Gemtuzumab Ozogamicin
Pronouncation: (jem-TOOZ-oo-mab OH-zoe-ga-MYE-sin)Class: Monoclonal antibody
Trade Names:
Mylotarg
- Powder for injection, lyophilized 5 mg (protein equivalent) per vial
Pharmacology
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Chemotherapy agent composed of a recombinant humanized immunoglobulin G 4 kappa antibody conjugated with a cytotoxic antitumor antibiotic, calicheamicin, isolated from fermentation of a bacterium. The antibody portion of gemtuzumab ozogamicin binds specifically to the CD33 antigen, which is expressed on the surface of leukemic blasts in patients with acute myeloid leukemia (AML). This ultimately results in DNA double-strand breaks and cell death.
Pharmacokinetics
Absorption
AUC doubles after second dose.
Metabolism
Many metabolites found in liver microsomes, cytosol, and HL-60 promyelocytic leukemia cells.
Elimination
First dose t ½ is about 40 h (total), 140 h (unconjugated). Second dose t ½ is about 60 h (total).
Indications and Usage
CD33-positive AML in first relapse in patients at least 60 yr of age who are not candidates for other antineoplastics.
Contraindications
Standard considerations.
Dosage and Administration
CD33-Positive AML in First Relapse in Patients at Least 60 Yr of Age Who Are Not Candidates for Other AntineoplasticsAdults
IV 9 mg/m 2 /dose for a total of 2 doses, given on days 0 and 14. The second dose may be given in the absence of full hematologic recovery.
General Advice
- Protect reconstituted and diluted solutions from sunlight and unshielded fluorescent light. Turn off the light in the biologic safety hood during preparation; ambient room lights may be left on.
- Allow vial to warm to room temperature before reconstitution.
- Reconstitute vial aseptically with 5ߙmL of sterile water for injection and swirl gently. The final gemtuzumab ozogamicin concentration will be 1 mg/mL.
- Withdraw appropriate dose from vial and dilute in 100 mL sodium chloride 0.9%. Visually inspect the solution for particulates and discoloration.
- Administer by IV infusion over 2 h. Do not administer as an IV push or bolus.
- Administer through a separate IV line with a low protein-binding 1.2 micron terminal filter.
Storage/Stability
After reconstitutionTotal max time allowed for storage of reconstituted and diluted solution and completion of infusion is 20 h, consisting of reconstitution at 2 h or less at room temperature or refrigeration, dilution at 16 h or less at room temperature, and administration over a 2-h infusion.
Store unopened vials in refrigerator (36° to 46°F). Protect from light.
Drug Interactions
Coadministration of drugs with similar pharmacologic effects may cause additive adverse reactions, including toxicity.
Laboratory Test Interactions
None well documented.
Adverse Reactions
Cardiovascular
Hypotension (20%); hypertension (16%); hemorrhage (11%); tachycardia (10%); venoocclusive disease (5%).
CNS
Headache (37%); dizziness, insomnia (12%); depression (9%); anxiety (8%).
Dermatologic
Cutaneous herpes simplex (21%); rash (18%); pruritus (6%).
EENT
Epistaxis (28%); pharyngitis (12%); rhinitis (8%).
GI
Nausea (68%); vomiting (58%); diarrhea (32%); anorexia, oral mucositis, stomatitis (25%); constipation (23%); dyspepsia (10%); gum hemorrhage (9%).
Genitourinary
Vaginal hemorrhage (4%); metrorrhagia (3%).
Hematologic-Lymphatic
Thrombocytopenia (treatment phase: 99% experienced grade 3 or 4; treatment emergent: 49% experienced grade 3 or 4); neutropenia (treatment phase: 98% experienced grade 3 or 4); anemia (treatment phase: 52% experienced grade 3 or 4; treatment emergent: 14% experienced grade 3 or 4); leukopenia (47%); petechiae (19%); neutropenic fever (17%); ecchymosis (10%).
Hepatic
Hyperbilirubinemia (29%); abnormal LFTs (24%); elevated AST (18%); elevated ALT (9%).
Metabolic-Nutritional
Hypokalemia (26%); increased LDH (16%); peripheral edema (14%); bilirubinemia (12%); hyperglycemia, hypocalcemia (10%); hypophosphatemia, increased alkaline phosphatase (8%); hypomagnesemia (6%).
