Amphotericin B (Liposomal)

Amphotericin B liposomal is injected into a vein through an IV. You will receive this injection in a clinic or hospital setting. Amphotericin B liposomal must be given slowly, and the IV infusion can take 1 or more hours to complete.

Amphotericin B liposomal may need to be given for up several weeks or months, depending on the infection being treated.

Your breathing, blood pressure, and other vital signs will be watched closely while you are receiving amphotericin B liposomal.

While using amphotericin B liposomal, you may need frequent blood tests. Your liver and kidney function may also need to be tested.

Seek emergency medical attention or call the Poison Help line at 1-800-222-1222.

Since amphotericin B liposomal is usually given while you are in the hospital, you are not likely to miss a dose.

If you are receiving amphotericin B liposomal in an outpatient clinic, call your doctor if you will miss an appointment for your amphotericin B liposomal injection.

>10%

Hypokalemia (31-51%)

Hypomagnesemia (15-50%)

Chills (29-48%)

Anemia (27-48%)

Nephrotoxicity (14-47%)

Nausea (16-40%)

Vomiting (11-32%)

Diarrhea (11-30%)

Rash (5-25%)

Dyspnea (18-23%)

Hyperglycemia (8-23%)

Insomnia (17-22%)

Alkaline phosphatase increase (7-22%)

Infusion reaction (4-21%)

Headache (9-20%)

Hypertension (8-20%)

Abdominal pain (7-20%)

Tachycardia (9-19%)

Lung disorder (14-18%)

Blood transfusion reaction (9-18%)

Hypocalcemia (5-18%)

Cough (2-18%)

Bilirubinemia (<18%)

Leukopenia (15-17%)

ALT increased (15%)

Constipation (15%)

Peripheral edema (15%)

Pain (14%)

Anorexia (10-14%)

Anxiety (7-14%)

Hypotension (7-14%)

Sepsis (7-14%)

AST increased (13%)

Pleural effusion (13%)

Confusion (9-13%)

Thrombocytopenia (6-13%)

Weakness (6-13%)

Back pain (12%)

Edema (10-12%)

Hyponatremia (9-12%)

Chest pain (8-12%)

Hypervolemia (8-12%)

Pruritus (11%)

Rhinitis (11%)

Phlebitis (9-11%)

1-10%

Abnormal thinking

Acidosis

Agitation

Alopecia

Arthralgia

Asthma

Bruising

Cardiovascular abnormalities

Coagulation disorder

Cellulitis

Depression

Dizziness

Electrolyte abnormalities

Fluid overload

Gastrointestinal hemorrhage

Hallucinations

Hyperventilation

Injection site reaction

Malaise

Mucositis

Petechia

Rash

Renal function abnormalities

Respiratory acidosis

Respiratory failure

Seizure

Stomatitis

Pregnancy Category: B

Lactation: Unknown whether distributed in breast milk, caution advised

Pregnancy Categories

A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

NA:Information not available.

• If you have an allergy to amphotericin or any other part of amphotericin B (liposomal).
• If you are allergic to any drugs like this one, any other drugs, foods, or other substances. Tell your doctor about the allergy and what signs you had, like rash; hives; itching; shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or any other signs.
• If you are receiving a transfusion of a certain kind of white blood cell (leukocyte).
• If you are breast-feeding or plan to breast-feed.

This is not a list of all drugs or health problems that interact with this medicine.

Tell your doctor and pharmacist about all of your drugs (prescription or OTC, natural products, vitamins) and health problems. You must check to make sure that it is safe for you to take amphotericin B with all of your drugs and health problems. Do not start, stop, or change the dose of any drug without checking with your doctor.

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Suspension Reconstituted, Intravenous:

AmBisome: 50 mg (1 ea) [contains cholesterol, distearoyl phosphatidylglycerol, hydrogenated soy phosphatidylcholine, sodium succinate hexahydrate, sucrose, tocopherol, dl-alpha]

Binds to ergosterol altering cell membrane permeability in susceptible fungi and causing leakage of cell components with subsequent cell death. Proposed mechanism suggests that amphotericin causes an oxidation-dependent stimulation of macrophages (Lyman 1992).

