Busulfan Kabi

Busulfan.

Each ml contains Busulfan 6 mg.
Busulfan is a bifunctional alkylating agent. Busulfan Injection is intended for intravenous administration. It is supplied as a sterile solution for injection, clear and colorless.
The chemical name for Busulfan, USP is 1,4-butanediol, dimethanesulfonate. The molecular formula of Busulfan, USP is C₆H₁₄O₆S₂ (molecular weight-246.30).
Excipients/Inactive Ingredients: Also contains N, N Dimethylacetamide and Polyethylene glycol 400.

Pharmacology: Pharmacodynamics: Busulfan is a bifunctional alkylating agent in which two labile methanesulfonate groups are attached to opposite ends of a four-carbon alkyl chain. In aqueous media, busulfan hydrolyzes to release the methanesulfonate groups. This produces reactive carbonium ions that can alkylate DNA. DNA damage is thought to be responsible for much of the cytotoxicity of busulfan.
Pharmacokinetics: The pharmacokinetics of busulfan was studied in 59 patients participating in a prospective trial of a busulfan-cyclophosphamide preparatory regimen prior to allogeneic hematopoietic progenitor stem cell transplantation. Patients received 0.8 mg/kg busulfan every six hours, for a total of 16 doses over four days. Fifty-five of fifty-nine patients (93%) administered busulfan maintained AUC values below the target value (<1500 µM·min). (See Table 1.)

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Busulfan pharmacokinetics showed consistency between dose 9 and dose 13 as demonstrated by reproducibility of steady state C_max and a low coefficient of variation for this parameter.
Distribution: Busulfan achieves concentrations in the cerebrospinal fluid approximately equal to those in plasma. Busulfan primarily binds to albumin (Mean ± standard deviation=32.4 ± 2.2%).
Metabolism: Busulfan is predominantly metabolized by conjugation with glutathione, both spontaneously and by glutathione S-transferase (GST) catalysis. This conjugate undergoes extensive oxidative metabolism in the liver.
Excretion: Following administration of ¹⁴C-labeled busulfan to humans, approximately 30% of the radioactivity was excreted into the urine over 48 hours; negligible amounts were recovered in feces.
Specific Populations: Pediatric Patients: In a pharmacokinetic study of busulfan in 24 pediatric patients, the population pharmacokinetic (PPK) estimates of busulfan for clearance (CL) and volume of distribution (V) were determined. For actual body weight, PPK estimates of CL and V were 4.04 L/hr/20 kg (3.37 ml/min/kg; interpatient variability 23%); and 12.8 L/20 kg (0.64 L/kg; interpatient variability 11%).

Busulfan Injection is indicated for use in combination with other chemotherapeutic agents and/or radiotherapy as a conditioning regimen prior to allogeneic hematopoietic progenitor cell transplantation including acute lymphocytic leukemia, acute non-lymphocytic leukemia, acute myeloid leukemia, chronic myelogenous leukemia (CML), non-Hodgkin's lymphoma, Hodgkin's disease, multiple myeloma and myelodysplastic syndrome.

