Altretamine

Altretamine
Black Box Warning
Adult Indications & Dosage
Pediatric Indications & Dosage
Contraindications
Warnings & Precautions
Adverse Reactions
Drug Interactions
Use in Specific Populations
Administration & Monitoring
Overdosage
Pharmacology
Clinical Studies
How Supplied
Images
Patient Counseling Information
Precautions with Alcohol
Brand Names
Look-Alike Names

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aparna Vuppala, M.B.B.S. [2]

Disclaimer

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Black Box Warning

WARNINGS See full prescribing information for complete Boxed Warning. HEXALEN® capsules should only be given under the supervision of a physician experienced in the use of antineoplastic agents. Peripheral blood counts should be monitored at least monthly, prior to the initiation of each course of HEXALEN® capsules, and as clinically indicated . Because of the possibility of HEXALEN® capsules-related neurotoxicity, neurologic examination should be performed regularly during HEXALEN® capsules administration

Overview

Altretamine is a {{{drugClass}}} that is FDA approved for the {{{indicationType}}} of {{{indication}}}. There is a Black Box Warning for this drug as shown here. Common adverse reactions include .

Adult Indications and Dosage

FDA-Labeled Indications and Dosage (Adult)

Condition1

• HEXALEN® (altretamine) capsules is indicated for use as a single agent in the palliative treatment of patients with persistent or recurrent ovarian cancer following first-line therapy with a cisplatin and/or alkylating agent-based combination.
• Dosing Information

• Dosage

Condition2

• Dosing Information

HEXALEN® capsules is administered orally. Doses are calculated on the basis of body surface area.

HEXALEN® capsules may be administered either for 14 or 21 consecutive days in a 28 day cycle at a dose of 260 mg/m2/day. The total daily dose should be given as 4 divided oral doses after meals and at bedtime. There is no pharmacokinetic information supporting this dosing regimen and the effect of food on HEXALEN® capsules bioavailability or pharmacokinetics has not been evaluated.

HEXALEN® capsules should be temporarily discontinued (for 14 days or longer) and subsequently restarted at 200 mg/m2/day for any of the following situations:

Gastrointestinal intolerance unresponsive to symptomatic measures; White blood count <2000/mm3 or granulocyte count <1000/mm3; Platelet count <75,000/mm3; Progressive neurotoxicity. If neurologic symptoms fail to stabilize on the reduced dose schedule, HEXALEN® capsules should be discontinued indefinitely.

Procedures for proper handling and disposal of anticancer drugs should be considered. Several guidelines on this subject have been published (2-9). There is no general agreement that all of the procedures recommended in the guidelines are necessary or appropriate.

• Dosage

Condition3

• Dosing Information

• Dosage

Condition4

• Dosing Information

• Dosage

Off-Label Use and Dosage (Adult)

Guideline-Supported Use

Condition1

• Developed by:

• Class of Recommendation:

• Strength of Evidence:

• Dosing Information

• Dosage

Condition2

There is limited information regarding Off-Label Guideline-Supported Use of Altretamine in adult patients.

Non–Guideline-Supported Use

Condition1

• Dosing Information

• Dosage

Condition2

There is limited information regarding Off-Label Non–Guideline-Supported Use of Altretamine in adult patients.

Pediatric Indications and Dosage

FDA-Labeled Indications and Dosage (Pediatric)

Condition1

• Dosing Information

• Dosage

Condition2

There is limited information regarding FDA-Labeled Use of Altretamine in pediatric patients.

Off-Label Use and Dosage (Pediatric)

Guideline-Supported Use

Condition1

• Developed by:

• Class of Recommendation:

• Strength of Evidence:

• Dosing Information

• Dosage

Condition2

There is limited information regarding Off-Label Guideline-Supported Use of Altretamine in pediatric patients.

Non–Guideline-Supported Use

Condition1

• Dosing Information

• Dosage

Condition2

There is limited information regarding Off-Label Non–Guideline-Supported Use of Altretamine in pediatric patients.

Contraindications

• HEXALEN® capsules is contraindicated in patients who have shown hypersensitivity to it. HEXALEN® capsules should not be employed in patients with preexisting severe bone marrow depression or severe neurologic toxicity. HEXALEN® capsules has been administered safely, however, to patients heavily pretreated with cisplatin and/or alkylating agents, including patients with preexisting cisplatin neuropathies. Careful monitoring of neurologic function in these patients is essential.

