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Arranon

Last reviewed on RxList: 12/7/2018
Drug Description

ARRANON®
(nelarabine) Injection

WARNING

NEUROLOGIC ADVERSE REACTIONS

Severe neurologic adverse reactions have been reported with the use of ARRANON®. These adverse reactions have included altered mental states including severe somnolence, central nervous system effects including convulsions, and peripheral neuropathy ranging from numbness and paresthesias to motor weakness and paralysis. There have also been reports of adverse reactions associated with demyelination, and ascending peripheral neuropathies similar in appearance to Guillain-Barré syndrome [see WARNINGS AND PRECAUTIONS].

Full recovery from these adverse reactions has not always occurred with cessation of therapy with ARRANON. Close monitoring for neurologic adverse reactions is strongly recommended, and ARRANON should be discontinued for neurologic adverse reactions of NCI Common Toxicity Criteria for Adverse Events (CTCAE) Grade 2 or greater [see WARNINGS AND PRECAUTIONS].

DESCRIPTION

ARRANON (nelarabine) is a prodrug of the cytotoxic deoxyguanosine analogue, 9-β-Darabinofuranosylguanine (ara-G).

The chemical name for nelarabine is 2-amino-9-β-D-arabinofuranosyl-6-methoxy-9H-purine. It has the molecular formula C11H15N5O5 and a molecular weight of 297.27. Nelarabine has the following structural formula:

ARRANON® (nelarabine) Structural Formula Illustration

Nelarabine is slightly soluble to soluble in water and melts with decomposition between 209°C and 217°C.

ARRANON Injection is supplied as a clear, colorless, sterile solution in glass single-dose vials. Each vial contains 250 mg of nelarabine (5 mg nelarabine per mL) and the inactive ingredient sodium chloride (4.5 mg per mL) in 50 mL Water for Injection, USP. ARRANON is intended for intravenous infusion.

Hydrochloric acid and sodium hydroxide may have been used to adjust the pH. The solution pH ranges from 5.0 to 7.0.

Indications & Dosage

INDICATIONS

ARRANON is indicated for the treatment of patients with T-cell acute lymphoblastic leukemia and T-cell lymphoblastic lymphoma whose disease has not responded to or has relapsed following treatment with at least two chemotherapy regimens. This use is based on the induction of complete responses. Randomized trials demonstrating increased survival or other clinical benefit have not been conducted.

DOSAGE AND ADMINISTRATION

Recommended Dosage

This product is for intravenous use only.

The recommended duration of treatment for adult and pediatric patients has not been clearly established. In clinical trials, treatment was generally continued until there was evidence of disease progression, the patient experienced unacceptable toxicity, the patient became a candidate for bone marrow transplant, or the patient no longer continued to benefit from treatment.

Adult Dosage

The recommended adult dose of ARRANON is 1,500 mg/m² administered intravenously over 2 hours on Days 1, 3, and 5 repeated every 21 days. ARRANON is administered undiluted.

Pediatric Dosage

The recommended pediatric dose of ARRANON is 650 mg/m² administered intravenously over 1 hour daily for 5 consecutive days repeated every 21 days. ARRANON is administered undiluted.

Dosage Modification

Discontinue ARRANON if the patient develops a neurologic adverse reaction of NCI CTCAE Grade 2 or greater. Dosage may be delayed for other toxicity including hematologic toxicity [see BOX WARNING, WARNINGS AND PRECAUTIONS].

Adjustment Of Dose In Special Populations

ARRANON has not been studied in patients with renal or hepatic dysfunction [see Use In Specific Populations]. No dose adjustment is recommended for patients with a creatinine clearance (CLCr) greater than or equal to 50 mL/min [see CLINICAL PHARMACOLOGY]. There are insufficient data to support a dose recommendation for patients with a CLCr less than 50 mL/min.

Prevention Of Hyperuricemia

Appropriate measures (e.g., hydration, urine alkalinization, and prophylaxis with allopurinol) must be taken to prevent hyperuricemia [see WARNINGS AND PRECAUTIONS].

Instructions For Handling, Preparation, And Administration

Handling

ARRANON is a cytotoxic agent. Caution should be used during handling and preparation. Use of gloves and other protective clothing to prevent skin contact is recommended. Proper aseptic technique should be used. Guidelines for proper handling and disposal of anticancer drugs have been published.1-4

Preparation And Administration

Do not dilute ARRANON prior to administration. The appropriate dose of ARRANON is transferred into polyvinylchloride (PVC) infusion bags or glass containers and administered as a 2-hour infusion in adult patients and as a 1-hour infusion in pediatric patients.

Prior to administration, inspect the drug product visually for particulate matter and discoloration.

Stability

ARRANON Injection is stable in polyvinylchloride (PVC) infusion bags and glass containers for up to 8 hours at up to 30°C.

HOW SUPPLIED

Dosage Forms And Strengths

Injection

250 mg/50 mL (5 mg/mL) single-dose vial

Storage And Handling

ARRANON Injection is supplied as a clear, colorless, sterile solution in Type I, clear glass single-dose vials with a gray bromobutyl rubber stopper (not made with natural rubber latex) and a red snap-off aluminum seal. Each vial contains 250 mg of nelarabine (5 mg nelarabine per mL) and the inactive ingredient sodium chloride (4.5 mg per mL) in 50 mL Water for Injection, USP.

Single-dose Vials (NDC 0078-0683-61) are available in the following carton size: NDC 0078-0683-06 (package of 6).

Store ARRANON (nelarabine) Injection at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). See USP Controlled Room Temperature.

