytoin is 15 to 20 mg PE/kg administered at 100 to 150 mg PE/min.

Because of the risk of hypotension, fosphenytoin should be administered no faster than 150 mg PE/min. Continuous monitoring of the ECG, blood pressure, and respiratory function is essential and the patient should be observed throughout the period where maximal serum phenytoin concentrations occur, approximately 10 to 20 minutes after the end of fosphenytoin infusions.

Because the full antiepileptic effect of phenytoin, whether given as fosphenytoin or parenteral phenytoin, is not immediate, other measures, including concomitant administration of an i.v. benzodiazepine, will usually be necessary for the control of status epilepticus.

The loading dose should be followed by maintenance doses of fosphenytoin, or phenytoin, either orally or parenterally.

If administration of fosphenytoin does not terminate seizures, the use of other anticonvulsants and other appropriate measures should be considered.

I.M. fosphenytoin should not be used in the treatment of status epilepticus because therapeutic phenytoin concentrations may not be reached as quickly as with i.v. administration. If i.v. access is impossible, loading doses of fosphenytoin have been given by the i.m. route for other indications.

Nonemergent Loading and Maintenance Dosing: The loading dose of fosphenytoin is 10 to 20 mg PE/kg given i.v. or i.m. The rate of administration for i.v fosphenytoin should be no greater than 150 mg PE/min. Continuous monitoring of the ECG, blood pressure, and respiratory function is essential and the patient should be observed throughout the period where maximal serum phenytoin concentrations occur, approximately 10 to 20 minutes after the end of fosphenytoin infusions.

The initial daily maintenance dose of fosphenytoin is 4 to 6 mg PE/kg/day.

I.M. or I.V. Substitution For Oral Phenytoin Therapy: Fosphenytoin can be substituted for oral phenytoin sodium therapy at the same total daily dose.

Dilantin capsules are approximately 90% bioavailable by the oral route. Phenytoin, supplied as fosphenytoin, is 100% bioavailable by both the i.m. and i.v. routes. For this reason, plasma phenytoin concentrations may increase modestly when i.m. or i.v. fosphenytoin is substituted for oral phenytoin sodium therapy.

The rate of administration for i.v. fosphenytoin should be no greater than 150 mg PE/min.

In controlled trials, i.m. fosphenytoin was administered as a single daily dose utilizing either 1 or 2 injection sites. Some patients may require more frequent dosing.

Dosing in Special Populations: Patients with Renal or Hepatic Disease: Due to an increased fraction of unbound phenytoin in patients with renal or hepatic disease, or in those with hypoalbuminemia, the interpretation of total phenytoin plasma concentrations should be made with caution (see Pharmacology, Special Populations). Unbound phenytoin concentrations may be more useful in these patient populations. After i.v. fosphenytoin administration to patients with renal and/or hepatic disease, or in those with hypoalbuminemia, fosphenytoin clearance to phenytoin may be increased without a similar increase in phenytoin clearance. This has the potential to increase the frequency and severity of adverse events (see Precautions).

Geriatrics: Age does not have a significant impact on the pharmacokinetics of fosphenytoin following administration. Phenytoin clearance is decreased slightly in elderly patients and lower or less frequent dosing may be required.

Children: The safety of fosphenytoin in pediatric patients has not been established.

Compatibility: Fosphenytoin added to 5% dextrose or 0.9% saline solution for injection in a concentration range from 2.5 to 40 mg/mL is stable for 8 hours at room temperature or 24 hours when stored under refrigeration (2 to 8°C).

Fosphenytoin is for parenteral use only. As with all parenteral formulations, fosphenytoin vials should be inspected visually for particulate matter and discoloration before administration whenever solution and container permit. Products with particulate matter or discoloration should be discarded.

Availability And Storage: Each mL of injection contains: fosphenytoin sodium 75 mg as heptahydrate, equivalent to phenytoin sodium 50 mg after administration. Nonmedicinal ingredients: tromethamine buffer (12 mg/mL) adjusted to pH 8.6 to 9.0 with either hydrochloric acid or sodium hydroxide and water for injection. Single-dose vials of 2 mL, packages of 5. Single-dose vials of 10 mL, packages of 1. Store under refrigeration at 2 to 8°C. The product should not be stored at room temperature for more than 48 hours. Vials that develop particulate matter should be discarded.

CEREBYX® Parke-Davis Fosphenytoin Sodium Antiepileptic

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