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linezolid injection in sodium chloride Adverse Reactions

6 ADVERSE REACTIONS

6.1 Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Adults

The safety of linezolid formulations was evaluated in 2,046 adult patients enrolled in seven Phase 3 comparator-controlled clinical trials, who were treated for up to 28 days. For all indications, 20.4% of linezolid-treated and 14.3% of comparator-treated patients experienced at least one drug-related adverse event.

Table 2 shows the incidence of all-causality, treatment-emergent adverse reactions reported in at least 1% of adult patients in these trials by dose of linezolid.

Table 2. Incidence (%) Treatment-Emergent Adverse Reactions Occurring in greater than 1% of Adult Patients Treated with Linezolid in Comparator-Controlled Clinical Trials
ADVERSE REACTIONSLinezolid 600 mg every 12 hours
(n = 1498)
All Other Comparators*
(n = 1464)
*
Comparators included cefpodoxime proxetil 200 mg by mouth every 12 hours; ceftriaxone 1 g intravenously every 12 hours; dicloxacillin 500 mg by mouth every 6 hours; oxacillin 2 g intravenously every 6 hours; vancomycin 1 g intravenously every 12 hours.
Headache5.74.4
Diarrhea8.36.4
Nausea6.64.6
Vomiting4.32.3
Dizziness1.81.5
Rash2.32.6
Anemia2.11.4
Taste alteration1.00.3
Vaginal moniliasis1.10.5
Oral moniliasis1.71.0
Abnormal liver function tests1.60.8
Fungal infection0.30.2
Tongue discoloration0.30
Localized abdominal pain1.20.8
Generalized abdominal pain1.21.0

Discontinuations due to drug-related adverse events occurred in 2.1% of linezolid-treated and 1.7% of comparator-treated patients. The most common reported drug-related adverse events leading to discontinuation of treatment were nausea, headache, diarrhea, and vomiting.

Pediatric Patients

The safety of linezolid formulations was evaluated in 215 pediatric patients ranging in age from birth through 11 years, and in 248 pediatric patients aged 5 through 17 years (146 of these 248 were age 5 through 11 and 102 were age 12 to 17). These patients were enrolled in two Phase 3 comparator-controlled clinical trials and were treated for up to 28 days. In the study of hospitalized pediatric patients (birth through 11 years) with Gram-positive infections, who were randomized 2 to 1 (linezolid: vancomycin), mortality was 6.0% (13/215) in the linezolid arm and 3.0% (3/101) in the vancomycin arm. However, given the severe underlying illness in the patient population, no causality could be established.

For all indications, 18.8% of linezolid-treated and 34.3% of comparator-treated patients experienced at least one drug-related adverse event.

Table 3 shows the incidence of all-causality, treatment-emergent adverse reactions reported in more than 1% of pediatric patients (and more than 1 patient) in either treatment group in the comparator-controlled Phase 3 trials.

Table 3. Incidence (%) of Treatment-Emergent Adverse Reactions Occurring in greater than 1% of Pediatric Patients (and greater than 1 Patient) in Either Treatment Group in Comparator-Controlled Clinical Trials*
ADVERSE REACTIONSLinezolid
(n = 215)
Vancomycin
(n = 101)
*
Patients from birth through 11 years of age received linezolid 10 mg/kg intravenously and/or by mouth every 8 hours or vancomycin 10 to 15 mg/kg intravenously every 6–24 hours, depending on age and renal clearance.
Diarrhea10.812.1
Vomiting9.49.1
Headache 0.90
Anemia5.67.1
Thrombocytopenia4.72.0
Nausea1.90
Generalized abdominal pain0.92.0
Localized abdominal pain0.51.0
Loose stools2.33.0
Eosinophilia1.91.0
Pruritus at non-application site1.42.0
Vertigo00

For all indications, discontinuations due to drug-related adverse events occurred in 0.9% of linezolid-treated and 6.1% of comparator-treated patients.

Laboratory Abnormalities

Linezolid has been associated with thrombocytopenia when used in doses up to and including 600 mg every 12 hours for up to 28 days. In Phase 3 comparator-controlled trials, the percentage of adult patients who developed a substantially low platelet count (defined as less than 75% of lower limit of normal and/or baseline) was 2.4% (range among studies: 0.3 to 10.0%) with linezolid and 1.5% (range among studies: 0.4 to 7.0%) with a comparator. In a study of hospitalized pediatric patients ranging in age from birth through 11 years, the percentage of patients who developed a substantially low platelet count (defined as less than 75% of lower limit of normal and/or baseline) was 12.9% with linezolid and 13.4% with vancomycin. In an outpatient study of pediatric patients aged from 5 through 17 years, the percentage of patients who developed a substantially low platelet count was 0% with linezolid and 0.4% with cefadroxil. Thrombocytopenia associated with the use of linezolid appears to be dependent on duration of therapy (generally greater than 2 weeks of treatment). The platelet counts for most patients returned to the normal range/baseline during the follow-up period. No related clinical adverse events were identified in Phase 3 clinical trials in patients developing thrombocytopenia. Bleeding events were identified in thrombocytopenic patients in a compassionate use program for linezolid; the role of linezolid in these events cannot be determined [see Warnings and Precautions (5.1)].

