looking ahead to [2000/mm:<1000/mm 3 , or platelet count> <75,000/mm 3 ), interrupt therapy for 14 days. 1 Upon resolution of hematologic toxicity, reinitiate at a reduced dosage of 200 mg/m 2 daily. 1 Special Populations No special population dosage recommendations at this time. 1 Cautions for Altretamine Contraindications Known hypersensitivity to altretamine. 1 Preexisting severe bone marrow depression. 1 (See Hematologic Effects under Cautions.) Preexisting severe neurologic toxicity. 1 (See Nervous System Effects under Cautions.) Warnings/Precautions Warnings Nervous System Effects Risk of dose-related neurotoxicity, manifested as peripheral neuropathy and CNS manifestations (e.g., mood disorders, disorders of consciousness, ataxia, dizziness, vertigo). 1 Neurotoxicity may be reversible upon discontinuance of the drug. 1 8 Perform neurologic examinations prior to the initiation of each course and regularly during therapy. 1 If manifestations of neurotoxicity occur, discontinue therapy; dosage modification may be required. 1 (See Dosage Modification for Toxicity under Dosage and Administration.) Careful monitoring of neurologic function required during therapy in patients who have received previous treatment with cisplatin and/or alkylating agents, particularly in patients with preexisting cisplatin-induced neuropathies. 1 Hematologic Effects Risk of mild to moderate dose-related myelosuppression, including leukopenia, anemia, and thrombocytopenia. 1 Perform peripheral blood cell counts at least monthly, prior to the initiation of each course of therapy, and as clinically indicated; 1 dosage modification may be required. 1 (See Dosage Modification for Toxicity under Dosage and Administration.) Fetal/Neonatal Morbidity and Mortality May cause fetal harm; 1 16 17 embryotoxic and teratogenic effects demonstrated in animals. 1 Avoid pregnancy during therapy. 1 If used during pregnancy or if patient becomes pregnant, apprise of potential fetal hazard. 1 Major Toxicities GI Effects Risk of dose-related nausea and vomiting; reported frequently with continuous high-dose therapy. 1 If required, administer antiemetic therapy; dose reduction or, rarely, discontinuance of therapy may be required for severe symptoms. 1 (See Dosage Modification for Toxicity under Dosage and Administration.) Tolerance to GI symptoms may develop after several weeks of therapy. 1 General Precautions Carcinogenic Effects Acute myeloid leukemia reported in one patient. 20 Studies not performed to evaluate carcinogenic potential; drugs with similar mechanisms of action have been shown to be carcinogenic. 1 Specific Populations Pregnancy Category D. 1 (See Fetal/Neonatal Morbidity and Mortality under Cautions.) Lactation Not known if distributed into milk. 1 Discontinue nursing because of potential risk to nursing infant. 1 Pediatric Use Safety and efficacy not established. 1 Geriatric Use Safety and efficacy in geriatric patients not studied. 26 Common Adverse Effects Nausea, vomiting, peripheral sensory neuropathy, leukopenia, thrombocytopenia, anemia, increased serum alkaline phosphatase, increased serum creatinine/BUN. 1 Interactions for Altretamine Specific Drugs Drug Interaction Comments Cimetidine Potentially increased half-life and toxicity of altretamine 1 21 MAO inhibitors (antidepressants) Potentially severe orthostatic hypotension 1 Usually resolves upon discontinuance of the antidepressant 1 3 Pyridoxine Reduced neurotoxicity but shortened response duration in patients receiving altretamine and cisplatin 1 18 Concomitant administration not recommended 1 Altretamine Pharmacokinetics Absorption Bioavailability Readily absorbed from GI tract, with peak plasma concentrations attained within 0.5 3 hours. 1 Food Food may delay and decrease extent of absorption. 14 Distribution Extent Distributed into tissues with a high lipid component (e.g., omentum and subcutaneous tissue). 2 3 19 Concentrations in primary tumor similar to plasma concentrations; 27 concentrations higher in metastases than in primary tumor. 