REFERENCES

1. “OSHA Hazardous Drugs.” OSHA. http://www.osha.gov/SLTC/hazardousdrugs/index.html

Distributed by: Novartis Pharmaceuticals Corporation East Hanover, New Jersey 07936. Revised: July 2018

Side Effects & Drug Interactions

SIDE EFFECTS

The following serious adverse reactions are discussed in greater detail in other sections of the label:

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 with rates in the clinical trials of another drug and may not reflect the rates observed in practice.

ARRANON was studied in 459 patients in Phase I and Phase II clinical trials.

Adults

The safety profile of ARRANON is based on data from 103 adult patients treated with the recommended dose and schedule in 2 studies: an adult T-cell acute lymphoblastic leukemia (T-ALL)/T-cell lymphoblastic lymphoma (T-LBL) trial and an adult chronic lymphocytic leukemia trial.

The most common adverse reactions in adults, regardless of causality, were fatigue; gastrointestinal (GI) disorders (nausea, diarrhea, vomiting, and constipation); hematologic disorders (anemia, neutropenia, and thrombocytopenia); respiratory disorders (cough and dyspnea); nervous system disorders (somnolence and dizziness); and pyrexia.

The most common adverse reactions in adults, by Body System, regardless of causality, including severe or lifethreatening adverse reactions (NCI CTCAE Grade 3 or Grade 4) and fatal adverse reactions (Grade 5) are shown in Table 1.

Table 1. Most Commonly Reported (≥5% Overall) Adverse Reactions Regardless of Causality in Adult Patients Treated with 1,500 mg/m2 of ARRANON Administered Intravenously over 2 Hours on Days 1, 3, and 5 Repeated Every 21 Days

Body System
Adverse Reaction
Percentage of Patients (N = 103)
Toxicity Grade
Grade 3
%
Grade 4 and 5a
%
All Grades
%
Blood and Lymphatic System Disorders
  Anemia 20 14 99
  Thrombocytopenia 37 22 86
  Neutropenia 14 49 81
  Febrile neutropenia 9 1 12
Cardiac Disorders
  Sinus tachycardia 1 0 8
Gastrointestinal Disorders
  Nausea 0 0 41
  Diarrhea 1 0 22
  Vomiting 1 0 22
  Constipation 1 0 21
  Abdominal pain 1 0 9
  Stomatitis 1 0 8
  Abdominal distension 0 0 6
General Disorders and Administration Site Conditions
  Fatigue 10 2 50
  Pyrexia 5 0 23
  Asthenia 0 1 17
  Edema, peripheral 0 0 15
  Edema 0 0 11
  Pain 3 0 11
  Rigors 0 0 8
  Gait, abnormal 0 0 6
  Chest pain 0 0 5
  Non-cardiac chest pain 0 1 5
Infections
  Infection 2 1 9
  Pneumonia 4 1 8
  Sinusitis 1 0 7
Hepatobiliary Disorders
  AST increased 1 1 6
Metabolism and Nutrition Disorders
  Anorexia 0 0 9
  Dehydration 3 1 7
  Hyperglycemia 1 0 6
Musculoskeletal and Connective Tissue Disorders
  Myalgia 1 0 13
  Arthralgia 1 0 9
  Back pain 0 0 8
  Muscular weakness 5 0 8
  Pain in extremity 1 0 7
Nervous System Disorders (see Table 2)
Psychiatric Disorders
  Confusional state 2 0 8
  Insomnia 0 0 7
  Depression 1 0 6
Respiratory, Thoracic, and Mediastinal Disorders
  Cough 0 0 25
  Dyspnea 4 2 20
  Pleural effusion 5 1 10
  Epistaxis 0 0 8
  Dyspnea, exertional 0 0 7
  Wheezing 0 0 5
Vascular Disorders
  Petechiae 2 0 12
  Hypotension 1 1 8
a Five patients had a fatal adverse reaction. Fatal adverse reactions included hypotension (n = 1), respiratory arrest (n = 1), pleural effusion/pneumothorax (n = 1), pneumonia (n = 1), and cerebral hemorrhage/coma/leukoencephalopathy (n = 1).

Other Adverse Reactions: Blurred vision was also reported in 4% of adult patients.

There was a single report of biopsy-confirmed progressive multifocal leukoencephalopathy in the adult patient population.

Neurologic Adverse Reactions: Nervous system adverse reactions, regardless of drug relationship, were reported for 76% of adult patients across the Phase I and Phase II trials. The most common neurologic adverse reactions (≥ 2%) in adult patients, regardless of causality, including all grades (NCI CTCAE) are shown in Table 2.

Table 2. Neurologic Adverse Reactions (≥ 2%) Regardless of Causality in Adult Patients Treated with 1,500 mg/m2 of ARRANON Administered Intravenously over 2 Hours on Days 1, 3, and 5 Repeated Every 21 Days

Nervous System Disorders Adverse Reaction Percentage of Patients (N =103)
Grade 1
%
Grade 2
%
Grade 3
%
Grade 4
%
All Grades
%
Somnolence 20 3 0 0 23
Dizziness 14 8 0 0 21
Peripheral neurologic disorders, any adverse
reaction
8 12 2 0 21
  Neuropathy 0 4 0 0 4
  Peripheral neuropathy 2 2 1 0 5
  Peripheral motor neuropathy 3 3 1 0 7
  Peripheral sensory neuropathy 7 6 0 0 13
Hypoesthesia 5 10 2 0 17
Headache 11 3 1 0 15
Paresthesia 11 4 0 0 15
Ataxia 1 6 2 0 9
Depressed level of consciousness 4 1 0 1 6
Tremor 2 3 0 0 5
Amnesia 2 1 0 0 3
Dysgeusia 2 1 0 0 3
Balance disorder 1 1 0 0 2
Sensory loss 0 2 0 0 2

One patient had a fatal neurologic adverse reaction, cerebral hemorrhage/coma/leukoencephalopathy.

