Powder for injection with solvent. Injections supplied as a unit pack comprising a vial containing 50mg sterile, anhydrous melphalan (as the hydrochloride) with one vial of 10mL solvent-diluent.
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Melphalan is a bifunctional alkylating agent. Formation of carbonium intermediates from each of the two bis- 2-chloroethyl groups enables alkylation through covalent binding with the 7-nitrogen of guanine on DNA, cross-linking two DNA strands and thereby preventing cell replication.
Pharmacokinetics
The absorption of melphalan was found to be highly variable in 13 patients given 0.6mg/kg bodyweight orally, with respect to both the time to first appearance of melphalan in plasma (range 0 to 336 minutes) and peak plasma concentration (range 70 to 630ng/mL). In 5 of the patients who were given an equivalent intravenous dose, the mean bioavailability of melphalan was found to be 56 27%. The terminal plasma half-life was 90 57 minutes with 11% of the agent being recovered in the urine over 24 hours. The pharmacokinetics of intravenous ALKERAN given at both conventional and high doses are best described by a bi-exponential, 2-compartment model. In 8 patients given a single bolus dose of 0.5 to 0.6mg/kg bodyweight, the composite initial and terminal half-lives were reported to be 7.7 3.3 minutes and 108 20.8 minutes, respectively. Following injection of melphalan, monohydroxymelphalan and dihydroxymelphalan were detected in the patients' plasma, reaching peak levels at approximately 60 minutes and 105 minutes, respectively. A similar half-life of 126 6 minutes was seen when melphalan was added to the patients' serum in vitro (37C), suggesting that spontaneous degradation rather than enzymic metabolism may be the major determinant of the melphalan's half-life in man. Following administration of a 2 minute infusion of doses ranging from 5 to 23 mg/m body surface area (approximately 0.1 to 0.6mg/kg bodyweight) to 10 patients with ovarian cancer or multiple myeloma, the pooled initial and terminal half-lives were, respectively, 8.1 6.6 minutes and 76.9 40.7 minutes. In this study, the mean volumes of distribution at steady state and central compartment were 29.1 13.6 litres and 12.2 6.5 litres, respectively, and a mean clearance of 342.7 96.8 mL/minute was recorded. In 15 children and 11 adults given high-dose intravenous ALKERAN (140mg/m body surface area) with forced diuresis, the mean initial and terminal half-lives were found to be 6.5 3.6 minutes and 41.4 16.5 minutes, respectively. Mean initial and terminal half-lives of 8.8 6.6 minutes and 73.1 45.9 minutes, respectively, were recorded in 28 patients with various malignancies who were given doses of between 70 and 200mg/m body surface area as a 2 to 20 minute infusion. The mean volumes of distribution at steady state and central compartment were, respectively, 40.2
18.3 litres and 18.2 11.7 litres, and the mean clearance was 564.6
159.1mL/minute.
Following hyperthermic (39C) perfusion of the lower limb with 1.75mg/kg bodyweight, mean initial and terminal half-lives of 3.6 1.5 minutes and 46.5
17.2 minutes, respectively, were recorded in 11 patients with advanced malignant melanoma. Mean volumes of distribution at steady state and central compartment were, respectively, 2.87 0.8 litres and 1.01 0.28 litres, and a mean clearance of 55.0 9.4mL/minute was recorded.
Preclinical safety data
Melphalan is mutagenic in animals.
Indications
ALKERAN Injection, administered by regional arterial perfusion, is indicated in the treatment of: localised malignant melanoma of the extremities; localised soft tissue sarcoma of the extremities. ALKERAN Injection, at conventional intravenous dosage, may be used in the treatment of:
multiple myeloma:
ALKERAN Injection, either alone or in combination with other cytotoxic agents, is as effective as the oral formulation in the treatment of multiple myeloma;
advanced ovarian cancer:
ALKERAN injection produces an objective response in approximately 50% of the patients with advanced ovarian adenocarcinoma, when given alone, or in combination with other cytotoxic.