Distribution

Vd: 0.1 to 0.16 L/kg

Half-Life Elimination

7 to 10 hours (following a single 24-hour dosing interval); Terminal half-life: 100 to 153 hours (following multiple dosing up to 49 days)

Candidiasis (invasive) in HIV-exposed/-infected patients (infants and children)

Based on the US Department of Health and Human Services (HHS) Guidelines for Prevention and Treatment of Opportunistic Infections among HIV-Exposed and HIV-Infected Children, amphotericin B (liposomal) is an effective and recommended alternative agent for the treatment of invasive candidiasis in HIV-exposed/-infected infants and children.

Candidiasis, empiric therapy (non-neutropenic ICU patients)

Based on the Infectious Diseases Society of America (IDSA) clinical practice guidelines for the management of candidiasis, amphotericin B (liposomal) is an effective and recommended agent for empiric therapy of suspected invasive candidiasis in non-neutropenic patients in the ICU.

Coccidioidomycosis in HIV-exposed/-infected patients (infants and children)

Based on the US Department of Health and Human Services (HHS) Guidelines for Prevention and Treatment of Opportunistic Infections among HIV-Exposed and HIV-Infected Children, amphotericin B (liposomal) is an effective and recommended agent in the management of severe coccidioidomycosis with respiratory compromise due to diffuse pulmonary or disseminated non-meningitic disease in HIV-exposed/-infected infants and children.

Coccidioidomycosis in HIV-infected patients (adolescents and adults)

Based on the US Department of Health and Human Services (HHS) Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents, amphotericin B (liposomal) is an effective and recommended agent in the management of severe, non-meningeal coccidioidomycosis infection (ie, diffuse pulmonary or severely ill with extrathoracic, disseminated disease) in adolescent and adult HIV-infected patients.

Cryptococcosis, disseminated (non-CNS) in HIV-exposed/-infected patients (infants and children)

Based on the US Department of Health and Human Services (HHS) Guidelines for Prevention and Treatment of Opportunistic Infections among HIV-Exposed and HIV-Infected Children, amphotericin B (liposomal) is an effective and recommended alternative agent in the management of disseminated (non-CNS) or severe pulmonary cryptococcosis in HIV-exposed/-infected infants and children.

Fungal meningitis (secondary to contaminated [eg, Exserohilum rostratum] steroid products)

Data from a limited number of patients studied (ie, case reports) from an outbreak of fungal infections associated with injections (epidural and intrarticular) of methylprednisolone contaminated with environmental molds (Exserohilum rostratum) suggest that amphotericin B (liposomal) in combination with voriconazole may be beneficial for the treatment of severe or refractory fungal meningitis [Kauffman 2012]. Additional data may be necessary to further define the role of amphotericin B (liposomal) in this condition.

Fungal osteoarticular infections (secondary to contaminated [eg, Exserohilum rostratum] steroid products)

Data from a limited number of patients studied (ie, case reports) from an outbreak of fungal infections associated with injections (epidural and intrarticular) of methylprednisolone contaminated with environmental molds (Exserohilum rostratum) suggest that amphotericin B (liposomal) in combination with voriconazole may be beneficial for the treatment of severe fungal osteoarticular infections [Kauffman 2012]. Additional data may be necessary to further define the role of amphotericin B (liposomal) in this condition.

Histoplasmosis in HIV-exposed/-infected patients (infants and children)

Based on the US Department of Health and Human Services (HHS) Guidelines for Prevention and Treatment of Opportunistic Infections among HIV-Exposed and HIV-Infected Children, amphotericin B (liposomal) is an effective and recommended agent in the management of moderately severe to severe disseminated histoplasmosis in HIV-exposed/-infected infants and children.

Histoplasmosis in HIV-infected patients (adolescents and adults)

Based on the US Department of Health and Human Services (HHS) Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents, amphotericin B (liposomal) is an effective and recommended agent for the treatment of histoplasmosis in adolescent and adult HIV-infected patients.

Leishmaniasis (cutaneous) in HIV-infected patients (adolescents and adults)

Based on the US Department of Health and Human Services (HHS) Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents, amphotericin B (liposomal) is an effective and recommended agent for the treatment of cutaneous leishmaniasis in adolescent and adult HIV-infected patients.

Leishmaniasis (visceral) in HIV-infected patients (adolescents and adults)

Based on the US Department of Health and Human Services (HHS) Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents, amphotericin B (liposomal) is an effective and recommended agent for the treatment of visceral leishmaniasis in adolescent and adult HIV-infected patients.