Most nervous system adverse reactions in the adult patients were evaluated as Grade 1 or 2. The additional Grade 3 adverse reactions in adult patients, regardless of causality, were aphasia, convulsion, hemiparesis, and loss of consciousness, each reported in 1 patient (1%). The additional Grade 4 adverse reactions, regardless of causality, were cerebral hemorrhage, coma, intracranial hemorrhage, leukoencephalopathy, and metabolic encephalopathy, each reported in one patient (1%).

The other neurologic adverse reactions, regardless of causality, reported as Grade 1, 2, or unknown in adult patients were abnormal coordination, burning sensation, disturbance in attention, dysarthria, hyporeflexia, neuropathic pain, nystagmus, peroneal nerve palsy, sciatica, sensory disturbance, sinus headache, and speech disorder, each reported in one patient (1%).

Pediatrics

The safety profile for children is based on data from 84 pediatric patients treated with the recommended dose and schedule in a T-cell acute lymphoblastic leukemia (T-ALL)/T-cell lymphoblastic lymphoma (T-LBL) treatment trial.

The most common adverse reactions in pediatric patients, regardless of causality, were hematologic disorders (anemia, leukopenia, neutropenia, and thrombocytopenia). Of the non-hematologic adverse reactions in pediatric patients, the most frequent adverse reactions reported were headache, increased transaminase levels, decreased blood potassium, decreased blood albumin, increased blood bilirubin, and vomiting.

The most common adverse reactions in pediatric patients, by System Organ Class, regardless of causality, including severe or life threatening adverse reactions (NCI CTCAE Grade 3 or Grade 4) and fatal adverse reactions (Grade 5) are shown in Table 3.

Table 3. Most Commonly Reported (≥ 5% Overall) Adverse Reactions Regardless of Causality in Pediatric Patients Treated with 650 mg/m2 of ARRANON Administered Intravenously over 1 Hour Daily for 5 Consecutive Days Repeated Every 21 Days

Body System
Adverse Reaction
Percentage of Patients (N = 84)
Toxicity Grade
Grade 3
%
Grade 4 and 5a
%
All Grades
%
Blood and Lymphatic System Disorders
  Anemia 45 10 95
  Neutropenia 17 62 94
  Thrombocytopenia 27 32 88
  Leukopenia 14 7 38
Hepatobiliary Disorders
  Transaminases increased 4 0 12
  Blood albumin decreased 5 1 10
  Blood bilirubin increased 7 2 10
Metabolic/Laboratory
  Blood potassium decreased 4 2 11
  Blood calcium decreased 1 1 8
  Blood creatinine increased 0 0 6
  Blood glucose decreased 4 0 6
  Blood magnesium decreased 2 0 6
Nervous System Disorders (see Table 4)
Gastrointestinal Disorders
  Vomiting 0 0 10
General Disorders & Administration Site Conditions
  Asthenia 1 0 6
Infections & Infestations
  Infection 2 1 5
a Three patients had a fatal adverse reaction. Fatal adverse reactions included neutropenia and pyrexia (n = 1), status epilepticus/seizure (n = 1), and fungal pneumonia (n = 1).

Neurologic Adverse Reactions: Nervous system adverse reactions, regardless of drug relationship, were reported for 42% of pediatric patients across the Phase I and Phase II trials. The most common neurologic adverse reactions (≥ 2%) in pediatric patients, regardless of causality, including all grades (NCI CTCAE) are shown in Table 4.

Table 4. Neurologic Adverse Reactions (≥ 2%) Regardless of Causality in Pediatric Patients Treated with 650 mg/m2 of ARRANON Administered Intravenously over 1 Hour Daily for 5 Consecutive Days Repeated Every 21 Days

Nervous System Disorders Adverse Reaction Percentage of Patients (N = 84)
Grade 1
%
Grade 2
%
Grade 3
%
Grade 4 and 5a
%
All Grades
%
Headache 8 2 4 2 17
Peripheral neurologic disorders, any adverse
reaction
1 4 7 0 12
  Peripheral neuropathy 0 4 2 0 6
  Peripheral motor neuropathy 1 0 2 0 4
  Peripheral sensory neuropathy 0 0 6 0 6
Somnolence 1 4 1 1 7
Hypoesthesia 1 1 4 0 6
Seizures 0 0 0 6 6
  Convulsions 0 0 0 3 4
  Grand mal convulsions 0 0 0 1 1
  Status epilepticus 0 0 0 1 1
Motor dysfunction 1 1 1 0 4
Nervous system disorder 1 2 0 0 4
Paresthesia 0 2 1 0 4
Tremor 1 2 0 0 4
Ataxia 1 0 1 0 2
a One (1) patient had a fatal neurologic adverse reaction, status epilepticus.

The other Grade 3 neurologic adverse reaction in pediatric patients, regardless of causality, was hypertonia reported in 1 patient (1%). The additional Grade 4 neurologic adverse reactions, regardless of causality, were 3rd nerve paralysis, and 6th nerve paralysis, each reported in 1 patient (1%).

The other neurologic adverse reactions, regardless of causality, reported as Grade 1, 2, or unknown in pediatric patients were dysarthria, encephalopathy, hydrocephalus, hyporeflexia, lethargy, mental impairment, paralysis, and sensory loss, each reported in 1 patient (1%).

Postmarketing Experience

The following adverse reactions have been identified during post-approval use of ARRANON. 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.

Infections And Infestations

Fatal opportunistic infections.

Metabolism And Nutrition Disorders

Tumor lysis syndrome.