Musculoskeletal
Back pain (14%); myalgia (6%).
Respiratory
Dyspnea (26%); increased cough (17%); pneumonia (13%); pulmonary physical findings (9%).
Miscellaneous
Fever (82%); chills (66%); asthenia (36%); abdominal pain (32%); infection (treatment phase: 30% experienced grade 3 or 4; treatment emergent: 9%); sepsis (26%); local reaction (22%); pain (18%); neutropenic fever (17%); bleeding events (treatment phase: 13% experienced grade 3 or 4); hypoxia (5%).
Precautions
WarningsAdministrationAdminister under supervision of a health care provider experienced in treatment of acute leukemia and in facilities equipped to monitor and treat such patients. Hypersensitivity/AnaphylaxisSevere hypersensitivity (including anaphylaxis) and other infusion-related reactions, including severe pulmonary reactions, may occur. Infrequently, these events may be fatal. In most cases, infusion-related symptoms occur during the infusion or within 24 h of administration. Monitor patients until all signs and symptoms completely resolve. Consider discontinuation of therapy for patients who develop anaphylaxis, pulmonary edema, or acute respiratory distress syndrome. Patients with high peripheral blast counts may be at greater risk for pulmonary reactions and tumor lysis syndrome. Consider leukoreduction prior to administration for patients with high peripheral blast counts. HepatotoxicitySevere and sometimes fatal hepatic venoocclusive disease has been reported with use. Increased risk in patients with hematopoietic stem-cell transplants, underlying liver disease, or abnormal liver function, and in patients receiving adjunctive chemotherapy. MyelosuppressionSevere myelosuppression will occur in all patients given the recommended dose of this agent. Careful hematologic monitoring is required. |
MonitorMonitor vital signs during infusion and for 4 h following infusion. Monitor electrolytes, hepatic function, CBCs, and platelet counts during therapy. |
Pregnancy
Category D .
Lactation
Undetermined. Because many drugs, including immunoglobulins, are excreted in breast milk, and because of the potential for serious adverse reactions in breast-feeding infants from gemtuzumab ozogamicin, decide whether to discontinue breast-feeding or the drug, taking into account the importance of the drug to the mother.
Children
Safety and efficacy not studied.
Renal Function
Not studied in adult patients with renal function impairment. Use with caution.
Hepatic Function
Not studied in patients with a bilirubin more than 2 mg/dL. Use with caution. Exercise caution when administering in patients with hepatic function impairment.
Infusion reactions
Infusion may be slowed or continued at the same rate if patient experiences a reaction. Interrupt infusion for dyspnea or profound hypotension. Symptoms may be treated with diphenhydramine (eg, Benadryl ), acetaminophen (eg, Tylenol ), bronchodilators, or IV fluids. Monitor the patient until symptoms resolve completely. Patients who react to the initial infusion may receive a second dose. Infusion duration may be increased at the health care provider's discretion.
Pretreatment regimens
Reduce incidence of infusion reactions with premedication. Give acetaminophen 650 to 1,000 mg (oral or rectal) and diphenhydramine 50 mg (oral or IV) 60 min before administering gemtuzumab ozogamicin.
Tumor lysis syndrome
May be a consequence of leukemia treatment. Take appropriate measures (eg, allopurinol, hydration) to prevent hyperuricemia.
Overdosage
Symptoms
No cases of overdose have been reported. Signs of overdose are unknown.
Patient Information
- Advise patient, family, or caregiver that medication will be prepared and administered by health care provider in a health care setting.
- Review dosing schedule with patient, family, or caregiver.
- Advise patient, family, or caregiver that additional medications will be given before administration to reduce adverse reactions of gemtuzumab.
- Advise patient, family, or caregiver to immediately report any of the following symptoms to health care provider: rash; difficulty breathing; fever, chills, or other signs of infection; sores in mouth; unusual bleeding or bruising.
- Advise patient, family, or caregiver to report any of the following symptoms to health care provider: persistent nausea, vomiting, diarrhea, or appetite loss; persistent or worsening general body weakness.
- Caution patient not to take any prescription or OTC medications, herbal preparations, or dietary supplements unless advised by health care provider.
- Advise women to avoid becoming pregnant while being treated.
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