(MEL fa lan)
- L-Phenylalanine Mustard
- Melphalan HCl
- Melphalan Hydrochloride
- Phenylalanine Mustard
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution Reconstituted, Intravenous:
Alkeran: 50 mg (1 ea) [contains alcohol, usp, propylene glycol]
Evomela: 50 mg (1 ea)
Generic: 50 mg (1 ea)
Solution Reconstituted, Intravenous [preservative free]:
Generic: 50 mg (1 ea)
Alkeran: 2 mg
Brand Names: U.S.
- Antineoplastic Agent, Alkylating Agent
- Antineoplastic Agent, Alkylating Agent (Nitrogen Mustard)
Alkylating agent which is a derivative of mechlorethamine that inhibits DNA and RNA synthesis via formation of carbonium ions; cross-links strands of DNA; acts on both resting and rapidly dividing tumor cells.
Oral: Variable and incomplete
Vd: 0.5 L/kg; Evomela: Penetrates CSF; Alkeran: Low penetration into CSF
Hepatic; chemical hydrolysis to monohydroxymelphalan and dihydroxymelphalan
Oral: Feces (20% to 50%); urine (~10% as unchanged drug)
Time to Peak
Serum: Oral: ~1 to 2 hours
Terminal: IV: ~75 minutes; Oral: 1.5 ± 0.83 hours
~50% to 92%; primarily to albumin (~40% to 60%), ~20% to alpha1-acid glycoprotein
Special Populations: Renal Function Impairment
A decrease in estimated creatinine clearance from 100 mL/minute to 30 mL/minute results in 28.2% reduction in clearance for a person with an ideal body weight (IBW) of 70 kg receiving IV melphalan.
Special Populations Note
Body weight: A patient with an IBW of 45 kg receiving IV melphalan has a 28% decrease in clearance relative to a patient with IBW of 70 kg, while a patient with an IBW of 100 kg has a 31% increase in clearance as compared to a patient with an IBW of 70 kg.
Use: Labeled Indications
Multiple myeloma: Palliative treatment of multiple myeloma (injection [Alkeran and Evomela] and tablets); high-dose conditioning treatment prior to hematopoietic stem cell transplantation (HSCT) (Evomela only).
Ovarian cancer: Palliative treatment of nonresectable epithelial ovarian carcinoma (tablets)
Hypersensitivity to melphalan or any component of the formulation; patients whose disease was resistant to prior melphalan therapy (Alkeran only).
Note: Intravenous melphalan is available in different formulations. Indications for use, product preparation, storage, and dosing differ between formulations. Use caution when selecting melphalan formulations for preparation and administration. Do not mix or combine the formulations. Melphalan is associated with a moderate emetic potential (depending on dose and/or administration route); antiemetics may be recommended to prevent nausea and vomiting. Adjust dose based on patient response and weekly blood counts.
Multiple myeloma (conditioning regimen prior to hematopoietic stem cell transplantation): IV (Evomela only): 100 mg/m2 daily for 2 days on day -3 and day -2 prior to autologous stem cell transplantation on day 0 (Hari 2015). Note: Per the manufacturer, if patients weigh more than 130% of their ideal body weight, body surface area should be calculated using adjusted ideal body weight.