Nervous System Disorders

Demyelination and ascending peripheral neuropathies similar in appearance to Guillain-Barré syndrome.

Musculoskeletal And Connective Disorders

Rhabdomyolysis, blood creatine phosphokinase increased.

DRUG INTERACTIONS

Administration of nelarabine in combination with adenosine deaminase inhibitors, such as pentostatin, is not recommended [see CLINICAL PHARMACOLOGY].

Warnings & Precautions

WARNINGS

Included as part of the "PRECAUTIONS" Section

PRECAUTIONS

Neurologic Adverse Reactions

Neurotoxicity is the dose-limiting toxicity of ARRANON. Patients undergoing therapy with ARRANON should be closely observed for signs and symptoms of neurologic toxicity [see BOX WARNING, DOSAGE AND ADMINISTRATION , ADVERSE REACTIONS]. Common signs and symptoms of nelarabine-related neurotoxicity include somnolence, confusion, convulsions, ataxia, paresthesias, and hypoesthesia. Severe neurologic toxicity can manifest as coma, status epilepticus, craniospinal demyelination, or ascending neuropathy similar in presentation to Guillain-Barré syndrome.

Nervous system adverse reactions, regardless of drug relationship, were reported for 76% of adult patients across the Phase I and Phase II trials; nervous system adverse reactions, regardless of drug relationship, were reported for 42% of pediatric patients across the Phase I and Phase II trials [see ADVERSE REACTIONS].

Full recovery from these adverse reactions has not always occurred with cessation of therapy with ARRANON. Close monitoring for neurologic adverse reactions is strongly recommended, and ARRANON should be discontinued for neurologic adverse reactions of NCI Common Toxicity Criteria for Adverse Events (CTCAE) Grade 2 or greater.

Patients treated previously or concurrently with intrathecal chemotherapy or previously with craniospinal irradiation may be at increased risk for neurologic adverse events.

Hematologic Adverse Reactions

Leukopenia, thrombocytopenia, anemia, and neutropenia, including febrile neutropenia, have been associated with ARRANON therapy. Complete blood counts including platelets should be monitored regularly [see DOSAGE AND ADMINISTRATION , ADVERSE REACTIONS].

Embryo-Fetal Toxicity

Based on its mechanism of action and findings in animal studies, ARRANON can cause fetal harm when administered to a pregnant woman [see CLINICAL PHARMACOLOGY]. In animal reproduction studies, intravenous administration of nelarabine to pregnant rabbits during the period of organogenesis resulted in teratogenicity at maternal doses below the recommended human adult dose of 1,500 mg/m2/day (see Data).

Advise pregnant women of the potential risk to the fetus. Advise females of reproductive potential to use effective contraception during treatment with ARRANON. Advise males with female partners of reproductive potential to use condoms during treatment with ARRANON and for 3 months after the last dose [see Use In Specific Populations , Nonclinical Toxicology].

Tumor Lysis Syndrome

Patients receiving ARRANON should receive intravenous hydration according to standard medical practice for the management of hyperuricemia in patients at risk for tumor lysis syndrome. Consideration should be given to the use of allopurinol in patients at risk of hyperuricemia [see DOSAGE AND ADMINISTRATION].

Vaccinations

Avoid the administration of live vaccines to immunocompromised patients.

Effects On Ability To Drive And Use Machines

Patients treated with ARRANON may experience somnolence during and for several days after treatment [see ADVERSE REACTIONS]. Advise patients to refrain from driving or engaging in hazardous occupations or activities until somnolence has resolved.

Patient Counseling Information

Advise the patient to read the FDA-approved patient labeling (PATIENT INFORMATION).

Patient labeling is provided at the end of this full prescribing information. However, inform the patients of the following:

Hematologic Adverse Reactions
  • Advise patients that leukopenia, thrombocytopenia, anemia, and neutropenia, including febrile neutropenia, have been associated with ARRANON.
  • Advise patients that complete blood counts, including platelets, will be monitored regularly during treatment [see WARNINGS AND PRECAUTIONS , ADVERSE REACTIONS].
Embryo-Fetal Toxicity
  • Advise pregnant females of reproductive potential and males with female partners of reproductive potential of the potential risk to the fetus. Advise females of reproductive potential to use effective contraception during treatment with ARRANON. Instruct females to inform their physician of a known or suspected pregnancy.
  • Advise male patients with partners of reproductive potential to use condoms during treatment with ARRANON and for 3 months after the last dose [see WARNINGS AND PRECAUTIONS , Use In Specific Populations].
Tumor Lysis Syndrome
  • Advise patients of the risk of tumor lysis syndrome [see WARNINGS AND PRECAUTIONS , ADVERSE REACTIONS].
Vaccinations
  • Instruct patients not to receive live vaccines during treatment with ARRANON [see WARNINGS AND PRECAUTIONS , ADVERSE REACTIONS].
Effects On Ability To Drive A nd Use Machines
  • Patients receiving ARRANON may experience somnolence during and for several days after treatment. Instruct patients to not drive or or engage in hazardous occupations or activities until somnolence has resolved [see WARNINGS AND PRECAUTIONS , ADVERSE REACTIONS].
Neurologic Adverse Reactions
  • Instruct patients to contact their physician if they experience new or worsening symptoms of peripheral neuropathy [see BOX WARNING, DOSAGE AND ADMINISTRATION , WARNINGS AND PRECAUTIONS , ADVERSE REACTIONS]. These signs and symptoms include: tingling or numbness in fingers, hands, toes, or feet; difficulty with the fine motor coordination tasks such as buttoning clothing; unsteadiness while walking; weakness arising from a low chair; weakness in climbing stairs; increased tripping while walking over uneven surfaces.
  • Advise patients of the risk of seizures [see ADVERSE REACTIONS]. If a seizure occurs, instruct patients to promptly notify the physician administering ARRANON.
Infection
  • Instruct patients to promptly notify their physician if they develop fever or signs of infection while on therapy [see ADVERSE REACTIONS].
Lactation
  • Advise women not to breastfeed during treatment with ARRANON [see Use In Specific Populations].

