Drug: Blenoxane

BLENOXANE® (bleomycin sulfate for injection, USP) is a mixture of cytotoxic glycopeptide antibiotics isolated from a strain of Streptomyces verticillus. It is freely soluble in water. Note: A unit of bleomycin is equal to the formerly used milligram activity. The term milligram activity is a misnomer and was changed to units to be more precise.

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Pulmonary The most serious side effects are pulmonary adverse reactions, occurring in approximately 10% of treated patients. The most frequent presentation is pneumonitis occasionally progressing to pulmonary fibrosis. Approximately 1% of patients treated have died of pulmonary fibrosis. Pulmonary toxicity is both dose and age related, being more common in patients over 70 years of age and in those receiving over 400 units total dose. This toxicity, however, is unpredictable and has been seen in young patients receiving low doses. Some published reports have suggested that the risk of pulmonary toxicity may be increased when bleomycin is used in combination with G-CSF (filgrastim) or other cytokines. However, randomized clinical studies completed to date have not demonstrated an increased risk of pulmonary complications in patients treated with bleomycin and G-CSF. Because of lack of specificity of the clinical syndrome, the identification of patients with pulmonary toxicity due to BLENOXANE (bleomycin sulfate injection) has been extremely difficult. The earliest symptom associated with BLENOXANE (bleomycin sulfate injection) pulmonary toxicity is dyspnea. The earliest sign is fine rales. Radiographically, BLENOXANE (bleomycin sulfate injection) -induced pneumonitis produces nonspecific patchy opacities, usually of the lower lung fields. The most common changes in pulmonary function tests are a decrease in total lung volume and a decrease in vital capacity. However, these changes are not predictive of the development of pulmonary fibrosis. The microscopic tissue changes due to BLENOXANE (bleomycin sulfate injection) toxicity include bronchiolar squamous metaplasia, reactive macrophages, atypical alveolar epithelial cells, fibrinous edema, and interstitial fibrosis. The acute stage may involve capillary changes and subsequent fibrinous exudation into alveoli producing a change similar to hyaline membrane formation and progressing to a diffuse interstitial fibrosis resembling the Hamman-Rich syndrome. These microscopic findings are nonspecific; eg, similar changes are seen in radiation pneumonitis and pneumocystic pneumonitis. To monitor the onset of pulmonary toxicity, roentgenograms of the chest should be taken every 1 to 2 weeks (see WARNINGS). If pulmonary changes are noted, treatment should be discontinued until it can be determined if they are drug related. Recent studies have suggested that sequential measurement of the pulmonary diffusion capacity for carbon monoxide (DLCO) during treatment with BLENOXANE (bleomycin sulfate injection) may be an indicator of subclinical pulmonary toxicity. It is recommended that the DLCO be monitored monthly if it is to be employed to detect pulmonary toxicities, and thus the drug should be discontinued when the DLCO falls below 30% to 35% of the pretreatment value. Because of bleomycin's sensitization of lung tissue, patients who have received bleomycin are at greater risk of developing pulmonary toxicity when oxygen is administered in surgery. While long exposure to very high oxygen concentrations is a known cause of lung damage, after bleomycin administration, lung damage can occur at lower concentrations that are usually considered safe. Suggested preventive measures are:
