Dose adjustments Dose reduction may be required in
combined renal and hepatic impairment.
l RENAL IMPAIRMENT Avoid in severe impairment.
Dose adjustments Dose reduction may be required in
combined renal and hepatic impairment.
l PRESCRIBING AND DISPENSING INFORMATION Dacarbazine
is a component of a commonly used combination for
Hodgkin’s disease (ABVD—doxorubicin [previously
Adriamycin ®], bleomycin, vinblastine, and dacarbazine).
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for infusion
▶ Dacarbazine (Non-proprietary)
Dacarbazine (as Dacarbazine citrate) 500 mg Dacarbazine 500mg
powder for solution for infusion vials | 1 vial P £37.50
Dacarbazine (as Dacarbazine citrate) 1 gram Dacarbazine 1g
powder for solution for infusion vials | 1 vial P £70.00
Powder for solution for injection
▶ Dacarbazine (Non-proprietary)
Dacarbazine (as Dacarbazine citrate) 100 mg Dacarbazine 100mg
powder for solution for injection vials | 10 vial P £90.00
Dacarbazine (as Dacarbazine citrate) 200 mg Dacarbazine 200mg
powder for solution for injection vials | 10 vial P £160.00
Estramustine phosphate 13-Jul-2018
▶ Adult: Initially 560–840 mg daily in divided doses;
maintenance 140–1400 mg daily in divided doses
RISKS OF INCORRECT DOSING OF ORAL ANTI-CANCER MEDICINES
l CONTRA-INDICATIONS Peptic ulceration . severe
cardiovascular disease .thromboembolic disorders
(such as epilepsy or migraine). congestive heart failure . diabetes . hypercalcaemia . hypertension
l INTERACTIONS → Appendix 1: alkylating agents
▶ Common or very common Anaemia . congestive heart
l CONCEPTION AND CONTRACEPTION Men should use
effective contraceptive methods during treatment. See
also Pregnancy and reproductive function in Cytotoxic drugs
l HEPATIC IMPAIRMENT Manufacturer advises caution—
monitor hepatic function; avoid in severe impairment.
l RENAL IMPAIRMENT Manufacturer advises caution.
l DIRECTIONS FOR ADMINISTRATION Each dose should be
taken not less than 1 hour before or 2 hours after meals
and should not be taken with products containing calcium,
magnesium or aluminium, including dairy products and
l PATIENT AND CARER ADVICE Patients should be given
advice on how to administer estramustine capsules.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
CAUTIONARY AND ADVISORY LABELS 5, 23
Estramustine phosphate (as Estramustine sodium phosphate)
140 mg Estracyt 140mg capsules | 100 capsule P £171.28
▶ Adult: (consult local protocol)
l CONTRA-INDICATIONS Acute infection . urinary-tract
infection . urinary-tract obstruction . urothelial damage
l CAUTIONS Avoid in Acute porphyrias p. 1058 . diabetes
l INTERACTIONS → Appendix 1: alkylating agents
▶ Uncommon Cardiotoxicity . diarrhoea . hypotension . oral
▶ Rare or very rare Skin reactions
disorders . growth retardation . haemolytic anaemia . heart
loss . metabolic acidosis . movement disorders . mucosal
disorders . pain . pancreatitis . panic attack . peripheral
reactions (SCARs). SIADH . sinusoidal obstruction
SIDE-EFFECTS, FURTHER INFORMATION Urothelial toxicity
Mesna is routinely given with ifosfamide to reduce
Secondary malignancy Use of ifosfamide is associated
with an increased incidence of acute leukaemia.
l CONCEPTION AND CONTRACEPTION Manufacturer advises
adequate contraception during and for at least 6 months
after treatment in men or women. See also Pregnancy and
reproductive function in Cytotoxic drugs p. 888.
l PREGNANCY Avoid (teratogenic and carcinogenic in
animals). See also Pregnancy and reproductive function in
l BREAST FEEDING Discontinue breast-feeding.
