There is no known antidote for overdoses of ARRANON. It is anticipated that overdosage would result in severe neurotoxicity (possibly including paralysis, coma), myelosuppression, and potentially death. In the event of overdose, supportive care consistent with good clinical practice should be provided.
Nelarabine has been administered in clinical trials up to a dose of 2,900 mg/m² Â on days 1, 3, and 5 to 2 adult patients. At a dose of 2,200 mg/m² Â given on days 1, 3, and 5 every 21 days, 2 patients developed a significant grade 3 ascending sensory neuropathy. MRI evaluations of the 2 patients demonstrated findings consistent with a demyelinating process in the cervical spine.
None.
The following serious adverse reactions are discussed in greater detail in other sections of the label:
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
ARRANON was studied in 459 patients in Phase I and Phase II clinical trials.
AdultsThe safety profile of ARRANON is based on data from 103 adult patients treated with the recommended dose and schedule in 2 studies: an adult T-cell acute lymphoblastic leukemia (T-ALL)/T-cell lymphoblastic lymphoma (T-LBL) study and an adult chronic lymphocytic leukemia study.
The most common adverse reactions in adults, regardless of causality, were fatigue; gastrointestinal (GI) disorders (nausea, diarrhea, vomiting, and constipation); hematologic disorders (anemia, neutropenia, and thrombocytopenia); respiratory disorders (cough and dyspnea); nervous system disorders (somnolence and dizziness); and pyrexia.
The most common adverse reactions in adults, by System Organ Class, regardless of causality, including severe or life threatening adverse reactions (NCI Common Toxicity Criteria grade 3 or grade 4) and fatal adverse reactions (grade 5) are shown in Table 1.
Table 1: Most Commonly Reported
( > 5% Overall) Adverse Reactions Regardless of Causality in Adult Patients
Treated with 1,500 mg/m² Â of ARRANON Administered Intravenously Over 2 Hours on
Days 1, 3, and 5 Repeated Every 21 Days
System Organ Class Preferred Term |
Percentage of Patients (N = 103) | ||
Toxicity Grade | |||
Grade 3 % |
Grade 4 and 5a % |
All Grades % |
|
Blood and Lymphatic System Disorders | |||
Anemia | 20 | 14 | 99 |
Thrombocytopenia | 37 | 22 | 86 |
Neutropenia | 14 | 49 | 81 |
Febrile neutropenia | 9 | 1 | 12 |
Cardiac Disorders | |||
Sinus tachycardia | 1 | 0 | 8 |
Gastrointestinal Disorders | |||
Nausea | 0 | 0 | 41 |
Diarrhea | 1 | 0 | 22 |
Vomiting | 1 | 0 | 22 |
Constipation | 1 | 0 | 21 |
Abdominal pain | 1 | 0 | 9 |
Stomatitis | 1 | 0 | 8 |
Abdominal distension | 0 | 0 | 6 |
General Disorders and Administration Site Conditions | |||
Fatigue | 10 | 2 | 50 |
Pyrexia | 5 | 0 | 23 |
Asthenia | 0 | 1 | 17 |
Edema, peripheral | 0 | 0 | 15 |
Edema | 0 | 0 | 11 |
Pain | 3 | 0 | 11 |
Rigors | 0 | 0 | 8 |
Gait, abnormal | 0 | 0 | 6 |
Chest pain | 0 | 0 | 5 |
Non-cardiac chest pain | 0 | 1 | 5 |
Infections | |||
Infection | 2 | 1 | 9 |
Pneumonia | 4 | 1 | 8 |
Sinusitis | 1 | 0 | 7 |
Hepatobiliary Disorders | |||
AST increased | 1 | 1 | 6 |
Metabolism and Nutrition Disorders | |||
Anorexia | 0 | 0 | 9 |
Dehydration | 3 | 1 | 7 |
Hyperglycemia | 1 | 0 | 6 |
Musculoskeletal and Connective Tissue Disorders | |||
Myalgia | 1 | 0 | 13 |
Arthralgia | 1 | 0 | 9 |
Back pain | 0 | 0 | 8 |
Muscular weakness | 5 | 0 | 8 |
Pain in extremity | 1 | 0 | 7 |
Nervous System Disorders (see Table 2) | |||
Psychiatric Disorders | |||
Confusional state | 2 | 0 | 8 |
Insomnia | 0 | 0 | 7 |
Depression | 1 | 0 | 6 |
Respiratory, Thoracic, and Mediastinal Disorders | |||
Cough | 0 | 0 | 25 |
Dyspnea | 4 | 2 | 20 |
Pleural effusion | 5 | 1 | 10 |
Epistaxis | 0 | 0 | 8 |
Dyspnea, exertional | 0 | 0 | 7 |
Wheezing | 0 | 0 | 5 |
Vascular Disorders | |||
Petechiae | 2 | 0 | 12 |
Hypotension | 1 | 1 | 8 |
a Five patients had a fatal adverse reaction. Fatal adverse reactions included hypotension (n = 1), respiratory arrest (n = 1), pleural effusion/pneumothorax (n = 1), pneumonia (n = 1), and cerebral hemorrhage/coma/leukoencephalopathy (n = 1). |
Other Adverse Events: Blurred vision was also reported in 4% of adult patients.
