Immediate treatment consists of gastric lavage, followed by supportive therapy for the cardiorespiratory systems if required. In the long term, careful monitoring of the haemopoietic system is essential and, if necessary, blood should be transfused.
Acute mucocutaneous toxicity has been reported in patients receiving hydroxycarbamide at a dosage several times greater than that recommended. Soreness, violet erythema, oedema on palms and foot soles followed by scaling of hands and feet, intense generalised hyperpigmentation of skin, and severe acute stomatitis were observed.
Marked leucopenia (<2.5wbcx109/L), thrombocytopenia (< 100x109/L), or severe anaemia.
Not applicable
Bone-marrow suppression is the major toxic effect of hydroxycarbamide
Cutaneous vasculitic toxicities including vasculitic ulcerations and gangrene have occurred in patients with myeloproliferative disorders during therapy with hydroxycarbamide. The risk of vasculitic toxicities is increased in patients who receive prior or concomitant interferon therapy.
In some patients, hyperpigmentation, atrophy of skin and nails, scaling, violet papules and alopecia have been observed following several years of long-term daily maintenance therapy with hydroxycarbamide.
Cases of fatal and non-fatal pancreatitis and hepatotoxicity and severe peripheral neuropathy have been observed in HIV patients when hydroxycarbamide was administered with antiretroviral agents, in particular didanosine plus stavudine. Patients treated with hydroxycarbamide in combination with didanosine, stavudine and indinavir showed a median decline in CD4 cells of approximately 100/mm3.
Adverse reactions observed with combined Hydroxyurea and irradiation therapy were similar to those reported with the use of Hydroxyurea alone, primarily bone marrow depression (leukopenia and anaemia) and gastric irritation. Nearly all patients receiving an adequate course of combined Hydroxyurea and irradiation therapy will develop leukopenia. Decreased platelet counts (<100,000/mm3) have occurred rarely and usually in the presence of marked leukopenia. Hydroxyurea may potentiate some adverse reactions usually seen with irradiation alone, such as gastric distress and mucositis.
The list is presented by system organ class, MedDRA preferred term, and frequency using the following frequency categories: very common (>1/10), common (>1/100, < 1/10), uncommon (>1/1000, <1/100), rare (>1/10000, <1/1000), very rare (< 1/10000), and not known (cannot be estimated from the available data).
| System Organ Class | Frequency | MedDRA Term |
| Infections and Infestations | Rare | Gangrene |
| Neoplasms Benign and Malignant (including cysts and polyps) | Common | Skin cancer |
| Blood and Lymphatic System Disorders | Very common | Bone marrow failure, CD4 lymphocytes decreased, leukopenia, thrombocytopenia, platelet count decreased, anaemia |
| Metabolism and Nutrition Disorders | Very common | Anorexia |
| Psychiatric Disorders | Common | Hallucination, disorientation |
| Nervous System Disorders | Common | Convulsion, dizziness, peripheral neuropathy1, somnolence, headache |
| Respiratory, Thoracic, and Mediastinal Disorders | Common | Pulmonary fibrosis, pulmonary oedema, lung infiltration, dyspnoea |
| Gastrointestinal Disorders | Very common | Pancreatitis1, nausea, vomiting, diarrhoea, stomatitis, constipation, mucositis, stomach discomfort, dyspepsia, abdominal pain, melaena |
| Hepatobiliary Disorders | Common | Hepatotoxicity1, hepatic enzyme increased, cholestasis, hepatitis |
| Skin and Subcutaneous Tissue Disorders | Very common | Cutaneous vasculitis, dermatomyositis, alopecia, rash maculo-papular, rash papular, skin exfoliation, skin atrophy, skin ulcer, erythema, skin hyperpigmentation, nail disorder |
| Renal and Urinary Disorders | Very common | Dysuria, blood creatinine increased, blood urea increased, blood uric acid increased |
| General Disorders and Administration Site Conditions | Very common | Pyrexia, asthenia, chills, malaise |
| Reproductive system and breast disorders | Very common | azoospermia, oligospermia |
| 1 Fatal and non-fatal pancreatitis and hepatotoxicity and severe peripheral neuropathy have been reported in HIV-infected patients who received hydroxyurea in combination with antiretroviral agents, in particular didanosine plus stavudine. | ||
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.
