(me klor ETH a meen)
- Chlorethazine Mustard
- Mechlorethamine Hydrochloride
- Nitrogen Mustard
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution Reconstituted, Injection, as hydrochloride:
Mustargen: 10 mg (1 ea)
Brand Names: U.S.
- Antineoplastic Agent, Alkylating Agent
- Antineoplastic Agent, Alkylating Agent (Nitrogen Mustard)
Bifunctional alkylating agent that inhibits DNA and RNA synthesis via formation of carbonium ions; produces interstrand and intrastrand cross-links in DNA resulting in miscoding, breakage, and failure of replication. Although not cell phase-specific per se, mechlorethamine effect is most pronounced in the S phase, and cell proliferation is arrested in the G2 phase.
Rapid hydrolysis in the plasma to active metabolites (Perry, 2012)
15-20 minutes (Perry, 2012)
Use: Labeled Indications
Hodgkin lymphoma: Palliative treatment of Hodgkin lymphoma
Malignant effusion: Palliative treatment of effusions from metastatic carcinomas
Additional approved uses (manufacturer labeling): Treatment of lymphosarcoma, chronic myelocytic or chronic lymphocytic leukemia, polycythemia vera, mycosis fungoides, and bronchogenic carcinoma
Hypersensitivity to mechlorethamine or any component of the formulation; presence of known infection
Dosage should be based on ideal dry weight (evaluate the presence of edema or ascites so that dosage is based on actual weight unaugmented by edema/ascites). Mechlorethamine is associated with a high emetic potential (Hesketh 2017; Roila 2016); antiemetics are recommended to prevent nausea and vomiting
Hodgkin lymphoma (off-label dosing): IV:
MOPP regimen: 6 mg/m2 on days 1 and 8 of a 28-day treatment cycle for 6 to 8 cycles (Canelos, 1992; DeVita, 1970)
Stanford V regimen: 6 mg/m2 as a single dose on day 1 in weeks 1, 5, and 9 (Horning, 2000; Horning, 2002)
Malignant effusion: Intracavitary: 0.4 mg/kg as a single dose; although 0.2 mg/kg (10-20 mg) as a single dose has been used by the intrapericardial route
Refer to adult dosing.
Dosing: Renal Impairment
No dosage adjustment provided in manufacturer’s labeling.
Dosing: Hepatic Impairment
No dosage adjustment provided in manufacturer’s labeling.
The following have also been reported:
Mild-to-moderate impairment: No dosage adjustment necessary (Ecklund, 2005).
Severe liver impairment: No dosage adjustment necessary; concomitant chemotherapy may require alteration until improvement in hepatic function (Ecklund, 2005)
ASCO Guidelines for appropriate chemotherapy dosing in obese adults with cancer: In general, utilize patient’s actual body weight (full weight) for calculation of body surface area- or weight-based dosing, particularly when the intent of therapy is curative; manage regimen-related toxicities in the same manner as for nonobese patients; if a dose reduction is utilized due to toxicity, consider resumption of full weight-based dosing with subsequent cycles, especially if cause of toxicity (eg, hepatic or renal impairment) is resolved (Griggs, 2012). Note: The manufacturer recommends dosing be based on ideal dry body weight and the presence of edema or ascites should be considered so the dose will be based on unaugmented weight.
Must be prepared immediately before use; degradation begins shortly after dilution. Dilute powder with 10 mL SWFI or NS to a final concentration of 1 mg/mL. May be further diluted in 50-100 mL NS for intracavitary administration.
IV: Administer as a slow IV push over a few minutes into a free-flowing IV solution. Mechlorethamine is associated with a high emetic potential (Dupuis 2011; Hesketh 2017; Roila 2016); antiemetics are recommended to prevent nausea and vomiting.
Intracavitary: May further dilute in 50-100 mL of normal saline prior to instillation; rotate patient position every 5-10 minutes for 1 hour after instillation to obtain uniform distribution.
Prepare immediately prior to administration.
Vesicant; ensure proper needle or catheter placement prior to and during infusion; avoid extravasation.
Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity.
Sodium thiosulfate 1/6 M solution: Inject subcutaneously into extravasation area using 2 mL for each mg of mechlorethamine suspected to have extravasated (Perez Fidalgo, 2012; Polovich, 2009). Apply ice for 6-12 hours after sodium thiosulfate administration (Mustargen prescribing information, 2013; Polovich, 2009) or may apply dry cold compresses for 20 minutes 4 times daily for 1-2 days (Perez Fidalgo, 2012).
Store intact vials at room temperature of 15°C to 30°C (59°F to 86°F). Protect from light. Protect from humidity. Must be prepared immediately before use; degradation begins shortly after dilution.