ALKERAN Injection, at high intravenous dosage, may be used in the treatment of:
multiple myeloma
: complete remissions have been achieved in up to 50% of patients given high-dose ALKERAN Injection, with or without haematopoietic stem cell rescue, either as first-line treatment or to consolidate a response to conventional cytoreductive chemotherapy;
advanced neuroblastoma in childhood:
high-dose ALKERAN Injection with haematopoietic stem cell rescue has been used either alone, or combined with radiotherapy and/or other cytotoxic agents, to consolidate a response to conventional treatment.
A significant increase in the duration of disease-free survival was demonstrated in a prospective randomised trial of high-dose ALKERAN injection versus no further treatment.
ALKERAN is a cytotoxic medicine which falls into the general class of alkylating agents. It should be prescribed only by physicians experienced in the management of malignant disease with such agents. Since ALKERAN is myelosuppressive, frequent blood counts are essential during therapy and the dosage should be delayed or adjusted if necessary (see Warnings and Precautions).
ALKERAN Injection has been used on an intermittent basis alone, or in combination with other cytotoxic agents, at doses varying between 8mg/m2 body surface area and 30mg/m2 body surface area, given at intervals of between 2 to 6 weeks. Additionally, administration of prednisone has been included in a number of regimens. The literature should be consulted for precise details on treatment protocols. When used as a single agent, a typical intravenous dosage schedule is 0.4 mg/kg bodyweight (16mg/m2 body surface area) repeated at appropriate intervals (e.g. once every 4 weeks), provided there has been recovery of the peripheral blood count during this period. High-dose regimens generally employ single intravenous doses of between 100 and 200mg/m2 body surface area (approximately 2.5 to 5.0mg/kg bodyweight), but haematopoietic stem cell rescue becomes essential following doses in excess of 140mg/m2 body surface area. In cases of renal impairment, the dose should be reduced by 50% (see Dosage in Renal Impairment). In view of the severe myelosuppression induced by high- dose ALKERAN Injection, treatment should be confined to specialist centres with the appropriate facilities, and only be administered by experienced clinicians (see Warnings and Precautions).
When used intravenously as a single agent, a dose of 1mg/kg bodyweight (approximately 40mg/m2 body surface area) given at intervals of 4 weeks has often been used. When combined with other cytotoxic agents, intravenous doses of between 0.3 and 0.4mg/kg bodyweight (12 to 16mg/m2 body surface area) have been used at intervals of 4 to 6 weeks.
Hyperthermic regional perfusion with ALKERAN has been used as an adjuvant to surgery for early malignant melanoma and as palliative treatment for advanced but localised disease. The scientific literature should be consulted for details of perfusion technique and dosage used.
Hyperthermic regional perfusion with ALKERAN has been used in the management of all stages of localised soft tissue sarcoma, usually in combination with surgery. ALKERAN has also been given with actinomycin D, and the scientific literature should be consulted for details of dosage regimens.
Doses of between 100 and 240mg/m2 body surface area (sometimes divided equally over 3 consecutive days) together with haematopoietic stem cell rescue, have been used either alone or in combination with radiotherapy and/or other cytotoxic agents.
(see Pharmaceutical Precautions).
ALKERAN Injection should be prepared, AT ROOM TEMPERATURE, by reconstituting the freeze-dried powder with the Solvent-Diluent provided. 10mL of this vehicle should be added, as a single quantity, and the vial immediately shaken vigorously until solution is complete. The resulting solution contains the equivalent of 5mg/mL anhydrous melphalan and has a pH of approximately 6.5. ALKERAN Injection solution has limited stability and should be prepared immediately before use. Any unused solution should be discarded (see Pharmaceutical Precautions). The reconstituted solution should not be refrigerated as this will cause precipitation.
Except in cases where regional arterial perfusion is indicated, ALKERAN Injection is for intravenous use only. For intravenous administration, it is recommended that ALKERAN Injection solution is injected slowly into a fast-running infusion solution via a swabbed injection port. If direct injection into a fast-running infusion is not appropriate, ALKERAN Injection solution may be administered diluted in an infusion bag. ALKERAN Injection is not compatible with infusion solutions containing dextrose, and it is recommended that ONLY Sodium Chloride Intravenous Infusion 0.9% w/v is used. When further diluted in an infusion solution, ALKERAN Injection has reduced stability and the rate of degradation increases rapidly with rise in temperature. If administration occurs at a room temperature of approximately 25C, the total time from preparation of the Injection solution to the completion of infusion should not exceed 1.5 hours. Should any visible turbidity or crystallization appear in the reconstituted or diluted solutions the preparation must be discarded. Care should be taken to avoid possible extravasation of ALKERAN and in cases of poor peripheral venous access, consideration should be given to use of a central venous line. If high-dose ALKERAN Injection is administered with or without autologous bone marrow transplantation, administration via a central venous line is recommended. For regional arterial perfusion, the literature should be consulted for detailed methodology.