27 Not known if distributed into milk. 1 Plasma Protein Binding Altretamine: 94%. 1 19 Pentamethylmelamine and tetramethylmelamine: 75% and 50%, respectively. 1 19 Elimination Metabolism Rapidly and extensively metabolized in the GI tract and liver; 1 19 oxidative N -demethylation occurs to form active hydroxymethyl derivatives, principally pentamethylmelamine and tetramethylmelamine. 1 2 3 19 Metabolism and activation also may occur in tumor cells or other extrahepatic sites. 2 19 Elimination Route Excreted in urine, mostly as metabolites. 1 2 3 19 Half-life Biphasic; terminal half-life is about 5 10 hours. 1 2 19 23 Special Populations Effect of hepatic and/or renal impairment on elimination not established. 1 Ascites does not appear to alter pharmacokinetics. 28 Stability Storage Oral Capsules 25 C (may be exposed to 15 30 C). 1 Actions Exact mechanism of action not known. 1 3 19 Structurally similar to triethylenemelamine (an alkylating agent); however, no evidence from in vitro tests of alkylating activity. 1 2 Efficacy established for certain ovarian tumors resistant to classic alkylating agents. 1 Must be metabolized to exert cytotoxic effect. 1 2 19 Hydroxymethyl derivatives are metabolized to release formaldehyde, which may contribute to cytotoxic activity. 2 3 19 Metabolites and synthetic monohydroxymethylmelamines form covalent adducts with tissue macromolecules (e.g., DNA); relevance to antitumor activity not known. 1 19 Advice to Patients Risk of nausea, vomiting, myelosuppression, and neurotoxicity. 1 Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses. 1 Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed; necessity for clinicians to advise women to avoid pregnancy during therapy. 1 Importance of informing patients of other important precautionary information. 1 (See Cautions.) Preparations Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details. Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations. Altretamine Routes Dosage Forms Strengths Brand Names Manufacturer Oral Capsules 50 mg Hexalen MGI Pharma AHFS DI Essentials. Copyright 2017, Selected Revisions June 1, 2009. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814. Use is not currently included in the labeling approved by the US Food and Drug Administration. References 1. MGI Pharma. Hexalen (altretamine) capsules prescribing information. Bloomington, MN; 2003 Nov. 2. Hansen LA, Hughes TE. Altretamine. DICP . 1991; 25:146-52. [PubMed 1905441] 3. Lee CR, Faulds D. Altretamine. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in cancer chemotherapy. Drugs . 1995; 49:932-53. [PubMed 7641606] 4. Anon. Drugs of choice for cancer. Treat Guidel Med Lett . 2003; 1:41-52. 5. Ovarian epithelial cancer. From: PDQ. Physician data query (database). Bethesda, MD: National Cancer Institute; 2007 Dec 21. 6. Rosen GF, Lurain JR, Newton M. Hexamethylmelamine in ovarian cancer after failure of cisplatin-based multiple-agent chemotherapy. Gynecol Oncol . 1987; 27:173-9. [PubMed 3106174] 7. Manetta A, MacNeill C, Lyter JA et al. Hexamethylmelamine as a single second-line agent in ovarian cancer. Gynecol Oncol . 1990; 36:93-6. [PubMed 2104819] 8. Vergote I, Himmelmann A, Frankendal B et al. Hexamethylmelamine as second-line therapy in platin-resistant ovarian cancer. Gynecol Oncol . 1992; 47:282-6. [PubMed 1473738] 9. Markman M, Blessing JA, Moore D et al. Altretamine (hexamethylmelamine) in platinum-resistant and platinum-refractory ovarian cancer: a Gynecologic Oncology Group phase II trial. Gynecol Oncol . 1998; 69:226-9. [PubMed 9648592] 10. Keldsen N, Havsteen H, Vergote I et al. Altretamine (hexamethylmelamine) in the treatment of platinum-resistant ovarian cancer: a phase II study. Gynecol Oncol . 2003; 88:118-22. [PubMed 12586589] 11. Moore DH, Valea F, Crumpler LS et al. Hexamethylmelamine/altretamine as second-line therapy for epithelial ovarian carcinoma. Gynecol Oncol . 