WARNING: NAVELBINE (vinorelbine tartrate) Injection should be administered under the supervision of a physician experienced in the use of cancer chemotherapeutic agents. This product is for intravenous use only. Intrathecal administration of other vinca alkaloids has resulted in death. Syringes containing this product should be labeled "WARNING - NAVELBINE FOR INTRAVENOUS USE ONLY."
Severe granulocytopenia resulting in increased susceptibility to infection may occur. Granulocyte counts should be greater than or equal 1000 cells/cubic mm prior to the administration of NAVELBINE. The dosage should be adjusted according to complete blood counts with differentials obtained on the day of treatment.
Caution - It is extremely important that the intravenous needle or catheter be properly positioned before NAVELBINE is injected. Improper administration of NAVELBINE may result in extravasation causing local tissue necrosis and/or thrombophlebitis (see Dosage and Administration: Administration Precautions).
DESCRIPTION: NAVELBINE (vinorelbine tartrate) Injection is for intravenous administration. Each vial contains vinorelbine tartrate equivalent to 10 mg (1 mL vial) or 50 mg (5 mL vial) vinorelbine in Water for Injection. No preservatives or other additives are present. The aqueous solution is sterile and nonpyrogenic.
Vinorelbine tartrate is a semi-synthetic vinca alkaloid with antitumor activity. The chemical name is 3',4'-didehydro-4'-deoxy-C-norvincaleukoblastine [R-(R,R)-2,3-dihydroxybutanedioate (1:2)(salt)].
|Vinorelbine tartrate has the following structure:|
Vinorelbine tartrate is a white to yellow or light brown amorphous powder with the molecular formula and molecular weight of 1079.12. The aqueous solubility is less than 1000 mg/mL in distilled water. The pH of NAVELBINE Injection is approximately 3.5.
CLINICAL PHARMACOLOGY: Vinorelbine is a vinca alkaloid that interferes with microtubule assembly. The vinca alkaloids are structurally similar compounds comprised of two multiringed units, vindoline and catharanthine. Unlike other vinca alkaloids, the catharanthine unit is the site of structural modification for vinorelbine. The antitumor activity of vinorelbine is thought to be due primarily to inhibition of mitosis at metaphase through its interaction with tubulin. Like other vinca alkaloids, vinorelbine may also interfere with: 1) amino acid, cyclic AMP, and glutathione metabolism, 2) calmodulindependent Ca++-transport ATPase activity, 3) cellular respiration, and 4) nucleic acid and lipid biosynthesis. In intact tectal plates from mouse embryos, vinorelbine, vincristine, and vinblastine inhibited mitotic microtubule formation at the same concentration (2 uM), inducing a blockade of cells at metaphase. Vincristine produced depolymerization of axonal microtubules at 5 uM, but vinblastine and vinorelbine did not have this effect until concentrations of 30 uM and 40 uM, respectively. These data suggest relative selectivity of vinorelbine for mitotic microtubules.
Pharmacokinetics: The pharmacokinetics of vinorelbine were studied in 49 patients who received doses of 30 mg/square m in four clinical trials. Doses were administered by 15 to 20-minute constant rate infusions. Following intravenous administration, vinorelbine concentration in plasma decays in a triphasic manner. The initial rapid decline primarily represents distribution of drug to peripheral compartments followed by metabolism and excretion of the drug during subsequent phases. The prolonged terminal phase is due to relatively slow efflux of vinorelbine from peripheral compartments. The terminal phase halflife averages 27.7 to 43.6 hours and the mean plasma clearance ranges from 0.97 to 1.26 L/hr/kg. Steady state volume of distribution (Vss) values range from 25.4 to 40.1 L/kg.
Vinorelbine demonstrated high binding to human platelets and Iymphocytes. The free fraction was approximately 0.11 in pooled human plasma over a concentration range of 234 to 1169 ng/ mL. The binding to plasma constituents in cancer patients ranged from 79.6% to 91.2%. Vinorelbine binding was not altered in the presence of cisplatin, 5-fluorouracil, or doxorubicin.
Vinorelbine undergoes substantial hepatic elimination in humans, with large amounts recovered in feces after intravenous administration to humans. One metabolite, deacetylvinorelbine, has been shown to possess antitumor activity. This metabolite has been detected but not quantified in human plasma. The effects of renal or hepatic dysfunction on the disposition of vinorelbine have not been assessed, but based on experience with other anticancer vinca alkaloids, dose adjustments are recommended for patients with impaired hepatic function (see DOSAGE AND ADMINISTRATION).