Talaromyces marneffei infection in HIV-infected patients (adolescents and adults)

Based on the US Department of Health and Human Services (HHS) Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents, amphotericin B (liposomal) is an effective and recommended agent for the treatment of Talaromyces marneffei infection in adolescent and adult HIV-infected patients.

Refer to adult dosing.

Note: Lipid-based amphotericin formulations (AmBisome) may be confused with conventional formulations (desoxycholate [Amphocin, Fungizone]) or with other lipid-based amphotericin formulations (amphotericin B lipid complex [Abelcet], amphotericin B cholesteryl sulfate complex [Amphotec]). Lipid-based and conventional formulations are not interchangeable and have different dosing recommendations. Overdoses have occurred when conventional formulations were dispensed inadvertently for lipid-based products.

Usual dosage range: Infants, Children, and Adolescents: IV: 3 to 6 mg/kg/day

Note: Premedication: For patients who experience nonanaphylactic immediate infusion-related reactions, premedicate with the following drugs 30 to 60 minutes prior to drug administration: A nonsteroidal anti-inflammatory agent ± diphenhydramine; or acetaminophen with diphenhydramine; or hydrocortisone. If the patient experiences rigors during the infusion, meperidine may be administered.

Indication-specific dosing:

Infants, Children, and Adolescents: IV:

Empiric therapy: 3 mg/kg/day

Cryptococcal meningitis in HIV-exposed/infected patients:

Infants and Children: 6 mg/kg/dose once daily with flucytosine; if flucytosine is unavailable or not tolerated, may administer amphotericin B liposomal alone or in combination with high-dose fluconazole (HHS [OI pediatric 2013]; off-label combination)

Adolescents: Refer to adult dosing.

Systemic fungal infections (Aspergillus, Candida, Cryptococcus); non-HIV-exposed/-infected: 3 to 5 mg/kg/day

Systemic fungal infections (HIV-exposed/-infected [HHS (OI pediatric 2013; OI adult 2015)]; off-label use):

Infants and Children:

Candidiasis, invasive: 5 mg/kg/dose once daily

Coccidioidomycosis (severe illness with respiratory compromise due to diffuse pulmonary or disseminated non-meningitic disease): 5 mg/kg/dose once daily until clinical improvement, then initiate triazole therapy (eg, fluconazole or itraconazole); dosage may be increased to 10 mg/kg/dose once daily for life-threatening infection.

Cryptococcus, disseminated (non-CNS): 3 to 5 mg/kg/dose once daily (may consider addition of oral flucytosine)

Histoplasmosis:

CNS infection: 5 mg/kg/dose once daily

Disseminated: 3 to 5 mg/kg/day once daily

Adolescents: Refer to adult dosing.

Leishmaniasis (cutaneous) in HIV-infected patients (off-label use): Adolescents: Refer to adult dosing.

Leishmaniasis (visceral):

Immunocompetent: 3 mg/kg/day on days 1 to 5, and 3 mg/kg/day on days 14 and 21; a repeat course may be given in patients who do not achieve parasitic clearance

Immunocompromised: 4 mg/kg/day on days 1 to 5, and 4 mg/kg/day on days 10, 17, 24, 31, and 38

Leishmaniasis (visceral) in HIV-infected patients (off-label use): Adolescents: Refer to adult dosing.

Talaromyces marneffei infection in HIV-infected patients (off-label use): Adolescents: Refer to adult dosing.

Falsely-elevated serum phosphate may occur when using the PHOSm assay.

The following adverse events are based on the experience of 592 adult patients (295 treated with Am B isome and 297 treated with amphotericin B deoxycholate) and 95 pediatric patients (48 treated with Am B isome and 47 treated with amphotericin B deoxycholate) in Study 94-0-002, a randomized double-blind, multi-center study in febrile, neutropenic patients. Am B isome and amphotericin B were infused over two hours.

The incidence of common adverse events (incidence of 10% or greater) occurring with Am B isome compared to amphotericin B deoxycholate, regardless of relationship to study drug, is shown in the following table:

Am B isome was well tolerated. Am B isome had a lower incidence of chills, hypertension, hypotension, tachycardia, hypoxia, hypokalemia, and various events related to decreased kidney function as compared to amphotericin B deoxycholate.

