BNF for Children 2011-2012

424 8.1.3 Antimetabolites BNFC 2011–20128 Malignant disease and immunosuppressionSide-effects see section 8.1; also diarrhoea, abdominalpain, jaundice; tachycardia, flushing, hypotension,pericardial effusion, oedema, haematoma;dyspnoea, cough; anxiety, agitation, dizziness, drowsiness,headache, paraesthesia, peripheral neuropathy,restlessness; haematuria; arthralgia, myalgia; rash,pruritus, hand-foot (desquamative) syndrome,increased sweating; pancreatitis also reportedLicensed use not licensed for use in children under 1yearIndication and doseRelapsed or refractory acute lymphoblasticleukaemia. By intravenous infusionConsult local treatment protocol for detailsEvoltra c (Genzyme) TAConcentrate for intravenous infusion, clofarabine1 mg/mL, net price 20-mL vial = £1153.20Electrolytes Na + 3.08 mmol/vialCYTARABINECautions see section 8.1 and notes above; interactions:Appendix 1 (cytarabine)Hepatic impairment reduce doseRenal impairment consult local treatment protocolsPregnancy avoid (teratogenic in animal studies); seealso Pregnancy and Reproductive Function, p. 416Breast-feeding discontinue breast-feedingSide-effects see section 8.1 and notes above;‘cytarabine syndrome’—6–12 hours after intravenousadministration—characterised by fever and malaise,myalgia, bone pain, maculopapular rash, and occasionallychest pain; less commonly conjunctivitis(consider prophylactic corticosteroid eye drops),neurotoxicity, renal and hepatic dysfunction, jaundice;rarely severe spinal cord toxicity following intrathecaladministrationLicensed use Depocyte c intrathecal injection notlicensed for use in childrenIndication and doseAcute lymphoblastic leukaemia, acute myeloidleukaemia, non-Hodgkin’s lymphoma. By intravenous injection, by intravenous infusion,or by subcutaneous injectionConsult local treatment protocol for detailsMeningeal leukaemia, meningeal neoplasms. By intrathecal injectionConsult local treatment protocol for detailsNote Based on weight or body-surface area, children maytolerate higher doses of cytarabine than adultsCytarabine (Non-proprietary) AInjection (for intravenous, subcutaneous or intrathecaluse), cytarabine 20 mg/mL, net price 5-mL vial =£4.00Injection (for intravenous or subcutaneous use),cytarabine 20 mg/mL, net price 5-mL vial = £3.90, 25-mL vial = £19.50Injection (for intravenous or subcutaneous use),cytarabine 100 mg/mL, net price 1-mL vial = £4.00; 5-mL vial = £20.00; 10-mL vial = £39.00; 20-mL vial =£77.50Lipid formulation for intrathecal useDepoCyte c (Napp) AIntrathecal injection, cytarabine encapsulated inliposomes, net price 50-mg vial = £1223.75FLUDARABINE PHOSPHATECautions see section 8.1 and notes above; monitor forsigns of haemolysis; monitor for neurological toxicity;worsening of existing and increased susceptibility toskin cancer; interactions: Appendix 1 (fludarabine)Contra-indications haemolytic anaemiaRenal impairment reduce dose by up to 50% ifcreatinine clearance 30–70 mL/minute/1.73 m 2 ;avoid if creatinine clearance less than 30 mL/minute/1.73 m 2Pregnancy avoid (embryotoxic and teratogenic inanimal studies); manufacturer advises effectivecontraception during and for at least 6 months aftertreatment in men or women; see also Pregnancy andReproductive Function, p. 416Breast-feeding discontinue breast-feedingSide-effects see section 8.1 and notes above; alsodiarrhoea, anorexia; oedema; pneumonia, cough;peripheral neuropathy, visual disturbances; chills,fever, malaise, weakness; rash; less commonly gastrointestinalhaemorrhage, pulmonary toxicity (includingpulmonary infiltrates, pneumonitis, and fibrosis), andconfusion; rarely heart failure, arrhythmia, coma,seizures, agitation, myelodysplastic syndrome, acutemyeloid leukaemia, optic neuropathy, blindness, Stevens-Johnsonsyndrome, toxic epidermal necrolysis,skin cancer, and haemorrhagic cystitisLicensed use not licensed for use in childrenIndication and dosePoor prognosis or relapsed acute myeloidleukaemia, relapsed acute lymphoblastic leukaemia,conditioning before bone marrowtransplantation. By mouth, by intravenous injection, or byintravenous infusionConsult local treatment protocol for detailsFludarabine phosphate (Non-proprietary) AInjection, powder for reconstitution, fludarabinephosphate, net price 50-mg vial = £140.40Fludara c (Genzyme) ATablets, f/c, pink, fludarabine phosphate 10 mg, netprice 15-tab pack = £268.12, 20-tab pack = £350.70Injection, powder for reconstitution, fludarabinephosphate, net price 50-mg vial = £147.07MERCAPTOPURINE6-MercaptopurineCautions see section 8.1 and notes above; thiopurinemethyltransferase status (see section 8.2.1); monitorliver function—discontinue if jaundice develops;interactions: Appendix 1 (mercaptopurine)Hepatic impairment may need dose reductionRenal impairment manufacturer advises considerreducing dosePregnancy avoid (teratogenic); see also Pregnancyand Reproductive Function, p. 416Breast-feeding discontinue breast-feedingSide-effects see section 8.1 and notes above; gastrointestinaleffects less common; hepatotoxicity (morefrequent at higher doses); rarely intestinal ulceration,