(pem e TREKS ed)
- Pemetrexed Disodium
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution Reconstituted, Intravenous:
Alimta: 100 mg (1 ea); 500 mg (1 ea)
Brand Names: U.S.
- Antineoplastic Agent, Antimetabolite
- Antineoplastic Agent, Antimetabolite (Antifolate)
Pemetrexed is an antifolate; it disrupts folate-dependent metabolic processes essential for cell replication. Pemetrexed inhibits thymidylate synthase (TS), dihydrofolate reductase (DHFR), glycinamide ribonucleotide formyltransferase (GARFT), and aminoimidazole carboxamide ribonucleotide formyltransferase (AICARFT), the enzymes involved in folate metabolism and DNA synthesis, resulting in inhibition of purine and thymidine nucleotide and protein synthesis.
Vdss: 16.1 L
Urine (70% to 90% as unchanged drug)
Normal renal function: 3.5 hours
Special Populations: Renal Function Impairment
Pemetrexed clearance decreases and AUC increases as renal function decreases; in patients with CrCl of 45, 50, and 80 mL/minute, AUC was increased 65%, 54%, and 13%, respectively, compared with patients with CrCl of 100 mL/minute.
Use: Labeled Indications
Mesothelioma: Initial treatment of unresectable malignant pleural mesothelioma (in combination with cisplatin) or in patients who are not otherwise candidates for curative surgery
Non-small cell lung cancer (NSCLC), nonsquamous: Initial treatment of locally advanced or metastatic nonsquamous NSCLC (in combination with cisplatin); maintenance treatment of locally advanced or metastatic nonsquamous NSCLC if no progression after 4 cycles of initial platinum-based first-line therapy; single-agent treatment (after prior chemotherapy) of recurrent/metastatic nonsquamous NSCLC
Limitation of use: Not indicated for the treatment of squamous cell NSCLC
Off Label Uses
Bladder cancer, metastatic
Data from a phase II study supports the use of pemetrexed as second-line treatment of locally advanced, metastatic, or relapsed transitional cell urothelium cancer [Sweeny 2006]. Additional trials may be necessary to further define the role of pemetrexed in this condition.
Cervical cancer, persistent or recurrent
Data from two phase II studies support the use of pemetrexed for persistent or recurrent cervical cancer [Lorusso 2010], [Miller 2008]. Additional trials may be necessary to further define the role of pemetrexed in this condition.
Malignant pleural mesothelioma (single agent and off-label combination)
Data from two phase II studies support the use of pemetrexed in combination with carboplatin in the treatment of malignant pleural mesothelioma [Castagneto 2008], [Ceresoli 2006]. Data from an expanded access study supports the use of pemetrexed as a single agent in the management of unresectable malignant pleural mesothelioma [Taylor 2008]. Additional trials may be necessary to further define the role of pemetrexed as a single agent or plus carboplatin in the management of malignant pleural mesothelioma.
Ovarian cancer, platinum-resistant
Data from a phase II study support the use of pemetrexed in platinum-resistant epithelial ovarian or primary peritoneal cancer [Vergote 2009]. Additional trials may be necessary to further define the role of pemetrexed in this condition.
Thymic malignancies, metastatic
Data from a phase II study support the use of pemetrexed in previously treated unresectable advanced thymoma or thymic carcinoma [Loehrer 2006]. Additional trials may be necessary to further define the role of pemetrexed in this condition.
Severe hypersensitivity to pemetrexed or any component of the formulation
Canadian labeling: Additional contraindications (not in the US labeling): Concomitant yellow fever vaccine
Note: Start vitamin supplements 1 week before initial pemetrexed dose: Folic acid 400 to 1,000 mcg orally once daily (begin 7 days prior to treatment initiation; continue daily during treatment and for 21 days after last pemetrexed dose) and vitamin B12 1,000 mcg IM 7 days prior to treatment initiation and then every 3 cycles. Give dexamethasone 4 mg orally twice daily for 3 days, beginning the day before treatment to minimize cutaneous reactions. New treatment cycles should not begin unless ANC ≥1,500/mm3, platelets ≥100,000/mm3, CrCl ≥45 mL/minute, and recovery of nonhematologic toxicity to ≤ grade 2.