The disposition of radiolabeled vinorelbine given intravenously was studied in a limited number of patients. Approximately 18% of the administered dose was recovered in the urine and 46% in the feces. Incomplete recovery in humans is consistent with results in animals where recovery is incomplete, even after prolonged sampling times. A separate study of the urinary excretion of vinorelbine using specific chromatographic analytical methodology showed that 10.9% +- 0.7% of a 30 mg/square m intravenous dose was excreted unchanged in the urine.
The pharmacokinetics of vinorelbine are not influenced by the concurrent administration of cisplatin with NAVELBINE (see PRECAUTIONS: Drug Interactions).
Clinical Trials: Data from two controlled clinical studies (823 patients), as well as additional data from more than 100 patients enrolled in two uncontrolled clinical trials, support the use of NAVELBINE in patients with advanced nonsmall cell lung cancer (NSCLC). In a large European clinical trial, 612 patients with Stage III or IV NSCLC, no prior chemotherapy, and WHO Performance Status of 0, 1, or 2 were randomized to treatment with single-agent NAVELBINE (30 mg/square m/week), NAVELBINE (30 mg/square m/week) plus cisplatin (120 mg/sqaure m days 1 and 29, then every 6 weeks), and vindesine (3 mg/sqaure m/week for 7 weeks, then every other week) plus cisplatin (120 mg/sqaure m days 1 and 29, then every 6 weeks). NAVELBINE plus cisplatin produced longer survival times than vindesine plus cisplatin (median survival 40 weeks vs. 32 weeks, P=0.03). The median survival time for patients receiving single-agent NAVELBINE was similar to that observed with vindesine plus cisplatin (31 weeks vs. 32 weeks). The 1-year survival rates were 35% for NAVELBINE plus cisplatin, 27% for vindesine plus cisplatin, and 30% for single-agent NAVELBINE. The overall objective response rate (all partial responses) was significantly higher in the patients treated with NAVELBINE plus cisplatin (28%) than in those treated with vindesine plus cisplatin (19%, P= 0.03) and in those treated with single-agent NAVELBINE (14%, P less than 0.001). The response rates reported for vindesine plus cisplatin and single-agent NAVELBINE were not significantly different. Significantly less nausea, vomiting, alopecia, and neurotoxicity were observed in patients receiving single-agent NAVELBINE compared to those receiving the combination of vindesine and cisplatin.
Single-agent NAVELBINE was studied in a North American, randomized clinical trial in which patients with Stage IV NSCLC, no prior chemotherapy, and Karnofsky Performance Status less than 70 were treated with NAVELBINE (30 mg/square m) weekly or 5-fluorouracil (5-FU) (425 mg/square m I.V. bolus) plus leucovorin (LV) (20 mg/square m I.V. bolus) daily for 5 days every 4 weeks. A total of 211 patients were randomized at a 2:1 ratio to NAVELBINE (143) or 5-FU/LV (68). NAVELBINE showed improved survival time compared to 5-FU/LV. In an intent-to-treat analysis the median survival time for patients receiving NAVELBINE was 30 weeks and for those receiving 5-FU/LV was 22 weeks (P=0.06). The 1-year survival rates were 24% (+- 4% S.E.) for NAVELBINE and 16% (+- 5% S.E.) for the 5-FU/ LV group, using the Kaplan-Meier productlimit estimates. The median survival time with 5-FU/LV was similar to, or slightly better than, that usually observed in untreated patients with advanced NSCLC, suggesting that the difference was not related to some unknown detrimental effect of 5-FU/ LV therapy. The response rates (all partial responses) for NAVELBINE and 5-FU/LV were 12% and 3%, respectively. Quality-of-life (QOL) was also an endpoint in this study. Patients completed a modified Southwest Oncology Group QOL questionnaire which assessed the domains of role functioning, physical functioning, symptom distress, and global QOL. Quality-of-life was not adversely affected by NAVELBINE when compared to control.
A dose-ranging study of NAVELBINE (20, 25, or 30 mg/square m/week) plus cisplatin (120 mg/square m days 1 and 29, then every 6 weeks) in 32 patients with NSCLC demonstrated a median survival of 44 weeks. There were no responses at the lowest dose level; the response rate was 33% in the 21 patients treated at the two highest dose levels.