There was a single report of biopsy confirmed progressive multifocal leukoencephalopathy in the adult patient population.
Neurologic Adverse Reactions: Nervous system adverse reactions, regardless of drug relationship, were reported for 76% of adult patients across the Phase I and Phase II studies. The most common neurologic adverse reactions ( > 2%) in adult patients, regardless of causality, including all grades (NCI Common Toxicity Criteria) are shown in Table 2.
Table 2: Neurologic Adverse Reactions ( > 2%) Regardless
of Causality in Adult Patients Treated with 1,500 mg/m² Â of ARRANON
Administered Intravenously Over 2 Hours on Days 1, 3, and 5 Repeated Every 21
Days
Nervous System Disorders Preferred Term |
Percentage of Patients (N =103) | ||||
Grade 1 % |
Grade 2 % |
Grade 3 % |
Grade 4 % |
All Grades % |
|
Somnolence | 20 | 3 | 0 | 0 | 23 |
Dizziness | 14 | 8 | 0 | 0 | 21 |
Peripheral neurologic disorders, any adverse reaction | 8 | 12 | 2 | 0 | 21 |
Neuropathy | 0 | 4 | 0 | 0 | 4 |
Peripheral neuropathy | 2 | 2 | 1 | 0 | 5 |
Peripheral motor neuropathy | 3 | 3 | 1 | 0 | 7 |
Peripheral sensory neuropathy | 7 | 6 | 0 | 0 | 13 |
Hypoesthesia | 5 | 10 | 2 | 0 | 17 |
Headache | 11 | 3 | 1 | 0 | 15 |
Paresthesia | 11 | 4 | 0 | 0 | 15 |
Ataxia | 1 | 6 | 2 | 0 | 9 |
Depressed level of consciousness | 4 | 1 | 0 | 1 | 6 |
Tremor | 2 | 3 | 0 | 0 | 5 |
Amnesia | 2 | 1 | 0 | 0 | 3 |
Dysgeusia | 2 | 1 | 0 | 0 | 3 |
Balance disorder | 1 | 1 | 0 | 0 | 2 |
Sensory loss | 0 | 2 | 0 | 0 | 2 |
One patient had a fatal neurologic adverse reaction, cerebral hemorrhage/coma/leukoencephalopathy.
Most nervous system adverse reactions in the adult patients were evaluated as grade 1 or 2. The additional grade 3 adverse reactions in adult patients, regardless of causality, were aphasia, convulsion, hemiparesis, and loss of consciousness, each reported in 1 patient (1%). The additional grade 4 adverse reactions, regardless of causality, were cerebral hemorrhage, coma, intracranial hemorrhage, leukoencephalopathy, and metabolic encephalopathy, each reported in one patient (1%).
The other neurologic adverse reactions, regardless of causality, reported as grade 1, 2, or unknown in adult patients were abnormal coordination, burning sensation, disturbance in attention, dysarthria, hyporeflexia, neuropathic pain, nystagmus, peroneal nerve palsy, sciatica, sensory disturbance, sinus headache, and speech disorder, each reported in one patient (1%).
