Ifex Side Effects

Generic Name: ifosfamide

Please note - some side effects for Ifex may not be reported. Always consult your doctor or healthcare specialist for medical advice. You may also report side effects to the FDA at http://www.fda.gov/medwatch/ or 1-800-FDA-1088 (1-800-332-1088).

Side Effects of Ifex - for the Consumer

Ifex

All medicines may cause side effects, but many people have no, or minor, side effects. Check with your doctor if any of these most COMMON side effects persist or become bothersome when using Ifex:

Hair loss; loss of appetite; nausea.

Severe allergic reactions (rash; hives; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); abdominal pain; blood in the urine; confusion; cough; dizziness; fever or chills; hallucinations; irregular or absent menstrual periods; joint pain; mood changes; painful or frequent urination; shortness of breath; sleepiness; sore throat; sores on the mouth or lips; unusual bruising or bleeding; unusual fatigue; vomiting; yellowing of the skin or eyes.

Ifex Solution

All medicines may cause side effects, but many people have no, or minor, side effects. Check with your doctor if any of these most COMMON side effects persist or become bothersome when using Ifex Solution:

Hair loss; loss of appetite; nausea.

Severe allergic reactions (rash; hives; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); abdominal pain; blood in the urine; confusion; cough; dizziness; fever or chills; hallucinations; irregular or absent menstrual periods; joint pain; mood changes; painful or frequent urination; shortness of breath; sleepiness; sore throat; sores on the mouth or lips; unusual bruising or bleeding; unusual fatigue; vomiting; yellowing of the skin or eyes.

Ifex Side Effects - for the Professional

Ifex

In patients receiving Ifex as a single agent, the dose-limiting toxicities are myelosuppression and urotoxicity. Dose fractionation, vigorous hydration, and a protector such as mesna can significantly reduce the incidence of hematuria, especially gross hematuria, associated with hemorrhagic cystitis. At a dose of 1.2 g/m2 daily for 5 consecutive days, leukopenia, when it occurs, is usually mild to moderate. Other significant side effects include alopecia, nausea, vomiting, and central nervous system toxicities.

Hematologic Toxicity

Myelosuppression was dose related and dose limiting. It consisted mainly of leukopenia and, to a lesser extent, thrombocytopenia. A WBC count<3000/µL is expected in 50% of the patients treated with Ifex single agent at doses of 1.2 g/m2 per day for 5 consecutive days. At this dose level, thrombocytopenia (platelets <100,000/µL) occurred in about 20% of the patients. At higher dosages, leukopenia was almost universal, and at total dosages of 10-12 g/m2/cycle, one half of the patients had a WBC count below 1000/µL and 8% of patients had platelet counts less than 50,000/µL. Myelosuppression was usually reversible and treatment can be given every 3 to 4 weeks. When Ifex is used in combination with other myelosuppressive agents, adjustments in dosing may be necessary. Patients who experience severe myelosuppression are potentially at increased risk for infection. Anemia has been reported as part of postmarketing surveillance.

Digestive System

Nausea and vomiting occurred in 58% of the patients who received Ifex. They were usually controlled by standard antiemetic therapy. Other gastrointestinal side effects include anorexia, diarrhea, and in some cases, constipation.

Urinary System

Urotoxicity consisted of hemorrhagic cystitis, dysuria, urinary frequency and other symptoms of bladder irritation. Hematuria occurred in 6% to 92% of patients treated with Ifex. The incidence and severity of hematuria can be significantly reduced by using vigorous hydration, a fractionated dose schedule and a protector such as mesna. At daily doses of 1.2 g/m2 for 5 consecutive days without a protector, microscopic hematuria is expected in about one half of the patients and gross hematuria in about 8% of patients.

Renal toxicity occurred in 6% of the patients treated with ifosfamide as a single agent. Clinical signs, such as elevation in BUN or serum creatinine or decrease in creatinine clearance, were usually transient. They were most likely to be related to tubular damage. One episode of renal tubular acidosis which progressed into chronic renal failure was reported. Proteinuria and acidosis also occurred in rare instances. Metabolic acidosis was reported in 31% of patients in one study when Ifex was administered at doses of 2.0 to 2.5 g/m2/day for 4 days. Renal tubular acidosis, Fanconi syndrome, renal rickets, and acute renal failure have been reported. Close clinical monitoring of serum and urine chemistries including phosphorus, potassium, alkaline phosphatase and other appropriate laboratory studies is recommended. Appropriate replacement therapy should be administered as indicated.