1993; 51:109-12. [PubMed 8244164] 12. Rothenberg ML, Liu PY, Wilczynski S et al. Phase II trial of oral altretamine for consolidation of clinical complete remission in women with stage III epithelial ovarian cancer: a Southwest Oncology Group trial (SWOG-9326). Gynecol Oncol . 2001; 82:317-22. [PubMed 11531286] 13. Alberts DS, Jiang C, Liu PY et al. Long-term follow-up of a phase II trial of oral altretamine for consolidation of clinical complete remission in women with stage III epithelial ovarian cancer in the Southwest Oncology Group. Int J Gynecol Cancer . 2004; 14:224-8. [PubMed 15086720] 14. Barker IK, Crawford SM, Fell AF. Determination of altretamine in human plasma with high-performance liquid chromatography. J Chromatogr B Biomed Appl . 1994; 660:121-6. [PubMed 7858704] 15. van der Hoop RG, van der Burg ME, ten Bokkel Huinink WW et al. Incidence of neuropathy in 395 patients with ovarian cancer treated with or without cisplatin. Cancer . 1990; 66:1697-702. [PubMed 2119878] 16. Food and Drug Administration. Labeling and prescription drug advertising; content and format for labeling for human prescription drugs. 21 CFR Parts 201 and 202. Final Rule. [Docket No. 75N-0066] Fed Regist . 1979; 44:37434-67. 17. Department of Health and Human Services, Food and Drug Administration. Subpart B Labeling requirements for prescription drugs and/or insulin. (21 CFR Ch. 1 (4-1-87 Ed.)). 1987:18-24. 18. Wiernik PH, Yeap B, Vogl SE et al. Hexamethylmelamine and low or moderate dose cisplatin with or without pyridoxine for treatment of advanced ovarian carcinoma: a study of the Eastern Cooperative Oncology Group. Cancer Invest . 1992; 10:1-9. [PubMed 1735009] 19. Damia G, D Incalci M. Clinical pharmacokinetics of altretamine. Clin Pharmacokinet . 1995; 28:439-48. [PubMed 7656502] 20. Grubb BP, Thant M. Acute myelocytic leukemia in a patient treated with hexamethylmelamine. Am J Med Sci . 1986; 292:393-4. [PubMed 3099573] 21. Hande K, Combs G, Swingle R et al. Effect of cimetidine and ranitidine on the metabolism and toxicity of hexamethylmelamine. Cancer Treat Rep . 1986; 70:1443-5. [PubMed 3098418] 22. Paolini A, D Incalci M. Effect of phenobarbital pretreatment on the metabolism and antitumor activity of hexamethylmelamine. Cancer Treat Rep . 1986; 70:513-6. [PubMed 3084083] 23. D Incalci M, Bolis G, Mangioni C et al. Variable oral absorption of hexamethylmelamine in man. Cancer Treat Rep . 1978; 62:2117-9. 24. Muggia F, Norris K Jr. Hexamethylmelamine in platinum-resistant ovarian cancer: how active? Gynecol Oncol . 1992; 47:279-81. 25. Reviewers comments (personal observations). 26. MGI Pharma. Bloomington, MN: Personal communication. 27. D Incalci M, Farina P, Sessa C et al. Hexamethylmelamine distribution in patients with ovarian and other pelvic cancers. Cancer Treat Rep . 1982; 66:231-5. 28. D Incalci M, Beggiolin G, Sessa C et al. Influence of ascites on the pharmacokinetics of hexamethylmelamine and N -demethylated metabolites in ovarian cancer patients. Eur J Cancer Clin Oncol . 1981; 17:1331-5. Next Interactions Print this page Add to My Med List More about altretamine Side Effects During Pregnancy Dosage Information Drug Interactions Support Group En Español 1 Review Add your own review/rating Drug class: miscellaneous antineoplastics Consumer resources Altretamine Altretamine (Advanced Reading) Professional resources Altretamine (Wolters Kluwer) Other brands: Hexalen Related treatment guides Ovarian Cancer> ]} FEATURED: CAR-T Cell Therapy Overview Mechanism of Action KTE-C19 Studies KTE-C19 Cancer Targets Adverse Events Manufacturing Drug Status Rx Availability Prescription only D Pregnancy Category Positive evidence of risk N/A CSA Schedule Not a controlled drug Approval History Drug history at FDA Drug Class Miscellaneous antineoplastics Related Drugs Ovarian Cancer Avastin , carboplatin , Taxol , cisplatin , cyclophosphamide , paclitaxel , gemcitabine , Gemzar , Cytoxan , bevacizumab , etoposide , Adriamycin , doxorubicin , Doxil , topotecan , Lynparza , olaparib , melphalan , Zejula , niraparib , thiotepa , Platinol , rucaparib , Hycamtin , Toposar , More... 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