Multiple myeloma conditioning regimen for autologous hematopoietic stem cell transplantation (off-label doses): IV:
200 mg/m2 alone 2 days prior to transplantation (Fermand 2005; Moreau 2002) or
140 mg/m2 2 days prior to transplantation (combined with busulfan) (Fermand 2005) or
140 mg/m2 2 days prior to transplantation (combined with total body irradiation [TBI]) (Moreau 2002) or
140 mg/m2 5 days prior to transplantation (combined with TBI) (Barlogie 2006)
Multiple myeloma (palliative treatment): Note: Response is gradual; may require repeated courses to realize benefit:
Oral: Usual dose (as described in the manufacturer’s labeling):
6 mg once daily for 2 to 3 weeks initially, followed by up to 4 weeks rest, then a maintenance dose of 2 mg daily as hematologic recovery begins or
10 mg daily for 7 to 10 days; institute 2 mg daily maintenance dose after WBC >4,000 cells/mm3 and platelets >100,000 cells/mm3 (~4 to 8 weeks); titrate maintenance dose to hematologic response or
0.15 mg/kg/day for 7 days, with a 2 to 6 week rest, followed by a maintenance dose of ≤0.05 mg/kg/day as hematologic recovery begins or
0.25 mg/kg/day for 4 days (or 0.2 mg/kg/day for 5 days); repeat at 4- to 6-week intervals as ANC and platelet counts return to normal
Other dosing regimens in combination therapy (off-label doses):
4 mg/m2/day for 7 days every 4 weeks (in combination with prednisone or with prednisone and thalidomide) (Palumbo 2006; Palumbo 2008) or
6 mg/m2/day for 7 days every 4 weeks (in combination with prednisone) (Palumbo 2004) or
0.25 mg/kg/day for 4 days every 6 weeks (in combination with prednisone [Facon 2006; Facon 2007] or with prednisone and thalidomide [Facon 2007]) or
9 mg/m2/day for 4 days every 6 weeks (in combination with prednisone or with prednisone and bortezomib) (Dimopoulos 2009; San Miguel 2008)
IV (Alkeran and Evomela): 16 mg/m2 administered at 2-week intervals for 4 doses, then administer at 4-week intervals after adequate hematologic recovery.
Ovarian cancer: Oral: 0.2 mg/kg/day for 5 days, repeat every 4 to 5 weeks or
Off-label dosing: 7 mg/m2/day in 2 divided doses for 5 days, repeat every 28 days (Wadler 1996)
Amyloidosis, light chain (off-label use): Oral: 0.22 mg/kg/day for 4 days every 28 days (in combination with oral dexamethasone) (Palladini 2004) or 10 mg/m2/day for 4 days every month (in combination with oral dexamethasone) for 12 to 18 treatment cycles (Jaccard 2007)
Hodgkin lymphoma, relapsed/refractory (off-label use): IV: 30 mg/m2 over 15 minutes on day 6 (in combination with carmustine, etoposide, and cytarabine [mini-BEAM regimen]); repeat cycle every 4 to 6 weeks (Colwill 1995; Martin 2001)
Refer to adult dosing. Use caution and begin at the lower end of dosing range.
Note: Intravenous melphalan is available in different formulations. Indications for use, product preparation, storage, and dosing differ between formulations. Use caution when selecting melphalan formulations for preparation and administration. Do not mix or combine the formulations. Melphalan is associated with a moderate emetic potential (depending on dose and/or administration route); antiemetics may be recommended to prevent nausea and vomiting (Dupuis 2011).
Conditioning regimen for autologous hematopoietic stem cell transplantation (off-label use): IV:
140 mg/m2 2 days prior to transplantation (combined with busulfan) (Canete 2009) or
180 mg/m2 (with pre- and posthydration) 12 to 30 hours prior to transplantation (Pritchard 2005) or
45 mg/m2/day for 4 days starting 8 days prior to transplantation (combined with busulfan or etoposide and carboplatin) (Berthold 2005)
Dosing: Renal Impairment
The manufacturer's labeling contains the following adjustment recommendations (for approved dosing levels) based on route of administration:
Oral: Moderate to severe renal impairment: Consider a reduced dose initially.
Conditioning regimen for multiple myeloma: No dosage adjustment is necessary.
Palliative treatment of multiple myeloma: BUN ≥30 mg/dL: Reduce dose by up to 50%.
Hemodialysis: Melphalan is not removed (to any significant degree) by hemodialysis.
The following adjustments have also been recommended:
Aronoff 2007: Adults: Oral (based on a 6 mg once-daily dose):
CrCl 10 to 50 mL/minute: Reduce dose to 75% of normal dose.