  1. Maintain FIO2 at concentrations approximating that of room air (25%) during surgery and the postoperative period.
  2. Monitor carefully fluid replacement, focusing more on colloid administration rather than crystalloid.
Sudden onset of an acute chest pain syndrome suggestive of pleuropericarditis has been reported during BLENOXANE (bleomycin sulfate injection) infusions. Although each patient must be individually evaluated, further courses of BLENOXANE (bleomycin sulfate injection) do not appear to be contraindicated. Pulmonary adverse events which may be related to the intrapleural administration of BLENOXANE (bleomycin sulfate injection) have been reported. Idiosyncratic Reactions In approximately 1% of the lymphoma patients treated with BLENOXANE (bleomycin sulfate injection) , an idiosyncratic reaction, similar to anaphylaxis clinically, has been reported. The reaction may be immediate or delayed for several hours, and usually occurs after the first or second dose (see WARNINGS). It consists of hypotension, mental confusion, fever, chills, and wheezing. Treatment is symptomatic including volume expansion, pressor agents, antihistamines, and corticosteroids. Integument and Mucous Membranes These adverse reactions have been reported in approximately 50% of treated patients. They consist of erythema, rash, striae, vesiculation, hyperpigmentation, and tenderness of the skin. Hyperkeratosis, nail changes, alopecia, pruritus, and stomatitis have also been reported. It was necessary to discontinue BLENOXANE (bleomycin sulfate injection) therapy in 2% of treated patients because of these toxicities. Scleroderma-like skin changes have been reported. Skin toxicity is a relatively late manifestation usually developing in the second and third week of treatment after 150 to 200 units of BLENOXANE (bleomycin sulfate injection) have been administered and appears to be related to the cumulative dose. Intrapleural administration of BLENOXANE (bleomycin sulfate injection) has been associated with local pain. Hypotension possibly requiring symptomatic treatment has been reported. Death has been reported in association with BLENOXANE (bleomycin sulfate injection) pleurodesis in seriously ill patients. Other Vascular toxicities coincident with the use of BLENOXANE (bleomycin sulfate injection) in combination with other antineoplastic agents have been reported. The events are clinically heterogeneous and may include myocardial infarction, cerebrovascular accident, thrombotic microangiopathy (HUS), or cerebral arteritis. Various mechanisms have been proposed for these vascular complications. There are also reports of Raynaud's phenomenon occurring in patients treated with BLENOXANE (bleomycin sulfate injection) in combination with vinblastine with or without cisplatin or, in a few cases, with BLENOXANE (bleomycin sulfate injection) as a single agent. It is currently unknown if the cause of Raynaud's phenomenon in these cases is the disease, underlying vascular compromise, BLENOXANE (bleomycin sulfate injection) , vinblastine, hypomagnesemia, or a combination of any of these factors. Fever, chills, and vomiting have been reported. Anorexia and weight loss have been reported and may persist long after termination of this medication. Pain at tumor site, phlebitis, and other local reactions have been reported. Malaise has been reported. Read the Blenoxane (bleomycin sulfate injection) Side Effects Center for a complete guide to possible side effectsLearn More »

