Names and pronunciation
(pem-ah-trex′ed) Alimta
PDF page 1034
Loading InternPractice…
Drug reference
(pem-ah-trex′ed) Alimta
PDF page 1034
Func. class.: Antineoplastic- antimetabolite
PDF page 1034
Chem. class.: Folic acid antagonist
PDF page 1034
Do not confuse: PEMEtrexed/PRALAtrexate
PDF page 1034
ACTION: Inhibits multiple enzymes that reduce folic acid, which is needed for cell replication
PDF page 1034
USES: Malignant pleural mesothelioma in combination with CISplatin; non–small-cell lung cancer as single agent; nonsquamous non–small-cell lung cancer (1st-line treatment) Unlabeled uses: Bladder, breast, colorectal, gastric, head/neck, renal cancers
PDF pages 1034, 1035
CONTRAINDICATIONS: Preg nancy, hypersensitivity, ANC <1500 cells/ mm3, CCr <45 mL/min, thrombocytopenia (<100,000/mm3), anemia Precautions: Breastfeeding, children, renal/hepatic disease
PDF page 1035
SIDE EFFECTS CNS: Fatigue, fever, mood alteration, neuropathy CV: Thrombosis, embolism, chest pain, arrhythmia exacerbation GI: Nausea, vomiting, anorexia, diar rhea, ulcerative stomatitis, constipa tion, dehydration GU: Renal failure, creatinine elevation HEMA: Neutropenia, leukopenia, throm- bocytopenia, myelosuppression, anemia INTEG: Rash, desquamation RESP: Dyspnea SYST: Infection with/without neutrope- nia, radiation recall reaction, toxic epider- mal necrolysis, Stevens-Johnson syn- drome, anaphylaxis
PDF page 1035
INTERACTIONS Decrease: clearance of PEMEtrexed— nephrotoxic products, avoid NSAIDs for 2-8 days before use
PDF page 1036
DOSAGE AND ROUTES • Adult: IV INFUSION 500-600 mg/m2 given over 10 min on day 1 of 21-day cycle with CISplatin 75 mg/m2 infused over 2 hr beginning 1/2 hr after end of PEMEtrexed infusion Renal dose • Adult: IV INFUSION CCr <45 mL/min, not recommended
PDF page 1035
Available forms: Inj, single-use vials, 100, 500 mg
PDF page 1035
Administer: • Store at 77°F, excursions permitted at 59°F to 86°F, not light sensitive, discard unused portions • Vit B12 and low-dose folic acid as pro- phylactic measure to treat related hema- tologic, GI toxicity; 400-1000 mcg/day × 7 days before 1st dose and × 21 days after last dose, vit B12 1 mg IM 1 wk be- fore 1st dose and q 3 cycles (9 wk) thereafter • Premedicate with corticosteroid (dexa- methasone) given PO bid day before, day of, and day after administration of PEME- trexed Intermittent IV INFUSION route • Use cytotoxic handling procedures • Reconstitute 500-mg vial/20 mL 0.9% NaCl inj (preservative free) = 25 mg/mL, swirl until dissolved, further dilute with 100 mL 0.9% NaCl inj (preservative free), give as IV infusion over 10 min • Use only 0.9% NaCl inj (preservative free) for reconstitution, dilution • Do not begin a new cycle unless neu- trophils (ANC) are ≥1500 cells/mm3, platelets are ≥100,000 cells/mm3, CCr is ≥45 mL/min • Platelet nadir <50,000/mm3 regard- less of the ANC: if necessary, delay until platelet count recovery, reduce PEME- trexed and CISplatin by 50%; if grade 3/4 toxicity occurs after 2 reductions, discon- tinue both products • ANC nadir <500/mm3 when platelet nadir is ≥50,000/mm3: if necessary, delay until ANC recovery, reduce PEME- trexed and CISplatin by 75%; if grade 3/4 toxicity occurs after 2 reductions, discon- tinue both products • CTC Grade 3/4 nonhematologic toxic- ity including diarrhea requiring hospi- talization and excluding neurotoxicity, mucositis, and grade 3 transaminase elevations: withhold therapy until pre- therapy value or condition, reduce by 75% both products; if grade 3 or 4 toxicity oc- curs after 2 reductions, discontinue both products • CTC grade 3/4 mucositis: withhold therapy until pretherapy condition, reduce 50% of PEMEtrexed; if grade 3 or 4 muco- sitis occurs after 2 dosage reductions, discontinue both products P • CTC grade 2 neurotoxicity: withhold therapy until pretherapy value or condi- tion, reduce dose of CISplatin by 50% • CTC grade 3/4 neurotoxicity: discon- tinue both products