CrCl <10 mL/minute: Reduce dose to 50% of normal dose.
Hemodialysis: Administer dose after hemodialysis.
Continuous ambulatory peritoneal dialysis (CAPD): Reduce dose to 50% of normal dose.
Continuous renal replacement therapy (CRRT): Reduce dose to 75% of normal dose.
Carlson 2005: Oral (for melphalan-prednisone combination therapy; based on a study evaluating toxicity with melphalan dosed at 0.25 mg/kg/day for 4 days/cycle):
CrCl >10 to <30 mL/minute: Reduce dose to 75% of normal dose
CrCl ≤10 mL/minute: Data is insufficient for a recommendation
Oral: Adjust dose in the presence of hematologic toxicity
CrCl 46 to 60 mL/minute: Reduce dose to 85% of normal dose.
CrCl 31 to 45 mL/minute: Reduce dose to 75% of normal dose.
CrCl <30 mL/minute: Reduce dose to 70% of normal dose.
Badros 2001: IV: Autologous stem cell transplant (single-agent conditioning regimen; no busulfan or irradiation): Serum creatinine >2 mg/dL: Reduce dose from 200 mg/m2 over 2 days (as 100 mg/m2/day for 2 days) to 140 mg/m2 given as a single-dose infusion
International Myeloma Working Group (IMWG) Recommendations (Dimopoulos 2016):
The IMWG recommends the use of the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation (preferred) or the Modification of Diet in Renal Disease (MDRD) formula to evaluate renal function estimation in multiple myeloma patients with a stable serum creatinine.
CrCl >60 mL/minute: Usual dose: 0.15 to 0.25 mg/kg/day for 4 to 7 days
CrCl 15 to 59 mL/minute: Reduce dose to 75% of usual dose
CrCl <15 mL/minute: Reduce dose to 50% of usual dose
Hemodialysis: Reduce dose to 50% of usual dose
IV (high-dose melphalan for autologous stem cell transplant conditioning regimen):
CrCl >60 mL/minute: Usual dose: 200 mg/m2 per treatment course
CrCl <15 to 59 mL/minute: Reduce dose to 140 mg/m2 per treatment course; 100 mg/m2 (per treatment course) may be appropriate in some patients
Hemodialysis: Reduce dose to 100 to 140 mg/m2 per treatment course
Dosing: Hepatic Impairment
Melphalan is hepatically metabolized; however, dosage adjustment does not appear to be necessary (King, 2001).
Dosing: Adjustment for Toxicity
WBC <3000/mm3: Withhold treatment until recovery
Platelets <100,000/mm3: Withhold treatment until recovery
IV: Palliative treatment of multiple myeloma: Adjust dose based on blood cell count at the nadir and day of treatment
American Society of Clinical Oncology (ASCO) Guidelines for appropriate chemotherapy dosing in obese adults with cancer (Note: Excludes HSCT dosing): 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).
American Society for Blood and Marrow Transplantation (ASBMT) practice guideline committee position statement on chemotherapy dosing in obesity: Utilize actual body weight (full weight) for calculation of body surface area in melphalan dosing for hematopoietic stem cell transplant conditioning regimens in adults (Bubalo 2014). Note: The manufacturer of Evomela recommends that if patients weigh more than 130% of their ideal body weight, body surface area should be calculated using adjusted ideal body weight.
Note: Intravenous melphalan is available in different formulations. Indications for use, product preparation, storage, and dosing differ between formulations. Use caution when selecting melphalan formulations for preparation and administration. Do not mix or combine the formulations.