INDICATIONS AND USAGE: NAVELBINE is indicated as a single agent or in combination with cisplatin for the first-line treatment of ambulatory patients with unresectable, advanced non-small cell lung cancer (NSCLC). In patients with Stage IV NSCLC, NAVELBINE is indicated as a single agent or in combination with cispiatin. In Stage III NSCLC, NAVELBINE is indicated in combination with cisplatin.
CONTRAINDICATIONS: Administration of NAVELBINE is contraindicated in patients with pretreatment granulocyte counts less than 1000 cells/cubic mm (see WARNINGS).
WARNINGS: NAVELBINE should be administered in carefully adjusted doses by or under the supervision of a physician experienced in the use of cancer chemotherapeutic agents.
Patients treated with NAVELBINE should be frequently monitored for myelosuppression both during and after therapy. Granulocytopenia is dose-limiting. Granulocyte nadirs occur between 7 and 10 days after dosing with granulocyte count recovery usually within the following 7 to 14 days. Complete blood counts with differentials should be performed and results reviewed prior to administering each dose of NAVELBINE. NAVELBINE should not be administered to patients with granulocyte counts less than 1000 cells/cubic mm. Patients developing severe granulocytopenia should be monitored carefully for evidence of infection and/or fever. See DOSAGE AND ADMINISTRATION for recommended dose adjustments for granulocytopenia.
Pregnancy: Pregnancy Category D. NAVELBINE may cause fetal harm if administered to a pregnant woman. A single dose of vinorelbine has been shown to be embryo- and/or fetotoxic in mice and rabbits at doses of 9 mg/square m and 5.5 mg/square m, respectively (one-third and one-sixth the human dose). At nonmaternotoxic doses, fetal weight was reduced and ossification was delayed. There are no studies in pregnant women. If NAVELBINE is used during pregnancy, or if the patient becomes pregnant while receiving this drug, the patient should be apprised of the potential hazard to the fetus. Women of childbearing potential should be advised to avoid becoming pregnant during therapy with NAVELBINE.
NAVELBINE should be used with extreme caution in patients whose bone marrow reserve may have been compromised by prior irradiation or chemotherapy, or whose marrow function is recovering from the effects of previous chemotherapy (see DOSAGE AND ADMINISTRATION).
Acute shortness of breath and severe bronchospasm have been reported infrequently following the administration of NAVELBINE and other vinca alkaloids, most commonly when the vinca alkaloid was used in combination with mitomycin. These adverse events may require treatment with supplemental oxygen, bronchodilators, and/or corticosteroids, particularly when there IS pre-existng pulmonary dysfunction. Care must be taken to avoid contamination of the eye with concentrations of NAVELBINE used clinically. Severe irritation of the eye has been reported with accidental exposure to another vinca alkaloid. If exposure occurs, the eye should immediately be thoroughly flushed with water.
Information for Patients: Patients should be informed that the major acute toxicities of NAVELBINE are related to bone marrow toxicity, specificaliy granulocytopenia with increased susceptibility to infection. They should be advised to report fever or chills Immediately. Women of childbearing potential should be advised to avoid becoming pregnant during treatment.
Laboratory Tests: Since dose-limiting clinical toxicity is the result of depression of the white blood cell count, it is imperative that complete blood counts with differentials be obtained and reviewed on the day of treatment prior to each dose of NAVELBINE (see ADVERSE REACTIONS: Hematologic).
Hepatic: There is no evidence that the toxicity of NAVELBINE is enhanced in patients with elevated liver enzymes. No data are available for patients with severe baseline cholestasis, but the liver plays an important role in the metabolism of NAVELBINE. Because clinical experience in patients with severe liver disease is limited, caution should be exercised when administering NAVELBINE to patients with severe hepatic injury or impairment (see DOSAGE AND ADMINISTRATION).
Drug Interactions: Acute pulmonary reactions have been reported with NAVELBINE and other anticancer vinca alkaloids used in conjunction with mitomycin. Although the pharmacokinetics of vinorelbine are not influenced by the concurrent administration of cisplatin, the incidence of granulocytopenia with NAVELBINE used in combination with cisplatin is significantly higher than with singleagent NAVELBINE.