BCG (Intravesical): Immunosuppressants may diminish the therapeutic effect of BCG (Intravesical). Avoid combination
BCG (Intravesical): Myelosuppressive Agents may diminish the therapeutic effect of BCG (Intravesical). Avoid combination
Chloramphenicol (Ophthalmic): May enhance the adverse/toxic effect of Myelosuppressive Agents. Monitor therapy
CloZAPine: Myelosuppressive Agents may enhance the adverse/toxic effect of CloZAPine. Specifically, the risk for neutropenia may be increased. Monitor therapy
Coccidioides immitis Skin Test: Immunosuppressants may diminish the diagnostic effect of Coccidioides immitis Skin Test. Monitor therapy
Deferiprone: Myelosuppressive Agents may enhance the neutropenic effect of Deferiprone. Avoid combination
Denosumab: May enhance the adverse/toxic effect of Immunosuppressants. Specifically, the risk for serious infections may be increased. Monitor therapy
Dipyrone: May enhance the adverse/toxic effect of Myelosuppressive Agents. Specifically, the risk for agranulocytosis and pancytopenia may be increased Avoid combination
Echinacea: May diminish the therapeutic effect of Immunosuppressants. Consider therapy modification
Fingolimod: Immunosuppressants may enhance the immunosuppressive effect of Fingolimod. Management: Avoid the concomitant use of fingolimod and other immunosuppressants when possible. If combined, monitor patients closely for additive immunosuppressant effects (eg, infections). 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. Consider therapy modification
Lenograstim: Antineoplastic Agents may diminish the therapeutic effect of Lenograstim. Management: Avoid the use of lenograstim 24 hours before until 24 hours after the completion of myelosuppressive cytotoxic chemotherapy. Consider therapy modification
Lipegfilgrastim: Antineoplastic Agents may diminish the therapeutic effect of Lipegfilgrastim. Management: Avoid concomitant use of lipegfilgrastim and myelosuppressive cytotoxic chemotherapy. Lipegfilgrastim should be administered at least 24 hours after the completion of myelosuppressive cytotoxic chemotherapy. Consider therapy modification
Natalizumab: Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. Specifically, the risk of concurrent infection may be increased. Avoid combination
Nivolumab: Immunosuppressants may diminish the therapeutic effect of Nivolumab. Consider therapy modification
Ocrelizumab: May enhance the immunosuppressive effect of Immunosuppressants. Monitor therapy
Palifermin: May enhance the adverse/toxic effect of Antineoplastic Agents. Specifically, the duration and severity of oral mucositis may be increased. Management: Do not administer palifermin within 24 hours before, during infusion of, or within 24 hours after administration of myelotoxic chemotherapy. Consider therapy modification
Pidotimod: Immunosuppressants may diminish the therapeutic effect of Pidotimod. Monitor therapy
Pimecrolimus: May enhance the adverse/toxic effect of Immunosuppressants. Avoid combination
Promazine: May enhance the myelosuppressive effect of Myelosuppressive Agents. Monitor therapy
Roflumilast: May enhance the immunosuppressive effect of Immunosuppressants. Consider therapy modification
Sipuleucel-T: Immunosuppressants may diminish the therapeutic effect of Sipuleucel-T. Monitor therapy
Tacrolimus (Topical): May enhance the adverse/toxic effect of Immunosuppressants. Avoid combination
Tertomotide: Immunosuppressants may diminish the therapeutic effect of Tertomotide. Monitor therapy
Tofacitinib: Immunosuppressants may enhance the immunosuppressive effect of Tofacitinib. Management: Concurrent use with antirheumatic doses of methotrexate or nonbiologic disease modifying antirheumatic drugs (DMARDs) is permitted, and this warning seems particularly focused on more potent immunosuppressants. Consider therapy modification
Trastuzumab: May enhance the neutropenic effect of Immunosuppressants. Monitor therapy
Vaccines (Inactivated): Immunosuppressants may diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting an immunosuppressant. If vaccinated during immunosuppressant therapy, revaccinate at least 3 months after immunosuppressant discontinuation. Consider therapy modification
Vaccines (Live): Immunosuppressants may enhance the adverse/toxic effect of Vaccines (Live). Immunosuppressants may diminish the therapeutic effect of Vaccines (Live). Management: Avoid use of live organism vaccines with immunosuppressants; live-attenuated vaccines should not be given for at least 3 months after immunosuppressants. Avoid combination
Frequency not defined.