Central Nervous System

CNS side effects were observed in 12% of patients treated with Ifex. Those most commonly seen were somnolence, confusion, depressive psychosis, and hallucinations. Other less frequent symptoms include dizziness, disorientation, and cranial nerve dysfunction. Seizures and coma with death were occasionally reported. The incidence of CNS toxicity may be higher in patients with altered renal function.

Other

Alopecia occurred in approximately 83% of the patients treated with Ifex as a single agent. In combination, this incidence may be as high as 100%, depending on the other agents included in the chemotherapy regimen. Increases in liver enzymes and/or bilirubin were noted in 3% of the patients. Other less frequent side effects included phlebitis, pulmonary symptoms, fever of unknown origin, allergic reactions, stomatitis, cardiotoxicity, and polyneuropathy.

Side Effects by Body System

General

In general, the two most common dose-limiting toxicities are myelosuppression and urotoxicity. Most side effects can be minimized by giving fractionated doses, assuring adequate hydration and frequent urination, and using uroprotective agents, such as mesna.

Genitourinary

Ifosfamide is more urotoxic than cyclophosphamide. Dose fractionation, vigorous hydration, frequent bladder emptying, and a protector such as mesna can significantly reduce the incidence of hematuria, especially gross hematuria, that is associated with hemorrhagic cystitis.

The diagnosis of ifosfamide-induced hemorrhagic cystitis is based on (a) a history of gross hematuria; (b) laboratory findings of microscopic hematuria; (c) platelet counts of greater than 50,000/mm3; and (d) lack of significant bacterial growth on urine culture.

Genitourinary side effects have been reported. Genitourinary epithelial cells within the bladder wall are sensitive to 4-OH-ifosfamide and acrolein, urotoxic metabolites that are probably the causative agents of acute, sterile hemorrhagic cystitis. At daily doses of 1.2 g/m2 for 5 consecutive days without mesna protection, microscopic hematuria is expected in approximately 50% to 100% of patients, and gross hematuria in approximately 8% of patients.

Renal

Ifosfamide may induce renal tubular damage, with excessive potassium loss, which has partially been described as Fanconi's syndrome. Mesna does not protect against the development of Fanconi's syndrome or any other renal toxicity. Mesna can be protective only against bladder toxicity.

One study (n=33) has reported histological changes in bladders of patient submitted to ifosfamide chemotherapy, even with mesna prophylaxis. Despite treatment with three doses of mesna, 66.7% of patients presented cystoscopic alterations and 100% showed bladder mucosa microscopic alterations such as edema, exocytosis, and hemorrhage.

Close monitoring of serum and urine chemistries (including phosphorus, potassium, and alkaline phosphatase) are strongly recommended. In addition, some experts recommend urinary beta-2 microglobulin and/or lysozyme studies as precise indicators of renal tubular dysfunction.

Renal side effects including new or worsened (and usually transient) renal insufficiency has been reported in 3% to 7% of patients. Patients with renal carcinoma or underlying renal insufficiency (including poorly hydrated patients) are at increased risk. Other renal side effects include dysuria, urinary frequency, proteinuria, a type II proximal renal tubular acidosis (Fanconi's syndrome), glomerular dysfunction, hemorrhagic cystitis, acute tubular necrosis (ATN) with acute renal failure, nephrogenic diabetes insipidus, and renal rickets.

Hematologic

Erythropoiesis is rarely affected. Myelosuppression is usually reversible.

Hematologic side effects, usually presenting as leukopenia, but occasionally as thrombocytopenia, is usually mild to moderate. A WBC count of less than 3,000/mm3 and a platelet count of less than 100,000/mm3 are expected in 50% and 20% of patients, respectively, treated with 1.2 g/m2/day for 5 days. At higher doses, nearly all patients develop leukopenia, and at total doses of 10 to 12 g/m2/cycle, 50% and 8% of patients develop WBC and platelet counts below 1,000/mm3 and 50,000/mm3, respectively. One case of methemoglobinemia has been reported.