Alkeran injection: Stability is limited; must be prepared fresh. The time between reconstitution/dilution and administration of parenteral melphalan (Alkeran) must be kept to a minimum (manufacturer recommends <60 minutes) because reconstituted and diluted solutions are unstable. Dissolve powder initially with 10 mL of supplied diluent to a concentration of 5 mg/mL; shake immediately and vigorously to dissolve. Immediately dilute dose in NS to a concentration of ≤0.45 mg/mL (manufacturer recommended concentration). Do not refrigerate solution; precipitation occurs if stored at 5°C. The manufacturer recommends administration within 60 minutes of reconstitution.
Evomela injection: Reconstitute each vial with 8.6 mL of NS to a 5 mg/mL concentration. The NS should appear to be “pulled” into the vial by negative pressure due to a partial vacuum present in the vial. If no vacuum is present, discard the vial. Further dilute the appropriate dose in NS to a concentration of 0.45 mg/mL.
Melphalan is associated with a moderate emetic potential (depending on dose and/or administration route); antiemetics may be recommended to prevent nausea and vomiting (Dupuis 2011).
Intravenous melphalan is available in different formulations. Indications for use, product preparation, storage, and dosing differ between formulations. Use caution when selecting melphalan formulations for preparation and administration. Do not mix or combine the formulations.
Oral: Administer on an empty stomach (Schmidt 2002)
Alkeran: Due to limited stability, complete administration of IV dose should occur within 60 minutes of reconstitution. Infuse over 15 to 20 minutes.
Evomela: Infuse over 15 to 20 minutes (palliative treatment for multiple myeloma) or 30 minutes (conditioning regimen for autologous stem cell transplantation).
Melphalan (IV) is an irritant; local reactions may occur (Perez Fidalgo 2012). Extravasation may cause local tissue damage; administration by slow injection into a fast running IV solution into an injection port or via a central line is recommended; do not administer by direct injection into a peripheral vein.
See Trissel’s IV Compatibility Database
Alkeran injection: Store intact vials at 15°C to 30°C (59°F to 86°F). Protect from light. The manufacturer recommends administration be completed within 60 minutes of reconstitution; immediately dilute dose in NS. Do not refrigerate reconstituted solution; precipitation occurs.
Evomela injection: Store intact vials at 25°C (77°F); excursions are permitted between 15°C to 30°C (59°F to 86°F). Protect from light (store in original container). The reconstituted solution is stable for 1 hour at room temperature or for 24 hours at 5°C (41°F). Solutions diluted in NS for infusion are stable for 4 hours at room temperature (in addition to the 1 hour at room temperature following reconstitution).
Tablet: Store at 2°C to 8°C (36°F to 46°F). Protect from light.
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
Carmustine: Melphalan may enhance the adverse/toxic effect of Carmustine. Specifically, melphalan may sensitize patients to carmustine lung toxicity. 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
CycloSPORINE (Systemic): Melphalan may enhance the nephrotoxic effect of CycloSPORINE (Systemic). 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. Consider therapy modification
Nalidixic Acid: May enhance the adverse/toxic effect of Melphalan. Necrotic enterocolitis has been reported in pediatric patients. Monitor therapy
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
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
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. Avoid combination
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
False-positive Coombs' test [direct]
Cardiovascular: Peripheral edema (conditioning: 33%)
Central nervous system: Fatigue (≥50%; conditioning: 77%), dizziness (conditioning: 38%)
Endocrine & metabolic: Hypokalemia (≥50% conditioning: 74%), hypophosphatemia (conditioning: 49%)