Cardiovascular: Local thrombophlebitis
Central nervous system: Brain disease (high dose), drowsiness, headache, lethargy, metallic taste, sedation, vertigo
Dermatologic: Alopecia, diaphoresis, erythema multiforme, maculopapular rash, skin rash
Endocrine & metabolic: Amenorrhea, hyperuricemia, oligomenorrhea
Gastrointestinal: Anorexia, diarrhea, mucositis, nausea, vomiting
Genitourinary: Inhibition of spermatogenesis
Hematologic & oncologic: Agranulocytosis, granulocytopenia (onset: 6 to 8 days; recovery: 10 to 21 days), hemolytic anemia, leukopenia, lymphocytopenia, pancytopenia, petechia, thrombocytopenia
Hypersensitivity: Anaphylaxis, hypersensitivity reaction
Infection: Herpes zoster
Neuromuscular & skeletal: Weakness
Otic: Deafness, tinnitus
Miscellaneous: Fever, tissue necrosis (extravasation)
Concerns related to adverse effects:
• Bone marrow suppression: May cause lymphopenia, leukopenia, granulocytopenia, thrombocytopenia and anemia. Agranulocytopenia may occur (rare); persistent pancytopenia has been reported. Monitor blood counts. Bleeding due to thrombocytopenia may occur. Use with caution in patients where neoplasm has bone marrow involvement or in those who have received prior myelosuppressive chemotherapy; marrow function may be further compromised (possibly fatal). Bone marrow function should recover after mechlorethamine administration prior to initiating radiation therapy or other chemotherapy regimens.
• Extravasation: [US Boxed Warning]: Mechlorethamine is a potent vesicant; extravasation results in painful inflammation with induration and sloughing. If extravasation occurs, promptly manage by infiltrating area with 1/6 molar sodium thiosulfate solution, followed by dry cold compresses for 6 to 12 hours. Ensure proper needle or catheter placement prior to and during infusion. Avoid extravasation.
• Fertility effects: Impaired spermatogenesis, azoospermia, and total germinal aplasia may occur in male patients treated with mechlorethamine, particularly when used in combination with other chemotherapy agents. Delayed menses, oligomenorrhea, or temporary or permanent amenorrhea may be observed in female patients treated with mechlorethamine.
• Gastrointestinal toxicities: Mechlorethamine is associated with a high emetic potential (Dupuis 2011; Hesketh 2017; Roila 2016); antiemetics are recommended to prevent nausea and vomiting.
• Hypersensitivity: Hypersensitivity reactions, including anaphylaxis, have been reported.
• Immunosuppression: Mechlorethamine has immunosuppressant properties. May predispose patients to infections (bacterial, viral, or fungal).
• Secondary malignancies: Alkylating agents, including mechlorethamine, are associated with in increased incidence of secondary malignancies; concurrent radiation therapy or combination chemotherapy may increase the risk.
• Tumor lysis syndrome: Hyperuricemia may occur, especially with lymphomas; ensure adequate hydration; consider antihyperuricemic therapy if appropriate.
• Chronic lymphocytic leukemia (CLL): Bone marrow failure and other toxicities are more common in CLL; in general, mechlorethamine is no longer used in the treatment of CLL.
• Nonresponding tumors: Bone and nervous system tumors typically respond poorly to treatment with mechlorethamine. The routine use of mechlorethamine in widely disseminated tumors is discouraged.
Concurrent drug therapy issues:
• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
• Pregnancy: [US Boxed Warning]: Avoid exposure during pregnancy.
• Hazardous agent: [US Boxed Warning]: Mechlorethamine is a highly toxic nitrogen mustard; avoid inhalation of vapors or dust; review and follow special handling procedures. Avoid dust or vapor contact with skin or eyes. If accidental skin exposure occurs, wash/irrigate thoroughly with water for at least 15 minutes, followed by 2% sodium thiosulfate solution; remove and destroy any contaminated clothing. If exposure to eye(s) occurs, promptly irrigate for at least 15 minutes with copious amounts of water, normal saline, or balanced salt ophthalmic irrigating solution; obtain ophthalmology consultation. The manufacturer recommends neutralizing remaining unused mechlorethamine, empty or partial vials, gloves, tubing, glassware, etc., after mechlorethamine administration; soak in an aqueous solution containing equal volumes of sodium thiosulfate (5%) and sodium bicarbonate (5%) for 45 minutes; rinse with water; dispose of properly.
• Experienced physician: [US Boxed Warning]: Should be administered under the supervision of an experienced cancer chemotherapy physician.
CBC with differential and platelet count; renal and hepatic function; signs/symptoms of hypersensitivity reactions, infection, and extravasation
Pregnancy Risk Factor
Adverse events have been observed in animal reproduction studies. Women of childbearing potential are advised not to become pregnant during treatment. [U.S. Boxed Warning]: Avoid exposure during pregnancy.
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience diarrhea, lack of appetite, nausea, or vomiting. Have patient report immediately to prescriber signs of infection, signs of bleeding (vomiting blood or vomit that looks like coffee grounds; coughing up blood; hematuria; black, red, or tarry stools; bleeding from the gums; abnormal vaginal bleeding; bruises without a reason or that get bigger; or any severe or persistent bleeding),severe loss of strength and energy, or severe injection site redness, burning, edema, pain, or irritation (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.
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- Drug class: alkylating agents
Other brands: Mustargen