Hydroxycarbamide is unequivocally genotoxic and a presumed transpecies carcinogen which implies a carcinogenic risk to humans.
The treatment of chronic myeloid leukaemia.
The treatment of cancer of the cervix in conjunction with radiotherapy.
Pharmacotherapeutic group: other antineoplastic agents
ATC Code: L01XX05
Hydroxycarbamide is an orally active antineoplastic agent. Although the mechanism of action has not yet been clearly defined, hydroxycarbamide appears to act by interfering with synthesis of DNA.
After oral administration hydroxycarbamide is readily absorbed from the gastrointestinal tract. Peak plasma concentrations are reached in 2 hours; by 24 hours the serum concentrations are virtually zero. Approximately 80% of an oral or intravenous dose of 7 to 30 mg/kg may be recovered from the urine within 12 hours. Hydroxycarbamide crosses the blood-brain barrier. Hydroxycarbamide is well distributed throughout the body.
The complete status of the blood, including bone marrow examination, if indicated, as well as kidney function and liver function should be determined prior to, and repeatedly during, treatment. If bone marrow function is depressed, treatment with Hydroxyurea should not be initiated. The determination of haemoglobin level, total leukocyte counts, and platelet counts should be performed at least once a week throughout the course of hydroxycarbamide therapy. If WBC falls below 2.5x109/L or platelet count to <100x109/L, therapy should be interrupted. Counts should be rechecked after 3 days and treatment resumed when they rise significantly towards normal.
Hydroxyurea may produce bone marrow suppression; leukopenia is generally its first and most common manifestation. Thrombocytopenia and anaemia occur less often and are seldom seen without a preceding leukopenia. Bone marrow depression is more likely in patients who have previously received radiotherapy or cytotoxic cancer chemotherapeutic agents; Hydroxyurea should be used cautiously in such patients. The recovery from myelosuppression is rapid when Hydroxyurea therapy is interrupted.
Severe anaemia must be corrected with whole blood replacement before initiating therapy with hydroxycarbamide. If, during treatment, anaemia occurs, correct without interrupting Hydroxyurea therapy. Erythrocytic abnormalities; megaloblastic erythropoeisis, which is self-limiting, is often seen early in the course of hydroxycarbamide therapy. The morphologic change resembles pernicious anaemia, but is not related to vitamin B12 or folic acid deficiency. The macrocytosis may mask the incidental development of folic acid deficiency; regular determinations of serum folic acid are recommended. Hydroxycarbamide may also delay plasma iron clearance and reduce the rate of iron utilisation by erythrocytes but it does not appear to alter the red blood cell survival time.
Patients who have received irradiation therapy in the past may have an exacerbation of postirradiation erythema when Hydroxyurea is given.
Hydroxycarbamide should be used with caution in patients with marked renal dysfunction.
Hydroxycarbamide is not licensed for use in combination with antiretroviral agents for HIV disease and it may cause treatment failure and toxicities (in some cases fatal) in HIV patients.
In patients receiving long-term therapy with hydroxycarbamide for myeloproliferative disorders, such as polycythemia, secondary leukaemia has been reported. It is unknown whether this leukaemogenic effect is secondary to hydroxycarbamide or associated with the patient's underlying disease. Skin cancer has also been reported in patients receiving long-term hydroxycarbamide. Patients should be advised to protect skin from sun exposure, conduct self-inspection of the skin and be screened for secondary malignancies during routine follow-up visits.
Cutaneous vasculitic toxicities including vasculitic ulcerations and gangrene have occurred in patients with myeloproliferative disorders during therapy with hydroxycarbamide. The risk of vasculitic toxicities is increased in patients who receive prior or concomitant interferon therapy. The digital distribution of these vasculitic ulcerations and progressive clinical behaviour of peripheral vasculitic insufficiency leading to digital infarct or gangrene were distinctly different than the typical skin ulcers generally described with Hydroxycarbamide. Due to potentially severe clinical outcomes for the cutaneous vasculitic ulcers reported in patients with myeloproliferative disease, hydroxycarbamide should be discontinued if cutaneous vasculitic ulcerations develop and alternative cytoreductive agents should be initiated as indicated.
The possibility of an increase in serum uric acid, resulting in the development of gout or, at worst, uric acid nephropathy, should be borne in mind in patients treated with hydroxycarbamide, especially when used with other cytotoxic agents. It is therefore important to monitor uric acid levels regularly and maintain a high fluid intake during treatment.