Initial Dosing Information: Administer busulfan in combination with cyclophosphamide as a conditioning regimen prior to bone marrow or peripheral blood progenitor cell replacement. For patients weighing more than 12 kg, the recommended doses are: Busulfan 0.8 mg per kg (ideal body weight or actual body weight, whichever is lower) intravenously via a central venous catheter as a two-hour infusion every six hours for four consecutive days for a total of 16 doses (Days -7, -6, -5 and -4).
Cyclophosphamide 60 mg per kg intravenously as a one-hour infusion on each of two days beginning no sooner than six hours following the 16^th dose of busulfan (Days -3 and -2).
Administer hematopoietic progenitor cells on Day 0.
Premedicate patients with anticonvulsants (e.g., benzodiazepines, phenytoin, valproic acid or levetiracetam) to prevent seizures reported with the use of high dose busulfan. Administer anticonvulsants 12 hours prior to busulfan to 24 hours after the last dose of busulfan.
Administer antiemetics prior to the first dose of busulfan and continue on a fixed schedule through busulfan administration.
Busulfan clearance is best predicted when the busulfan dose is administered based on adjusted ideal body weight. Dosing busulfan based on actual body weight, ideal body weight or other factors can produce significant differences in busulfan clearance among lean, normal and obese patients.
Calculate ideal body weight (IBW) as follows (height in cm, and weight in kg): Men: IBW (kg)=50+0.91x (height in cm -152); Women: IBW (kg)=45+0.91x (height in cm -152).
For obese or severely obese patients, base busulfan dosing on adjusted ideal body weight: (AIBW): AIBW=IBW +0.25x (actual weight -IBW).
Preparation and Administration Precautions: DO NOT USE POLYCARBONATE SYRINGES OR POLYCARBONATE FILTER NEEDLES WITH BUSULFAN.
Use an administration set with minimal residual hold-up volume (2-5cc) for product administration.
Preparation for Intravenous Administration: Busulfan must be diluted prior to intravenous infusion with either 0.9% Sodium Chloride Injection, USP (normal saline) or 5% Dextrose Injection, USP. The diluent quantity should be 10 times the volume of busulfan, so that the final concentration of busulfan is approximately 0.5 mg/ml. Calculation of the dose for a 70 kg patient would be performed as follows: (70 kg patient) × (0.8 mg/kg) ÷ (6 mg/ml) = 9.3 ml busulfan (56 mg total dose).
To prepare the final solution for infusion, add 9.3 ml of busulfan to 93 ml of diluent (normal saline or 5% Dextrose Injection) as calculated as follows: (9.3 ml busulfan) × (10) = 93 ml of either diluent plus the 9.3 ml of busulfan to yield a final concentration of busulfan of 0.54 mg/ml (9.3 ml × 6 mg/ml ÷102.3 ml = 0.54 mg/ml).
All transfer procedures require strict adherence to aseptic techniques, preferably employing a vertical laminar flow safety hood while wearing gloves and protective clothing.
Do not put the busulfan into an intravenous bag or large-volume syringe that does not contain normal saline or 5% Dextrose Injection. Always add the busulfan to the diluent, not the diluent to the busulfan. Mix thoroughly by inverting several times.
Infusion pumps should be used to administer the diluted busulfan solution. Set the flow rate of the pump to deliver the entire prescribed busulfan dose over two hours. Prior to and following each infusion, flush the indwelling catheter line with approximately 5 ml of 0.9% Sodium Chloride Injection, USP or 5% Dextrose Injection, USP. WARNING: RAPID INFUSION OF BUSULFAN HAS NOT BEEN TESTED AND IS NOT RECOMMENDED.
Pediatric Use: The effectiveness of busulfan in the treatment of CML has not been specifically studied in pediatric patients. An open-label, uncontrolled study evaluated the pharmacokinetics of busulfan in 24 pediatric patients receiving busulfan as part of a conditioning regimen administered prior to hematopoietic progenitor cell transplantation for a variety of malignant hematologic (N=15) or non-malignant diseases (N=9). Patients ranged in age from 5 months to 16 years (median 3 years). Busulfan dosing was targeted to achieve an area under the plasma concentration curve (AUC) of 900-1350 µM·min with an initial dose of 0.8 mg/kg or 1.0 mg/kg (based on ABW) if he patient was > 4 or ≤ 4 years, respectively. The dose was adjusted based on plasma concentration after completion of dose 1.
Patients received busulfan doses every six hours as a two-hour infusion over four days for a total of 16 doses, followed by cyclophosphamide 50 mg/kg once daily for four days. After one rest day, hematopoietic progenitor cells were infused. All patients received phenytoin as seizure prophylaxis. The target AUC (900-1350±5% µM·min) for busulfan was achieved at dose 1 in 71% (17/24) of patients. Steady state pharmacokinetic testing was performed at dose 9 and 13. Busulfan levels were within the target range for 21 of 23 evaluable patients. All 24 patients experienced neutropenia (absolute neutrophil count <0.5×10⁹/L) and thrombocytopenia (platelet transfusions or platelet count <20,000/mm³). Seventy-nine percent (19/24) of patients experienced lymphopenia (absolute lymphocyte count <0.1×10⁹). In 23 patients, the ANC recovered to >0.5×10⁹/L (median time to recovery = BMT day +13; range = BMT day +9 to +22). One patient who died on day +20 had not recovered to an ANC >0.5×10⁹/L.
Four (17%) patients died during the study. Two patients died within 28 days of transplant; one with pneumonia and capillary leak syndrome, and the other with pneumonia and veno-occlusive disease. Two patients died prior to day 100; one due to progressive disease and one due to multi-organ failure.
Adverse events were reported in all 24 patients during the study period (BMT day -10 through BMT day +28) or post-study surveillance period (day +29 through +100). These included vomiting (100%), nausea (83%), stomatitis (79%), hepatic veno-occlusive disease (HVOD) (21%), graft-versus host disease (GVHD) (25%), and pneumonia (21%).
Based on the results of this 24-patient clinical trial, a suggested dosing regimen of busulfan in pediatric patients is shown in the following dosing nomogram: (See Table 2.)