Malignant pleural mesothelioma: IV: 500 mg/m2 on day 1 of each 21-day cycle (in combination with cisplatin); continue until disease progression or unacceptable toxicity or (off-label) in combination with carboplatin (Castagneto 2008; Ceresoli 2006) or (off-label) as single-agent therapy (Taylor 2008)
Non-small cell lung cancer, nonsquamous: IV:
Initial treatment of locally advanced or metastatic NSCLC: 500 mg/m2 on day 1 of each 21-day cycle (in combination with cisplatin) for up to 6 cycles or until disease progression or unacceptable toxicity
Maintenance treatment of locally advanced or metastatic NSCLC (after 4 cycles of initial platinum-based therapy): 500 mg/m2 on day 1 of each 21-day cycle (as a single-agent); continue until disease progression or unacceptable toxicity
Second-line treatment of recurrent/metastatic disease (after prior chemotherapy): 500 mg/m2 on day 1 of each 21-day cycle (as a single-agent); continue until disease progression or unacceptable toxicity
Bladder cancer, metastatic (off-label use): IV: 500 mg/m2 on day 1 of each 21-day cycle until disease progression or unacceptable toxicity (Sweeney 2006)
Cervical cancer, persistent or recurrent (off-label use): IV: 500 mg/m2 on day 1 of each 21-day cycle until disease progression or unacceptable toxicity occurs (Lorusso 2010) or 900 mg/m2 on day 1 of each 21-day cycle (Miller 2008)
Ovarian cancer, platinum-resistant (off-label use): IV: 500 mg/m2 on day 1 of each 21-day cycle (Vergote 2009)
Thymic malignancies, metastatic (off-label use): IV: 500 mg/m2 on day 1 of each 21-day cycle for 6 cycles or until disease progression or unacceptable toxicity occurs (Loehrer 2006)
Refer to adult dosing.
Dosing: Renal Impairment
Renal function may be estimated using the Cockcroft-Gault formula.
CrCl ≥45 mL/minute: No dosage adjustment necessary.
CrCl <45 mL/minute: Use is not recommended by the manufacturer (an insufficient number of patients have been studied for dosage recommendations).
Renal toxicity during treatment: Withhold pemetrexed until CrCl is 45 mL/minute or higher.
According to a phase I study in advanced cancer patients with renal impairment, pemetrexed doses up to 500 mg/m2 (with vitamin supplementation) were well tolerated in patients with glomerular filtration rate (GFR) 40 to 79 mL/minute; however, accrual was halted in patients with GFR <29 mL/minute (due to toxicity) and accrual did not occur in patients with GFR 30 to 39 mL/minute. Patients with GFR ≥80 mL/minute tolerated doses of 600 mg/m2 (Mita 2006).
Concomitant ibuprofen use with renal dysfunction:
CrCl ≥80 mL/minute: No dosage adjustment necessary.
CrCl 45 to 79 mL/minute: Avoid ibuprofen for 2 days before, the day of, and for 2 days following a dose of pemetrexed. Monitor more frequently for myelosuppression, renal, and GI toxicities if concomitant ibuprofen administration cannot be avoided.
Dosing: Hepatic Impairment
There are no dosage adjustments provided in the manufacturer's labeling; however, pemetrexed pharmacokinetics do not appear to be affected based on elevated ALT, AST, or total bilirubin.
Dosing: Adjustment for Toxicity
Note: Concomitant combination chemotherapy agents (eg cisplatin) may also require dosage modification.
Hematologic toxicity: Upon recovery, reinitiate therapy as follows:
ANC <500/mm3 and platelets ≥50,000/mm3: Reduce pemetrexed dose to 75% of previous dose
Platelets <50,000/mm3 without bleeding: Reduce pemetrexed dose to 75% of previous dose
Platelets <50,000/mm3 with bleeding: Reduce pemetrexed dose to 50% of previous dose
Recurrent grade 3 or 4 myelosuppression after 2 dose reductions: Discontinue
Nonhematologic toxicity: Withhold treatment until recovery to ≤ grade 2; upon recovery, reinitiate or discontinue therapy as follows:
Grade 3 or 4 toxicity (excluding mucositis and neurotoxicity): Reduce pemetrexed dose to 75% of previous dose
Grade 3 or 4 diarrhea or any diarrhea requiring hospitalization: Reduce pemetrexed dose to 75% of previous dose
Grade 3 or 4 mucositis: Reduce pemetrexed dose to 50% of previous dose
Grade 3 or 4 neurotoxicity: Permanently discontinue
Interstitial pneumonitis: Permanently discontinue
Radiation recall signs/symptoms: Permanently discontinue
Severe or life-threatening dermatologic toxicity: Permanently discontinue
Recurrent grade 3 or 4 nonhematologic toxicity after 2 dose reductions: Permanently discontinue
ASCO Guidelines for appropriate chemotherapy dosing in obese adults with cancer: 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).