Carcinogenesis, Mutagenesis, Impairment of Fertility: The carcinogenic potential of NAVELBINE has not been studied. Vinorelbine has been shown to affect chromosome number and possibly structure in vivo (polyploidy in bone marrow cells from Chinese hamsters and a positive micronucleus test in mice). It was not mutagenic in the Ames test and gave inconclusive results in the mouse Iymphoma TK Locus assay. The significance of these or other short term test results for human risk is unknown. Vinorelbine did not affect fertility to a statistically significant extent when administered to rats on either a once weekly (9 mg/square m, approximately one-third the human dose) or alternate day schedule (4.2 mg/square m, approximately one-seventh the human dose) prior to and during mating. However, biweekly administration for 13 or 26 weeks in the rat at 2.1 and 7.2 mg/square m (approximately one-fifteenth and one-fourth the human dose) resulted in decreased spermatogenesis and prostate/ seminal vesicle secretion.
Pregnancy: Pregnancy Category D. See WARNINGS section.
Nursing Mothers: It is not known whether the drug is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from NAVELBINE, it is recommended that nursing be discontinued in women who are receiving therapy with NAVELBINE.
Pediatric Use: Safety and effectiveness in children have not been established.
Geriatric Use: Of the total number of patients in North American clinical studies of I.V. NAVELBINE, approximately one third were 65 years of age or greater. No overall differences in effectiveness or safety were observed between these patients and younger patients. Other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.
ADVERSE REACTIONS: Granulocytopenia is the major dose-limiting toxicity with NAVELBINE. Dose adjustments are required for hematologic toxicity and hepatic insufficiency (see Dosage and Administration).
Data in the following table are based on the experience of 365 patients (143 patients with NSCLC; 222 patients with advanced breast cancer) treated with l.V. NAVELBINE as a single agent in three clinical studies. The dosing schedule in each study was 30 mg/square m NAVELBINE on a weekly basis.
__________________________________________________________________________________ All Patients NSCLC Adverse Event (n=365) (n=143) (% Incidence) (% Incidence) __________________________________________________________________________________ Bone Marrow | | Granulocytopenia less than 2,000 cells/cubic mm | 90 | 80 less than 500 cells/cubic mm | 36 | 29 | | Leukopenia less than 4,000 cells/cubic mm | 92 | 81 less than 1,000 cells/cubic mm | 15 | 12 | | Thrombocytopenia less than 100,000 cells/cubic mm | 5 | 4 less than 50,000 cells/cubic mm | 1 | 1 | | Anemia less than 11 g/dL | 83 | 77 less than 8 g/dL | 9 | 1 Hospitalizations due | | to granulocytopenic | | complications | 9 | 8 _____________________________________________________|_________|___________________ ___________________________________________________________________________________ Adverse Events | All Grades | Grade 3 | Grade 4 | (% Incidence) | (% Incidence) | (% Incidence) | All | All | All | Patience NSCLC | Patience NSCLC | Patience NSCLC ___________________________________________________________________________________ Clinical Chemistry | | | Elevations | | | Total Bilirubin (n=351) | 13 9 | 4 3 | 3 2 SGOT (n=346) | 67 54 | 5 2 | 1 1 | | | General | | | Asthenia | 36 27 | 7 5 | 0 0 Injection Site Reactions| 28 38 | 2 5 | 0 0 Injection Site Pain | 16 13 | 2 1 | 0 0 Phlebitis | 7 10 | LT 1 1 | 0 0 | | | Digestive | | | Nausea | 44 34 | 2 1 | 0 0 Vomiting | 20 15 | 2 1 | 0 0 Constipation | 35 29 | 3 2 | 0 0 Diarrhea | 17 13 | 1 1 | 0 0 | | | Peripheral Neuropathy** | 25 20 | 1 1 | LT 1 0 | | | Dyspnea | 7 3 | 2 2 | 1 0 | | | Alopecia | 12 12 | LE 1 1 | 0 0 _________________________|__________________|___________________|__________________ * None of the Reported toxicities were influenced by age. Grade based on modified criteria from the National Cancer Institute. # Patients with NSCLC had not recieved prior chemotherapy. The Majority of the remaining patients had revieved prior chemotherapy. ** Incidence of paresthesia plus hypesthesia
Hematologic: Granulocytopenia was the major dose-limiting toxicity with NAVELBINE, it was generally reversible and not cumulative over time. Granulocyte nadirs occurred 7 to 10 days after the dose with granulocyte recovery, usually within the following 7 to 14 days. Granulocytopenia resulted in hospitalizations for fever and/or sepsis in 8% of patients. Septic deaths occurred in approximately 1% of patients. Prophylactic hematologic growth factors have not been routinely used with NAVELBINE. If medically necessary, growth factors may be administered at recommended doses no earlier than 24 hours after the administration of cytotoxic chemotherapy. Growth factors should not be administered in the period 24 hours before the administration of chemotherapy.