In pediatric patients (16 years of age or less) in this double-blind study, Am B isome compared to amphotericin B deoxycholate had a lower incidence of hypokalemia (37% versus 55%), chills (29% versus 68%), vomiting (27% versus 55%), and hypertension (10% versus 21%). Similar trends, although with a somewhat lower incidence, were observed in open-label, randomized Study 104-14 involving 205 febrile neutropenic pediatric patients (141 treated with Am B isome and 64 treated with amphotericin B deoxycholate). Pediatric patients appear to have more tolerance than older individuals for the nephrotoxic effects of amphotericin B deoxycholate.

The following adverse events are based on the experience of 244 patients (202 adult and 42 pediatric patients) of whom 85 patients were treated with Am B isome 3 mg/kg, 81 patients were treated with Am B isome 5 mg/kg and 78 patients treated with amphotericin B lipid complex 5 mg/kg in Study 97-0-034, a randomized double-blind, multi-center study in febrile, neutropenic patients. Am B isome and amphotericin B lipid complex were infused over two hours. The incidence of adverse events occurring in more than 10% of subjects in one or more arms regardless of relationship to study drug are summarized in the following table:

The following adverse events are based on the experience of 267 patients (266 adult patients and 1 pediatric patient) of whom 86 patients were treated with Am B isome 3 mg/kg, 94 patients were treated with Am B isome 6 mg/kg and 87 patients treated with amphotericin B deoxycholate 0.7 mg/kg in Study 94-0-013 a randomized, double-blind, comparative multi-center trial, in the treatment of cryptococcal meningitis in HIV positive patients. The incidence of adverse events occurring in more than 10% of subjects in one or more arms regardless of relationship to study drug are summarized in the following table:

Infusion Related Reactions

In Study 94-0-002, the large, double-blind study of pediatric and adult febrile neutropenic patients, no premedication to prevent infusion related reaction was administered prior to the first dose of study drug (Day 1). Am B isome-treated patients had a lower incidence of infusion related fever (17% versus 44%), chills/rigors (18% versus 54%), and vomiting (6% versus 8%) on Day 1 as compared to amphotericin B deoxycholate-treated patients.

The incidence of infusion related reactions on Day 1 in pediatric and adult patients is summarized in the following table:

Cardiorespiratory events, except for vasodilatation (flushing), during all study drug infusions were more frequent in amphotericin B-treated patients as summarized in the following table:

The percentage of patients who received drugs either for the treatment or prevention of infusion related reactions (e.g., acetaminophen, diphenhydramine, meperidine and hydrocortisone) was lower in Am B isome-treated patients compared with amphotericin B deoxycholate-treated patients.

In the empirical therapy study 97-0-034, on Day 1, where no premedication was administered, the overall incidence of infusion related events of chills/rigors was significantly lower for patients administered Am B isome compared with amphotericin B lipid complex. Fever, chills/rigors and hypoxia were significantly lower for each Am B isome group compared with the amphotericin B lipid complex group. The infusion related event hypoxia was reported for 11.5% of amphotericin B lipid complex-treated patients compared with 0% of patients administered 3 mg/kg per day Am B isome and 1.2% of patients treated with 5 mg/kg per day Am B isome.

Day 1 body temperature increased above the temperature taken within 1 hour prior to infusion (preinfusion temperature) or above the lowest infusion value (no preinfusion temperature recorded).

Patients were not administered premedications to prevent infusion related reactions prior to the Day 1 study drug infusion.

In study 94-0-013, a randomized double-blind multicenter trial comparing Am B isome and amphotericin B deoxycholate as initial therapy for cryptococcal meningitis, premedications to prevent infusion related reactions were permitted. Am B isome treated patients had a lower incidence of fever, chills/rigors and respiratory adverse events as summarized in the following table:

There have been a few reports of flushing, back pain with or without chest tightness, and chest pain associated with Am B isome administration; on occasion this has been severe. Where these symptoms were noted, the reaction developed within a few minutes after the start of infusion and disappeared rapidly when the infusion was stopped. The symptoms do not occur with every dose and usually do not recur on subsequent administrations when the infusion rate is slowed.

Toxicity and Discontinuation of Dosing

In Study 94-0-002, a significantly lower incidence of grade 3 or 4 toxicity was observed in the Am B isome group compared with the amphotericin B group. In addition, nearly three times as many patients administered amphotericin B required a reduction in dose due to toxicity or discontinuation of study drug due to an infusion related reaction compared with those administered Am B isome.