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment Of Fertility

Carcinogenicity testing of nelarabine has not been done. However, nelarabine was mutagenic when tested in vitro in L5178Y/TK mouse lymphoma cells with and without metabolic activation. No studies have been conducted in animals to assess genotoxic potential or effects on fertility. The effect on human fertility is unknown.

Use In Specific Populations

Pregnancy

Risk Summary

Based on its mechanism of action and findings in animal studies, ARRANON can cause fetal harm when administered to a pregnant woman [see CLINICAL PHARMACOLOGY]. Limited available data with ARRANON use in pregnant women are insufficient to determine a drug-associated risk for major birth defects, miscarriage or adverse maternal or fetal outcomes. There are risks to the pregnant woman associated with untreated leukemia or lymphoma (see Clinical Considerations). In animal reproduction studies, intravenous administration of nelarabine to pregnant rabbits during the period of organogenesis resulted in teratogenicity at maternal doses below the recommended human adult dose of 1500 mg/m2/day (see Data). Advise pregnant women of the potential risk to the fetus.

The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies are 2% to 4% and 15% to 20%, respectively.

Clinical Considerations

Disease-associated maternal and/or embryo-fetal risk

There are risks to the mother from untreated leukemia or lymphoma, including anemia, thrombocytopenia, and death.

Data

Animal Data

In an embryo-fetal development study in which pregnant rabbits were administered daily doses of nelarabine during organogenesis, increased incidences of fetal malformations, anomalies, and variations were observed at doses greater than or equal to 360 mg/m2/day (8-hour IV infusion; approximately 25% of the recommended human adult dose compared on a mg/m2 basis), which was the lowest dose tested. Cleft palate was seen in rabbits given 3,600 mg/m2/day (approximately 2-fold the adult dose), absent pollices (digits) in rabbits given greater than or equal to 1,200 mg/m2/day (approximately 75% of the recommended adult dose), while absent gall bladder, absent accessory lung lobes, fused or extra sternebrae, and delayed ossification was seen at all doses. Maternal body weight gain and fetal body weights were reduced in rabbits given 3,600 mg/m2/day (approximately 2-fold the adult dose), but could not account for the increased incidence of malformations seen at this or lower administered doses.

Lactation

Risk Summary

There are no data on the presence of nelarabine or ara-G in human or animal milk, the effect on the breastfed child, or the effect on milk production. Because of the potential for serious adverse reactions in the breastfed child from ARRANON, such as severe neurological reactions, advise women not to breastfeed during treatment with ARRANON.

Females And Males Of Reproductive Potential

Pregnancy Testing

ARRANON can cause fetal harm when administered to a pregnant woman [see Pregnancy]. Verify the pregnancy status of females of reproductive potential prior to starting treatment with ARRANON.

Contraception

Females

ARRANON can cause fetal harm when administered to a pregnant woman [see WARNINGS AND PRECAUTIONS , Pregnancy]. Because of the potential for genotoxicity, advise females of reproductive potential to use effective contraception during treatment with ARRANON.

Males

Because of the potential for genotoxicity, advise males (including those who have had vasectomies) with female partners of reproductive potential to use condoms during treatment with ARRANON and for 3 months after the last dose [see Nonclinical Toxicology].

Pediatric Use

The safety and effectiveness of ARRANON has been established in pediatric patients. The safety and effectiveness of ARRANON in pediatric patients has been studied in a clinical trial which included 84 patients aged 21 years and younger, who had relapsed or refractory T-cell acute lymphoblastic leukemia (T-ALL) or Tcell lymphoblastic lymphoma (T-LBL). The most frequent adverse events of any grade occurring on treatment in this study were hematologic laboratory abnormalities, most considered to be possibly related to nelarabine. Hematologic toxicity observed in the pediatric population was higher than that seen in the adult population. However, the incidence observed on this study was similar to that observed with other cytotoxic agents used for treatment of relapsed /refractory T-ALL/ T-LBL in this population [see DOSAGE AND ADMINISTRATION , ADVERSE REACTIONS , Clinical Studies].

Nervous system adverse reactions, regardless of drug relationship, have been reported for 42% of pediatric patients across the Phase I and Phase II trials. The incidence of nervous system adverse reactions was less in the pediatric population than that seen in adult patients with relapsed/refractory T-ALL/T-LBL [see ADVERSE REACTIONS].

Due to lack of long-term follow up data, a determination of the impact of ARRANON on the growth and pubertal development of pediatric patients cannot be made.

Geriatric Use

Clinical studies of ARRANON did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from younger patients. In an exploratory analysis, increasing age, especially age 65 years and older, appeared to be associated with increased rates of neurologic adverse reactions. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.

Renal Impairment

Ara-G clearance decreased as renal function decreased [see CLINICAL PHARMACOLOGY]. Because the risk of adverse reactions to this drug may be greater in patients with moderate (CLCr 30 to 50 mL/min) or severe (CLCr less than 30 mL/min) renal impairment, these patients should be closely monitored for toxicities when treated with ARRANON [see DOSAGE AND ADMINISTRATION].

Hepatic Impairment

The influence of hepatic impairment on the pharmacokinetics of nelarabine has not been evaluated. Because the risk of adverse reactions to this drug may be greater in patients with severe hepatic impairment (total bilirubin greater than 3 times upper limit of normal), these patients should be closely monitored for toxicities when treated with ARRANON.