PediatricsThe safety profile for children is based on data from 84 pediatric patients treated with the recommended dose and schedule in a T-cell acute lymphoblastic leukemia (T- ALL)/T-cell lymphoblastic lymphoma (T-LBL) treatment study.
The most common adverse reactions in pediatric patients, regardless of causality, were hematologic disorders (anemia, leukopenia, neutropenia, and thrombocytopenia). Of the non- hematologic adverse reactions in pediatric patients, the most frequent adverse reactions reported were headache, increased transaminase levels, decreased blood potassium, decreased blood albumin, increased blood bilirubin, and vomiting.
The most common adverse reactions in pediatric patients, by System Organ Class, regardless of causality, including severe or life threatening adverse reactions (NCI Common Toxicity Criteria grade 3 or grade 4) and fatal adverse reactions (grade 5) are shown in Table 3.
Table 3: Most Commonly Reported ( > 5% Overall) Adverse
Reactions Regardless of Causality in Pediatric Patients Treated with 650 mg/m² Â of
ARRANON Administered Intravenously Over 1 Hour Daily for 5 Consecutive Days
Repeated Every 21 Days
System Organ Class Preferred Term |
Percentage of Patients (N = 84) | ||
Toxicity Grade | |||
Grade 3 % |
Grade 4 and 5a % |
All Grades % |
|
Blood and Lymphatic System Disorders | |||
Anemia | 45 | 10 | 95 |
Neutropenia | 17 | 62 | 94 |
Thrombocytopenia | 27 | 32 | 88 |
Leukopenia | 14 | 7 | 38 |
Hepatobiliary Disorders | |||
Transaminases increased | 4 | 0 | 12 |
Blood albumin decreased | 5 | 1 | 10 |
Blood bilirubin increased | 7 | 2 | 10 |
Metabolic/Laboratory | |||
Blood potassium decreased | 4 | 2 | 11 |
Blood calcium decreased | 1 | 1 | 8 |
Blood creatinine increased | 0 | 0 | 6 |
Blood glucose decreased | 4 | 0 | 6 |
Blood magnesium decreased | 2 | 0 | 6 |
Nervous System Disorders (see Table 4) | |||
Gastrointestinal Disorders | |||
Vomiting | 0 | 0 | 10 |
General Disorders & Administration Site Conditions | |||
Asthenia | 1 | 0 | 6 |
Infections & Infestations | |||
Infection | 2 | 1 | 5 |
a Three patients had a fatal adverse reaction. Fatal adverse reactions included neutropenia and pyrexia (n = 1), status epilepticus/seizure (n = 1), and fungal pneumonia (n = 1). |
Neurologic Adverse Reactions: Nervous system adverse reactions, regardless of drug relationship, were reported for 42% of pediatric patients across the Phase I and Phase II studies. The most common neurologic adverse reactions ( > 2%) in pediatric patients, regardless of causality, including all grades (NCI Common Toxicity Criteria) are shown in Table 4.
Table 4: Neurologic Adverse Reactions ( > 2%) Regardless
of Causality in Pediatric Patients Treated with 650 mg/m² Â of ARRANON
Administered Intravenously Over 1 Hour Daily for 5 Consecutive Days Repeated
Every 21 Days
Nervous System Disorders Preferred Term |
Percentage of Patients (N = 84) |
||||
Grade 1 % |
Grade 2 % |
Grade 3 % |
Grade 4 and 5a % |
All Grades % |
|
Headache | 8 | 2 | 4 | 2 | 17 |
Peripheral neurologic disorders, any adverse reaction | 1 | 4 | 7 | 0 | 12 |
Peripheral neuropathy | 0 | 4 | 2 | 0 | 6 |
Peripheral motor neuropathy | 1 | 0 | 2 | 0 | 4 |
Peripheral sensory neuropathy | 0 | 0 | 6 | 0 | 6 |
Somnolence | 1 | 4 | 1 | 1 | 7 |
Hypoesthesia | 1 | 1 | 4 | 0 | 6 |
Seizures | 0 | 0 | 0 | 6 | 6 |
Convulsions | 0 | 0 | 0 | 3 | 4 |
Grand mal convulsions | 0 | 0 | 0 | 1 | 1 |
Status epilepticus | 0 | 0 | 0 | 1 | 1 |
Motor dysfunction | 1 | 1 | 1 | 0 | 4 |
Nervous system disorder | 1 | 2 | 0 | 0 | 4 |
Paresthesia | 0 | 2 | 1 | 0 | 4 |
Tremor | 1 | 2 | 0 | 0 | 4 |
Ataxia | 1 | 0 | 1 | 0 | 2 |
a One (1) patient had a fatal neurologic adverse reaction, status epilepticus. |
The other grade 3 neurologic adverse reaction in pediatric patients, regardless of causality, was hypertonia reported in 1 patient (1%). The additional grade 4 neurologic adverse reactions, regardless of causality, were 3rd nerve paralysis, and 6th nerve paralysis, each reported in 1 patient (1%).