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Simulations based on a pediatric population pharmacokinetic model indicate that approximately 60% of pediatric patients will achieve a target busulfan exposure (AUC) between 900 to 1350 µM·min with the first dose of busulfan using this dosing nomogram. Therapeutic drug monitoring and dose adjustment following the first dose of busulfan is recommended.
Dose Adjustment Based on Therapeutic Drug Monitoring: Instructions for measuring the AUC of busulfan at dose 1 (see Blood Sample Collection for AUC Determination as follows), and the formula for adjustment of subsequent doses to achieve the desired target AUC (1125 µM∙min), are provided as follows.
Adjusted dose (mg) = Actual Dose (mg) × Target AUC (µM·min)/Actual AUC (µM·min)
For example, if a patient received a dose of 11 mg busulfan and if the corresponding AUC measured was 800 µM·min, for a target AUC of 1125 µM·min, the target mg dose would be: Mg dose =11 mg ×1125 µM·min/800 µM∙min=15.5 mg.
Busulfan dose adjustment may be made using this formula and instructions as follows.
Blood Sample Collection for AUC Determination: Calculate the AUC (µM·min) based on blood samples collected at the following time points: For dose 1:2 hr (end of infusion), 4 hr and 6 hr (immediately prior to the next scheduled busulfan administration). Actual sampling times should be recorded.
For doses other than dose 1: Pre-infusion (baseline), 2 hr (end of infusion), 4 hr and 6 hr (immediately prior to the next scheduled busulfan administration).
AUC calculations based on fewer than the three specified samples may result in inaccurate AUC determinations.
For each scheduled blood sample, collect one to three ml of blood into heparinized (Na or Li heparin) Vacutainer tubes. The blood samples should be placed on wet ice immediately after collection and should be centrifuged (at 4°C) within one hour. The plasma, harvested into appropriate cryovial storage tubes, is to be frozen immediately at -20°C. All plasma samples are to be sent in a frozen state (i.e., on dry ice) to the assay laboratory for the determination of plasma busulfan concentrations.
Calculation of AUC: Busulfan AUC calculations may be made using the following instructions and appropriate standard pharmacokinetic formula: Dose 1 AUC_infinity Calculation: AUC_infinity = AUC_0-6hr + AUC_extrapolated, where AUC_0-6hr is to be estimated using the linear trapezoidal rule and AUC extrapolated can be computed by taking the ratio of the busulfan concentration at Hour 6 and the terminal elimination rate constant, λz. The λz must be calculated from the terminal elimination phase of the busulfan concentration vs. time curve. A "0" pre-dose busulfan concentration should be assumed, and used in the calculation of AUC.
If the AUC is assessed subsequent to Dose 1, steady-state AUC_ss (AUC_0-6hr) is to be estimated from the trough, 2 hr, 4 hr and 6 hr concentrations using the linear trapezoidal rule.
Instructions for Drug Administration and Blood Sample Collection for Therapeutic Drug Monitoring: Use an administration set with minimal residual hold up (priming) volume (1-3 ml) for drug infusion to ensure accurate delivery of the entire prescribed dose and to ensure accurate collection of blood samples for therapeutic drug monitoring and dose adjustment.
Prime the administration set tubing with drug solution to allow accurate documentation of the start time of busulfan infusion. Collect the blood sample from a peripheral IV line to avoid contamination with infusing drug. If the blood sample is taken directly from the existing central venous catheter (CVC), DO NOT COLLECT THE BLOOD SAMPLE WHILE THE DRUG IS INFUSING to ensure that the end of infusion sample is not contaminated with any residual drug. At the end of infusion (2 hr), disconnect the administration tubing and flush the CVC line with 5 cc of normal saline prior to the collection of the end of infusion sample from the CVC port. Collect the blood samples from a different port than that used for the busulfan infusion. When recording the busulfan infusion stop time, do not include the time required to flush the indwelling catheter line. Discard the administration tubing at the end of the two-hour infusion.
See Preparation for intravenous administration as previously mentioned for detailed instructions on drug preparation.