Warnings

WARNINGS See full prescribing information for complete Boxed Warning. HEXALEN® capsules should only be given under the supervision of a physician experienced in the use of antineoplastic agents. Peripheral blood counts should be monitored at least monthly, prior to the initiation of each course of HEXALEN® capsules, and as clinically indicated . Because of the possibility of HEXALEN® capsules-related neurotoxicity, neurologic examination should be performed regularly during HEXALEN® capsules administration

• Concurrent administration of HEXALEN® capsules and antidepressants of the monoamine oxidase (MAO) inhibitor class may cause severe orthostatic hypotension. Four patients, all over 60 years of age, were reported to have experienced symptomatic hypotension after 4 to 7 days of concomitant therapy with HEXALEN® capsules and MAO inhibitors.

HEXALEN® capsules causes mild to moderate myelosuppression and neurotoxicity. Blood counts and a neurologic examination should be performed prior to the initiation of each course of therapy and the dose of HEXALEN® capsules adjusted as clinically indicated

Precautions

General Neurologic examination should be performed regularly

• Description

Adverse Reactions

Clinical Trials Experience

Gastrointestinal With continuous high-dose daily HEXALEN® capsules, nausea and vomiting of gradual onset occur frequently. Although in most instances these symptoms are controllable with anti-emetics, at times the severity requires HEXALEN® capsules dose reduction or, rarely, discontinuation of HEXALEN® capsules therapy. In some instances, a tolerance of these symptoms develops after several weeks of therapy. The incidence and severity of nausea and vomiting are reduced with moderate-dose administration of HEXALEN® capsules. In 2 clinical studies of single-agent HEXALEN® capsules utilizing a moderate, intermittent dose and schedule, only 1 patient (1%) discontinued HEXALEN® capsules due to severe nausea and vomiting.

Neurotoxicity Peripheral neuropathy and central nervous system symptoms (mood disorders, disorders of consciousness, ataxia, dizziness, vertigo) have been reported. They are more likely to occur in patients receiving continuous high-dose daily HEXALEN® (altretamine) capsules than moderate-dose HEXALEN® capsules administered on an intermittent schedule. Neurologic toxicity has been reported to be reversible when therapy is discontinued. Data from a randomized trial of HEXALEN® capsules and cisplatin plus or minus pyridoxine in ovarian cancer indicated that pyridoxine significantly reduced neurotoxicity; however, it adversely affected response duration suggesting that pyridoxine should not be administered with HEXALEN® capsules and/or cisplatin (1).

Hematologic HEXALEN® capsules causes mild to moderate dose-related myelosuppression. Leukopenia below 3000 WBC/mm3 occurred in <15% of patients on a variety of intermittent or continuous dose regimens. Less than 1% had leukopenia below 1000 WBC/mm3. Thrombocytopenia below 50,000 platelets/mm3 was seen in <10% of patients. When given in doses of 8-12 mg/kg/day over a 21 day course, nadirs of leukocyte and platelet counts were reached by 3-4 weeks, and normal counts were regained by 6 weeks. With continuous administration at doses of 6-8 mg/kg/day, nadirs are reached in 6-8 weeks (median).

Data in the following table are based on the experience of 76 patients with ovarian cancer previously treated with a cisplatin-based combination regimen who received single-agent HEXALEN® capsules. In one study, HEXALEN® capsules, 260 mg/m2/day, was administered for 14 days of a 28 day cycle. In another study, HEXALEN® capsules, 6-8 mg/kg/day, was administered for 21 days of a 28 day cycle.

This image is provided by the National Library of Medicine.

Additional adverse reaction information is available from 13 single-agent altretamine studies (total of 1014 patients) conducted under the auspices of the National Cancer Institute. The treated patients had a variety of tumors and many were heavily pretreated with other chemotherapies; most of these trials utilized high, continuous daily doses of altretamine (612 mg/kg/day). In general, adverse reaction experiences were similar in the two trials described above. Additional toxicities, not reported in the above table, included hepatic toxicity, skin rash, pruritus and alopecia, each occurring in <1% of patients.

Body as a Whole

Cardiovascular

Digestive

Endocrine

Hematologic and Lymphatic

Metabolic and Nutritional

Musculoskeletal

Neurologic

Respiratory

Skin and Hypersensitivy Reactions

Special Senses

Urogenital

Miscellaneous

Postmarketing Experience

There is limited information regarding Postmarketing Experience of Altretamine in the drug label.