Gastrointestinal: Diarrhea (≥50%; conditioning: 93%), nausea (≥50%; conditioning: 90%), vomiting (≥50%; conditioning: 64%), decreased appetite (conditioning: 49%), constipation (conditioning: 48%), mucositis (conditioning: 38%), abdominal pain (conditioning: 28%), dysgeusia (conditioning: 28%), stomatitis (conditioning: 28%), dyspepsia (conditioning: 26%)
Hematologic & oncologic: Anemia (≥50%), decreased absolute lymphocyte count (≥50%), decreased neutrophils (≥50%), decreased platelet count (≥50%; nadir: 14 to 21 days; recovery: 28 to 35 days), decreased white blood cell count (≥50%; nadir: 14 to 21 days; recovery: 28 to 35 days), febrile neutropenia (conditioning: 41%; grades 3/4: 28%)
Miscellaneous: Fever (conditioning: 48%)
1% to 10%:
Genitourinary: Amenorrhea (9%)
Hypersensitivity: Hypersensitivity reaction (IV: 2%; less common in oral formula; includes bronchospasm, dyspnea, edema, hypotension, pruritus, skin rash, tachycardia, urticaria), anaphylaxis (≤2%)
Renal: Renal failure
Frequency not defined:
Cardiovascular: Hepatic veno-occlusive disease (hepatic sinusoidal obstruction syndrome; SOS), vasculitis
Central nervous system: Flushing sensation, tingling sensation
Endocrine & metabolic: SIADH (dose related; Greenbaum-Lefkoe 1985)
Genitourinary: Infertility, inhibition of testicular function
Hematologic & oncologic: Bone marrow depression
Hepatic: Hepatitis, increased serum transaminases, jaundice
Renal: Increased blood urea nitrogen
Miscellaneous: Chromosomal abnormality
<1%, postmarketing, and/or case reports: Alopecia, bone marrow failure (irreversible), hemolytic anemia, interstitial pneumonitis, maculopapular rash, pulmonary fibrosis, skin ulceration at injection site, tissue necrosis at injection site (rarely requiring skin grafting)
Concerns related to adverse effects:
• Bone marrow suppression: [US Boxed Warning]: Bone marrow suppression is common; may be severe and result in infection or bleeding; has been demonstrated more with the IV formulation (compared to oral). Myelosuppression is dose-related; myeloablation is expected when used in high doses for conditioning regimens prior to stem cell transplantation. Do not administer melphalan-containing conditioning regimen unless the stem cell product is available for rescue. Monitor blood counts; supportive care for infections, anemia, and thrombocytopenia may be necessary. When used for palliative treatment, may require treatment delay or dose modification for thrombocytopenia or neutropenia. Use with caution in patients with prior bone marrow suppression, impaired renal function (consider dose reduction), or who have received prior (or concurrent) chemotherapy or irradiation. Myelotoxicity is generally reversible, although irreversible bone marrow failure has been reported. In patients who are candidates for autologous transplantation, avoid melphalan-containing induction regimens if future transplant may be necessary (due to the effects on stem cell reserve).
• Extravasation: Melphalan is an irritant; local reactions may occur (Perez Fidalgo 2012). Extravasation may cause local tissue damage. Administration by slow injection into a fast running IV solution into an injection port or via a central line is recommended; do not administer directly into a peripheral vein.
• Fertility effects: Suppresses ovarian function and produces amenorrhea; may also cause reversible or irreversible testicular suppression.
• Gastrointestinal toxicity: Gastrointestinal toxicities, including nausea, vomiting, diarrhea, and mucositis are common, particularly when used in high doses for conditioning regimens (the incidence of grade 3 or 4 mucositis was 13% in clinical trials). When administering high-dose melphalan in autologous transplantation, cryotherapy is recommended to prevent oral mucositis (Lalla 2014). Melphalan is associated with a moderate emetic potential (depending on dose and/or administration route); antiemetics may be recommended to prevent nausea and vomiting (Dupuis 2011). Nutritional support and/or analgesics may be necessary in patients with severe mucositis.
• Hepatotoxicity: Abnormal liver function tests may occur; hepatitis and jaundice have also been reported. Hepatic sinusoidal obstruction syndrome (SOS; formerly called veno-occlusive disease [VOD]) has been reported with IV melphalan. Monitor liver function tests.