OVERDOSE AND TREATMENT: There is no known antidote to busulfan other than hematopoietic progenitor cell transplantation. In the absence of hematopoietic progenitor cell transplantation, the recommended dosage for busulfan would constitute an overdose of busulfan. The principal toxic effect is profound bone marrow hypoplasia/aplasia and pancytopenia, but the central nervous system, liver, lungs, and gastrointestinal tract may be affected. The hematologic status should be closely monitored and vigorous supportive measures instituted as medically indicated. Survival after a single 140 mg dose of busulfan Tablets in an 18 kg, 4-year old child has been reported. Inadvertent administration of a greater than normal dose of oral busulfan (2.1 mg/kg; total dose of 23.3 mg/kg) occurred in a 2-year old child prior to a scheduled bone marrow transplant without sequelae. An acute dose of 2.4 g was fatal in a 10-year old boy. There is one report that busulfan is dialyzable, thus dialysis should be considered in the case of overdose.

Busulfan is contraindicated in patients with a history of hypersensitivity to any of its components.

Busulfan Injection causes severe and prolonged myelosuppression at the recommended dosage. Hematopoietic progenitor cell transplantation is required to prevent potentially fatal complications of the prolonged myelosuppression.

The following warnings pertain to different physiologic effects of busulfan in the setting of allogeneic transplantation.
Myelosuppression: The most frequent serious consequence of treatment with busulfan at the recommended dose and schedule is prolonged myelosuppression, occurring in all patients (100%). Severe granulocytopenia, thrombocytopenia, anemia, or any combination thereof may develop. Hematopoietic progenitor cell transplantation is required to prevent potentially fatal complications of the prolonged myelosuppression. Monitor complete blood counts, including white blood cell differentials, and quantitative platelet counts daily during treatment and until engraftment is demonstrated. Absolute neutrophil counts dropped below 0.5x10⁹/L at a median of 4 days post-transplant in 100% of patients treated in the busulfan clinical trial. The absolute neutrophil count recovered at a median of 13 days following allogeneic transplantation when prophylactic G-CSF was used in the majority of patients. Thrombocytopenia (less than 25,000/mm³ or requiring platelet transfusion) occurred at a median of 5-6 days in 98% of patients. Anemia (hemoglobin less than 8.0 g/dL) occurred in 69% of patients. Use antibiotic therapy and platelet and red blood cell support when medically indicated.
Seizures: Seizures have been reported in patients receiving high-dose oral busulfan at doses producing plasma drug levels similar to those achieved following the recommended dosage of busulfan. Despite prophylactic therapy with phenytoin, one seizure (1/42 patients) was reported during an autologous transplantation clinical trial of busulfan. This episode occurred during the cyclophosphamide portion of the conditioning regimen, 36 hours after the last busulfan dose. Anti-convulsant prophylactic therapy should be initiated prior to busulfan treatment. Caution should be exercised when administering the recommended dose of busulfan to patients with a history of a seizure disorder or head trauma or who are receiving other potentially epileptogenic drugs.
