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(see BOXED WARNING)
TRISENOX (arsenic trioxide injection) should be administered under the supervision of a physician who is experienced in the management of patients with acute leukemia.
APL Differentiation Syndrome
(see BOXED WARNING): Nine of 40 patients with APL treated with TRISENOX (arsenic trioxide injection) , at a dose of 0.15 mg/kg, experienced the APL differentiation syndrome (see BOXED WARNING and ADVERSE REACTIONS).
Treatment with TRISENOX (arsenic trioxide injection) has been associated with the development of hyperleukocytosis ( ≥ 10 x 103/µL) in 20 of 40 patients. A relationship did not exist between baseline WBC counts and development of hyperleukocytosis nor baseline WBC counts and peak WBC counts. Hyperleukocytosis was not treated with additional chemotherapy. WBC counts during consolidation were not as high as during induction treatment.
(see BOXED WARNING): QT/QTc prolongation should be expected during treatment with arsenic trioxide and torsade de pointes as well as complete heart block has been reported. Over 460 ECG tracings from 40 patients with refractory or relapsed APL treated with TRISENOX (arsenic trioxide injection) were evaluated for QTc prolongation. Sixteen of 40 patients (40%) had at least one ECG tracing with a QTc interval greater than 500 msec. Prolongation of the QTc was observed between 1 and 5 weeks after TRISENOX (arsenic trioxide injection) infusion, and then returned towards baseline by the end of 8 weeks after TRISENOX (arsenic trioxide injection) infusion. In these ECG evaluations, women did not experience more pronounced QT prolongation than men, and there was no correlation with age.
Complete AVblock: Complete AV block has been reported with arsenic trioxide in the published literature including a case of a patient with APL.
Carcinogenicity studies have not been conducted with TRISENOX (arsenic trioxide injection) by intravenous administration. The active ingredient of TRISENOX, arsenic trioxide is a human carcinogen.
TRISENOX (arsenic trioxide injection) may cause fetal harm when administered to a pregnant woman. Studies in pregnant mice, rats, hamsters, and primates have shown that inorganic arsenicals cross the placental barrier when given orally or by injection. The reproductive toxicity of arsenic trioxide has been studied in a limited manner. An increase in resorptions, neural-tube defects, anophthalmia and microphthalmia were observed in rats administered 10 mg/kg of arsenic trioxide on gestation day 9 (approximately 10 times the recommended human daily dose on a mg/m2 basis). Similar findings occurred in mice administered a 10 mg/kg dose of a related trivalent arsenic, sodium arsenite, (approximately 5 times the projected human dose on a mg/m2 basis) on gestation days 6, 7, 8 or 9. Intravenous injection of 2 mg/kg sodium arsenite (approximately equivalent to the projected human daily dose on a mg/m2 basis) on gestation day 7 (the lowest dose tested) resulted in neural-tube defects in hamsters.
There are no studies in pregnant women using TRISENOX (arsenic trioxide injection) . If this drug is used during pregnancy or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential harm to the fetus. One patient who became pregnant while receiving arsenic trioxide had a miscarriage. Women of childbearing potential should be advised to avoid becoming pregnant.
The patient's electrolyte, hematologic and coagulation profiles should be monitored at least twice weekly, and more frequently for clinically unstable patients during the induction phase and at least weekly during the consolidation phase. ECGs should be obtained weekly, and more frequently for clinically unstable patients, during induction and consolidation.
Carcinogenesis, Mutagenesis, Impairment of Fertility
See WARNINGS section for information on carcinogenesis. Arsenic trioxide and trivalent arsenite salts have not been demonstrated to be mutagenic to bacteria, yeast or mammalian cells. Arsenite salts are clastogenic in vitro (human fibroblast, human lymphocytes, Chinese hamster ovary cells, Chinese hamster V79 lung cells). Trivalent arsenic produced an increase in the incidence of chromosome aberrations and micronuclei in bone marrow cells of mice. The effect of arsenic on fertility has not been adequately studied.
Pregnancy Category D. See WARNINGS section.
Arsenic is excreted in human milk. Because of the potential for serious adverse reactions in nursing infants from TRISENOX (arsenic trioxide injection) , a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.
There are limited clinical data on the pediatric use of TRISENOX (arsenic trioxide injection) . Of 5 patients below the age of 18 years (age range: 5 to 16 years) treated with TRISENOX (arsenic trioxide injection) , at the recommended dose of 0.15 mg/kg/day, 3 achieved a complete response.
In an additional study, the toxicity profile observed in 13 pediatric patients with APL between the ages of 4 and 20 receiving TRISENOX (arsenic trioxide injection) at 0.15 mg/kg/day was similar to that observed in adult patients (see ADVERSE REACTIONS).
Safety and effectiveness in relapsed APL pediatric patients below the age of 4 years have not been studied.
Patients with Renal Impairment
Exposure of arsenic trioxide may be higher in patients with severe renal impairment (see CLINICAL PHARMACOLOGY, Special Populations). Patients with severe renal impairment (creatinine clearance less than 30 mL/min) should be closely monitored for toxicity when these patients are treated with TRISENOX (arsenic trioxide injection) , and a dose reduction may be warranted.
The use of TRISENOX (arsenic trioxide injection) in patients on dialysis has not been studied.
Patients with Hepatic Impairment
Since limited data are available across all hepatic impairment groups, caution is advised in the use of TRISENOX in patients with hepatic impairment (see CLINICAL PHARMACOLOGY, Special Populations). Patients with severe hepatic impairment (Child-Pugh class C) should be closely monitored for toxicity when these patients are treated with TRISENOX (arsenic trioxide injection) .
Last reviewed on RxList: 8/13/2010
This monograph has been modified to include the generic and brand name in many instances.
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