This product contains lactose, patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicinal product.
Vaccinations
Concomitant use of Hydroxyurea with a live virus vaccine may potentiate the replication of the vaccine virus and/or may increase some of the adverse reactions of the vaccine virus because normal defence mechanisms may be suppressed by hydroxycarbamide. Vaccination with a live vaccine in a patient taking Hydroxyurea may result in severe infection. The patient's antibody response to vaccines may be decreased. The use of live vaccines should be avoided during treatment and for at least six months after treatment has finished and individual specialist advice sought.
Hydroxycarbamide may cause drowsiness. Patients receiving it should not drive or operate machinery unless it has been shown not to affect physical or mental ability.
Posology
Adults
Treatment regimens can be continuous or intermittent. The continuous regimen is particularly suitable for chronic myeloid leukaemia, while the intermittent regimen, with its diminished effect on the bone marrow, is more satisfactory for the management of cancer of the cervix.
Hydroxyurea should be started 7 days before concurrent irradiation therapy. If Hydroxyurea is used concomitantly with radiotherapy, adjustment of radiation dosage is not usually necessary.
An adequate trial period for determining the antineoplastic effect of Hydroxyurea is six weeks. Where there is a significant clinical response therapy may be continued indefinitely, provided that the patient is kept under adequate observation and shows no unusual or severe reactions. Therapy should be interrupted if the white cell count drops below 2.5x109L or the platelet count below 100x109/L.
In these cases, the counts should be reevaluated after three days and therapy resumed when the counts return to acceptable levels. Hematopoietic rebound is usually rapid. If rapid rebound has not occurred during combined Hydroxyurea and irradiation therapy, irradiation may also be interrupted. Anemia, even if severe, can be managed without interrupting Hydroxyurea therapy.
Severe gastric distress, such as nausea, vomiting, and anorexia, resulting from combined therapy may usually be controlled by interruption of Hydroxyurea administration.
Pain or discomfort from inflammation of the mucous membranes at the irradiated site (mucositis) is usually controlled by measures such as topical anesthetics and orally administered analgesics. If the reaction is severe, Hydroxyurea therapy may be temporarily interrupted; if it is extremely severe, irradiation dosage may, in addition, be temporarily postponed.
Continuous therapy
Hydroxyurea 20-30 mg/kg should be given daily in single doses. Dosage should be based on the patient's actual or ideal weight, whichever is the less. Therapy should be monitored by repeat blood counts.
Intermittent therapy
Hydroxyurea 80 mg/kg in single doses should be given every third day. Using the intermittent regimes the likelihood of WBC depression is diminished, but if low counts are produced, 1 or more doses of Hydroxyurea should be omitted.
Concurrent use of Hydroxyurea with other myelosuppressive agents may require adjustments of dosages.
Special Populations
Children
Because of the rarity of these conditions in children, dosage regimens have not been established.
Elderly
Elderly patients may be more sensitive to the effects of hydroxycarbamide, and may require a lower dosage regimen.
Renal Impairment
Since renal excretion is a pathway of elimination, consideration should be given to decreasing the dosage of Hydroxyurea in this population.
Method of administration
For oral use.
NB: If the patient prefers, or is unable to swallow capsules, the contents of the capsules may be emptied into a glass of water and taken immediately. The contents of capsules should not be inhaled or allowed to come into contact with the skin or mucous membranes. Spillages must be wiped immediately.
People who are not taking Hydroxyurea should not be exposed to it. To decrease the risk of exposure, wear disposable gloves when handling Hydroxyurea. Anyone handling Hydroxyurea should wash their hands before and after contact with the capsules. If the powder is spilled, it should be immediately wiped with a damp disposable towel and discarded in a closed container, such as a plastic bag, as should the empty capsules. Hydroxyurea should be kept away from children. Pregnant women should not handle Hydroxyurea.
To minimise the risk of dermal exposure, always wear impervious gloves when handling capsules containing Hydroxyurea. This includes all handling activities in clinical settings, pharmacies, storerooms and home healthcare settings, including during unpacking and inspection, transport within a facility, and dose preparation and administration. Any unused medicinal product or waste material should be disposed of in accordance with local requirements.
