Decreased Renal Function

ALIMTA is primarily eliminated unchanged by renal excretion. No dosage adjustment is needed in patients with creatinine clearance ≥45 mL/min. Insufficient numbers of patients have been studied with creatinine clearance <45 mL/min to give a dose recommendation. Therefore, ALIMTA should not be administered to patients whose creatinine clearance is <45 mL/min (see Dose Reduction Recommendations under DOSAGE AND ADMINISTRATION).

One patient with severe renal impairment (creatinine clearance 19 mL/min) who did not receive folic acid and vitamin B₁₂ died of drug-related toxicity following administration of ALIMTA alone.

Bone Marrow Suppression

ALIMTA can suppress bone marrow function, as manifested by neutropenia, thrombocytopenia, and anemia (or pancytopenia) (see ADVERSE REACTIONS); myelosuppression is usually the dose-limiting toxicity. Dose reductions for subsequent cycles are based on nadir ANC, platelet count, and maximum nonhematologic toxicity seen in the previous cycle (see Dose Reduction Recommendations under DOSAGE AND ADMINISTRATION).

Need for Folate and Vitamin B₁₂ Supplementation

Patients treated with ALIMTA must be instructed to take folic acid and vitamin B₁₂ as a prophylactic measure to reduce treatment-related hematologic and GI toxicity (see DOSAGE AND ADMINISTRATION). In clinical studies, less overall toxicity and reductions in Grade 3/4 hematologic and nonhematologic toxicities such as neutropenia, febrile neutropenia, and infection with Grade 3/4 neutropenia were reported when pretreatment with folic acid and vitamin B₁₂ was administered.

Pregnancy Category D

ALIMTA may cause fetal harm when administered to a pregnant woman. Pemetrexed was fetotoxic and teratogenic in mice at i.p. doses of 0.2 mg/kg (0.6 mg/m²) or 5 mg/kg (15 mg/m²) when given on gestation days 6 through 15. Pemetrexed caused fetal malformations (incomplete ossification of talus and skull bone) at 0.2 mg/kg (about 1/833 the recommended i.v. human dose on a mg/m² basis), and cleft palate at 5 mg/kg (about 1/33 the recommended i.v. human dose on a mg/m² basis). Embryotoxicity was characterized by increased embryo-fetal deaths and reduced litter sizes. There are no studies of ALIMTA in pregnant women. Patients should be advised to avoid becoming pregnant. If ALIMTA is used during pregnancy, or if the patient becomes pregnant while taking ALIMTA, the patient should be apprised of the potential hazard to the fetus.

General

ALIMTA should be administered under the supervision of a qualified physician experienced in the use of antineoplastic agents. Appropriate management of complications is possible only when adequate diagnostic and treatment facilities are readily available. Treatment-related adverse events of ALIMTA seen in clinical trials have been reversible. Skin rash has been reported more frequently in patients not pretreated with a corticosteroid in clinical trials. Pretreatment with dexamethasone (or equivalent) reduces the incidence and severity of cutaneous reaction (see DOSAGE AND ADMINISTRATION).

The effect of third space fluid, such as pleural effusion and ascites, on ALIMTA is unknown. In patients with clinically significant third space fluid, consideration should be given to draining the effusion prior to ALIMTA administration.

Laboratory Tests

Complete blood cell counts, including platelet counts and periodic chemistry tests, should be performed on all patients receiving ALIMTA. Patients should be monitored for nadir and recovery, which were tested in the clinical study before each dose and on days 8 and 15 of each cycle. Patients should not begin a new cycle of treatment unless the ANC is ≥1500 cells/mm³, the platelet count is ≥100,000 cells/mm³, and creatinine clearance is ≥45 mL/min.

Carcinogenesis, Mutagenesis, Impairment of Fertility

No carcinogenicity studies have been conducted with pemetrexed. Pemetrexed was clastogenic in the in vivo micronucleus assay in mouse bone marrow but was not mutagenic in multiple in vitro tests (Ames assay, CHO cell assay). Pemetrexed administered at i.v. doses of 0.1 mg/kg/day or greater to male mice (about 1/1666 the recommended human dose on a mg/m² basis) resulted in reduced fertility, hypospermia, and testicular atrophy.

Pregnancy

Pregnancy Category D (see WARNINGS).

Nursing Mothers

It is not known whether ALIMTA or its metabolites are excreted in human milk. Because many drugs are excreted in human milk, and because of the potential for serious adverse reactions in nursing infants from ALIMTA, it is recommended that nursing be discontinued if the mother is treated with ALIMTA.

Pediatric Use

The safety and effectiveness of ALIMTA in pediatric patients have not been established.

Geriatric Use

Dose adjustments based on age other than those recommended for all patients have not been necessary (see Special Populations under CLINICAL PHARMACOLOGY and DOSAGE AND ADMINISTRATION).

Gender

Dose adjustments based on gender other than those recommended for all patients have not been necessary (see Special Populations under CLINICAL PHARMACOLOGY and DOSAGE AND ADMINISTRATION).

Patients with Hepatic Impairment

Patients with bilirubin >1.5 times the upper limit of normal were excluded from clinical trials of ALIMTA. Patients with transaminase >3.0 times the upper limit of normal were routinely excluded from clinical trials if they had no evidence of hepatic metastases. Patients with transaminase from 3 to 5 times the upper limit of normal were included in the clinical trial of ALIMTA if they had hepatic metastases.

Dose adjustments based on hepatic impairment experienced during treatment with ALIMTA are provided in Table 9 (see Special Populations under CLINICAL PHARMACOLOGY and DOSAGE AND ADMINISTRATION).

Patients with Renal Impairment

ALIMTA is known to be primarily excreted by the kidney. Decreased renal function will result in reduced clearance and greater exposure (AUC) to ALIMTA compared with patients with normal renal function. Cisplatin coadministration with ALIMTA has not been studied in patients with moderate renal impairment (see Special Populations under CLINICAL PHARMACOLOGY).

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