Grade 3 or 4 anemia occurred in 1% of patients, although blood products were administered to 18% of patients who received NAVELBINE. Grade 3 or 4 thrombocytopenia was reported in 1% of patients.
Neurologic: Mild to moderate peripheral neuropathy manifested by paresthesia and hypesthesia were the most frequently reported neurologic toxicities. Loss of deep tendon reflexes occurred in less than 5% of patients. The development of severe peripheral neuropathy was infrequent (1%) and generally reversible.
Skin: Alopecia was reported in 12% of patients and was usually mild.
Like other anticancer vinca alkaloids, NAVELBINE is a moderate vesicant. Injection site reactions, including erythema, pain at injection site, and vein discoloration occurred in approximately one-third of patients; 5% were severe. Chemical phlebitis along the vein proximal to the site of injection was reported in 10% of patients.
Gastrointestinal: Mild or moderate nausea occurred in 34% of patients treated with NAVELBINE; severe nausea was infrequent (less than 2%). Prophylactic administration of antiemetics was not routine in patients treated with singleagent NAVELBINE. Due to the low incidence of severe nausea and vomiting with singleagent NAVELBINE, the use of serotonin antagonists is generally not required. Constipation occurred in 29% of patients, with paralytic ileus occurring in 1%. Vomiting, diarrhea, anorexia, and stomatitis were usually mild or moderate and each occurred in less than 20% of patients.
Hepatic: Transient elevations of liver enzymes were reported without clinical symptoms.
Cardiovascular: Chest pain was reported in 5% of patients. Most reports of chest pain were in patients who had either a history of cardiovascular disease or tumor within the chest. There have been rare reports of myocardial infarction.
Pulmonary: Shortness of breath was reported in 3% of patients; it was severe in 2% (see Precautions: General). Interstitial pulmonary changes were documented in a few patients.
Other: Fatigue occurred in 27% of patients. It was usually mild or moderate but tended to increase with cumulative dosing.
Other toxicities that have been reported in less than 5% of patients include jaw pain, myalgia, arthralgia, and rash. Hemorrhagic cystitis and the syndrome of inappropriate ADH secretion were each reported in less than 1% of patients.
Combination Use: In a randomized study, 206 patients received treatment with NAVELBINE plus cisplatin and 206 patients received single-agent NAVELBINE. The toxicity profile of cisplatin is known (see full prescribing information for cisplatin). The incidence of severe nausea and vomiting was 30% for NAVELBINE/cisplatin compared to less than 2% for single-agent NAVELBINE. Cisplatin did not appear to increase the incidence of neurotoxicity observed with single-agent NAVELBINE. However, myelosuppression, specifically Grade 3 and 4 granulocytopenia, was greater with the combination of NAVELBINE cisplatin (79%) than with single-agent NAVELBINE (53%). The incidence of fever and infection may be increased with the combination.
OVERDOSAGE: There is no known antidote for overdoses of NAVELBINE. The primary anticipated complications of overdosage would consist of bone marrow suppression and peripheral neurotoxicity. If overdosage occurs, general supportive measures together with appropriate blood transfusions and antibiotics should be instituted as deemed necessary by the physician.
DOSAGE AND ADMINISTRATION: The usual initial dose of NAVELBINE is 30 mg/square m administered weekly. The recommended method of administration is an intravenous injection over 6 to 10 minutes. In controlled trials, single-agent NAVELBINE was given weekly until progression or dose-limiting toxicity. NAVELBINE was used at the same dose in combination with 120 mg/square m of cisplatin, given on days 1 and 29, then every 6 weeks.
No dose adjustments are required for renal insufficiency. If moderate or severe neurotoxicity develops, NAVELBINE should be discontinued. The dosage should be adjusted according to hematologic toxicity or hepatic insufficiency, whichever results in the lower dose.
