Alitretinoin (Topical) (Monograph)

Brand name: Panretin
Drug class: Antiproliferants

Medically reviewed by Drugs.com on May 10, 2024. Written by ASHP.

Introduction

A vitamin A derivative; naturally occurring endogenous retinoid with topical antineoplastic activity.^{1 2 16 17}

Uses for Alitretinoin (Topical)

AIDS-related Kaposi’s Sarcoma

Treatment of cutaneous lesions associated with AIDS-related Kaposi’s sarcoma.^{1 3 4 9 10 11 14 15 16 17 18}

Not recommended for treatment of systemic AIDS-related Kaposi’s sarcoma, characterized by ≥10 new lesions in the prior month, symptomatic lymphedema, symptomatic pulmonary Kaposi’s sarcoma, or symptomatic visceral disease.¹

No clinical experience to date in patients receiving systemic therapy for Kaposi’s sarcoma.¹

Alitretinoin (Topical) Dosage and Administration

Administration

Topical Administration

Apply topically to skin.¹

Wait 20 minutes after bathing or showering before applying gel; avoid use of occlusive dressings or wrappings.^{1 18}

Avoid contact with healthy skin or mucous membranes (e.g., eyes, nostrils, mouth, lips, vagina, tip of penis, rectum, anus); irritation may occur.^{1 2 18}

Allow gel to dry for 3–5 minutes before covering treated area with clothing.¹

If possible, do not bathe, shower, or swim for at least 3 hours after application.¹⁸

If application-site toxicity occurs, reduce application frequency.¹

If severe irritation occurs, discontinue temporarily until manifestations subside.¹

Dosage

Adults

AIDS-related Kaposi’s Sarcoma

Topical

Initially, apply twice daily in sufficient amounts (to cover only affected areas).¹ May increase application frequency gradually to 3 and then 4 times daily, according to individual lesion tolerance.¹

In some patients, appreciable response occurred only after ≥14 weeks of therapy.¹

Continue therapy as long as the patient derives benefit¹ (has been applied for up to 175 weeks in clinical trials).¹⁹

Cautions for Alitretinoin (Topical)

Contraindications

• Known hypersensitivity to retinoids or any ingredient in the formulation.¹

Warnings/Precautions

Warnings

Fetal/Neonatal Morbidity and Mortality

May cause fetal harm; teratogenicity and embryotoxicity demonstrated in animals receiving oral alitretinoin.¹ No reproduction studies in animals with topical alitretinoin.^{1 12}

No adequate and well-controlled studies in humans.¹ Avoid pregnancy during therapy.¹ If used during pregnancy, apprise of potential hazard to the fetus.¹

Sensitivity Reactions

Photosensitivity

Retinoids associated with photosensitivity; in vitro data indicate alitretinoin may have weak photosensitizing effect.¹

Minimize exposure of treated areas to natural or artificial (e.g., sunlamps) sunlight.¹

Major Toxicities

Dermatologic Effects

Possible severe local skin reactions (e.g., intense erythema, edema, vesiculation).¹ Patients with cutaneous T-cell lymphoma exhibit less tolerance to these effects than those with Kaposi’s sarcoma.¹

Specific Populations

Pregnancy

Category D.¹ (See Fetal/Neonatal Morbidity and Mortality under Cautions.)

Lactation

Not known whether alitretinoin or its metabolites are distributed into milk; discontinue nursing due to risk in nursing infants.¹

Pediatric Use

Safety and efficacy not established in children <18 years of age.¹

Geriatric Use

Insufficient clinical experience in patients ≥65 years of age to determine whether they respond differently than younger adults.¹

Common Adverse Effects

Rash,¹ pruritus,¹ exfoliative dermatitis,¹ skin disorders (excoriation,¹ cracking,¹ scabbing,¹ crusting,¹ drainage,¹ eschar,¹ fissure,¹ oozing¹ ), pain,¹ paresthesia,¹ edema.¹

Drug Interactions

Metabolized by CYP2C9, CYP3A4, CYP1A1, and CYP1A2.¹

No data available on interactions between topical alitretinoin and systemically administered drugs for Kaposi’s sarcoma.¹

Specific Drugs

Alitretinoin (Topical) Pharmacokinetics

Absorption

Bioavailability

Not substantially absorbed systemically following topical application.^{1 9 17}

Following repeated, multiple-daily-dose topical applications of alitretinoin (9-cis-retinoic acid) in patients with cutaneous lesions associated with Kaposi’s sarcoma, plasma concentrations of 9-cis-retinoic acid were similar to those of naturally occurring 9-cis-retinoic acid found in healthy untreated patients.^{1 9 17}

Distribution

Extent

Not known whether alitretinoin or its metabolites are distributed into milk.¹

Elimination

Metabolism

Alitretinoin metabolized to 4-hydroxy-9-cis-retinoic acid and 4-oxo-9-cis-retinoic acid by CYP2C9, CYP3A4, CYP1A1, and CYP1A2 in vitro; major circulating metabolite in vivo following oral alitretinoin is 4-oxo-9-cis-retinoic acid.¹

Elimination Route

Principally by metabolism; no unchanged drug excreted in urine.^b

Half-life

1.3–2.4 hours following oral administration.^b

Stability

Storage

Topical

Gel

25°C (may be exposed to 15–30°C).¹

Actions

• Binds to and activates both intracellular retinoic acid receptors (RAR) (e.g., RARα, RARβ, RARγ) and retinoid X receptors (RXR) (e.g., RXRα, RXRβ, RXRγ) that appear to enhance gene transcription.^{1 2 5 6 7 14 16 17}

• Exact mechanism of action in Kaposi’s sarcoma not fully elucidated; appears to affect expression of genes that inhibit cell proliferation, induce cell differentiation, and trigger apoptosis in both healthy and cancer cells.^{1 2 8 12 13 16 17}

• In vitro, alitretinoin appears to inhibit Kaposi’s sarcoma cell growth.¹

Advice to Patients

• Provide patients with a copy of manufacturer’s patient information.¹⁸

• Describe risk of photosensitivity and associated precautions.¹

• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.^{1 18} Necessity of advising women to avoid pregnancy during therapy.^{1 18}

• Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses.¹

• Importance of informing patients of other important precautionary information.¹ (See Cautions.)

Additional Information

The American Society of Health-System Pharmacists, Inc. represents that the information provided in the accompanying monograph was formulated with a reasonable standard of care, and in conformity with professional standards in the field. Readers are advised that decisions regarding use of drugs are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and that the information contained in the monograph is provided for informational purposes only. The manufacturer’s labeling should be consulted for more detailed information. The American Society of Health-System Pharmacists, Inc. does not endorse or recommend the use of any drug. The information contained in the monograph is not a substitute for medical care.

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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