Reconstitute with NS (preservative free); add 4.2 mL to the 100 mg vial and 20 mL to the 500 mg vial, resulting in a 25 mg/mL concentration. Gently swirl until powder is completely dissolved. Solution may be colorless to green-yellow. Further dilute in 100 mL NS prior to infusion (the manufacturer recommends a total volume of 100 mL).
IV: Infuse over 10 minutes. When used in combination with cisplatin, administer prior to cisplatin.
Initiate folic acid supplementation 1 week before first dose of pemetrexed, continue for full course of therapy, and for 21 days after last pemetrexed dose. Institute vitamin B12 1 week before the first dose; administer every 9 weeks thereafter.
Store intact vials at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Reconstituted solution and solution diluted for infusion are stable for 24 hours when refrigerated at 2°C to 8°C (36°F to 46°F).
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
Ibuprofen: May increase the serum concentration of PEMEtrexed. Management: In patients with an estimated creatinine clearance of 45 to 79 mL/min, avoid ibuprofen for 2 days before, the day of, and 2 days following the administration of pemetrexed. Monitor for increased pemetrexed toxicities if combined. 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
Pyrimethamine: May enhance the adverse/toxic effect of PEMEtrexed. 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
Teriflunomide: May increase the serum concentration of OAT3 Substrates. Monitor therapy
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
Central nervous system: Fatigue (18% to 34%)
Dermatologic: Desquamation (≤14%), skin rash (≤14%)
Gastrointestinal: Nausea (12% to 31%), anorexia (19% to 22%), vomiting (6% to 16%), stomatitis (≤15%), diarrhea (5% to 13%)
Hematologic & oncologic: Anemia (15% to 19%; grades 3/4: 3% to 5%), neutropenia (6% to 11%; grades 3/4: 3% to 5%)
Respiratory: Pharyngitis (≤15%)
1% to 10%:
Cardiovascular: Edema (5%)
Central nervous system: Neuropathy (sensory: 9%; motor: ≤5%)
Dermatologic: Pruritus (7%), alopecia (6%), erythema multiforme (≤5%)
Gastrointestinal: Mucositis (≤7%), constipation (6%), abdominal pain (1% to <5%)
Hematologic & oncologic: Thrombocytopenia (8%; grades 3/4: 2%), febrile neutropenia (<5%)
Hepatic: Increased serum ALT (8% to 10%), increased serum AST (7% to 8%)
Hypersensitivity: Hypersensitivity reaction (<5%)
Infection: Infection (1% to <5%), sepsis (1%)
Ophthalmic: Conjunctivitis (≤5%), increased lacrimation (1% to <5%)
Miscellaneous: Fever (8%)
<1%, postmarketing, and/or case reports: Bullous rash, colitis, depression, esophagitis, gastrointestinal obstruction, hemolytic anemia, interstitial pneumonitis, pain, pancreatitis, pulmonary embolism, radiation recall phenomenon, renal failure, Stevens-Johnson syndrome, supraventricular cardiac arrhythmia, syncope, toxic epidermal necrolysis, ventricular tachycardia
Concerns related to adverse effects:
• Bone marrow suppression: Pemetrexed may cause severe myelosuppression, including anemia, neutropenia, thrombocytopenia and/or pancytopenia; frequent laboratory monitoring is necessary (myelosuppression is often dose-limiting). Severe myelosuppression may require blood transfusion. Prophylactic folic acid and vitamin B12 supplements are necessary to reduce hematologic toxicity, febrile neutropenia and infection; initiate supplementation 1 week before the first dose of pemetrexed and continue for 21 days after the last pemetrexed dose (the risk for myelosuppression is higher in patients who did not receive vitamin supplementation). Monitor blood counts at the beginning of each cycle, and as clinically indicated. Dose reductions in subsequent cycles may be required due to myelosuppression.