Body as a Whole

Cardiovascular

Digestive

Endocrine

Hematologic and Lymphatic

Metabolic and Nutritional

Musculoskeletal

Neurologic

Respiratory

Skin and Hypersensitivy Reactions

Special Senses

Urogenital

Miscellaneous

Drug Interactions

• Concurrent administration of HEXALEN® capsules and antidepressants of the MAO inhibitor class may cause severe orthostatic hypotension (see WARNINGS section). Cimetidine, an inhibitor of microsomal drug metabolism, increased altretamine's half-life and toxicity in a rat model.

Data from a randomized trial of HEXALEN® capsules and cisplatin plus or minus pyridoxine in ovarian cancer indicated that pyridoxine significantly reduced neurotoxicity; however, it adversely affected response duration suggesting that pyridoxine should not be administered with HEXALEN® capsules and/or cisplatin (1).

Use in Specific Populations

Pregnancy

Pregnancy Category (FDA): D Pregnancy: Category D HEXALEN® capsules has been shown to be embryotoxic and teratogenic in rats and rabbits when given at doses 2 and 10 times the human dose. HEXALEN® capsules may cause fetal damage when administered to a pregnant woman. If HEXALEN® capsules is used during pregnancy, or if the patient becomes pregnant while taking the drug, the patient should be apprised of the potential hazard to the fetus. Women of childbearing potential should be advised to avoid becoming pregnant.
Pregnancy Category (AUS):

• Australian Drug Evaluation Committee (ADEC) Pregnancy Category

There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Altretamine in women who are pregnant.

Labor and Delivery

There is no FDA guidance on use of Altretamine during labor and delivery.

Nursing Mothers

It is not known whether altretamine is excreted in human milk. Because there is a possibility of toxicity in nursing infants secondary to HEXALEN® capsules treatment of the mother, it is recommended that breast feeding be discontinued if the mother is treated with HEXALEN® capsules.

Pediatric Use

The safety and effectiveness of HEXALEN® capsules in children have not been established.

Geriatic Use

There is no FDA guidance on the use of Altretamine with respect to geriatric patients.

Gender

There is no FDA guidance on the use of Altretamine with respect to specific gender populations.

Race

There is no FDA guidance on the use of Altretamine with respect to specific racial populations.

Renal Impairment

There is no FDA guidance on the use of Altretamine in patients with renal impairment.

Hepatic Impairment

There is no FDA guidance on the use of Altretamine in patients with hepatic impairment.

Females of Reproductive Potential and Males

There is no FDA guidance on the use of Altretamine in women of reproductive potentials and males.

Immunocompromised Patients

There is no FDA guidance one the use of Altretamine in patients who are immunocompromised.

Administration and Monitoring

Administration

• Oral

• Intravenous

Monitoring

Peripheral blood counts should be monitored at least monthly, prior to the initiation of each course of HEXALEN® capsules, and as clinically indicated .

• Description

IV Compatibility

There is limited information regarding IV Compatibility of Altretamine in the drug label.

Overdosage

No case of acute overdosage in humans has been described. The oral LD50 dose in rats was 1050 mg/kg and 437 mg/kg in mice.

Signs and Symptoms

• Description

Management

• Description

Chronic Overdose

There is limited information regarding Chronic Overdose of Altretamine in the drug label.

Pharmacology

This image is provided by the National Library of Medicine.

Mechanism of Action

• The precise mechanism by which HEXALEN® capsules exerts its cytotoxic effect is unknown, although a number of theoretical possibilities have been studied. Structurally, HEXALEN® capsules resembles the alkylating agent triethylenemelamine, yet in vitro tests for alkylating activity of HEXALEN® capsules and its metabolites have been negative. HEXALEN® capsules has been demonstrated to be efficacious for certain ovarian tumors resistant to classical alkylating agents. Metabolism of altretamine is a requirement for cytotoxicity. Synthetic monohydroxymethylmelamines, and products of altretamine metabolism, in vitro and in vivo, can form covalent adducts with tissue macromolecules including DNA, but the relevance of these reactions to antitumor activity is unknown.

Structure

• HEXALEN® (altretamine) capsules, is a synthetic cytotoxic antineoplastic s-triazine derivative. HEXALEN® capsules contain 50 mg of altretamine for oral administration. Inert ingredients include lactose, anhydrous and calcium stearate. Altretamine, known chemically as N,N,N',N',N”,N”-hexamethyl-1,3,5-triazine-2,4,6-triamine, has the following structural formula:

This image is provided by the National Library of Medicine.