896 Cytotoxic responsive malignancy BNF 78
Immune system and malignant disease
l HEPATIC IMPAIRMENT Manufacturer advises avoid.
l RENAL IMPAIRMENT Avoid if serum creatinine
concentration greater than 120 micromol/litre.
l MONITORING REQUIREMENTS Ensure satisfactory
electrolyte balance and renal function before each course
(risk of tubular dysfunction, Fanconi’s syndrome or
diabetes insipidus if renal toxicity not treated promptly).
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for injection
▶ Ifosfamide (Non-proprietary)
Ifosfamide 1 gram Ifosfamide 1g powder for concentrate for solution
for injection vials | 1 vial P £115.79–£119.27
Ifosfamide 2 gram Ifosfamide 2g powder for concentrate for solution
for injection vials | 1 vial P £228.09–£234.94
l DRUG ACTION Lomustine is a lipid-soluble nitrosourea.
Hodgkin’s disease resistant to conventional therapy |
Malignant melanoma | Certain solid tumours
▶ Adult: 120–130 mg/m2 every 6–8 weeks, dose is for
RISKS OF INCORRECT DOSING OF ORAL ANTI-CANCER MEDICINES
l CONTRA-INDICATIONS Coeliac disease
l INTERACTIONS → Appendix 1: alkylating agents
▶ Common or very common Leucopenia
▶ Frequency not known Alopecia . anaemia . apathy . appetite
disorders . lethargy . nausea . neoplasms . neurological
effects .renal disorders .renal impairment.respiratory
disorders . speech impairment. stomatitis . thrombocytopenia . vision loss (irreversible). vomiting
SIDE-EFFECTS, FURTHER INFORMATION Prolonged use of
lomustine is associated with an increased incidence of
l CONCEPTION AND CONTRACEPTION Manufacturer advises
effective contraception during and for at least 6 months
after treatment in men or women. See also Pregnancy and
reproductive function in Cytotoxic drugs p. 888.
l PREGNANCY Avoid. See also Pregnancy and reproductive
function in Cytotoxic drugs p. 888.
l BREAST FEEDING Discontinue breast-feeding.
l RENAL IMPAIRMENT Avoid in severe impairment.
l PRESCRIBING AND DISPENSING INFORMATION The brand
name CCNU ® has been used for lomustine capsules.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: capsule
Lomustine 40 mg Lomustine 40mg capsules | 20 capsule P £780.82
▶ CeeNU (Imported (United States))
Lomustine 10 mg CeeNU 10mg capsules | 20 capsule P s
Lomustine 100 mg CeeNU 100mg capsules | 20 capsule P s
▶ Adult: 150 micrograms/kg daily for 4 days, dose to be
repeated every 6 weeks, dose may vary according to
▶ BY INTRAVENOUS INJECTION, OR BY INTRAVENOUS INFUSION
▶ Adult: (consult product literature)
▶ Adult: Initially 6–10 mg daily for 5-7 days, then
reduced to 2–4 mg daily until satisfactory response,
then reduced to 2–6 mg once weekly
Localised malignant melanoma of the extremities |
Localised soft-tissue sarcoma of the extremities
▶ BY REGIONAL ARTERIAL PERFUSION
▶ Adult: (consult local protocol)
RISKS OF INCORRECT DOSING OF ORAL ANTI-CANCER MEDICINES
l INTERACTIONS → Appendix 1: alkylating agents
▶ Common or very common Alopecia . anaemia . bone marrow
depression (delayed). diarrhoea . nausea . stomatitis . thrombocytopenia . vomiting
▶ Rare or very rare Haemolytic anaemia . hepatic disorders . respiratory disorders . skin reactions
▶ With parenteral use Feeling hot. myalgia . myopathy . paraesthesia
▶ With parenteral use Peripheral vascular disease
SIDE-EFFECTS, FURTHER INFORMATION Secondary
malignancy Use of melphalan is associated with an
increased incidence of acute leukaemias.
l CONCEPTION AND CONTRACEPTION Manufacturer advises
adequate contraception during treatment in men or
women. See also Pregnancy and reproductive function in
l PREGNANCY Avoid. See also Pregnancy and reproductive
function in Cytotoxic drugs p. 888.
l BREAST FEEDING Discontinue breast-feeding.