PDF page 1035
Assess: • Previous radiation treatments; radiation recall reactions have occurred (erythema, exfoliative dermatitis, pain, burning) • Bone marrow depression: CBC, differen- tial, platelet count; monitor for nadir, recovery on days 8, 15 of the cycle; new cycle should not begin if ANC <1500 cells/mm3, platelets <100,000 cells/mm3, CCr <45 mL/min • Nephrotoxicity: Renal studies: BUN, serum uric acid, urine CCr, electrolytes before, during therapy; I&O ratio; report fall in urine output to <30 mL/hr • Monitor temperature; fever may indi- cate beginning infection; no rectal tem- perature • Neurotoxicity: CTC grade 2: withhold until resolution to at least pretherapy value/condition, reduce CISplatin by 50%; CTC grade 3-4: immediately discontinue product and CISplatin if given in combina- tion • Mucositis: CTC 3/4: withhold until resolution to at least pretherapy value/ condition, reduce dose by 50%; if grade 3/4 occurs after 2 dosage reductions, discontinue product and CISplatin • Bleeding: bleeding time, coagulation time during treatment; bleeding: hematu- ria, guaiac, bruising or petechiae, mucosa or orifices • Buccal cavity for dryness, sores, ulcer- ation, white patches, oral pain, bleeding, dysphagia • Severe allergic reaction, toxic epi- dermal necrolysis: rash, urticaria, itch- ing, flushing • Rinsing of mouth tid-qid with water, club soda; brushing of teeth bid-tid with soft brush or cotton-tipped applicators for stomatitis; use unwaxed dental floss • Pregnancy/breastfeeding: do not use in pregnancy, breastfeeding
PDF page 1036
Evaluate: • Therapeutic response: decreased spread of malignancy
PDF page 1036
CLINICAL CONSIDERATIONS
PDF page 1036
Patient and caregiver information: • To report any complaints, side effects to nurse or prescriber: black, tarry stools; chills, fever, sore throat, bleeding, bruis- ing, cough, SOB, dark or bloody urine • To discuss with provider all OTC, Rx, herbals, supplements taken, to avoid alcohol • To avoid foods with citric acid, hot temperature, or rough texture if stomati- tis is present • To report stomatitis: any bleeding, white spots, ulcerations in mouth to prescriber; to examine mouth daily; to report symp- toms to nurse; to use good oral hygiene • That prophylactic folic acid and B12 injections may be necessary 1 wk before therapy to prevent bone marrow sup- pression and GI symptoms • To avoid use of razors, commercial mouthwash • To eat foods high in folic acid; to take supplements as prescribed • That contraceptive measures are recom- mended during therapy, for ≥8 wk after cessation of therapy; to discontinue breastfeeding because toxicity to infant may occur
PDF page 1036
PHARMACOKINETICS Not metabolized; excreted in urine (unchanged 70%-90%); not known if excreted in breast milk; half-life 3.5 hr, 81% protein binding
PDF page 1036
• Adult: IV INFUSION 500-600 mg/m2 given over 10 min on day 1 of 21-day cycle with CISplatin 75 mg/m2 infused over 2 hr beginning 1/2 hr after end of PEMEtrexed infusion Renal dose
PDF page 1035
• Adult: IV INFUSION CCr <45 mL/min, not recommended
PDF page 1035