Overdosage & Contraindications

OVERDOSE

There is no known antidote for overdoses of ARRANON. It is anticipated that overdosage would result in severe neurotoxicity (possibly including paralysis, coma), myelosuppression, and potentially death. In the event of overdose, supportive care consistent with good clinical practice should be provided.

At a dose of 2,200 mg/m2 given on Days 1, 3, and 5 every 21 days, 2 patients developed a significant Grade 3 ascending sensory neuropathy. MRI evaluations of the 2 patients demonstrated findings consistent with a demyelinating process in the cervical spine.

CONTRAINDICATIONS

None

Clinical Pharmacology

CLINICAL PHARMACOLOGY

Mechanism Of Action

Nelarabine is a prodrug of the deoxyguanosine analogue 9-β-D-arabinofuranosylguanine (ara-G), a nucleoside metabolic inhibitor. Nelarabine is demethylated by adenosine deaminase (ADA) to ara-G, mono-phosphorylated by deoxyguanosine kinase and deoxycytidine kinase, and subsequently converted to the active 5’-triphosphate, ara-GTP. Accumulation of ara-GTP in leukemic blasts allows for incorporation into deoxyribonucleic acid (DNA), leading to inhibition of DNA synthesis and cell death. Other mechanisms may contribute to the cytotoxic and systemic toxicity of nelarabine.

Pharmacokinetics

Absorption

Following intravenous administration of nelarabine to adult patients with refractory leukemia or lymphoma, plasma ara-G Cmax values generally occurred at the end of the nelarabine infusion and were generally higher than nelarabine Cmax values, suggesting rapid and extensive conversion of nelarabine to ara-G. Mean plasma nelarabine and ara-G Cmax values were 5.0 ± 3.0 mcg/mL and 31.4 ± 5.6 mcg/mL, respectively, after a 1,500 mg/m2 nelarabine dose infused over 2 hours in adult patients. The area under the concentrationtime curve (AUC) of ara-G is 37 times higher than that for nelarabine on Day 1 after nelarabine IV infusion of 1,500 mg/m2 dose (162 ± 49 mcg.h/mL versus 4.4 ± 2.2 mcg.h/mL, respectively). Comparable Cmax and AUC values were obtained for nelarabine between Days 1 and 5 at the nelarabine adult dosage of 1,500 mg/m2, indicating that nelarabine does not accumulate after multiple-dosing. There are not enough ara-G data to make a comparison between Day 1 and Day 5. After a nelarabine adult dose of 1,500 mg/m2, intracellular Cmax for ara- GTP appeared within 3 to 25 hours on Day 1. Exposure (AUC) to intracellular ara-GTP was 532 times higher than that for nelarabine and 14 times higher than that for ara-G (2,339 ± 2,628 mcg.h/mL versus 4.4 ± 2.2 mcg.h/mL and 162 ± 49 mcg.h/mL, respectively). Because the intracellular levels of ara-GTP were so prolonged, its elimination half-life could not be accurately estimated.

Distribution

Nelarabine and ara-G are extensively distributed throughout the body. For nelarabine, VSS values were 197 ± 216 L/m2 in adult patients. For ara-G, VSS/F values were 50 ± 24 L/m2 in adult patients.

Nelarabine and ara-G are not substantially bound to human plasma proteins (< 25%) in vitro, and binding is independent of nelarabine or ara-G concentrations up to 600 μM.

Metabolism

The principal route of metabolism for nelarabine is O-demethylation by adenosine deaminase to form ara-G, which undergoes hydrolysis to form guanine. In addition, some nelarabine is hydrolyzed to form methylguanine, which is O-demethylated to form guanine. Guanine is N-deaminated to form xanthine, which is further oxidized to yield uric acid.

Excretion

Nelarabine and ara-G are partially eliminated by the kidneys. Mean urinary excretion of nelarabine and ara-G was 6.6 ± 4.7% and 27 ± 15% of the administered dose, respectively, in 28 adult patients over the 24 hours after nelarabine infusion on Day 1. Renal clearance averaged 24 ± 23 L/h for nelarabine and 6.2 ± 5.0 L/h for ara-G in 21 adult patients. Combined Phase I pharmacokinetic data at nelarabine doses of 199 to 2,900 mg/m2 (n = 66 adult patients) indicate that the mean clearance (CL) of nelarabine is 197 ± 189 L/h/m2 on Day 1. The apparent clearance of ara-G (CL/F) is 10.5 ± 4.5 L/h/m2 on Day 1. Nelarabine and ara-G are rapidly eliminated from plasma with a mean half-life of 18 minutes and 3.2 hours, respectively, in adult patients.

Pediatrics

No pharmacokinetic data are available in pediatric patients at the once-daily 650 mg/m2 nelarabine dosage. Combined Phase I pharmacokinetic data at nelarabine doses of 104 to 2,900 mg/m2 indicate that the mean clearance (CL) of nelarabine is about 30% higher in pediatric patients than in adult patients (259 ± 409 L/h/m2 versus 197 ± 189 L/h/m2, respectively) (n = 66 adults, n = 22 pediatric patients) on Day 1. The apparent clearance of ara-G (CL/F) is comparable between the two groups (10.5 ± 4.5 L/h/m2 in adult patients and 11.3 ± 4.2 L/h/m2 in pediatric patients) on Day 1. Nelarabine and ara-G are extensively distributed throughout the body. For nelarabine, VSS values were 213 ± 358 L/m2 in pediatric patients. For ara-G, VSS/F values were 33 ± 9.3 L/m2 in pediatric patients. Nelarabine and ara-G are rapidly eliminated from plasma in pediatric patients, with a half-life of 13 minutes and 2 hours, respectively.