Gastrointestinal

Gastrointestinal side effects may be expected in most patients. Nausea or vomiting has been reported in 60% to 80% of patients receiving standard doses and up to 100% of patients receiving high doses. These problems may be seen a few hours after administration, are typically controlled by good antiemetic therapy, and usually last only up to three days. Other GI side effects include anorexia, diarrhea, constipation, mucositis and stomatitis. Pancreatitis has been reported rarely.

Nervous system

Nervous system side effects have been observed in 5% to 30% of patients, and can be persistent and serious. High doses administered over a short time, preexisting neurologic or renal dysfunction, and low serum albumin appear to be significant risk factors. Most common are hallucinations (may be the sole or first manifestation of neurotoxicity), somnolence, confusion, and depressive psychosis. Less common symptoms include dizziness, disorientation, anxiety, irritability, cranial nerve dysfunction, blurred vision, extrapyramidal signs and polyneuropathy. Seizures and fatal comas have been occasionally associated with high doses (greater than or equal to 2 g/m2) of orally administered ifosfamide. High doses can rarely cause peripheral sensory neuropathies and distal extremity motor dysfunction. CNS toxicity may be more likely in his patients with renal dysfunction.

A byproduct of dechloroethylation of ifosfamide, chloroacetaldehyde, has been associated with CNS toxicity. Chloroacetaldehyde is structurally related to the hypnotic agent chloral hydrate and to aldehyde, a metabolite of ethanol alcohol. Limited and indirect data have shown that the metabolism of ifosfamide after oral administration may produce higher concentrations of chloroacetaldehyde than after intravenous administration. Whether this is due to a first-pass effect is questionable since the bioavailability of ifosfamide approaches 100%, suggestive of insignificant first-pass metabolism.

Limited information suggests the average time to onset of encephalopathy in affected patients is 46 hours (range 12 to 146 hours), and the median duration is 3 days (range 1 to 12 days) if this side effect is promptly recognized and ifosfamide is immediately stopped.

Ifosfamide should be stopped in cases of seizure, stupor, severe weakness, ataxia, irritability, anxiety or coma. Other potentially sedating drugs should be stopped (or minimized if they are necessary).

Hypoalbuminemia, renal impairment, and a short infusion schedule may be associated with an increased incidence of neurotoxicity.

Dermatologic

Hyperpigmentation usually occurs on the dorsal surfaces and plantar surfaces of the hands and feet. It can also be seen on large areas of the trunk. Hyperpigmentation is more common in patients that are dark-skinned, and is often reversible.

Dermatologic side effects include alopecia which has been reported in approximately 74% of patients (ranging from 29% to 100%). Other dermatologic problems include hyperpigmentation, stomatitis, rashes due to (rare) allergic reactions, and enhanced radiation reactions in patients secondary to IV site extravasation.

Hepatic

Hepatic side effects include elevated hepatic transaminases which have been reported in 1% to 3% of patients.

Respiratory

Respiratory system side effects include interstitial pneumonitis, allergic alveolitis, and acute pulmonary edema which have rarely been reported.

Hypersensitivity

Hypersensitivity side effects to ifosfamide are extremely rare.

Cardiovascular

Cardiovascular side effects are rare. Retrospective data from 52 consecutive patients who were given 10 to 18 g/m2 (in combination with carboplatin and etoposide or lomustine and vincristine) reveal evidence of heart failure in 17% associated with objective evidence of decreased cardiac contractility. Limited data have also revealed the development of atrial fibrillation, paroxysmal SVT associated with ischemic changes, premature ventricular depolarizations, tachycardia, and QRS or ST segment prolongations during ifosfamide therapy.

In dogs and rhesus monkeys very high doses of ifosfamide have caused changes in ECG, cardiac histology, and heart function (negative chrono- and inotropic effects).

Endocrine

The case of SIADH was associated with the use of ifosfamide in a patient with adenocarcinoma of the prostate.

Endocrine side effects have included a single case of the syndrome of inappropriate antidiuretic hormone (SIADH).

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