2 DOSAGE AND ADMINISTRATION
2.1 Recommended Dosage for Non-Squamous NSCLC
- The recommended dose of Pemetrexed Injection when administered with cisplatin for initial treatment of locally advanced or metastatic non-squamous NSCLC in patients with a creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater is 500 mg/m2 as an intravenous infusion over 10 minutes administered prior to cisplatin on Day 1 of each 21-day cycle for up to six cycles in the absence of disease progression or unacceptable toxicity.
- The recommended dose of Pemetrexed Injection for maintenance treatment of non-squamous NSCLC in patients with a creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater is 500 mg/m2 as an intravenous infusion over 10 minutes on Day 1 of each 21-day cycle until disease progression or unacceptable toxicity after four cycles of platinum-based first-line chemotherapy.
- The recommended dose of Pemetrexed Injection for treatment of recurrent non-squamous NSCLC in patients with a creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater is 500 mg/m2 as an intravenous infusion over 10 minutes on Day 1 of each 21-day cycle until disease progression or unacceptable toxicity.
2.2 Recommended Dosage for Mesothelioma
The recommended dose of Pemetrexed Injection when administered with cisplatin in patients with a creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater is 500 mg/m2 as an intravenous infusion over 10 minutes on Day 1 of each 21-day cycle until disease progression or unacceptable toxicity.
2.3 Renal Impairment
Pemetrexed Injection dosing recommendations are provided for patients with a creatinine clearance (calculated by Cockcroft-Gault equation) of 45 mL/min or greater [see Dosage and Administration (2.1, 2.2)]. There is no recommended dose for patients whose creatinine clearance is less than 45 mL/min [see Use in Specific Populations (8.6)].
2.4 Premedication and Concomitant Medications to Mitigate Toxicity
Vitamin Supplementation
- Initiate folic acid 400 mcg to 1000 mcg orally once daily, beginning 7 days before the first dose of Pemetrexed Injection and continuing until 21 days after the last dose of Pemetrexed Injection [see Warnings and Precautions (5.1)].
- Administer vitamin B12, 1 mg intramuscularly, 1 week prior to the first dose of Pemetrexed Injection and every 3 cycles thereafter. Subsequent vitamin B12 injections may be given the same day as treatment with Pemetrexed Injection [see Warnings and Precautions (5.1)]. Do not substitute oral vitamin B12 for intramuscular vitamin B12.
2.5 Dosage Modification of Ibuprofen in Patients with Mild to Moderate Renal Impairment Receiving Pemetrexed Injection
In patients with creatinine clearances between 45 mL/min and 79 mL/min, modify administration of ibuprofen as follows [see Warnings and Precautions (5.6), Drug Interactions (7) and Clinical Pharmacology (12.3)]:
- Avoid administration of ibuprofen for 2 days before, the day of, and 2 days following administration of Pemetrexed Injection.
- Monitor patients more frequently for myelosuppression, renal, and gastrointestinal toxicity, if concomitant administration of ibuprofen cannot be avoided.
2.6 Dosage Modifications for Adverse Reactions
Obtain complete blood count on Days 1, 8, and 15 of each cycle. Assess creatinine clearance prior to each cycle. Do not administer Pemetrexed Injection if the creatinine clearance is less than 45 mL/min.
Delay initiation of the next cycle of Pemetrexed Injection until:
- Recovery of non-hematologic toxicity to Grade 0–2,
- Absolute neutrophil count (ANC) is 1500 cells/mm3 or higher, and
- Platelet count is 100,000 cells/mm3 or higher.
Upon recovery, modify the dosage of Pemetrexed Injection in the next cycle as specified in Table 1.
For dosing modifications for cisplatin, refer to the prescribing information for cisplatin.
| Toxicity in Most Recent Treatment Cycle | Pemetrexed Injection Dose Modification for Next Cycle |
|---|---|
| |
| Myelosuppressive toxicity [see Warnings and Precautions (5.1)] | |
| ANC less than 500/mm3 and platelets greater than or equal to 50,000/mm3 OR Platelet count less than 50,000/mm3 without bleeding | 75% of previous dose |
| Platelet count less than 50,000/mm3 with bleeding | 50% of previous dose |
| Recurrent Grade 3 or 4 myelosuppression after 2 dose reductions | Discontinue |
| Non-hematologic toxicity | |
| Any Grade 3 or 4 toxicities EXCEPT mucositis or neurologic toxicity or diarrhea requiring hospitalization | 75% of previous dose |
| Grade 3 or 4 mucositis | 50% of previous dose |
| Renal toxicity [see Warnings and Precautions (5.2)] | Withhold until creatinine clearance is 45 mL/min or greater |
| Grade 3 or 4 neurologic toxicity | Permanently discontinue |
| Recurrent Grade 3 or 4 non-hematologic toxicity after 2 dose reductions | Permanently discontinue |
| Severe and life-threatening Skin Toxicity [see Warnings and Precautions (5.3)] | Permanently discontinue |
| Interstitial Pneumonitis [see Warnings and Precautions (5.4)] | Permanently discontinue |
2.7 Preparation for Administration
Pemetrexed Injection is a hazardous drug. Follow applicable special handling and disposal procedures.1
- Calculate the dose of Pemetrexed Injection and determine the number of vials needed.
- Withdraw the calculated dose of Pemetrexed Injection from the vial(s) and discard vial with any unused portion.
- Dilute Pemetrexed Injection with 0.9% Sodium Chloride Injection, USP (preservative-free) to achieve a total volume of 100 mL for intravenous infusion.
- Visually inspect for particulate matter and discoloration prior to administration. Discard if particulate matter or discoloration is observed.
- Administer Pemetrexed Injection as an intravenous infusion over 10 minutes.
- If not used immediately, store diluted product under refrigerated conditions [2°C to 8°C (36°F to 46°F)] for no more than 24 hours from the time of dilution. Discard after 24 hours.