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Because of the possibility of an anaphylactoid reaction, lymphoma patients should be treated with 2 units or less for the first 2 doses. If no acute reaction occurs, then the regular dosage schedule may be followed. The following dose schedule is recommended: Squamous cell carcinoma, non-Hodgkin's lymphoma, testicular carcinoma - 0.25 to 0.50 units/kg (10 to 20 units/m²) given intravenously, intramuscularly, or subcutaneously weekly or twice weekly. Hodgkin's disease - 0.25 to 0.50 units/kg (10 to 20 units/m²) given intravenously, intramuscularly, or subcutaneously weekly or twice weekly. After a 50% response, a maintenance dose of 1 unit daily or 5 units weekly intravenously or intramuscularly should be given. Pulmonary toxicity of BLENOXANE (bleomycin sulfate injection) appears to be dose-related with a striking increase when the total dose is over 400 units. Total doses over 400 units should be given with great caution. Note: When BLENOXANE (bleomycin sulfate injection) is used in combination with other antineoplastic agents, pulmonary toxicities may occur at lower doses. Improvement of Hodgkin's disease and testicular tumors is prompt and noted within 2 weeks. If no improvement is seen by this time, improvement is unlikely. Squamous cell cancers respond more slowly, sometimes requiring as long as 3 weeks before any improvement is noted. Malignant Pleural Effusion - 60 units administered as a single dose bolus intrapleural injection (see Administration: Intrapleural). Use in Patients with Renal Insufficiency The following dosing reductions are proposed for patients with creatinine clearance (CrCL) values of less than 50 mL/min: Patient CrCL (mL/min) BLENOXANE Dose (%) 50 and above 100 40-50 70 30-40 60 20-30 55 10-20 45 5-10 40 CrCL can be estimated from the individual patient's measured serum creatinine (Scr) values using the Cockcroft and Gault formula: Males CrCL = [weight × (140 – Age)]/(72 × Scr) Females CrCL = 0.85 × [weight × (140 – Age)]/(72 × Scr) Where CrCL in mL/min/1.73m², weight in kg, age in years, and Scr in mg/dL. Administration BLENOXANE (bleomycin sulfate injection) may be given by the intramuscular, intravenous, subcutaneous, or intrapleural routes. Administration Precautions Caution should be exercised when handling BLENOXANE (bleomycin sulfate injection) for injection. Procedures for proper handling and disposal of anticancer drugs should be utilized. Several guidelines on this subject have been published.1-4 To minimize the risk of dermal exposure, always wear impervious gloves when handling vials containing BLENOXANE (bleomycin sulfate injection) for injection. If BLENOXANE (bleomycin sulfate injection) for injection contacts the skin, immediately wash the skin thoroughly with soap and water. If contact with mucous membranes occurs, the membranes should be flushed immediately and thoroughly with water. More information is available in the references listed below. Intramuscular or Subcutaneous The BLENOXANE (bleomycin sulfate injection) 15 units vial should be reconstituted with 1 to 5 mL of Sterile Water for Injection, USP, Sodium Chloride for Injection, 0.9%, USP, or Sterile Bacteriostatic Water for Injection, USP. The BLENOXANE (bleomycin sulfate injection) 30 units vial should be reconstituted with 2 to 10 mL of the above diluents. Intravenous The contents of the 15 units or 30 units vial should be dissolved in 5 mL or 10 mL, respectively, of Sodium Chloride for Injection, 0.9%, USP, and administered slowly over a period of 10 minutes. Intrapleural Sixty units of BLENOXANE (bleomycin sulfate injection) are dissolved in 50 to 100 mL Sodium Chloride for Injection, 0.9%, USP, and administered through a thoracostomy tube following drainage of excess pleural fluid and confirmation of complete lung expansion. The literature suggests that successful pleurodesis is, in part, dependent upon complete drainage of the pleural fluid and reestablishment of negative intrapleural pressure prior to instillation of a sclerosing agent. Therefore, the amount of drainage from the chest tube should be as minimal as possible prior to instillation of BLENOXANE (bleomycin sulfate injection) . Although there is no conclusive evidence to support this contention, it is generally accepted that chest tube drainage should be less than 100 mL in a 24-hour period prior to sclerosis. However, BLENOXANE (bleomycin sulfate injection) instillation may be appropriate when drainage is between 100 to 300 mL under clinical conditions that necessitate sclerosis therapy. The thoracostomy tube is clamped after BLENOXANE (bleomycin sulfate injection) instillation. The patient is moved from the supine to the left and right lateral positions several times during the next four hours. The clamp is then removed and suction reestablished. The amount of time the chest tube remains in place following sclerosis is dictated by the clinical situation. The intrapleural injection of topical anesthetics or systemic narcotic analgesia is generally not required. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit.