The other neurologic adverse reactions, regardless of causality, reported as grade 1, 2, or unknown in pediatric patients were dysarthria, encephalopathy, hydrocephalus, hyporeflexia, lethargy, mental impairment, paralysis, and sensory loss, each reported in 1 patient (1%).
Postmarketing ExperienceThe following adverse reactions have been identified during post-approval use of ARRANON. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
Infections and Infestations: Fatal opportunistic infections.
Metabolism and Nutrition Disorders: Tumor lysis syndrome.
Nervous System Disorders: Demyelination and ascending peripheral neuropathies similar in appearance to Guillain-Barre syndrome.
Musculoskeletal and Connective Disorders: Rhabdomyolysis, blood creatine phosphokinase increased.
ARRANON® is indicated for the treatment of patients with T-cell acute lymphoblastic leukemia and T-cell lymphoblastic lymphoma whose disease has not responded to or has relapsed following treatment with at least two chemotherapy regimens. This use is based on the induction of complete responses. Randomized trials demonstrating increased survival or other clinical benefit have not been conducted.
Following intravenous administration of nelarabine to adult patients with refractory leukemia or lymphoma, plasma ara- G Cmax values generally occurred at the end of the nelarabine infusion and were generally higher than nelarabine Cmax values, suggesting rapid and extensive conversion of nelarabine to ara-G. Mean plasma nelarabine and ara-G Cmax values were 5.0 ± 3.0 μg/mL and 31.4 ± 5.6 μg/mL, respectively, after a 1,500 mg/m² Â nelarabine dose infused over 2 hours in adult patients. The area under the concentration-time curve (AUC) of ara-G is 37 times higher than that for nelarabine on Day 1 after nelarabine IV infusion of 1,500 mg/m² Â dose (162 ± 49 μg.h/mL versus 4.4 ± 2.2 μg.h/mL, respectively). Comparable Cmax and AUC values were obtained for nelarabine between Days 1 and 5 at the nelarabine adult dosage of 1,500 mg/m² , indicating that nelarabine does not accumulate after multiple-dosing. There are not enough ara-G data to make a comparison between Day 1 and Day 5. After a nelarabine adult dose of 1,500 mg/m , intracellular Cmax for ara-GTP appeared within 3 to 25 hours on Day 1. Exposure (AUC) to intracellular ara-GTP was 532 times higher than that for nelarabine and 14 times higher than that for ara-G (2,339 ± 2,628 μg.h/mL versus 4.4 ± 2.2 μg.h/mL and 162 ± 49 μg.h/mL, respectively). Because the intracellular levels of ara-GTP were so prolonged, its elimination halflife could not be accurately estimated.
DistributionNelarabine and ara-G are extensively distributed throughout the body. For nelarabine, Vss values were 197 ± 216 L/m² Â in adult patients. For ara-G, Vss/F values were 50 ± 24 L/m² Â in adult patients.
Nelarabine and ara-G are not substantially bound to human plasma proteins ( < 25%) in vitro, and binding is independent of nelarabine or ara-G concentrations up to 600 μM.
MetabolismThe principal route of metabolism for nelarabine is O-demethylation by adenosine deaminase to form ara-G, which undergoes hydrolysis to form guanine. In addition, some nelarabine is hydrolyzed to form methylguanine, which is O-demethylated to form guanine. Guanine is N-deaminated to form xanthine, which is further oxidized to yield uric acid.