Hepatic Veno-Occlusive Disease (HVOD): Current literature suggests that high busulfan area under the plasma concentration verses time curve (AUC) values (>1,500 µM·min) may be associated with an increased risk of developing hepatic veno-occlusive disease (HVOD). Patients who have received prior radiation therapy, greater than or equal to three cycles of chemotherapy, or a prior progenitor cell transplant may be at an increased risk of developing HVOD with the recommended busulfan dose and regimen. Based on clinical examination and laboratory findings, hepatic veno-occlusive disease was diagnosed in 8% (5/61) of patients treated with busulfan in the setting of allogeneic transplantation, was fatal in 2/5 cases (40%), and yielded an overall mortality from HVOD in the entire study population of 2/61 (3%). Three of the five patients diagnosed with HVOD were retrospectively found to meet the Jones' criteria. The incidence of HVOD reported in the literature from the randomized, controlled trials was 7.7%-12%. Monitor serum transaminases, alkaline phosphatase, and bilirubin daily through BMT Day +28 to detect hepatotoxicity, which may herald the onset of HVOD.
Cardiac Tamponade: Cardiac tamponade has been reported in pediatric patients with thalassemia (8/400 or 2% in one series) who received high doses of oral busulfan and cyclophosphamide as the preparatory regimen for hematopoietic progenitor cell transplantation. Six of the eight children died and two were saved by rapid pericardiocentesis. Abdominal pain and vomiting preceded the tamponade in most patients. Monitor for signs and symptoms, promptly evaluate and treat if cardiac tamponade is suspected.
Bronchopulmonary Dysplasia: Bronchopulmonary dysplasia with pulmonary fibrosis is a rare but serious complication following chronic busulfan therapy. The average onset of symptoms is 4 years after therapy (range 4 months to 10 years).
Cellular Dysplasia: Busulfan may cause cellular dysplasia in many organs. Cytologic abnormalities characterized by giant, hyperchromatic nuclei have been reported in lymph nodes, pancreas, thyroid, adrenal glands, liver, lungs and bone marrow. This cytologic dysplasia may be severe enough to cause difficulty in the interpretation of exfoliative cytologic examinations of the lungs, bladder, breast and the uterine cervix.
Carcinogenesis, Mutagenesis and Impairment of Fertility: Busulfan is a mutagen and a clastogen. In in vitro tests it caused mutations in Salmonella typhimurium and Drosophila melanogaster. Chromosomal aberrations induced by busulfan have been reported in vivo (rats, mice, hamsters, and humans) and in vitro (rodent and human cells). The intravenous administration of busulfan (48 mg/kg given as biweekly doses of 12 mg/kg, or 30% of the total busulfan dose on a mg/m² basis) has been shown to increase the incidence of thymic and ovarian tumors in mice.
Busulfan depleted oocytes of female rats and induced sterility in male rats and hamsters. The solvent DMA ((Dimethylacetamide) may also impair fertility. A DMA daily dose of 0.45 g/kg/d given to rats for nine days (equivalent to 44% of the daily dose of DMA contained in the recommended dose of Busulfan on a mg/m² basis) significantly decreased spermatogenesis in rats. A single sc dose of 2.2 g/kg (27% of the total DMA dose contained in busulfan on a mg/m² basis) four days after insemination terminated pregnancy in 100% of tested hamsters.
Renal Impairment: Busulfan has not been studied in patients with renal impairment.
Hepatic Impairment: Busulfan has not been administered to patients with hepatic insufficiency.
Use in Pregnancy: Embryo-fetal Toxicity: Busulfan can cause fetal harm when administered to a pregnant woman based on animal data. Busulfan was teratogenic in mice, rats, and rabbits. The solvent, DMA, may also cause fetal harm when administered to a pregnant woman based on findings in animals. Advise pregnant women of the potential risk to a fetus. Advise females and males of reproductive potential to use effective contraception during and after treatment with busulfan.
Use in the Elderly: Five of sixty-one patients treated in the busulfan clinical trial were over the age of 55 (range 57-64). All achieved myeloablation and engraftment.

