INFORMATION FOR HEALTH PROFESSIONALS
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BiCNU (carmustine) injection vials 100mg. Each package includes a vial containing 100 mg carmustine, a pale yellow powder for reconstitution, and a vial or ampoule containing 3 ml sterile diluent.
BiCNU (1,3-bis (2-chloroethyl)-1-nitrosourea) is one of the nitrosoureas. It is a pale yellow powder with a molecular weight of 214.06. It is highly soluble in alcohol and poorly soluble in water. It is also highly soluble in lipids.
BiCNU alkylates DNA and RNA and has been shown to inhibit several enzymes by carbamoylation of amino acids in proteins. BiCNU is not cross resistant with other alkylators. The oncolytic effect of BiCNU is considered in part to be due to the inhibition of the synthesis of DNA and RNA by preventing the synthesis of purine nucleosides and their conversion to components of DNA. In addition BiCNU interferes selectively with the utilisation of histidine or histidine metabolites.
Intravenously administered BiCNU is rapidly degraded, with no intact drug detectable after 15 minutes. However, in studies with C14 -labelled drug, prolonged levels of the isotope were observed in the plasma and tissue, probably representing radioactive fragments of the parent compound.
It is thought that the antineoplastic and toxic activities of BiCNU may be due to metabolites. Approximately 60 to 70 percent of a total dose is excreted in the urine in 96 hours and about 10 percent as respiratory CO2. The fate of the remainder is undetermined.
Because of the high lipid solubility and the relative lack of ionization at a physiological pH, BiCNU crosses the blood brain barrier quite effectively. Levels of radioactivity in the CSF are 50 percent or greater than those measured concurrently in plasma.
BiCNU is indicated as palliative therapy as a single agent or in established combination therapy with other approved chemotherapeutic agents in patients with the following malignancies:-
For adults and children: The recommended dose of BiCNU as single agent in previously untreated patients is 200 mg/m2 intravenously every 6 weeks. This may be given as a single dose or divided into daily injections such as 100 mg/m2 on two successive days. When BiCNU is used in combination with other myelosuppressive drugs or in patients in whom bone marrow reserve is depleted, the doses should be adjusted accordingly.
A repeat course of BiCNU should not be given until circulating blood elements have returned to acceptable levels (platelets above 100,000/mm3; leukocytes above 4,000/mm3); this usually occurs within 6 weeks. Blood counts should be monitored frequently and repeat courses should not be given before 6 weeks because of delayed toxicity.
Doses subsequent to the initial dose should be adjusted according to the haematologic response of the patient to the preceding dose. The following schedule is suggested as a guide to dosage adjustment:
| Nadir After Prior Dose | Percentage of Prior Dose to be Given |
|
|---|---|---|
| Leukocytes | Platelets | |
| >4,000 | >100,000 | 100 percent |
| 3,000 - 3,999 | 75,000 - 99,999 | 100 percent |
| 2,000 - 2,999 | 25,000 - 74,999 | 70 percent |
| <2,000 | <25,000 | 50 percent |
Preparation of Intravenous Solutions. To facilitate reconstitution, allow BiCNU
and the supplied sterile diluent (absolute ethanol) to come to controlled room
temperature (15° to 30°C) before mixing. Dissolve BiCNU completely with 3 ml of
the supplied sterile diluent and then aseptically add 27 ml of Sterile Water for
Injection to the alcohol solution. Each ml of the resulting solution will
contain 3.3 mg of BiCNU in 10 percent ethanol having a pH of 5.6 to 6.0.
(Solution in the ethanol must be complete before Sterile Water for Injection is
added.) Accidental contact of reconstituted BiCNU with the skin has caused
transient hyperpigmentation of the affected areas. If BiCNU lyophilized material
or solution contacts the skin or mucosa, immediately wash the skin or mucosa
thoroughly with soap and water.