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No information provided. Read the Blenoxane Drug Interactions Center for a complete guide to possible interactions Learn More »

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BLENOXANE (bleomycin sulfate injection) should be considered a palliative treatment. It has been shown to be useful in the management of the following neoplasms either as a single agent or in proven combinations with other approved chemotherapeutic agents: Squamous Cell Carcinoma Head and neck (including mouth, tongue, tonsil, nasopharynx, oropharynx, sinus, palate, lip, buccal mucosa, gingivae, epiglottis, skin, larynx), penis, cervix, and vulva. The response to BLENOXANE (bleomycin sulfate injection) is poorer in patients with previously irradiated head and neck cancer. Lymphomas Hodgkin's disease, non-Hodgkin's lymphoma. Testicular Carcinoma Embryonal cell, choriocarcinoma, and teratocarcinoma. BLENOXANE (bleomycin sulfate injection) has also been shown to be useful in the management of: Malignant Pleural Effusion BLENOXANE (bleomycin sulfate injection) is effective as a sclerosing agent for the treatment of malignant pleural effusion and prevention of recurrent pleural effusions.

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BLENOXANE (bleomycin sulfate injection) is contraindicated in patients who have demonstrated a hypersensitive or an idiosyncratic reaction to it. Last reviewed on RxList: 6/22/2010
This monograph has been modified to include the generic and brand name in many instances.

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No information provided.

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BLENOXANE® (bleomycin sulfate for injection, USP) is available as follows: NDC 0015-3010-20, 15 units per vial as bleomycin sulfate for injection, USP.
NDC 0015-3063-01, 30 units per vial as bleomycin sulfate for injection, USP. Stability The sterile powder is stable under refrigeration 2°C (36°F) to 8°C (46°F) and should not be used after the expiration date is reached. BLENOXANE (bleomycin sulfate injection) should not be reconstituted or diluted with D5W or other dextrose containing diluents. When reconstituted in D5W and analyzed by HPLC, BLENOXANE (bleomycin sulfate injection) demonstrates a loss of A2 and B2 potency that does not occur when BLENOXANE (bleomycin sulfate injection) is reconstituted in Sodium Chloride for Injection, 0.9%, USP. BLENOXANE (bleomycin sulfate injection) is stable for 24 hours at room temperature in Sodium Chloride. REFERENCES 1. NIOSH Alert: Preventing occupational exposures to antineoplastic and other hazardous drugs in healthcare settings. 2004. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2004 165. 2. OSHA Technical Manual, TED 1-0.15A, Section VI: Chapter 2. Controlling occupational exposure to hazardous drugs. OSHA, 1999. http://www.osha.gov/dts/osta/otm/otm_vi/otm_vi_2.html 3. American Society of Health-System Pharmacists. ASHP guidelines on handling hazardous drugs. Am J Health-Syst Pharm. 2006;63:1172-1193. 4. Polovich M, White JM, Kelleher LO, eds. 2005. Chemotherapy and biotherapy guidelines and recommendations for practice. 2nd ed. Pittsburgh, PA: Oncology Nursing Society. Manufactured by: Nippon Kayaku Co., Ltd. Tokyo, Japan. Distributed by: Bristol-Myers Squibb Company Princeton, NJ 08543 USA. Rev April 2010 Last reviewed on RxList: 6/22/2010
This monograph has been modified to include the generic and brand name in many instances.

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General Patients with creatinine clearance values of less than 50 mL/min should be treated with caution and their renal function should be carefully monitored during the administration of bleomycin. Lower doses of BLENOXANE (bleomycin sulfate injection) may be required in these patients than those with normal renal function (see CLINICAL PHARMACOLOGY and DOSAGE AND ADMINISTRATION). Carcinogenesis, Mutagenesis, Impairment of Fertility The carcinogenic potential of BLENOXANE (bleomycin sulfate injection) in humans is unknown. A study in F344type male rats demonstrated an increased incidence of nodular hyperplasia after induced lung carcinogenesis by nitrosamines, followed by treatment with bleomycin. In another study where the drug was administered to rats by subcutaneous injection at 0.35 mg/kg weekly (3.82 units/m² weekly or about 30% at the recommended human dose), necropsy findings included dose-related injection site fibrosarcomas as well as various renal tumors. Bleomycin has been shown to be mutagenic both in vitro and in vivo. The effects of bleomycin on fertility have not been studied. Pregnancy Pregnancy Category D See WARNINGS. Nursing Mothers It is not known whether the drug is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants, it is recommended that nursing be discontinued by women receiving BLENOXANE (bleomycin sulfate injection) therapy. Pediatric Use Safety and effectiveness of BLENOXANE (bleomycin sulfate injection) in pediatric patients have not been established. Geriatric Use In clinical trials, pulmonary toxicity was more common in patients older than 70 years than in younger patients (see BOXED WARNING, WARNINGS, and ADVERSE REACTIONS: Pulmonary). Other reported clinical experience has not identified other differences in responses between elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. Bleomycin is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. 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.Last reviewed on RxList: 6/22/2010
This monograph has been modified to include the generic and brand name in many instances.

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