ExcretionNelarabine and ara-G are partially eliminated by the kidneys. Mean urinary excretion of nelarabine and ara-G was 6.6 ± 4.7% and 27 ± 15% of the administered dose, respectively, in 28 adult patients over the 24 hours after nelarabine infusion on Day 1. Renal clearance averaged 24 ± 23 L/h for nelarabine and 6.2 ± 5.0 L/h for ara-G in 21 adult patients.Combined Phase 1 pharmacokinetic data at nelarabine doses of 199 to 2,900 mg/m² Â (n = 66 adult patients) indicate that the mean clearance (CL) of nelarabine is 197 ± 189 L/h/m² Â on Day 1. The apparent clearance of ara-G (CL/F) is 10.5 ± 4.5 L/h/m² Â on Day 1. Nelarabine and ara-G are rapidly eliminated from plasma with a mean half-life of 18 minutes and 3.2 hours, respectively, in adult patients.
PediatricsNo pharmacokinetic data are available in pediatric patients at the once daily 650 mg/m² Â nelarabine dosage. Combined Phase 1 pharmacokinetic data at nelarabine doses of 104 to 2,900 mg/m² Â indicate that the mean clearance (CL) of nelarabine is about 30% higher in pediatric patients than in adult patients (259 ± 409 L/h/m² Â versus 197 ± 189 L/h/m² , respectively) (n = 66 adults, n = 22 pediatric patients) on Day 1. The apparent clearance of ara-G (CL/F) is comparable between the two groups (10.5 ± 4.5 L/h/m² Â in adult patients and 11.3 ± 4.2 L/h/m² Â in pediatric patients) on Day 1. Nelarabine and ara-G are extensively distributed throughout the body. For nelarabine, Vss values were 213 ± 358 L/m² Â in pediatric patients. For ara-G,Vss/F values were 33 ± 9.3 L/m² Â in pediatric patients. Nelarabine and ara-G are rapidly eliminated from plasma in pediatric patients, with a half-life of 13 minutes and 2 hours, respectively.
Effect of AgeAge has no effect on the pharmacokinetics of nelarabine or ara-G in adults. Decreased renal function, which is more common in the elderly, may reduce ara-G clearance.
Effect of GenderGender has no effect on nelarabine or ara-G pharmacokinetics.
Effect of RaceIn general, nelarabine mean clearance and volume of distribution values tend to be higher in Whites (n = 63) than in Blacks (by about 10%) (n = 15). The opposite is true for ara-G; mean apparent clearance and volume of distribution values tend to be lower in Whites than in Blacks (by about 15-20%). No differences in safety or effectiveness were observed between these groups.
Effect of Renal ImpairmentThe pharmacokinetics of nelarabine and ara-G have not been specifically studied in renally impaired or hemodialyzed patients. Nelarabine is excreted by the kidney to a small extent (5 to 10% of the administered dose). Ara-G is excreted by the kidney to a greater extent (20 to 30% of the administered nelarabine dose). In the combined Phase 1 studies, patients were categorized into 3 groups: normal with CLcr > 80 mL/min (n = 67), mild with CLcr= 50-80 mL/min (n = 15), and moderate with CLcr < 50 mL/min (n = 3). The mean apparent clearance (CL/F) of ara-G was about 15% and 40% lower in patients with mild and moderate renal impairment, respectively, than in patients with normal renal function. No differences in safety or effectiveness were observed.
Effect of Hepatic ImpairmentThe influence of hepatic impairment on the pharmacokinetics of nelarabine has not been evaluated.
ARRANON can cause fetal harm when administered to a pregnant woman.
Nelarabine administered during the period of organogenesis caused increased incidences of fetal malformations, anomalies, and variations in rabbits (see Use In Specific Populations].
There are no adequate and well-controlled studies of ARRANON in pregnant women. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus. Women of child-bearing potential should be advised to avoid becoming pregnant while receiving treatment with ARRANON.