Reconstitution as recommended results in a clear, colourless to light yellow solution which may be further diluted with either Sodium Chloride for Injection or 5 percent Dextrose for Injection. The reconstituted solution should be used intravenously only and should be administered by IV drip over a 1 to 2 hour period. Injection of BiCNU over shorter periods of time may produce intense pain and burning at the site of injection. Rapid IV infusion of BiCNU may produce intensive flushing of the skin and suffusion of the conjunctiva within 2 hours, lasting 4 hours.
Important Note: The lyophilized dosage formulation contains no preservatives and is not intended as a multiple dose vial.
BiCNU should not be given to individuals who have demonstrated a previous hypersensitivity to it.
BiCNU should not be given to individuals with decreased circulating platelets, leukocytes, or erythrocytes either from previous chemotherapy or other causes.
BiCNU should be administered preferably by individuals experienced in antineoplastic therapy. Bone marrow suppression, notably thrombocytopenia and leukopenia, which may contribute to bleeding and overwhelming infections in an already compromised patient, is the most common and severe of the toxic effects of BiCNU.
Since delayed bone marrow toxicity is a major toxicity, complete blood counts should be monitored frequently for at least 6 weeks after a dose. Repeat doses of BiCNU should not be given more frequently than every 6 weeks. The bone marrow toxicity of BiCNU is cumulative, and therefore dosage adjustment must be considered on the basis of nadir blood counts from prior dose (see dosage adjustment table under Dosage And Administration).
BiCNU induced pulmonary toxicity has been reported to occur with a frequnecy ranging up to 30% but may be as high as 100% in children. Early onset pulmonary toxicity usually occurs within 3 years of therapy and is characterized by pulmonary infiltrates and/or fibrosis, and cases of fatal pulmonary toxicity have occurred. Cases of late pulmonary fibrosis, occurring up to 17 years after treatment, have also been reported. Age of onset has been reported from1 year and 10 months to 72 years of age.
Risk factors include smoking, the presence of a respiratory condition, pre-existing radiographic abnormalities, sequential or concomitant thoracic irradiation, previous thoracic irradiation, and association with other agents that cause lung damage. The incidence appears to be dose related with total cumulative doses of 1200-1500mg/m2 being associated with increased likelihood of lung fibrosis. Baseline pulmonary function studies should be conducted along with frequent pulmonary function tests during treatment. Patients with a baseline below 70% of the predicted Forced Vital Capacity (FVC) or Carbon Monoxide Diffusing Capacity (DLCO) are particularly at risk.
In a recent long-term follow-up of 17 patients who survived childhood brain tumors, eight (47%) died of lung fibrosis. Of these eight deaths, two occurred within 3 years of treatment, and six occurred 8-13 years after treatment. Of the patients who died, the median age at treatment was 2.5 years (ranging from 1-12); the median age of the long term survivors was 10 years (5-16 years at treatment). All five patients treated below the age of 5 years have died of pulmonary fibrosis. In this series, dose of BiCNU did not influence fatal outcome nor did co-administration of vincristine or spinal irradiation. Of the remaining survivors available for follow-up, evidence of slowly progressive lung fibrosis was detected in all patients.
The risks and benefits of BiCNU therapy must be carefully considered, especially in young patients, due to the extremely high risk of pulmonary toxicity.
Baseline pulmonary function studies should be conducted along with frequent pulmonary function tests during treatment. Patients with a baseline below 70 percent of the predicted Forced Vital Capacity (FVC) or Carbon Monoxide Diffusing Capacity (DLCO) are particularly at risk.
Safe use in pregnancy has not been established. BiCNU is embryotoxic and teratogenic in rats and embryotoxic in rabbits at dose levels equivalent to the human dose. BiCNU also affects fertility in male rats at doses somewhat higher than the human dose. BiCNU is carcinogenic in rats and mice, producing a marked increase in tumour incidence in doses approximating those employed clinically.
Therefore, the benefit to the mother versus the risk of toxicity to the mother and foetus must be carefully weighed.
It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions from BiCNU in nursing infants, nursing should be discontinued while using BiCNU.