Pregnancy: Risk Summary: Busulfan can cause fetal harm when administered to a pregnant woman based on animal data. Busulfan was teratogenic in mice, rats, and rabbits following administration during organogenesis. The solvent, DMA, may also cause fetal harm when administered to a pregnant woman. In rats, DMA doses of approximately 40% of the daily dose of DMA in the busulfan dose on a mg/m² basis given during organogenesis caused significant developmental anomalies. There are no available human data informing the drug-associated risk. Advise pregnant women of the potential risk to a fetus.
The background risk of major birth defects and miscarriage for the indicated populations are unknown. However, the background risk in the U.S. general population of major birth defects is 2-4% and of miscarriage is 15-20% of clinically recognized pregnancies.
Animal Data: Following administration during organogenesis in animals, busulfan caused malformations and anomalies, including significant alterations in the musculoskeletal system, body weight gain, and size. In pregnant rats, busulfan produced sterility in both male and female offspring due to the absence of germinal cells in the testes and ovaries. The solvent, DMA, administered to rats at doses of 400 mg/kg/day (about 40% of the daily dose of DMA in the busulfan dose on a mg/m² basis) during organogenesis caused significant developmental anomalies. The most striking abnormalities included anasarca, cleft palate, vertebral anomalies, rib anomalies, and serious anomalies of the vessels of the heart.
Lactation: It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for tumorigenicity shown for busulfan in human and animal studies, discontinue breastfeeding during treatment with busulfan.
Females and Males of Reproductive Potential: Contraception: Females: Busulfan can cause fetal harm when administered to a pregnant woman. Advise females of reproductive potential to use effective contraception during and after treatment with busulfan.
Males: Busulfan may damage spermatozoa and testicular tissue, resulting in possible genetic fetal abnormalities. Males with female sexual partners of reproductive potential should use effective contraception during and after treatment with busulfan.
Infertility: Females: Ovarian suppression and amenorrhea commonly occur in premenopausal women undergoing chronic, low-dose busulfan therapy for chronic myelogenous leukemia.
Males: Sterility, azoospermia, and testicular atrophy have been reported in male patients.

The following adverse reactions are discussed in more detail in Precautions of the labeling: Myelosuppression; Seizures; HVOD; Embryo-fetal Toxicity; Cardiac Tamponade; Bronchopulmonary Dysplasia; Cellular Dysplasia.
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.
Adverse reaction information is primarily derived from the clinical study (N=61) of busulfan and the data obtained for high-dose oral busulfan conditioning in the setting of randomized, controlled trials identified through a literature review.
In the busulfan Injection allogeneic stem cell transplantation clinical trial, all patients were treated with busulfan 0.8 mg/kg as a two-hour infusion every six hours for 16 doses over four days, combined with cyclophosphamide 60 mg/kg × 2 days. Ninety-three percent (93%) of evaluable patients receiving this dose of busulfan maintained an AUC less than 1,500 µM·min for dose 9, which has generally been considered the level that minimizes the risk of HVOD.
Table 3 lists the non-hematologic adverse reactions events through BMT Day +28 at a rate greater than or equal to 20% in patients treated with busulfan prior to allogeneic hematopoietic cell transplantation. (See Table 3.)