250 mg/50 mL (5 mg/mL) vial
Storage And HandlingARRANON Injection is supplied as a clear, colorless, sterile solution in Type I, clear glass vials with a gray butyl rubber (latex-free) stopper and a red snap-off aluminum seal. Each vial contains 250 mg of nelarabine (5 mg nelarabine per mL) and the inactive ingredient sodium chloride (4.5 mg per mL) in 50 mL Water for Injection, USP. Vials are available in the following carton size:
NDC 0007-4401-06 (package of 6)
Store at 25° C (77° F); excursions permitted to 15° to 30° C (59° to 86° F).
REFERENCES
1. Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care Settings. NIOSH Alert 2004-165.
2. OSHA Technical Manual, TED 1-0.15A, Section VI: Chapter 2. Controlling Occupational Exposure to Hazardous Drugs. OSHA, 1999. http://www.osha.gov/dts/osta/otm/otm vi/otm vi 2.html
3. American Society of Health-System Pharmacists. ASHP Guidelines on Handling Hazardous Drugs. Am JHealth-Syst Pharm. 2006;63:1172-1193.
4. Polovich M, White JM, Kelleher LO (eds.) 2005. Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. (2nd ed) Pittsburgh, PA: Oncology Nursing Society.
GlaxoSmithKline, Research Triangle Park, NC 27709. December 2011
Included as part of the PRECAUTIONS section.
PRECAUTIONS Neurologic Adverse ReactionsNeurotoxicity is the dose-limiting toxicity of nelarabine. Patients undergoing therapy with ARRANON should be closely observed for signs and symptoms of neurologic toxicity. Common signs and symptoms of nelarabine-related neurotoxicity include somnolence, confusion, convulsions, ataxia, paresthesias, and hypoesthesia. Severe neurologic toxicity can manifest as coma, status epilepticus, craniospinal demyelination, or ascending neuropathy similar in presentation to Guillain-Barre syndrome.
Patients treated previously or concurrently with intrathecal chemotherapy or previously with craniospinal irradiation may be at increased risk for neurologic adverse events.
Hematologic Adverse ReactionsLeukopenia, thrombocytopenia, anemia, and neutropenia, including febrile neutropenia have been associated with nelarabine therapy. Complete blood counts including platelets should be monitored regularly.
Pregnancy Pregnancy Category DARRANON can cause fetal harm when administered to a pregnant woman.
Nelarabine administered during the period of organogenesis caused increased incidences of fetal malformations, anomalies, and variations in rabbits (see Use In Specific Populations].
There are no adequate and well-controlled studies of ARRANON in pregnant women. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus. Women of child-bearing potential should be advised to avoid becoming pregnant while receiving treatment with ARRANON.
HyperuricemiaPatients receiving ARRANON should receive intravenous hydration according to standard medical practice for the management of hyperuricemia in patients at risk for tumor lysis syndrome. Consideration should be given to the use of allopurinol in patients at risk of hyperuricemia.
VaccinationsAdministration of live vaccines to immunocompromised patients should be avoided.
Patient Counseling InformationPatient labeling is provided as a tear-off leaflet at the end of this full prescribing information. However, inform the patients of the following:
Carcinogenicity testing of nelarabine has not been done. However, nelarabine was mutagenic when tested in vitro in L5178Y/TK mouse lymphoma cells with and without metabolic activation. No studies have been conducted in animals to assess genotoxic potential or effects on fertility. The effect on human fertility is unknown.
Use In Specific Populations PregnancyPregnancy Category D
ARRANON can cause fetal harm when administered to a pregnant woman. Nelarabine administered to rabbits during the period of organogenesis caused increased incidences of fetal malformations, anomalies, and variations at doses > 360 mg/m² /day (8-hour IV infusion; approximately V the adult dose compared on a mg/m² Â basis), which was the lowest dose tested. Cleft palate was seen in rabbits given 3,600 mg/m² /day (approximately 2-fold the adult dose), absent pollices (digits) in rabbits given > 1,200 mg/m /day (approximately % the adult dose), while absent gall bladder, absent accessory lung lobes, fused or extra sternebrae and delayed ossification was seen at all doses. Maternal body weight gain and fetal body weights were reduced in rabbits given 3,600 mg/m² /day (approximately 2-fold the adult dose), but could not account for the increased incidence of malformations seen at this or lower administered doses.