Effect Of Age

Age has no effect on the pharmacokinetics of nelarabine or ara-G in adults. Decreased renal function, which is more common in the elderly, may reduce ara-G clearance [see Use In Specific Populations].

Effect Of Gender

Gender has no effect on nelarabine or ara-G pharmacokinetics.

Effect Of Race

In general, nelarabine mean clearance and volume of distribution values tend to be higher in whites (n = 63) than in blacks (by about 10%) (n = 15). The opposite is true for ara-G; mean apparent clearance and volume of distribution values tend to be lower in whites than in blacks (by about 15% to 20%). No differences in safety or effectiveness were observed between these groups.

Effect Of Renal Impairment

The pharmacokinetics of nelarabine and ara-G have not been specifically studied in renally impaired or hemodialyzed patients. Nelarabine is excreted by the kidney to a small extent (5% to 10% of the administered dose). Ara-G is excreted by the kidney to a greater extent (20% to 30% of the administered nelarabine dose). In the combined Phase I trials, patients were categorized into 3 groups: normal with CLCr greater than 80 mL/min (n = 67), mild with CLCr = 50 to 80 mL/min (n = 15), and moderate with CLCr less than 50 mL/min (n = 3). The mean apparent clearance (CL/F) of ara-G was about 15% and 40% lower in patients with mild and moderate renal impairment, respectively, than in patients with normal renal function [see Use In Specific Populations , DOSAGE AND ADMINISTRATION]. No differences in safety or effectiveness were observed.

Effect Of Hepatic Impairment

The influence of hepatic impairment on the pharmacokinetics of nelarabine has not been evaluated [see Use In Specific Populations].

Drug Interactions

Cytochrome P450

Nelarabine and ara-G did not significantly inhibit the activities of the human hepatic cytochrome P450 isoenzymes 1A2, 2A6, 2B6, 2C8, 2C9, 2C19, 2D6, or 3A4 in vitro at concentrations of nelarabine and ara-G up to 100 μM.

Fludarabine

Administration of fludarabine 30 mg/m2 as a 30-minute infusion 4 hours before a 1,200-mg/m2 infusion of nelarabine did not affect the pharmacokinetics of nelarabine, ara-G, or ara-GTP in 12 patients with refractory leukemia.

Pentostatin

There is in vitro evidence that pentostatin is a strong inhibitor of adenosine deaminase. Inhibition of adenosine deaminase may result in a reduction in the conversion of the prodrug nelarabine to its active moiety and consequently in a reduction in efficacy of nelarabine and/or change in adverse reaction profile of either drug [see DRUG INTERACTIONS].

Clinical Studies

Adult Clinical Trial

The safety and efficacy of ARRANON in adult patients were studied in a clinical trial which included 39 treated patients, 28 who had T-cell acute lymphoblastic leukemia (T-ALL) or T-cell lymphoblastic lymphoma (T-LBL) that had relapsed following or was refractory to at least two prior induction regimens. A 1,500-mg/m2 dose of ARRANON was administered intravenously over 2 hours on Days 1, 3, and 5 repeated every 21 days. Patients who experienced signs or symptoms of Grade 2 or greater neurologic toxicity on therapy were to be discontinued from further therapy with ARRANON. Seventeen patients had a diagnosis of T-ALL and 11 had a diagnosis of T-LBL. For patients with ≥ 2 prior inductions, the age range was 16 to 65 years (mean: 34 years) and most patients were male (82%) and Caucasian (61%). Patients with central nervous system (CNS) disease were not eligible.

Complete response (CR) in this trial was defined as bone marrow blast counts ≤ 5%, no other evidence of disease, and full recovery of peripheral blood counts. Complete response without complete hematologic recovery (CR*) was also assessed. The results of the trial for patients who had received ≥ 2 prior inductions are shown in Table 5.

Table 5. Efficacy Results in Adult Patients with ≥ 2 Prior Inductions Treated with 1,500 mg/m2 of ARRANON Administered Intravenously over 2 Hours on Days 1, 3, and 5 Repeated Every 21 Days

  N = 28
CR plus CR* % (n) [95% CI] 21% (6) [8%, 41%]
  CR % (n) [95% CI] 18% (5) [6%, 37%]
  CR* % (n) [95% CI] 4% (1) [0%, 18%]
Duration of CR plus CR* (range in weeks)a 4 to 195+
Median overall survival (weeks) [95% CI] 20.6 weeks [10.4, 36.4]
CR = Complete response.
CR* = Complete response without hematologic recovery.
CI = Confidence Interval
a Does not include 1 patient who was transplanted (duration of response was 156+ weeks).

The mean number of days on therapy was 56 days (range of 10 to 136 days). Time to CR plus CR* ranged from 2.9 to 11.7 weeks.

Pediatric Clinical Trial

The safety and efficacy of ARRANON in pediatric patients were studied in a clinical trial which included patients aged 21 years and younger, who had relapsed or refractory T-cell acute lymphoblastic leukemia (TALL) or T-cell lymphoblastic lymphoma (T-LBL). Eighty-four (84) patients, 39 of whom had received two or more prior induction regimens, were treated with 650 mg/m2/day of ARRANON administered intravenously over 1 hour daily for 5 consecutive days repeated every 21 days (see Table 6). Patients who experienced signs or symptoms of Grade 2 or greater neurologic toxicity on therapy were to be discontinued from further therapy with ARRANON.

