Zevalin Side Effects Center
Medical Editor: John P. Cunha, DO, FACOEP
Zevalin (ibritumomab tiuxetan) is used in combination with other medicines to treat non-Hodgkin's lymphoma. It is a protein that targets white blood cells in the body. Common side effects include nausea, vomiting, diarrhea, abdominal/stomach pain, cough, dizziness, headache, flushing, or loss of appetite.
A physician will determine the dosage of Zevalin and the dosing schedule. Zevalin may interact with any type of blood thinner or medication use to prevent blood clots, such as: warfarin, alteplase, anistreplase, clopidogrel, dipyridamole, streptokinase, sulfinpyrazone, ticlopidine, or urokinase. Tell your doctor all medications and supplements you use. Zevalin is not recommended for use during pregnancy. If you become pregnant or think you may be pregnant, tell your doctor. It is unknown if this drug passes into breast milk. Because of the possible risk to the infant, breastfeeding while using this drug is not recommended.
Our Zevalin (ibritumomab tiuxetan) Side Effects Drug Center provides a comprehensive view of available drug information on the potential side effects when taking this medication.
This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
What is Patient Information in Detail?
Easy-to-read and understand detailed drug information and pill images for the patient or caregiver from Cerner Multum.
Zevalin in Detail - Patient Information: Side Effects
Some people receiving an ibritumomab injection have had a reaction to the infusion (when the medicine is injected into the vein). Tell your caregiver right away if you feel dizzy, nauseated, light-headed, sweaty, itchy, or have a fast heartbeat, trouble breathing, chest pain or heavy feeling, or pain spreading to the arm or shoulder. These reactions can occur during the injection or within 24 hours afterward.
Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have any of these serious side effects:
- pain, burning, redness, or skin changes where the medicine was injected;
- fever, sore throat, and headache with a severe blistering, peeling, and red skin rash;
- fever with chills, body aches, and other flu symptoms;
- easy bruising or bleeding, unusual weakness; or
- white patches or sores inside your mouth or on your lips.
Less serious side effects may include:
- nausea, vomiting, loss of appetite;
- dizziness; or
- joint pain.
This is not a complete list of side effects and others may occur. Tell your doctor about any unusual or bothersome side effect. You may report side effects to FDA at 1-800-FDA-1088.
Read the entire detailed patient monograph for Zevalin (Ibritumomab Tiuxetan) »
What is Patient Information Overview?
A concise overview of the drug for the patient or caregiver from First DataBank.
Zevalin Overview - Patient Information: Side Effects
Nausea, vomiting, diarrhea, abdominal/stomach pain, cough, dizziness, headache, flushing, or loss of appetite may occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly.
People using this medication may have serious side effects. However, your doctor has prescribed this drug because he or she has judged that the benefit to you is greater than the risk of side effects. Careful monitoring by your doctor may decrease your risk.
Tell your doctor right away if you have any serious side effects, including: pain/swelling at injection site, swelling ankles/feet, mental/mood changes (e.g., anxiety), black stools, vomit that looks like coffee grounds, vaginal bleeding.
Get medical help right away if any of these rare but very serious side effects occur: weakness on one side of the body, vision problems, confusion, slurred speech.
This medication is made from human blood. Even though donors are carefully screened and this medication goes through a special manufacturing process, there is a very small chance that you may get infections from the medication (e.g., viruses). Tell the doctor immediately if you develop any signs of infection, including fever or persistent sore throat.
This medication has infrequently caused another type of cancer (acute myelogenous leukemia-AML). This condition can lead to very serious blood disorders. See also Warning section for symptoms.
A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.
This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.
In the US -
Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.
In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.
Read the entire patient information overview for Zevalin (Ibritumomab Tiuxetan)»
What is Prescribing information?
The FDA package insert formatted in easy-to-find categories for health professionals and clinicians.
Zevalin FDA Prescribing Information: Side Effects
The following serious adverse reactions are discussed in greater detail in other sections of the label:
- Serious Infusion Reactions [see BOXED WARNING and WARNINGS AND PRECAUTIONS].
- Prolonged and Severe Cytopenias [see BOXED WARNING and WARNINGS AND PRECAUTIONS].
- Severe Cutaneous and Mucocutaneous Reactions [see BOXED WARNING and WARNINGS AND PRECAUTIONS].
- Leukemia and Myelodysplastic Syndrome [see WARNINGS AND PRECAUTIONS].
Because the Zevalin therapeutic regimen includes the use of rituximab, see prescribing information for rituximab.
Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
The reported safety data reflects exposure to Zevalin in 349 patients with relapsed or refractory, low-grade, follicular or transformed NHL across 5 trials (4 single arm and 1 randomized) and in 206 patients with previously untreated follicular NHL in a randomized trial (Study 4) who received any portion of the Zevalin therapeutic regimen. The safety data reflect exposure to Zevalin in 270 patients with relapsed or refractory NHL with platelet counts ≥ 150,000/mm3 who received 0.4 mCi/kg (14.8 MBq/kg) of Y-90 Zevalin (Group 1 in Table 4), 65 patients with relapsed or refractory NHL with platelet counts of 100,000 to 149,000/mm3 who received 0.3 mCi/kg (11.1 MBq/kg) of Y-90 Zevalin (Group 2 in Table 4), and 204 patients with previously untreated NHL with platelet counts > 150,000/mm3 who received 0.4 mCi/kg (14.8 MBq/kg) of Y-90 Zevalin; all patients received a single course of Zevalin.
Table 2 displays selected adverse reaction incidence rates in patients who received any portion of the Zevalin therapeutic regimen (n=206) or no further therapy (n=203) following first-line chemotherapy (Study 4).
Table 2. Per-Patient Incidence (%) of Selecteda
Adverse Reactions Occurring in ≥ 5% of Patients with Previously Untreated
Follicular NHL Treated with the Zevalin Therapeutic Regimen
|Zevalin (n=206)||Observation (n=203)|
|All Gradesb||Gradeb 3-4||All Gradesb||Gradeb 3-4|
|Abdominal pain||17||2||13||< 1|
|Body as a Whole|
|Respiratory, Thoracic & Media|
|Skin & Subcutaneous|
|Infections & Infestations|
|Sinusitis||7||< 1||< 1||0|
|Urinary tract infection||7||< 1||3||0|
|Blood and Lymphatic System|
| a) Between-group difference of ≥ 5%
b) NCI CTCAE version 2.0
Table 3 shows hematologic toxicities in 349 Zevalin-treated patients with relapsed or refractory, low-grade, follicular or transformed B-cell NHL. Grade 2-4 hematologic toxicity occurred in 86% of Zevalin-treated patients.
Table 3. Per-Patient Incidence (%) of Hematologic Adverse
Reactions in Patients with Relapsed or Refractory Low-grade, Follicular or Transformed
B-cell NHLa (N = 349)
| All Grades
| Grade 3-4
|a) Occurring within the 12 weeks following the first rituximab infusion of the Zevalin therapeutic regimen|
Prolonged and Severe Cytopenias
Patients in clinical studies were not permitted to receive hematopoietic growth factors beginning 2 weeks prior to administration of the Zevalin therapeutic regimen.
The incidence and duration of severe hematologic toxicity in previously treated NHL patients (N=335) and in previously untreated patients (Study 4) receiving Y-90 Zevalin are shown in Table 4.
Table 4. Severe Hematologic Toxicity in Patients Receiving
|Baseline Platelet Count|| Group 1
| Group 2
100,000 to 149,000/mm3
| Study 4
|Y-90 Zevalin Dose|| 0.4 mCi/kg
| 0.3 mCi/kg
| 0.4 mCi/kg
|Median nadir (per mm3)||800||600||721|
|Per Patient Incidence ANC < 1000/mm3||57%||74%||65%|
|Per Patient Incidence ANC < 500/mm3||30%||35%||26%|
|Median Duration (Days) ANC < 1000/mm3||22||29||29|
|Median Time to Recoveryb||12||13||15|
|Median nadir (per mm3)||41,000||24,000||42,000|
|Per Patient Incidence Platelets < 50,000/mm3||61%||78%||61%|
|Per Patient Incidence Platelets < 10,000/mm3||10%||14%||4%|
|QMedian Duration (Days)c Platelets < 50,000/mm3||24||35||26|
|Median Time to Recoveryb||13||14||14|
|a) Day from last ANC ≥ 1000/mm3 to first ANC
≥ 1000/mm3 following nadir, censored at next treatment or death
b) Day from nadir to first count at level of Grade 1 toxicity or baseline
c) Day from last platelet count ≥ 50,000/mm3 to day of first platelet count ≥ 50,000/mm3 following nadir, censored at next treatment or death
Cytopenias were more severe and more prolonged among eleven (5%) patients who received Zevalin after first-line fludarabine or a fludarabine-containing chemotherapy regimen as compared to patients receiving non-fludarabine-containing regimens. Among these eleven patients, the median platelet nadir was 13,000/mm3 with a median duration of platelets below 50,000/mm3 of 56 days and the median time for platelet recovery from nadir to Grade 1 toxicity or baseline was 35 days. The median ANC was 355/mm3, with a median duration of ANC below 1,000/mm3 of 37 days and the median time for ANC recovery from nadir to Grade 1 toxicity or baseline was 20 days.