Its empirical formula is C9H18N6 with a molecular weight of 210.28. Altretamine is a white crystalline powder, melting at 172°± 1°C. Altretamine is practically insoluble in water but is increasingly soluble at pH 3 and below.

Pharmacodynamics

There is limited information regarding Pharmacodynamics of Altretamine in the drug label.

Pharmacokinetics

• HEXALEN® capsules is well-absorbed following oral administration in humans, but undergoes rapid and extensive demethylation in the liver, producing variation in altretamine plasma levels. The principal metabolites are pentamethylmelamine and tetramethylmelamine.
• Pharmacokinetic studies were performed in a limited number of patients and should be considered preliminary. After oral administration of HEXALEN® capsules to 11 patients with advanced ovarian cancer in doses of 120-300 mg/m2, peak plasma levels (as measured by gas-chromatographic assay) were reached between 0.5 and 3 hours, varying from 0.2 to 20.8 mg/l. Half-life of the β-phase of elimination ranged from 4.7 to 10.2 hours. Altretamine and metabolites show binding to plasma proteins. The free fractions of altretamine, pentamethylmelamine and tetramethylmelamine are 6%, 25% and 50%, respectively.
• Following oral administration of 14C-ring-labeled altretamine (4 mg/kg), urinary recovery of radioactivity was 61% at 24 hours and 90% at 72 hours. Human urinary metabolites were Ndemethylated homologues of altretamine with <1% unmetabolized altretamine excreted at 24 hours.
• After intraperitoneal administration of 14C-ring-labeled altretamine to mice, tissue distribution was rapid in all organs, reaching a maximum at 30 minutes. The excretory organs (liver and kidney) and the small intestine showed high concentrations of radioactivity, whereas relatively low concentrations were found in other organs, including the brain.
• There have been no formal pharmacokinetic studies in patients with compromised hepatic and/or renal function, though HEXALEN® capsules has been administered both concurrently and following nephrotoxic drugs such as cisplatin.
• HEXALEN® capsules has been administered in 4 divided doses, with meals and at bedtime, though there is no pharmacokinetic data on this schedule nor information from formal interaction studies about the effect of food on its bioavailability or pharmacokinetics.
• In two studies in patients with persistent or recurrent ovarian cancer following first-line treatment with cisplatin and/or alkylating agent-based combinations, HEXALEN® capsules was administered as a single agent for 14 or 21 days of a 28 day cycle. In the 51 patients with measurable or evaluable disease, there were 6 clinical complete responses, 1 pathologic complete response, and 2 partial responses for an overall response rate of 18%. The duration of these responses ranged from 2 months in a patient with a palpable pelvic mass to 36 months in a patient who achieved a pathologic complete response. In some patients, tumor regression was associated with improvement in symptoms and performance status.

Nonclinical Toxicology

Carcinogenesis, Mutagenesis and Impairment of Fertility The carcinogenic potential of HEXALEN® capsules has not been studied in animals, but drugs with similar mechanisms of action have been shown to be carcinogenic. HEXALEN® capsules was weakly mutagenic when tested in strain TA100 of Salmonella typhimurium. HEXALEN® capsules administered to female rats 14 days prior to breeding through the gestation period had no adverse effect on fertility, but decreased post-natal survival at 120 mg/m2/day and was embryocidal at 240 mg/m2/day. Administration of 120 mg/m2/day HEXALEN® capsules to male rats for 60 days prior to mating resulted in testicular atrophy, reduced fertility and a possible dominant lethal mutagenic effect. Male rats treated with HEXALEN® capsules at 450 mg/m2/day for 10 days had decreased spermatogenesis, atrophy of testes, seminal vesicles and ventral prostate.

Clinical Studies

There is limited information regarding Clinical Studies of Altretamine in the drug label.

How Supplied

• HEXALEN® (altretamine) capsules is available in 50 mg clear, hard gelatin capsules imprinted with the following inscription:

USB 001. Bottles of 100 capsules (NDC 58063-001-70)

Storage

Store up to 25ºC (77ºF); excursions permitted to 15° to 30°C (59° to 86°F).

Images

Drug Images

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Package and Label Display Panel

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Patient Counseling Information

There is limited information regarding Patient Counseling Information of Altretamine in the drug label.

Precautions with Alcohol

• Alcohol-Altretamine interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

Brand Names

• ®

Look-Alike Drug Names

• A® — B®

Drug Shortage Status

Price

References

The contents of this FDA label are provided by the National Library of Medicine.

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