• Cutaneous reactions: Serious and occasionally fatal dermatologic toxicity may occur; pretreatment with dexamethasone is necessary to reduce the incidence and severity of cutaneous reactions. Rarely, Stevens-Johnson syndrome and toxic epidermal necrolysis have been reported. Permanently discontinue pemetrexed for severe and life-threatening bullous, blistering, or exfoliating dermatologic toxicity.
• Gastrointestinal toxicity: Gastrointestinal toxicity may occur; prophylactic folic acid and vitamin B12 supplements are necessary to reduce gastrointestinal toxicity. Initiate supplementation 1 week before the first dose of pemetrexed and continue for 21 days after the last pemetrexed dose.
• Hypersensitivity: Hypersensitivity (including allergic reaction) has been reported with pemetrexed.
• Nephrotoxicity: Pemetrexed may cause severe (and potentially fatal) renal toxicity (renal toxicity may occur with single-agent pemetrexed or when used in combination with other chemotherapy agents). Measure creatinine clearance prior to each dose and monitor renal function throughout treatment. May require therapy discontinuation. Withhold pemetrexed treatment for creatinine clearance <45 mL/minute.
• Pulmonary toxicity: Interstitial pneumonitis has been observed with use; may be serious and/or fatal. Interrupt therapy and evaluate promptly for acute onset new or progressive pulmonary symptoms (eg, dyspnea, cough, or fever). If interstitial pneumonitis is confirmed, permanently discontinue pemetrexed.
• Radiation recall: Radiation recall may occur in patients administered pemetrexed who received radiation previously (weeks to years). Monitor for inflammation or blistering in areas of prior radiation treatment; permanently discontinue pemetrexed if radiation recall is confirmed.
• Renal impairment: Pemetrexed is primarily cleared by the kidneys; decreased renal function results in increased toxicity. The manufacturer does not recommend use if CrCl <45 mL/minute. Use caution in patients receiving concurrent nephrotoxins; may result in delayed pemetrexed clearance.
• Third space fluid: Although the effect of third space fluid on pemetrexed pharmacokinetics has not been fully defined, studies have determined pemetrexed concentrations in patients with mild-to-moderate ascites/pleural effusions were similar to concentrations in trials of patients without third space fluid accumulation.
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.
• Ibuprofen: Ibuprofen may reduce the clearance of pemetrexed. In patients with CrCl 45 to 79 mL/minute, interrupt ibuprofen therapy 2 days prior to, during, and 2 days after pemetrexed therapy. If concomitant use cannot be avoided, monitor for myelosuppression, renal, and gastrointestinal toxicity.
CBC with differential and platelets (before each cycle, on days 8 and 15 of each cycle, and as needed; monitor for nadir and recovery); renal function tests (serum creatinine, creatinine clearance, BUN; prior to each cycle and as needed) total bilirubin, ALT, AST (periodic); signs/symptoms of mucositis and diarrhea, pulmonary toxicity, dermatologic toxicity, and radiation recall.
Adverse effects were observed in animal reproduction studies. Based on the mechanism of action, pemetrexed may cause fetal harm if administered to a pregnant woman. Women of reproductive potential should use effective contraception during treatment and for at least 6 months after the last pemetrexed dose. Males with female partners of reproductive potential should use effective contraception during treatment and for 3 months after the last pemetrexed dose. Pemetrexed may impair fertility in males.
• 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 nausea, vomiting, diarrhea, constipation, change in taste, lack of appetite, or hair loss. 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), signs of dehydration (dry skin, dry mouth, dry eyes, increased thirst, tachycardia, dizziness, fast breathing, or confusion), signs of kidney problems (urinary retention, hematuria, change in amount of urine passed, or weight gain), signs of Stevens-Johnson syndrome/toxic epidermal necrolysis (red, swollen, blistered, or peeling skin [with or without fever]; red or irritated eyes; or sores in mouth, throat, nose, or eyes), signs of a severe pulmonary disorder (lung or breathing problems like difficulty breathing, shortness of breath, or a cough that is new or worse), edema, severe loss of strength and energy, severe mouth pain or irritation, burning or numbness feeling, or pale skin (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.
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- Drug class: antimetabolites
Other brands: Alimta