Dose adjustments Reduce dose initially (consult product
l MONITORING REQUIREMENTS Monitor full blood count
before and throughout treatment.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder and solvent for solution for injection
Melphalan (as Melphalan hydrochloride) 50 mg Melphalan 50mg
powder and solvent for solution for injection vials | 1 vial P £137.37
Melphalan 2 mg Melphalan 2mg tablets | 25 tablet P £45.38 DT
BNF 78 Cytotoxic responsive malignancy 897
Immune system and malignant disease
l DRUG ACTION Streptozocin is an antibiotic antineoplastic
Neuroendocrine tumours of pancreatic origin (specialist
▶ Adult: (consult product literature)
l INTERACTIONS → Appendix 1: streptozocin
disorder. urine abnormalities . vomiting
l CONCEPTION AND CONTRACEPTION Manufacturer advises
women of childbearing potential should use effective
contraception during treatment and for 30 days after last
treatment; male patients should use effective
contraception during treatment and for 90 days after last
treatment if their partner is of childbearing potential. See
also Pregnancy and reproductive function in Cytotoxic drugs
l PREGNANCY Manufacturer advises avoid unless potential
benefit outweighs risk—toxicity in animal studies. See also
Pregnancy and reproductive function in Cytotoxic drugs
l BREAST FEEDING Manufacturer advises avoid—no
l HEPATIC IMPAIRMENT Manufacturer advises caution.
Dose adjustments Manufacturer advises consider dose
l RENAL IMPAIRMENT Manufacturer advises caution—
evaluate benefit/risk ratio if eGFR
Dose adjustments Manufacturer advises reduce dose if
▶ Manufacturer advises monitor renal function (plasma
creatinine and eGFR derived from the MDRD formula)
immediately before treatment initiation and 2 weeks after
each course of therapy; proteinuria and serum electrolytes
should also be monitored before treatment initiation and
2–4 weeks after the last cycle of treatment.
▶ Manufacturer advises monitor liver function tests, blood
glucose levels and complete blood counts regularly.
l HANDLING AND STORAGE Manufacturer advises store in a
refrigerator (2–8°C) and protect from light—consult
product literature for storage conditions after
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for infusion
▶ Zanosar (Intrapharm Laboratories Ltd)
Streptozocin 1 gram Zanosar 1g powder for concentrate for solution
for infusion vials | 1 vial P £570.00
l DRUG ACTION Temozolomide is structurally related to
Newly diagnosed glioblastoma multiforme in adults (in
combination with radiotherapy) and subsequently as
monotherapy | Second-line treatment of malignant
▶ Adult: (consult product literature)
RISKS OF INCORRECT DOSING OF ORAL ANTI-CANCER MEDICINES
l CAUTIONS Pneumocystis jirovecii pneumonia—consult
product literature for monitoring and prophylaxis
l INTERACTIONS → Appendix 1: alkylating agents
▶ Common or very common Alopecia . anxiety . appetite
decreased . arthralgia . asthenia . chills . concentration
impaired . confusion . constipation . cough . decreased
disorders . vomiting . weight changes
▶ Uncommon Altered smell sensation . anaemia . behaviour
infections .thirst.tinnitus .tongue discolouration . vasodilation
l CONCEPTION AND CONTRACEPTION Manufacturer advises
adequate contraception during treatment. Men should
avoid fathering a child during and for at least 6 months
after treatment. See also Pregnancy and reproductive
function in Cytotoxic drugs p. 888.
l PREGNANCY Avoid (teratogenic and embryotoxic in animal
studies). See also Pregnancy and reproductive function in
l BREAST FEEDING Discontinue breast-feeding.
l HEPATIC IMPAIRMENT Manufacturer advises caution in
severe impairment (no information available).
l RENAL IMPAIRMENT Manufacturer advises caution—no
▶ Monitor liver function before treatment initiation, after
each treatment cycle and midway through 42-day
treatment cycles—consider the balance of benefits and
risks of treatment if results are abnormal at any point
(fatal liver injury reported).
898 Cytotoxic responsive malignancy BNF 78
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