The median time to cytopenia was similar across patients with relapsed/refractory NHL and those completing first-line chemotherapy, with median ANC nadir at 61-62 days, platelet nadir at 49-53 days, and hemoglobin nadir at 68-69 days after Y-90-Zevalin administration.
Information on hematopoietic growth factor use and platelet transfusions is based on 211 patients with relapsed/refractory NHL and 206 patients following first-line chemotherapy. Filgrastim was given to 13% of patients and erythropoietin to 8% with relapsed or refractory disease; 14% of patients receiving Zevalin following first-line chemotherapy received granulocyte-colony stimulating factors and 5% received erythopoiesis-stimulating agents. Platelet transfusions were given to approximately 22% of all Zevalin-treated patients. Red blood cell transfusions were given to 20% of patients with relapsed or refractory NHL and 2% of patients receiving Zevalin following first-line chemotherapy.
In relapsed or refractory NHL patients, infections occurred in 29% of 349 patients during the first 3 months after initiating the Zevalin therapeutic regimen and 3% developed serious infections (urinary tract infection, febrile neutropenia, sepsis, pneumonia, cellulitis, colitis, diarrhea, osteomyelitis, and upper respiratory tract infection). Life-threatening infections were reported in 2% (sepsis, empyema, pneumonia, febrile neutropenia, fever, and biliary stent-associated cholangitis). From 3 months to 4 years after Zevalin treatment, 6% of patients developed infections; 2% were serious (urinary tract infection, bacterial or viral pneumonia, febrile neutropenia, perihilar infiltrate, pericarditis, and intravenous drug-associated viral hepatitis) and 1% were life-threatening infections (bacterial pneumonia, respiratory disease, and sepsis).
When administered following first-line chemotherapy (Table 2), Grade 3-4 infections occurred in 8% of Zevalin treated patients and in 2% of controls and included neutropenic sepsis (1%), bronchitis, catheter sepsis, diverticulitis, herpes zoster, influenza, lower respiratory tract infection, sinusitis, and upper respiratory tract infection.
Leukemia and Myelodysplastic Syndrome
Among 746 patients with relapsed/refractory NHL, 19 (2.6%) patients developed MDS/AML with a median follow-up of 4.4 years. The overall incidence of MDS/AML among the 211 patients included in the clinical studies was 5.2% (11/211), with a median follow-up of 6.5 years and median time to development of MDS/AML of 2.9 years. The cumulative Kaplan-Meier estimated incidence of MDS/secondary leukemia in this patient population was 2.2% at 2 years and 5.9% at 5 years. The incidence of MDS/AML among the 535 patients in the expanded access programs was 1.5% (8/535) with a median follow-up of 4.4 years and median time to development of MDS/AML of 1.5 years. Multiple cytogenetic abnormalities were described, most commonly involving chromosomes 5 and/or 7. The risk of MDS/AML was not associated with the number of prior treatments (0-1 versus 2-10).
Among 204 patients receiving Y-90-Zevalin following first-line treatment, 2(1%) developed AML at approximately 2 and 3.3 years after Zevalin administration, respectively.
As with all therapeutic proteins, there is a potential for immunogenicity. The incidence of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparisons of the incidence of HAMA/HACA to the Zevalin therapeutic regimen with the incidence of antibodies to other products may be misleading.
KAMA and HACA response data on 446 patients from 8 clinical studies conducted over a 10-year time period are available. Overall, 11/446 (2.5%) had evidence of either KAMA formation (N=8) or HACA formation (N=4). Six of these patients developed HAMA/HACA after treatment with Zevalin and 5 were HAMA/HACA positive at baseline. Of the 6 who were HAMA/HACA positive, only one was positive for both. Furthermore, in 6 of the 11 patients, the HAMA/HACA reverted to negative within 2 weeks to 3 months. No patients had increasing levels of HAMA/HACA at the end of the studies.
Only 6/446 patients (1.3%) had developed evidence of antibody formation after treatment with Zevalin, and of these, many either reverted to negative or decreased over time. This data demonstrates that HAMA/HACA develop infrequently, are typically transient, and do not increase with time.
The following adverse reactions have been identified during post-approval use of the Zevalin therapeutic regimen in hematologic malignancies. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Decisions to include these reactions in labeling are typically based on one or more of the following factors: (1) seriousness of the reaction, (2) frequency of reporting, or (3) strength of causal connection to the Zevalin therapeutic regimen.
- Cutaneous and mucocutaneous reactions: erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, bullous dermatitis, and exfoliative dermatitis [see BOXED WARNING and WARNINGS AND PRECAUTIONS].
- Infusion site erythema and ulceration following extravasation [see WARNINGS AND PRECAUTIONS].
- Radiation injury in tissues near areas of lymphomatous involvement within a month of Zevalin administration.
Read the entire FDA prescribing information for Zevalin (Ibritumomab Tiuxetan) »
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