Dose Modifications tor Hematologic Toxicity: Granulocyte counts should be less than 1000 cells/cubic mm prior to the administration of NAVELBINE. Adjustments in the dosage of NAVELBINE should be based on granulocyte counts obtained on the day of treatment according to Table 2.
|Dose Adjustments Based on Granulocyte Counts|
Granulocyte (cells/cubic mm)
on Days of Treatment
|Dose of NAVELBINE (mg/square m)|
|greater than or equal to 1500||30|
|1000 to 1499||15|
|less than 1000||
Do not administer Repeat granulocyte count in 1 week.
If 3 consecutive weekly doses are held because
granulocyte count is less than 1000 cells/cubic mm,
Dose Moditication for Hepatic Insufficiency: NAVELBINE should be administered with caution to patients with hepatic insufficiency. In patients who develop hyperbilirubinemia during treatment with NAVELBINE, the dose should be adjusted for total bilirubin according to Table 3.
|Dose Modification Based on Total Bilirubin|
|Total Bilirubin (mg/dL)||Dose of NAVELBINE (mg/square m)|
|less than or equal to 2.0||30|
|2.1 to 3.0||15|
|greater than 3.0||7.5|
Dose Modification for Concurrent Hematologic Toxicity and Hepatic Insufficiency: In patients with both hematologic toxicity and hepatic insufficiency, the lower of the doses determined from Table 2 and Table 3 should be administered.
Administration Precautions: Caution - NAVELBINE must be administered intravenously. It is extremely important that the intravenous needle or catheter be properly positioned before any NAVELBINE is injected. Leakage into surrounding tissue during intravenous administration of NAVELBINE may cause considerable irritation, local tissue necrosis, and/or thrombophlebitis. If extravasation occurs, the injection should be discontinued immediately, and any remaining portion of the dose should then be introduced into another vein. Since there are no established guidelines for the treatment of extravasation injuries with NAVELBINE, institutional guidelines may be used. The ONS Chemotherapy Guidelines provide additional recommendations for the prevention of extravasation injuries.
As with other toxic compounds, caution should be exercised in handling and preparing the solution of NAVELBINE. Skin reactions may occur with accidental exposure. The use of gloves is recommended. If the solution of NAVELBINE contacts the skin or mucosa, immediately wash the skin or mucosa thoroughly with soap and water. Severe irritation of the eye has been reported with accidental contamination of the eye with another vinca alkaloid. If this happens with NAVELBINE, the eye should be flushed with water immediately and thoroughly.
Procedures for proper handling and disposal of anticancer drugs should be used. Several guidelines on this subject have been published.[2-8] There is no general agreement that all of the procedures recommended in the guidelines are necessary or appropriate.
NAVELBINE Injection is a clear, colorless to pale yellow solution. Parenteral drug products should be visually inspected for particulate matter and discoloration prior to administration whenever solution and container permit. If particulate matter is seen, NAVELBINE should not be administered.
Preparation for Administration: NAVELBINE Injection must be diluted in either a syringe or I.V. bag using one of the recommended solutions. The diluted NAVELBINE should be administered over 6 to 10 minutes into the side port of a freeflowing I.V. closest to the l.V. bag followed by flushing with at least 75 to 125 mL of one of the solutions. Diluted NAVELBINE may be used for up to 24 hours under normal room light when stored in polypropylene syringes or polyvinyl chloride bags at 5 degrees to 30 degrees C (41 degrees to 86 degrees F).
HOW SUPPLIED: NAVELBINE Injection is a clear colorless to pale yellow solution in Water for Injection, containing 10 mg vinorelbine per mL. NAVELBINE Injection is available in single-use, clear glass vials with black elastomeric stoppers and royal blue caps, individually packaged in a carton in the following vial sizes:
10 mg/1 mL single-use vial, Carton of 1 (NDC 00810656-01).
50 mg/5 mL single-use vial, Carton of 1 (NDC 00810656-44).
Store the vials under refrigeration at 2 degrees to 8 degrees C (36 degrees to 46 degrees F) in the carton. Protect from light. DO NOT FREEZE.
U.S. Patent No. 4307100
Under license of Pierre Fabre Medicament - Centre National de la Recherche Scientifique-France
Pierre Fabre Medicament
81106 Castres Cedex
for GLAXO WELLCOME INC.
Research Triangle Park, NC 27709
Printed in U.S.A. December 1994 558503