Nelarabine (Monograph)

Brand name: Arranon
Drug class: Antineoplastic Agents
VA class: AN300
Chemical name: 2-Amino-9-β-D-arabinofuranosyl-6-methoxy-9H-purine
Molecular formula: C₁₁H₁₅N₅O₅
CAS number: 121032-29-9

Introduction

Antimetabolite antineoplastic agent.

Uses for Nelarabine

Acute Lymphocytic Leukemia (ALL)

Treatment of acute T-cell lymphocytic (lymphoblastic) leukemia (ALL) and T-cell lymphoblastic lymphoma in patients whose disease is refractory to or has relapsed after ≥2 prior chemotherapy regimens (designated an orphan drug by FDA for these conditions).

Nelarabine Dosage and Administration

General

• Consult specialized references for procedures for proper handling and disposal of antineoplastics.

• Appropriate measures (e.g., administration of IV fluids, allopurinol, and alkalinization of urine) should be taken to prevent hyperuricemia of tumor lysis syndrome. (See Tumor Lysis Syndrome under Cautions.)

Administration

IV Administration

Administer by IV infusion.

Nelarabine injection should not be diluted prior to administration.

Withdraw appropriate dose from the required number of vials and transfer into empty PVC infusion bags or glass containers prior to administration.

Rate of Administration

Adults: Administer by IV infusion over 2 hours.

Pediatric patients: Administer by IV infusion over 1 hour.

Dosage

Pediatric Patients

Acute Lymphocytic Leukemia

Relapsed or Refractory T-cell ALL or T-cell Lymphoblastic Lymphoma

IV

650 mg/m² daily for 5 consecutive days; repeat every 21 days.

Optimal duration of treatment not established. In clinical studies, treatment was continued until evidence of disease progression, unacceptable toxicity, bone marrow transplantation, or lack of clinical benefit was observed.

Adults

Acute Lymphocytic Leukemia

Relapsed or Refractory T-cell ALL or T-cell Lymphoblastic Lymphoma

IV

1500 mg/m² on days 1, 3, and 5; repeat every 21 days.

Optimal duration of treatment not established. In clinical studies, treatment was continued until evidence of disease progression, unacceptable toxicity, bone marrow transplantation, or lack of clinical benefit was observed.

Special Populations

Hepatic Impairment

No specific dosage recommendations at this time.

Renal Impairment

No dosage adjustment required in patients with mild renal impairment (Cl_cr ≥50 mL/minute); not studied in patients with moderate to severe renal impairment.

Geriatric Patients

No specific dosage recommendations at this time.

Cautions for Nelarabine

Contraindications

• Known hypersensitivity to nelarabine or any ingredient in the formulation.

Warnings/Precautions

Warnings

Adequate Patient Monitoring and Evaluation

Administer only under the supervision of qualified clinicians experienced in the use of cancer chemotherapy agents.

Neurotoxicity

Potentially irreversible and dose-limiting neurotoxicity, usually manifested by somnolence, confusion, seizures, and peripheral neuropathy (ranging from numbness to motor weakness and paralysis). Coma, status epilepticus, craniospinal demyelination, and ascending peripheral neuropathy (similar in presentation to Guillain-Barré syndrome) reported.

Increased risk of neurotoxicity in patients who have received prior or concomitant intrathecal chemotherapy or prior craniospinal irradiation; discontinue therapy in patients experiencing neurologic events of NCI Common Toxicity Criteria grade ≥2.

Fetal/Neonatal Morbidity and Mortality

May cause fetal harm; teratogenicity demonstrated in animals. Avoid pregnancy during therapy; if used during pregnancy or patient becomes pregnant, apprise of potential fetal hazard.

General Precautions

Hematologic Effects

Leukopenia, thrombocytopenia, anemia, and neutropenia reported. Perform CBC, including platelet count, regularly while patient is receiving the drug.

Tumor Lysis Syndrome

May occur as a result of nelarabine therapy; consider measures (e.g., hydration, urinary alkalinization, allopurinol) to prevent hyperuricemia in patients at risk for tumor lysis syndrome.

Immunization

Avoid administration of live virus vaccines during therapy.

Specific Populations

Pregnancy

Category D. (See Fetal/Neonatal Morbidity and Mortality under Cautions.)

Lactation

Not known whether nelarabine or ara-G is distributed into milk; discontinue nursing because of potential risk to nursing infants.

Pediatric Use

Safety and efficacy established in patients 2.5–21 years of age.

Geriatric Use

Possible inreased incidence of neurologic effects compared with younger adults. (See Neurotoxicity under Cautions.)

Hepatic Impairment

Not studied in patients with hepatic impairment; possible increased risk of adverse reactions in patients with severe hepatic impairment (serum bilirubin >3 mg/dL).

Renal Impairment

Possible increased risk of adverse reactions in patients with severe renal impairment (Cl_cr <30 mL/minute).

Common Adverse Effects

In adults: Myelosuppresion, somnolence, dizziness, peripheral neurologic disorders, hypoesthesia, headache, paresthesia, fatigue, pyrexia, asthenia, edema, pain, myalgia, nausea, diarrhea, vomiting, constipation, cough, dyspnea, pleural effusion, petechiae.

In pediatric patients: Myelosuppression, headache, peripheral neurologic disorders, elevated serum transaminase concentrations, hyperbilirubinemia, hypokalemia, hypoalbuminemia, vomiting.

Drug Interactions

Does not appear to inhibit CYP isoenzymes, including 1A2, 2A6, 2B6, 2C8, 2C9, 2C19, 2D6, or 3A4 in vitro.

Specific Drugs

Nelarabine Pharmacokinetics

Distribution

Extent

Extensively distributed throughout the body.

Not known whether nelarabine crosses the placenta or is distributed into milk.

Plasma Protein Binding

<25%.

Elimination

Metabolism

Metabolized to ara-G, principally via O-demethylation by adenosine deaminase; ara-G undergoes further hydrolysis to guanine.

Elimination Route

Nelarabine and ara-G are partially eliminated by the kidneys.

Half-life

Nelarabine: 0.5 hour.

Ara-G: 3 hours.

Special Populations

In pediatric patients, clearance of nelarabine is increased by 30%; ara-G clearance is comparable to that in adults.

Renal impairment may reduce clearance.

In white patients, clearance and volume of distribution of nelarabine increased by 10%; clearance and volume of distribution of ara-G decreased by 15–20% when compared with black patients.

Stability

Storage

Parenteral

Solution

25°C (may be exposed to 15–30°C).

Stable in PVC bags and glass containers at ≤30°C for up to 8 hours.

Actions

• Prodrug of the deoxyguanosine analog ara-G, which is subsequently converted to the active 5′-triphosphate, ara-GTP.

• Ara-GTP accumulates in leukemic blasts and incorporates into DNA, inducing fragmentation and apoptosis.

Advice to Patients

• Risk of neurotoxicity; importance of informing clinician immediately if any changes in mental status, signs and symptoms of peripheral neuropathy (e.g., tingling or numbness in extremities, unsteadiness while walking, difficulty with fine motor coordination, increased tripping, weakness when rising from a low chair or climbing stairs), or seizures occur.

• Risk of sleepiness; avoid driving or operating machinery.

• Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs and dietary or herbal supplements, as well as concomitant illnesses.

• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed; necessity for clinicians to advise women to avoid pregnancy during therapy; advise pregnant women of risk to the fetus.

• Importance of informing patients of other important precautionary information. (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

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