High-dose ALKERAN Injection, in association with bone marrow rescue, has been used in childhood neuroblastoma and dosage guidelines based on body surface area are used in this situation (see Dosage in children, Advanced neuroblastoma in childhood). ALKERAN, within the conventional dosage range, is only rarely indicated in children and absolute dosage guidelines cannot be provided.
Although ALKERAN is frequently used at conventional dosage in the elderly, there is no specific information available relating to its administration to this patient sub-group. Experience in the use of high-dose ALKERAN in elderly patients is limited. Consideration should therefore be given to ensure adequate performance status and organ function before using high-dose ALKERAN Injection in elderly patients.
(See Warnings and Precautions). ALKERAN clearance, though variable, is decreased in renal impairment. When ALKERAN Injection is used at conventional intravenous dosage (8 to 40mg/m2 body surface area), it is recommended that the initial dose should be reduced by 50% in patients with moderate to severe renal impairment and subsequent dosage determined according to the degree of haematological suppression. For high intravenous doses of ALKERAN (100 to 240mg/m2 body surface area), the need for dose reduction depends upon the degree of renal impairment, whether haematopoietic stem cells are reinfused, and therapeutic need. As a guide, for high dose ALKERAN treatment without haematopoietic stem cell rescue in patients with moderate renal impairment (creatinine clearance 30 to 50mL/min) a dose reduction of 50% is usual. High-dose ALKERAN without haematopoietic stem cell rescue is not recommended in patients with more severe renal impairment. High dose ALKERAN with haematopoietic stem cell rescue has been used successfully even in dialysis dependent patients with end-stage renal failure. The relevant literature should be consulted for details.
ALKERAN should not be given to patients who have suffered a previous hypersensitivity reaction to melphalan.
ALKERAN IS AN ACTIVE CYTOTOXIC AGENT FOR USE UNDER THE DIRECTION OF PHYSICIANS EXPERIENCED IN THE ADMINISTRATION OF SUCH AGENTS. Immunisation using a live organism vaccine has the potential to cause infection in immunocompromised hosts. Therefore, immunisations with live organism vaccines are not recommended. ALKERAN Injection solution may cause local tissue damage should extravasation occur, and consequently it should not be administered by direct injection into a peripheral vein. It is recommended that ALKERAN Injection solution is administered by injecting slowly into a fast- running intravenous infusion via a swabbed injection port, or via a central venous line. In view of the hazards involved and the level of supportive care required, the administration of high-dose ALKERAN Injection should be confined to specialist centres, with the appropriate facilities, and only be conducted by experienced clinicians. In patients receiving high-dose ALKERAN Injection, consideration should be given to the prophylactic administration of anti-infective agents, the administration of blood products as required. Consideration should be given to ensure adequate performance status and organ function before using high-dose ALKERAN Injection.
(See Instructions for Use/Handling).
The handling of ALKERAN formulations should follow guidelines for the handling of cytotoxic medicines according to prevailing local recommendations and/or regulations (for example, Royal Pharmaceutical Society of Great Britain Working Party on the Handling of Cytotoxic Medicines).
Since ALKERAN is a potent myelosuppressive agent, it is essential that careful attention should be paid to the monitoring of blood counts to avoid the possibility of excessive myelosuppression and the risk of irreversible bone marrow aplasia. Blood counts may continue to fall after treatment is stopped, so at the first sign of an abnormally large fall in leucocyte or platelet counts, treatment should be temporarily interrupted. ALKERAN should be used with caution in patients who have undergone recent radiotherapy or chemotherapy in view of increased bone marrow toxicity.
ALKERAN clearance may be reduced in patients with renal impairment, who may also have uraemic bone marrow suppression. Dosage reduction may therefore be necessary (see Dosage and Administration), and these patients should be closely observed.
Chromosome aberrations have been observed in patients being treated with ALKERAN.