There are no adequate and well-controlled studies of ARRANON in pregnant women. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus. Women of child-bearing potential should be advised to avoid becoming pregnant while receiving treatment with ARRANON.
Nursing MothersIt is not known whether nelarabine or ara-G are excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from ARRANON, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.
Pediatric UseThe safety and effectiveness of ARRANON has been established in pediatric patients .
Geriatric UseClinical studies of ARRANON did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from younger patients. In an exploratory analysis, increasing age, especially age 65 years and older, appeared to be associated with increased rates of neurologic adverse reactions. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.
Renal ImpairmentAra-G clearance decreased as renal function decreased. Because the risk of adverse reactions to this drug may be greater in patients with moderate (CLcr 30 to 50 mL/min) or severe (CLcr < 30 mL/min) renal impairment, these patients should be closely monitored for toxicities when treated with ARRANON.
Hepatic ImpairmentThe influence of hepatic impairment on the pharmacokinetics of nelarabine has not been evaluated. Because the risk of adverse reactions to this drug may be greater in patients with severe hepatic impairment (total bilirubin > 3 times upper limit of normal), these patients should be closely monitored for toxicities when treated with ARRANON.
This product is for intravenous use only.
The recommended duration of treatment for adult and pediatric patients has not been clearly established. In clinical trials, treatment was generally continued until there was evidence of disease progression, the patient experienced unacceptable toxicity, the patient became a candidate for bone marrow transplant, or the patient no longer continued to benefit from treatment.
Adult DosageThe recommended adult dose of ARRANON is 1,500 mg/m² Â administered intravenously over 2 hours on days 1, 3, and 5 repeated every 21 days. ARRANON is administered undiluted.
Pediatric DosageThe recommended pediatric dose of ARRANON is 650 mg/m² Â administered intravenously over 1 hour daily for 5 consecutive days repeated every 21 days. ARRANON is administered undiluted.
Dosage ModificationARRANON administration should be discontinued for neurologic adverse reactions of NCI Common Toxicity Criteria grade 2 or greater. Dosage may be delayed for other toxicity including hematologic toxicity.
Adjustment of Dose in Special Populations
ARRANON has not been studied in patients with renal or hepatic dysfunction. No dose adjustment is recommended for patients with a creatinine clearance (CLcr) > 50 mL/min. There are insufficient data to support a dose recommendation for patients with a CLcr < 50 mL/min.
Prevention of HyperuricemiaAppropriate measures (e.g., hydration, urine alkalinization, and prophylaxis with allopurinol) must be taken to prevent hyperuricemia.
Instructions for Handling, Preparation, and Administration HandlingARRANON is a cytotoxic agent. Caution should be used during handling and preparation. Use of gloves and other protective clothing to prevent skin contact is recommended. Proper aseptic technique should be used. Guidelines for proper handling and disposal of anticancer drugs have been published.1-4
Preparation and AdministrationDo not dilute ARRANON prior to administration.The appropriate dose of ARRANON is transferred into polyvinylchloride (PVC) infusion bags or glass containers and administered as a two-hour infusion in adult patients and as a one-hour infusion in pediatric patients.
Prior to administration, inspect the drug product visually for particulate matter and discoloration.
Stability: ARRANON Injection is stable in polyvinylchloride (PVC) infusion bags and glass containers for up to 8 hours at up to 30° C.
Cytochrome P450: Nelarabine and ara-G did not significantlyinhibit the activities of the human hepatic cytochrome P450 isoenzymes 1A2, 2A6, 2B6, 2C8, 2C9, 2C19, 2D6, or 3A4 in vitro at concentrations of nelarabine and ara-G up to 100 μM.
Fludarabine: Administration of fludarabine 30 mg/m² Â as a 30-minute infusion 4 hours before a 1,200 mg/m² Â infusion of nelarabine did not affect the pharmacokinetics of nelarabine, ara-G, or ara-GTP in 12 patients with refractory leukemia.
Pentostatin: There is in vitro evidence that pentostatin is a strong inhibitor of adenosine deaminase. Inhibition of adenosine deaminase may result in a reduction in the conversion of the pro-drug nelarabine to its active moiety and consequently in a reduction in efficacy of nelarabine and/or change in adverse reaction profile of either drug.