BiCNU should be used with extreme caution in children due to the high risk of pulmonary toxicity (see Warnings And Precautions).
Nitrosourea therapy does have carcinogenic potential. The occurrence of acute leukaemia and bone marrow dysplasias have been reported in patients following nitrosourea therapy.
BiCNU has been administered through an intraarterial intracarotid route; this procedure is investigational and has been associated with ocular toxicity.
It is recommended that liver and renal function tests also be monitored.
The most frequent and most serious toxicity of BiCNU is delayed myelosuppression. It usually occurs 4 to 6 weeks after drug administration and is dose-related. Platelet nadirs occur at 4 to 5 weeks; leukocyte nadirs occur at 5 to 6 weeks post therapy. Thrombocytopenia is generally more severe than leukopenia, however, both may be dose limiting toxicities. Anaemia also occurs, but is generally less severe.
BiCNU may produce cumulative myelosuppression, manifested by more depressed indices or longer duration of suppression after repeated doses.
The occurrence of acute leukaemia and bone marrow dysplasias have been reported in patients following long term nitrosourea therapy.
Nausea and vomiting after IV administration of BiCNU are noted frequently. This toxicity appears within 2 hours of dosing, usually lasting 4 to 6 hours, and is dose-related. Prior administration of antiemetics is effective in diminishing and sometimes preventing this side effect.
When high doses of BiCNU have been employed, a reversible type of hepatic toxicity manifested by increased transaminase, alkaline phosphatase and bilirubin levels, has been reported in a small percentage of patients.
(See Warnings And Precautions)
Renal abnormalities consisting of decrease in kidney size, progressive azotaemia and renal failure have been reported in patients who receive large cumulative doses after prolonged therapy with BiCNU and related nitrosoureas. Kidney damage has also been reported occasionally in patients receiving lower total doses.
Hypotension, tachycardia.
Burning at the site of injection is common but true thrombosis is rare. Accidental contact of reconstituted BiCNU with the skin has caused burning and hyperpigmentation of the affected areas.
Rapid IV infusion of BiCNU may produce intensive flushing of the skin and suffusion of the conjunctiva within 2 hours, lasting about 4 hours.
Neuroretinitis has been reported.
Chest pain, headache, allergic reactions have been reported.
The unopened vial may have a physical appearance ranging from lacy flakes to a congealed mass, with no evident degradation of the BCNU active ingredient. Do not use if product has liquified.
Unopened vials of the dry powder should be shipped and stored under refrigeration (2°C-8°C). Alternatively, BiCNU may be shipped on dry ice and subsequently stored under refrigeration (2°C-8°C). The recommended storage of unopened vials prevents significant decomposition until expiration date indicated on package.
After reconstitution as recommended, BiCNU is stable for 24 hours under refrigeration (2°C - 8°C). Reconstituted vials stored under refrigeration should be examined for crystal formation prior to use. If crystals are observed, they may be redissolved by warming the vial to room temperature with agitation.
Glass containers were used for the stability data provided in this section. Only use glass containers for BiCNU preparation and administration.
BiCNU has a low melting point (approximately 30.5°C-32.0°C). Exposure of the drug to this temperature or above will cause the drug to liquify and appear as an oil film in the bottom of the vials. This is a sign of decomposition and vials should be discarded. If there is a question of adequate refrigeration upon receipt of this product, immediately inspect the larger vial in each individual carton. Hold the vial to a bright light for inspection. The BiCNU will appear as a very small amount of dry flakes or dry congealed mass. If this is evident, the BiCNU is suitable for use and should be refrigerated immediately.
Procedures for proper handling and disposal of anti-cancer drugs should be considered. Several guidelines on this subject have been published.
To minimise the risk of dermal exposure, always wear impervious gloves when handling vials containing BiCNU (carmustine) powder for injection. 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.
Prescription Medicine.
100 mg Injection vial with diluent.
Bristol-Myers Squibb (NZ) Ltd
Simpson Grierson
88 Shortland Street
Auckland
December 2008
BICNU5