Melphalan, in common with other alkylating agents, has been reported to be leukaemogenic in man. There have been reports of acute leukaemia occurring after melphalan treatment for diseases such as amyloid, malignant melanoma, multiple myeloma, macroglobulinaemia, cold agglutinin syndrome and ovarian cancer. A comparison of patients with ovarian cancer who received alkylating agents with those who did not showed that the use of alkylating agents, including melphalan, significantly increased the incidence of acute leukaemia. The leukaemogenic risk must be balanced against the potential therapeutic benefit when considering the use of melphalan.
Pregnancy and Lactation
The teratogenic potential of ALKERAN has not been studied. In view of its mutagenic properties and structural similarity to known teratogenic compounds, it is possible that melphalan could cause congenital defects in the offspring of patients treated with ALKERAN.
ALKERAN causes suppression of ovarian function in premenopausal women resulting in amenorrhoea in a significant number of patients. There is evidence from some animal studies that ALKERAN can have an adverse effect on spermatogenesis. Therefore, it is possible that ALKERAN may cause temporary or permanent sterility in male patients.
As with all cytotoxic chemotherapy, adequate contraceptive precautions should be practised when either partner is receiving ALKERAN. The use of melphalan should be avoided whenever possible during pregnancy, particularly during the first trimester. In any individual case the potential hazard to the foetus must be balanced against the expected benefit to the mother.
Mothers receiving ALKERAN should not breast-feed.
Effects on Ability to Drive and Use Machines
No data.
For this product there is no modern clinical documentation which can be used as support for determining the frequency of undesirable effects. Undesirable effects may vary in their incidence depending on the indication and dose received and also when given in combination with other therapeutic agents. The following convention has been utilised for the classification of frequency:- Very common 1/10, common 1/100, <1/10, uncommon 1/1000 and <1/100, rare 1/10,000 and <1/1000, very rare <1/10,000, not known (cannot be estimated from the available data).
Blood and Lymphatic System Disorders
Very common:bone marrow depression leading to leucopenia, thrombocytopenia and anaemia Rare:haemolytic anaemia
Immune System Disorders
Rare:allergic reactions (see Skin and Subcutaneous Tissue Disorders) Allergic reactions to melphalan such as urticaria, oedema, skin rashes and anaphylactic shock have been reported uncommonly following initial or subsequent dosing, particularly after intravenous administration. Cardiac arrest has also been reported rarely in association with such events.
Respiratory, Thoracic and Mediastinal Disorders
Rare:interstitial pneumonitis and pulmonary fibrosis (including fatal reports)
Gastrointestinal Disorders
Very common:nausea, vomiting and diarrhoea; stomatitis at high dose Rare:stomatitis at conventional dose The incidence of diarrhoea, vomiting and stomatitis becomes the dose-limiting toxicity in patients given high intravenous doses of melphalan in association with autologous bone marrow transplantation. Cyclophosphamide pretreatment appears to reduce the severity of gastro-intestinal damage induced by high-dose melphalan and the literature should be consulted for details.
Hepatobiliary Disorders
Rare:hepatic disorders ranging from abnormal liver function tests to clinical manifestations such as hepatitis and jaundice; veno-occlusive disease following high dose treatment
Musculoskeletal and Connective Tissue Disorders
Musculoskeletal and Connective Tissue Disorders Injection, following isolated limb perfusion:
Very common:muscle atrophy, muscle fibrosis, myalgia, blood creatine phosphokinase increased. Common:compartment syndrome Not known:muscle necrosis, rhabdomyolysis Skin and Subcutaneous Tissue Disorders Very common:alopecia at high dose Common:alopecia at conventional dose Rare:maculopapular rashes and pruritus (see Immune System Disorders)
Renal and Urinary Disorders
Common:temporary significant elevation of the blood urea has been seen in the early stages of melphalan therapy in myeloma patients with renal damage
General Disorders and Administration Site Conditions
Very common:subjective and transient sensation of warmth and/or tingling
Vaccinations with live organism vaccines are not recommended in immunocompromised individuals (see Warnings and Precautions). Nalidixic acid together with high-dose intravenous melphalan has caused deaths in children due to haemorrhagic enterocolitis. Impaired renal function has been described in bone marrow transplant patients who were conditioned with high-dose intravenous melphalan and who subsequently received cyclosporin to prevent graft-versus-host disease.