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Additional Adverse Reactions by Body System: Hematologic: Prolonged prothrombin time.
Gastrointestinal: Esophagitis, ileus, hematemesis, pancreatitis, rectal discomfort.
Hepatic: Alkaline phosphatase increases, jaundice, hepatomegaly.
Graft-versus-host disease: Graft-versus-host disease. There were 3 deaths (5%) attributed to GVHD.
Edema: Hypervolemia, or documented weight increase.
Infection: Infection, pneumonia (fatal in one patient and life-threatening in 3% of patients).
Cardiovascular: Arrhythmia, atrial fibrillation, ventricular extrasystoles, third degree heart block, thrombosis (all episodes were associated with the central venous catheter), hypotension, flushing and hot flashes, cardiomegaly, ECG abnormality, left-sided heart failure, and pericardial effusion.
Pulmonary: Hyperventilation, alveolar hemorrhage (fatal in 3%), pharyngitis, hiccup, asthma, atelectasis, pleural effusion, hypoxia, hemoptysis, sinusitis, and interstitial fibrosis (fatal in a single case).
Neurologic: Cerebral hemorrhage, coma, delirium, agitation, encephalopathy, confusion, hallucinations, lethargy, somnolence.
Renal: BUN increased, dysuria, oliguria, hematuria, hemorrhagic cystitis.
Skin: Alopecia, vesicular rash, maculopapular rash, vesiculo-bullous rash, exfoliative dermatitis, erythema nodosum, acne, skin discoloration.
Metabolic: Hypophosphatemia, hyponatremia.
Other Events: Injection site pain, myalgia, arthralgia, ear disorder.
Other adverse reactions: Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to establish a causal relationship to drug exposure. The following adverse reactions have been identified: Blood and Lymphatic System Disorders: febrile neutropenia.
Gastrointestinal Disorders: tooth hypoplasia.
Metabolism and Nutrition Disorders: tumor lysis syndrome.
Vascular Disorders: thrombotic microangiopathy (TMA).
Infections and Infestations: severe bacterial, viral (e.g., cytomegalovirus viremia) and fungal infections; and sepsis.
Oral Busulfan Literature Review: A literature review identified four randomized, controlled trials that evaluated a high dose oral busulfan containing conditioning regimen for allogeneic bone marrow transplantation in the setting of chronic myelogenous leukemia (CML). The safety outcomes reported in those trials are summarized in Table 4 as follows for a mixed population of hematological malignancies [acute lymphoblastic leukemia (ALL), acute myelogenous leukemia (AML) and CML]. (See Table 4.)

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Itraconazole decreases busulfan clearance by up to 25%, and may produce an AUC >1500 µM·min in some patients. Fluconazole (200 mg) has been used with busulfan.
Phenytoin increases the clearance of busulfan by 15% or more, possibly due to the induction of glutathione-S-transferase. Since the pharmacokinetics of busulfan was studied in patients treated with phenytoin, the clearance of busulfan at the recommended dose may be lower and exposure (AUC) higher in patients not treated with phenytoin.
Because busulfan is eliminated from the body via conjugation with glutathione, use of acetaminophen prior to (less than 72 hours) or concurrent with busulfan may result in reduced busulfan clearance based upon the known property of acetaminophen to decrease glutathione levels in the blood and tissues.

Incompatibilities: DO NOT infuse concomitantly with another intravenous solution of unknown compatibility.
HANDLING AND DISPOSAL: Busulfan is a cytotoxic drug. Follow applicable special handling and disposal procedures. Skin reactions may occur with accidental exposure. Use gloves when preparing busulfan. If busulfan or diluted busulfan solution contacts the skin or mucosa, wash the skin or mucosa thoroughly with water.
Visually inspect parenteral drug products for particulate matter and discoloration prior to administration whenever the solution and container permit. Do not use if particulate matter is seen in the busulfan vial.

Store under refrigeration at 2°-8°C (36°-46°F).
Shelf-Life: Do not use after expiry date.
Unopened vials of busulfan are stable until the date indicated on the package when stored under refrigeration at 2°-8°C (36°-46°F).
Busulfan diluted in 0.9% Sodium Chloride Injection, USP or 5% Dextrose Injection, USP is stable at room temperature (25°C) for up to 8 hours but the infusion must be completed within that time. Busulfan diluted in 0.9% Sodium Chloride Injection, USP is stable at refrigerated conditions (2°-8°C) for up to 12 hours but the infusion must be completed within that time.

Cytotoxic Chemotherapy

L01AB01 - busulfan ; Belongs to the class of alkylating agents, alkyl sulfonates. Used in the treatment of cancer.

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