Table 6. Pediatric Clinical Trial - Patient Allocation

Patient Population N
Patients treated at 650 mg/m2/day x 5 days every 21 days. 84
Patients with T-ALL or T-LBL with two or more prior induction treated at 650 mg/m2/day x 5 days every 21 days. 39
Patients with T-ALL or T-LBL with one prior induction treated at 650 mg/m2/day x 5 days every 21 days. 31

The 84 patients ranged in age from 2.5 to 21.7 years (overall mean: 11.9 years), 52% were 3 to 12 years of age and most were male (74%) and Caucasian (62%). The majority (77%) of patients had a diagnosis of T-ALL.

Complete response (CR) in this trial was defined as bone marrow blast counts ≤ 5%, no other evidence of disease, and full recovery of peripheral blood counts. Complete response without full hematologic recovery (CR*) was also assessed as a meaningful outcome in this trial. Duration of response is reported from date of response to date of relapse, and may include subsequent stem cell transplant. Efficacy results are presented in Table 7.

Table 7. Efficacy Results in Patients Aged 21 Years and Younger at Diagnosis with ≥ 2 Prior Inductions Treated with 650 mg/m2 of ARRANON Administered Intravenously over 1 Hour Daily for 5 Consecutive Days Repeated Every 21 Days

  N = 39
CR plus CR* % (n) [95% CI] 23% (9) [11%, 39%]
  CR % (n) [95% CI] 13% (5) [4%, 27%]
  CR* % (n) [95% CI] 10% (4) [3%, 24%]
Duration of CR plus CR* (range in weeks)a 3.3 to 9.3
Median overall survival (weeks) [95% CI] 13.1 [8.7, 17.4]
CR = Complete response.
CR* = Complete response without hematologic recovery.
CI = Confidence Interval
a Does not include 5 patients who were transplanted or had subsequent systemic chemotherapy (duration of response in these 5 patients was 4.7 to 42.1 weeks).

The mean number of days on therapy was 46 days (range: 7 to 129 days). Median time to CR plus CR* was 3.4 weeks (95% CI: 3.0, 3.7).

Medication Guide

PATIENT INFORMATION

ARRANON®
(AIR-ra-non)
(nelarabine) Injection

Read the Patient Information that comes with ARRANON before you or your child starts treatment with ARRANON. Read the information you get each time before each treatment with ARRANON. There may be new information. This information does not take the place of talking with the doctor about your or your child’s medical condition or treatment. Talk to your or your child’s doctor, if you have any questions.

What is the most important information I should know about ARRANON?

ARRANON may cause blood related adverse reactions. Your doctor will do blood tests regularly during treatment to monitor blood counts, including platelets.

ARRANON may cause serious nervous system problems including:

  • extreme sleepiness
  • seizures
  • coma
  • numbness and tingling in the hands, fingers, feet, or toes (peripheral neuropathy)
  • weakness and paralysis

Call the doctor right away if you or your child has the following symptoms:

  • seizures
  • numbness and tingling in the hands, fingers, feet, or toes
  • problems with fine motor skills such as buttoning clothes
  • unsteadiness while walking
  • increased tripping while walking
  • weakness when getting out of a chair or walking upstairs

These symptoms may not go away even when treatment with ARRANON is stopped.

What is ARRANON?

ARRANON is an anti-cancer medicine used to treat adults and children who have:

  • T-cell acute lymphoblastic leukemia
  • T-cell lymphoblastic lymphoma

What should you tell the doctor before you or your child starts ARRANON?

Tell the doctor about all health conditions you or your child have, including if you or your child:

  • have any nervous system problems.
  • have kidney problems.
  • are breastfeeding or plan to breastfeed. It is not known whether ARRANON passes through breast milk. You should not breastfeed during treatment with ARRANON.
  • are pregnant or plan to become pregnant. ARRANON can harm your unborn baby. You should not become pregnant while you are taking ARRANON. You should use effective birth control to avoid getting pregnant. Talk with your doctor about your choices.
  • are male (including if you have had a vasectomy) with a sexual partner who is pregnant, think that they may be pregnant, or who could become pregnant. You should use condoms during sexual intercourse during treatment with ARRANON and for 3 months after last dose.

Tell the doctor about all the medicines you or your child take, including prescription and nonprescription medicines, vitamins, and herbal supplements.

How is ARRANON given?

ARRANON is an intravenous medicine. This means it is given through a tube in your vein.

What should you or your child avoid during treatment with ARRANON?

  • You or your child should not drive or operate dangerous machines. ARRANON may cause sleepiness during and for several days after treatment.
  • You or your child should not receive vaccines made with live germs during treatment with ARRANON.

What are the possible side effects of ARRANON?

ARRANON may cause serious nervous system problems. See “What is the most important information I should know about ARRANON?”

ARRANON may also cause:

  • decreased blood counts such as low red blood cells, low white blood cells, and low platelets. Blood tests should be done regularly to check blood counts. Call the doctor right away if you or your child:
    • is more tired than usual, pale, or has trouble breathing
    • has a fever or other signs of an infection
    • bruises easy or has any unusual bleeding
  • stomach area problems such as nausea, vomiting, diarrhea, and constipation
  • headache
  • sleepiness
  • blurry eyesight

Call your doctor right away if you experience unexplained muscle pain, tenderness, or weakness while taking ARRANON. This is because on rare occasions, muscle problems can be serious.

These are not all the side effects associated with ARRANON. Ask your doctor or pharmacist for more information.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

General Advice about ARRANON

This leaflet summarizes important information about ARRANON. If you have questions or problems, talk with your or your child’s doctor. You can ask your doctor or pharmacist for information about ARRANON that is written for healthcare providers or it is available at www.pharma.us.novartis.com.

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Report Problems to the Food and Drug Administration

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit the FDA MedWatch website or call 1-800-FDA-1088.

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