Changes seen in other laboratory parameters, without regard to drug relationship, revealed no substantial differences between linezolid and the comparators. These changes were generally not clinically significant, did not lead to discontinuation of therapy, and were reversible. The incidence of adult and pediatric patients with at least one substantially abnormal hematologic or serum chemistry value is presented in Tables 4, 5, 6, and 7.

Table 4. Percent of Adult Patients who Experienced at Least One Substantially Abnormal* Hematology Laboratory Value in Comparator-Controlled Clinical Trials with Linezolid
Laboratory AssayLinezolid
600 mg every 12 hours
All Other Comparators
*
Less than 75% (less than 50% for neutrophils) of Lower Limit of Normal (LLN) for values normal at baseline; less than 75% (less than 50% for neutrophils) of LLN and of baseline for values abnormal at baseline.
Comparators included cefpodoxime proxetil 200 mg by mouth every 12 hours; ceftriaxone 1 g intravenously every 12 hours; dicloxacillin 500 mg by mouth every 6 hours; oxacillin 2 g intravenously every 6 hours; vancomycin 1 g intravenously every 12 hours.
Hemoglobin (g/dL)7.16.6
Platelet count (× 103/mm3)3.01.8
WBC (× 103/mm3)2.21.3
Neutrophils (× 103/mm3)1.11.2
Table 5. Percent of Adult Patients who Experienced at Least One Substantially Abnormal* Serum Chemistry Laboratory Value in Comparator-Controlled Clinical Trials with Linezolid
Laboratory AssayLinezolid
600 mg every 12 hours
All Other Comparators
*
Greater than 2× Upper Limit of Normal (ULN) for values normal at baseline; greater than 2× ULN and greater than 2× baseline for values abnormal at baseline.
Comparators included cefpodoxime proxetil 200 mg by mouth every 12 hours; ceftriaxone 1 g intravenously every 12 hours; dicloxacillin 500 mg by mouth every 6 hours; oxacillin 2 g intravenously every 6 hours; vancomycin 1 g intravenously every 12 hours.
AST (U/L)5.06.8
ALT (U/L)9.69.3
LDH (U/L)1.81.5
Alkaline phosphatase (U/L)3.53.1
Lipase (U/L)4.34.2
Amylase (U/L)2.42.0
Total bilirubin (mg/dL)0.91.1
BUN (mg/dL)2.11.5
Creatinine (mg/dL)0.20.6
Table 6. Percent of Pediatric Patients who Experienced at Least One Substantially Abnormal* Hematology Laboratory Value in Comparator-Controlled Clinical Trials with Linezolid
Laboratory AssayLinezolidVancomycin
*
Less than 75% ( less than 50% for neutrophils) of Lower Limit of Normal (LLN) for values normal at baseline; less than 75% (less than 50% for neutrophils) of LLN and less than 75% (less than 50% for neutrophils, less than 90% for hemoglobin if baseline less than LLN) of baseline for values abnormal at baseline.
Patients from birth through 11 years of age received linezolid 10 mg/kg intravenously and/or by mouth every 8 hours or vancomycin 10 to 15 mg/kg intravenously every 6–24 hours, depending on age and renal clearance.
Hemoglobin (g/dL)15.712.4
Platelet count (× 103/mm3)12.913.4
WBC (× 103/mm3)12.410.3
Neutrophils (× 103/mm3)5.94.3
Table 7. Percent of Pediatric Patients who Experienced at Least One Substantially Abnormal* Serum Chemistry Laboratory Value in Comparator-Controlled Clinical Trials with Linezolid
Laboratory AssayLinezolidVancomycin
*
Greater than 2 × Upper Limit of Normal (ULN) for values normal at baseline; greater than 2× ULN and greater than 2 (greater than 1.5 for total bilirubin) × baseline for values abnormal at baseline.
Patients from birth through 11 years of age received linezolid 10 mg/kg intravenously and/or by mouth every 8 hours or vancomycin 10 to 15 mg/kg intravenously every 6–24 hours, depending on age and renal clearance.
ALT (U/L)10.112.5
Lipase (U/L)------
Amylase (U/L)0.61.3
Total bilirubin (mg/dL)6.35.2
Creatinine (mg/dL)2.41.0

6.2 Postmarketing Experience

The following adverse reactions have been identified during postapproval use of linezolid. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure:

  • Myelosuppression (including anemia, leukopenia, pancytopenia, and thrombocytopenia) [see Warnings and Precautions (5.1)]; sideroblastic anemia.
  • Peripheral neuropathy, and optic neuropathy sometimes progressing to loss of vision [see Warnings and Precautions (5.2)].
  • Lactic acidosis [see Warnings and Precautions (5.7)]. Although these reports have primarily been in patients treated for longer than the maximum recommended duration of 28 days, these events have also been reported in patients receiving shorter courses of therapy.
  • Serotonin syndrome has been reported in patients receiving concomitant serotonergic agents, including antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and opioids, and linezolid [see Warnings and Precautions (5.3)].
  • Convulsions [see Warnings and Precautions (5.8)].
  • Anaphylaxis, angioedema, bullous skin disorders including severe cutaneous adverse reactions (SCAR) such as toxic epidermal necrolysis and Stevens-Johnson syndrome, and hypersensitivity vasculitis.
  • Superficial tooth discoloration and tongue discoloration have been reported with the use of linezolid. The tooth discoloration was removable with professional dental cleaning (manual descaling) in cases with known outcome.
  • Hypoglycemia, including symptomatic episodes [see Warnings and Precautions (5.9)].
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