• Hypersensitivity reactions: [US Boxed Warning]: Hypersensitivity reactions (including anaphylaxis) have occurred in ~2% of patients receiving IV melphalan, usually after multiple treatment cycles. Symptoms may include urticaria, pruritus, edema, skin rashes, tachycardia, bronchospasm, dyspnea, and hypotension. Discontinue infusion and treat symptomatically. Hypersensitivity may also occur (rarely) with oral melphalan. Do not readminister (oral or IV) in patients who experience hypersensitivity to melphalan.
• Pulmonary toxicity: Pulmonary fibrosis (some fatal) and interstitial pneumonitis have been observed with treatment.
• Secondary malignancy: [US Boxed Warning]: Produces chromosomal abnormalities in vitro and in vivo. Melphalan should be considered potentially leukemogenic in humans. Secondary malignancies (including acute myeloid leukemia, myeloproliferative disease, and carcinoma) have been reported (some patients were receiving combination chemotherapy or radiation therapy); the risk is increased with increased treatment duration and cumulative doses.
• Renal impairment: Dosage reduction is recommended with IV melphalan in patients with renal impairment (when used for palliative treatment); reduced initial doses may also be recommended with oral melphalan. Closely monitor patients with azotemia. High-dose melphalan with autologous stem cell transplant is feasible in patients with multiple myeloma and renal impairment (Dimopoulos 2016). Prolonged mucositis has occurred when standard melphalan doses were administered to patients with chronic kidney disease (Bodge 2014).
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.
• Elderly: Toxicity may be increased in elderly; start with lowest recommended adult doses.
Dosage form specific issues:
• Formulations: Intravenous melphalan is available in different formulations. Evomela (melphalan for injection) is a lyophilized powder which is reconstituted with normal saline to a 5 mg/mL concentration. Alkeran (melphalan hydrochloride for injection) and generic melphalan hydrochloride are also powder formulations which are reconstituted with the supplied diluent (which contains propylene glycol and ethanol) to a 5 mg/mL concentration. Indications for use, product preparation, storage, and dosing differ between formulations. Use caution when selecting melphalan formulations for preparation and administration. Do not mix or combine the formulations.
• Propylene glycol: Some dosage forms may contain propylene glycol; large amounts are potentially toxic and have been associated hyperosmolality, lactic acidosis, seizures and respiratory depression; use caution (AAP 1997; Zar 2007).
• Experienced physician: [US Boxed Warning]: Should be administered under the supervision of an experienced cancer chemotherapy physician.
• Immunizations: Avoid vaccination with live vaccines during treatment if immunocompromised.
CBC with differential and platelet count, serum electrolytes, renal/liver function tests, serum uric acid; signs/symptoms of hypersensitivity reaction, pulmonary toxicity, and gastrointestinal toxicity; monitor infusion site.
Pregnancy Risk Factor
Adverse effects have been observed in animal reproduction studies. May cause fetal harm if administered during pregnancy. Women of reproductive potential should be advised to avoid pregnancy while on and after melphalan therapy. Males with female partners of reproductive potential should use effective contraception during and after melphalan treatment. Therapy may suppress ovarian function leading to amenorrhea. Reversible and irreversible testicular suppression has been reported in male patients after melphalan administration.
• 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, constipation, lack of appetite, change in taste, mouth irritation, hair loss, abdominal pain, or mouth sores. Have patient report immediately to prescriber signs of infection, signs of liver problems (dark urine, fatigue, lack of appetite, nausea, abdominal pain, light-colored stools, vomiting, or jaundice), signs of electrolyte problems (mood changes, confusion, muscle pain or weakness, abnormal heartbeat, seizures, lack of appetite, or severe nausea or vomiting), severe nausea, vomiting, bruising, bleeding, severe loss of strength and energy, pale skin, angina, tachycardia, dizziness, passing out, shortness of breath, edema, excessive weight loss, amenorrhea, skin growths, blurred vision, signs of a severe pulmonary disorder (lung or breathing problems like difficulty breathing, shortness of breath, or a cough that is new or worse), or severe injection site redness, pain, edema, 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