The immediate effects of acute intravenous overdosage are nausea and vomiting. Damage to the gastro-intestinal mucosa may also ensue, and diarrhoea, sometimes haemorrhagic, has been reported after overdosage. The principal toxic effect is bone marrow suppression, leading to leucopenia, thrombocytopenia and anaemia.
General supportive measures, together with appropriate blood and platelet transfusions, should be instituted if necessary, and consideration given to hospitalisation, cover with anti-infective agents, and the use of haematological growth factors. There is no specific antidote. The blood picture should be closely monitored for at least 4 weeks following overdosage until there is evidence of recovery.
Instructions for Use/Handling
ALKERAN Injection should be prepared for administration either by or under the direct supervision of a pharmacist who is familiar with its properties and safe handling requirements. ALKERAN Injection should be prepared for use in the aseptic unit of a pharmacy equipped with a suitable vertical laminar flow cabinet. Where such a facility is not available, a specially designated side room of a ward or clinic may be used. Personnel preparing or handling ALKERAN Injection should wear the following protective clothing:- Disposable gloves of surgical latex or polyvinylchloride of a suitable quality (rubber gloves are not adequate); Surgical facemask of suitable quality; Protective goggles or glasses which should be washed thoroughly with water after use; Disposable apron. In an aseptic facility, other suitable clothing will be required. Any spillage should be dealt with immediately (by personnel wearing suitable protective clothing), by mopping with damp, disposable paper towels which are placed in a high-risk waste disposal bag after use and disposed of in compliance with relevant local legislation. Contaminated surfaces should be washed with copious quantities of water. Should ALKERAN Injection solution come into contact with the skin, wash immediately and thoroughly with soap and plenty of cold water. In such instances it may be prudent to seek medical advice. In case of contact with eyes, IMMEDIATE irrigation with sodium chloride eye wash should be carried out and medical attention sought without delay. If sodium chloride solution is not available, large volumes of water may be used.
ALKERAN Injection solution should be disposed of in compliance with relevant local legislation. In the absence of such guidelines, the solution should be disposed of in a manner appropriate for toxic chemicals, for example, high-temperature incineration or deep burial. Disposal of sharp objects, such as needles, syringes, administration sets and ampoules should be in rigid containers labelled with a suitable hazard warning seal. Personnel involved in disposal should be aware of the precautions to be observed, and the material should be destroyed by incineration if appropriate. All disposal must be in accordance with local regulatory requirements.
(see also above, Safe Handling of ALKERAN Injection). ALKERAN Injection should be prepared, AT ROOM TEMPERATURE, by reconstituting the freeze-dried powder with the Solvent-Diluent provided. 10mL of this vehicle should be added, as a single quantity, and the vial immediately shaken vigorously until solution is complete. The resulting solution contains the equivalent of 5mg/mL anhydrous melphalan and has a pH of approximately 6.5. ALKERAN Injection solution has limited stability and should be prepared immediately before use. Any unused solution should be discarded (see Disposal, above). The reconstituted solution should not be refrigerated as this will cause precipitation. When further diluted in an infusion solution, ALKERAN Injection has reduced stability and the rate of degradation increases rapidly with rise in temperature. If administration occurs at a room temperature of approximately 25C, the total time from preparation of the Injection solution to the completion of infusion should not exceed 1.5 hours. Should any visible turbidity or crystallization appear in the reconstituted or diluted solutions the preparation must be discarded.
Incompatibilities
ALKERAN Injection is not compatible with infusion solutions containing dextrose, and it is recommended that ONLY Sodium Chloride Intravenous Infusion 0.9% w/v is used.
Shelf life
36 months.
Special precautions for Storage
Store below 30C. Protect from light.
Prescription Only Medicine
Carton containing one vial freeze-dried melphalan 50mg and one vial 10mL solvent-diluent.
Pharmacy Retailing Pty Ltd t/a Healthcare Logistics 58 Richard Pearse Drive Airport Oaks Auckland New Zealand
Date: 22 December 2006 Issue: 7 Date of most recent amendment: 5th July 2010 ALKERAN is a trade mark of Aspen. All rights reserved