Altretamine

MEDICATION SAFETY ISSUES
High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error.

International issues:
Hexalen®: Brand name for hexetidine in Greece

U.S. BRAND NAMES — Hexalen®

PHARMACOLOGIC CATEGORY
Antineoplastic Agent, Miscellaneous

DOSING: ADULTS — Refer to individual protocols.

Ovarian cancer: Oral: 260 mg/m2/day in 4 divided doses for 14 or 21 days of a 28-day cycle
Alternatively (unlabeled use): 4-12 mg/kg/day in 3-4 divided doses for 21-90 days
Alternatively (unlabeled use): 240-320 mg/m2/day in 3-4 divided doses for 21 days, repeated every 6 weeks
Alternatively (unlabeled use): 150 mg/m2/day in 3-4 divided doses for 14 days of a 28-day cycle

DOSING: ELDERLY — Refer to adult dosing.

DOSING: ADJUSTMENT FOR TOXICITY — Temporarily withhold for 14 days or longer, and resume dose at 200 mg/m2/day for any of the following:
Platelet count <75,000/mm3
White blood cell count <2000/mm3 or granulocyte count <1000/mm3
Progressive neurotoxicity
Gastrointestinal intolerance not responsive to antiemetic regimens

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

Gelcap:
Hexalen®: 50 mg

DOSAGE FORMS: CONCISE
Gelcap:
Hexalen®: 50 mg

GENERIC EQUIVALENT AVAILABLE — No

ADMINISTRATION — Administer total daily dose as 3-4 divided doses after meals and at bedtime.

USE — Palliative treatment of persistent or recurrent ovarian cancer

ADVERSE REACTIONS SIGNIFICANT
>10%:
Central nervous system: Peripheral sensory neuropathy (31%; moderate-to-severe 9%), neurotoxicity (21%; may be progressive and dose limiting)
Gastrointestinal: Nausea/vomiting (33% to 70%; severe 1%), diarrhea (48%)
Hematologic: Anemia (33%), leukopenia (5% to 15%; grade 4: 1%), neutropenia

1% to 10%:
Central nervous system: Fatigue (1%), seizure (1%)
Gastrointestinal: Stomach cramps, anorexia (1%)
Hematologic: Thrombocytopenia (9%)
Hepatic: Alkaline phosphatase increased (9%)

<1% (Limited to important or life-threatening): Alopecia, ataxia, depression, dizziness, hepatotoxicity, mood disorders, pruritus, rash, tremor, vertigo

CONTRAINDICATIONS — Hypersensitivity to altretamine or any component of the formulation; pre-existing severe bone marrow suppression or severe neurologic toxicity; pregnancy

WARNINGS / PRECAUTIONS
Boxed warnings: Bone marrow suppression: . Experienced physician: . Neurotoxicity: .

Special handling: Hazardous agent: Use appropriate precautions for handling and disposal.

Concerns related to adverse effects: Bone marrow suppression: [U.S. Boxed Warning]: Peripheral blood counts should be done routinely before and after drug therapy; bone marrow suppression is common. Use with caution in patients previously treated with other myelosuppressive drugs. Neurotoxicity: [U.S. Boxed Warning]: Neurologic examinations should be done routinely before and after drug therapy; neurotoxicity is common. USe with caution in patients with pre-existing neurotoxicity.

Disease-related concerns: Hepatic impairment: Use with caution in patients with hepatic impairment. Renal impairment: Use with caution in patients with renal impairment.

Special populations: Pediatrics: Safety and efficacy have not been established in children.

Other warnings/precautions: Experienced physician: [U.S. Boxed Warning]: Should be administered under the supervision of an experienced cancer chemotherapy physician.

DRUG INTERACTIONS
Echinacea: May diminish the therapeutic effect of Immunosuppressants. Risk D: Consider therapy modification

Leflunomide: Immunosuppressants may enhance the adverse/toxic effect of Leflunomide. Specifically, the risk for hematologic toxicity such as pancytopenia, agranulocytosis, and/or thrombocytopenia may be increased. Management: Consider not using a leflunomide loading dose in patients receiving other immunosuppressants. Patients receiving both leflunomide and another immunosuppressant should be monitored for bone marrow suppression at least monthly. Risk D: Consider therapy modification

MAO Inhibitors: Altretamine may enhance the orthostatic effect of MAO Inhibitors. Risk C: Monitor therapy

MAO Inhibitors: May enhance the orthostatic effect of Orthostasis Producing Agents. Risk C: Monitor therapy

Natalizumab: Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. Specifically, the risk of concurrent infection may be increased. Risk X: Avoid combination

Pyridoxine: May diminish the therapeutic effect of Altretamine. Specifically when altretamine is used in combination with Cisplatin the response duration may be diminished. Risk D: Consider therapy modification

Trastuzumab: May enhance the neutropenic effect of Immunosuppressants. Risk C: Monitor therapy

Tricyclic Antidepressants: Altretamine may enhance the orthostatic effect of Tricyclic Antidepressants. Risk C: Monitor therapy

Vaccines (Inactivated): Immunosuppressants may diminish the therapeutic effect of Vaccines (Inactivated). Risk C: Monitor therapy

Vaccines (Live): Immunosuppressants may enhance the adverse/toxic effect of Vaccines (Live). Vaccinial infections may develop. Immunosuppressants may diminish the therapeutic effect of Vaccines (Live). Risk X: Avoid combination

PREGNANCY RISK FACTOR — D (show table)

PREGNANCY IMPLICATIONS — Teratogenic effects were noted in animal studies. There are no adequate and well-controlled studies in pregnant women. Women of childbearing potential should avoid becoming pregnant while on therapy.

LACTATION — Excretion in breast milk unknown/not recommended

BREAST-FEEDING CONSIDERATIONS — Due to the potential toxicity in the nursing infant, breast-feeding is not recommended.

DIETARY CONSIDERATIONS — Should be taken after meals at bedtime.

PRICING — (data from drugstore.com)
Capsules (Hexalen)
50 mg (100): $1167.31

MONITORING PARAMETERS — CBC with differential, liver function tests; neurologic examination

CANADIAN BRAND NAMES — Hexalen®

INTERNATIONAL BRAND NAMES — Hexalen (AU, BG, GB, IL, JP, NO, NZ, SE, TH); Hexastat (AR, FR, IT, PT); Hexinawas (ES)

MECHANISM OF ACTION — Although altretamine's clinical antitumor spectrum resembles that of alkylating agents, the drug has demonstrated activity in alkylator-resistant patients. The drug selectively inhibits the incorporation of radioactive thymidine and uridine into DNA and RNA, inhibiting DNA and RNA synthesis; reactive intermediates covalently bind to microsomal proteins and DNA; can spontaneously degrade to demethylated melamines and formaldehyde which are also cytotoxic.

PHARMACODYNAMICS / KINETICS
Absorption: Well absorbed (75% to 89%)

Distribution: Highly concentrated hepatically and renally; low in other organs

Protein binding: 50% to 94%

Metabolism: Hepatic; rapid and extensive demethylation to active metabolites (pentamethylmelamine and tetramethylmelamine)

Half-life elimination: 13 hours

Time to peak, plasma: 0.5-3 hours

Excretion: Urine (90%, <1% as unchanged drug)

PATIENT INFORMATION — Report any numbness or tingling in extremities. Nausea and vomiting may occur.