In empirical therapy study 97-0-034, a greater proportion of patients in the amphotericin B lipid complex group discontinued the study drug due to an adverse event than in the Am B isome groups.

Less Common Adverse Events

The following adverse events also have been reported in 2% to 10% of Am B isome-treated patients receiving chemotherapy or bone marrow transplantation, or had HIV disease in six comparative, clinical trials:

Body as a Whole --abdomen enlarged, allergic reaction, cellulitis, cell mediated immunological reaction, face edema, graft versus host disease, malaise, neck pain, and procedural complication.

Cardiovascular System --arrhythmia, atrial fibrillation, bradycardia, cardiac arrest, cardiomegaly, hemorrhage, postural hypotension, valvular heart disease, vascular disorder, and vasodilatation (flushing).

Digestive System --anorexia, constipation, dry mouth/nose, dyspepsia, dysphagia, eructation, fecal incontinence, flatulence, hemorrhoids, gum/oral hemorrhage, hematemesis, hepatocellular damage, hepatomegaly, liver function test abnormal, ileus, mucositis, rectal disorder, stomatitis, ulcerative stomatitis, and veno-occlusive liver disease.

Hemic & Lymphatic System --anemia, coagulation disorder, ecchymosis, fluid overload, petechia, prothrombin decreased, prothrombin increased, and thrombocytopenia.

Metabolic & Nutritional Disorders --acidosis, amylase increased, hyperchloremia, hyperkalemia, hypermagnesemia, hyperphosphatemia, hyponatremia, hypophosphatemia, hypoproteinemia, lactate dehydrogenase increased, nonprotein nitrogen (NPN) increased, and respiratory alkalosis.

Musculoskeletal System --arthralgia, bone pain, dystonia, myalgia, and rigors.

Nervous System --agitation, coma, convulsion, cough, depression, dysesthesia, dizziness, hallucinations, nervousness, paresthesia, somnolence, thinking abnormality, and tremor.

Respiratory System --asthma, atelectasis, hemoptysis, hiccup, hyperventilation, influenza-like symptoms, lung edema, pharyngitis, pneumonia, respiratory insufficiency, respiratory failure, and sinusitis.

Skin & Appendages --alopecia, dry skin, herpes simplex, injection site inflammation, maculopapular rash, purpura, skin discoloration, skin disorder, skin ulcer, urticaria, and vesiculobullous rash.

Special Senses --conjunctivitis, dry eyes, and eye hemorrhage.

Urogenital System --abnormal renal function, acute kidney failure, acute renal failure, dysuria, kidney failure, toxic nephropathy, urinary incontinence, and vaginal hemorrhage.

The following infrequent adverse experiences have been reported in post-marketing surveillance, in addition to those mentioned above: angioedema, erythema, urticaria, cyanosis/hypoventilation, pulmonary edema, agranulocytosis, hemorrhagic cystitis.

Clinical Laboratory Values

The effect of Am B isome on renal and hepatic function and on serum electrolytes was assessed from laboratory values measured repeatedly in Study 94-0-002. The frequency and magnitude of hepatic test abnormalities were similar in the Am B isome and amphotericin B groups. Nephrotoxicity was defined as creatinine values increasing 100% or more over pretreatment levels in pediatric patients, and creatinine values increasing 100% or more over pretreatment levels in adult patients provided the peak creatinine concentration was >1.2 mg/dL. Hypokalemia was defined as potassium levels </=2.5 mmol/L any time during treatment.

Incidence of nephrotoxicity, mean peak serum creatinine concentration, mean change from baseline in serum creatinine, and, incidence of hypokalemia in the double-blind randomized study were lower in the Am B isome group as summarized in the following table:

The effect of Am B isome (3 mg/kg/day) vs. amphotericin B (0.6 mg/kg/day) on renal function in adult patients enrolled in this study is illustrated in the following figure:

In empirical therapy study 97-0-034, the incidence of nephrotoxicity as measured by increases of serum creatinine from baseline was significantly lower for patients administered Am B isome (individual dose groups and combined) compared with amphotericin B lipid complex.

The following graph shows the average serum creatinine concentrations in the compassionate use study and shows that there is a drop from pretreatment concentrations for all patients, especially those with elevated (greater than 1.7 mg/dL) pretreatment creatinine concentrations.

The incidence of nephrotoxicity in Study 94-0-013, comparative trial in cryptococcal meningitis was lower in the Am B isome groups as shown in the following table: