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Drug overview for ADCETRIS (brentuximab vedotin):
Generic name: BRENTUXIMAB VEDOTIN (bren-TUX-i-mab)
Drug class: Antineoplastic Monoclonal Antibodies
Therapeutic class: Antineoplastics
Brentuximab vedotin, a chimeric human-murine anti-CD30 antibody conjugated with the microtubule inhibitor monomethyl auristatin E (MMAE), is an antineoplastic agent.
No enhanced Uses information available for this drug.
Generic name: BRENTUXIMAB VEDOTIN (bren-TUX-i-mab)
Drug class: Antineoplastic Monoclonal Antibodies
Therapeutic class: Antineoplastics
Brentuximab vedotin, a chimeric human-murine anti-CD30 antibody conjugated with the microtubule inhibitor monomethyl auristatin E (MMAE), is an antineoplastic agent.
No enhanced Uses information available for this drug.
DRUG IMAGES
ADCETRIS 50 MG VIAL
The following indications for ADCETRIS (brentuximab vedotin) have been approved by the FDA:
Indications:
CD30-positive mycosis fungoides
Hodgkin's lymphoma
Peripheral T-cell lymphoma
Primary cutaneous anaplastic large cell lymphoma
Systemic anaplastic large cell lymphoma
Professional Synonyms:
Anaplastic large T-cell systemic malignant lymphoma
Anemia lymphatica
CD30 positive primary cutaneous anaplastic large cell lymphoma
Hodgkin's disease
Ki-1+ lymphoma
Indications:
CD30-positive mycosis fungoides
Hodgkin's lymphoma
Peripheral T-cell lymphoma
Primary cutaneous anaplastic large cell lymphoma
Systemic anaplastic large cell lymphoma
Professional Synonyms:
Anaplastic large T-cell systemic malignant lymphoma
Anemia lymphatica
CD30 positive primary cutaneous anaplastic large cell lymphoma
Hodgkin's disease
Ki-1+ lymphoma
The following dosing information is available for ADCETRIS (brentuximab vedotin):
In patients who weigh 100 kg or less, dosage of brentuximab vedotin should be based on actual body weight; however, in patients who weigh more than 100 kg, dosage should be calculated based on a weight of 100 kg.
Dosing interruption and/or dosage reduction or discontinuance of brentuximab vedotin therapy may be necessary based on severity of an adverse effect as described in Tables 1, 2, and 3.
Table 1: Dosage Modifications for Toxicity of Single-agent Brentuximab Vedotin
Toxicity Dosage Modification Relapsed cHL, Consolidation Therapy for cHL, Relapsed sALCL, or Relapsed pcALCL or Mycosis Fungoides (Initial Dosage = 1.8 mg/kg every 3 weeks) Peripheral neuropathy New or worsening grade 2 or 3: Interrupt brentuximab vedotin; when toxicity resolves to grade 1 or baseline, resume at reduced dosage of 1.2 mg/kg (maximum 120 mg) every 3 weeks Grade 4: Discontinue brentuximab vedotin Neutropenia Grade 3 or 4: Interrupt brentuximab vedotin; when toxicity improves to grade 2 or less or to baseline, resume at same dosage; consider G-CSF use during subsequent cycles Recurrent grade 4 (despite G-CSF use): Consider drug discontinuance or dosage reduction (i.e., reduced brentuximab vedotin dosage of 1.2 mg/kg (maximum 120 mg) every 3 weeks)
Table 2: Dosage Modifications for Brentuximab Vedotin During Combination Therapy with Doxorubicin, Vinblastine, and Dacarbazine (AVD)
Toxicity Dosage Modification Previously Untreated cHL (Initial Dosage = 1.2 mg/kg every 2 weeks) Peripheral neuropathy Grade 2: Reduce brentuximab vedotin dosage to 0.9 mg/kg (maximum 90 mg) every 2 weeks Grade 3: Consider dosage modification of concomitant neurotoxic drugs and interrupt brentuximab vedotin; when toxicity improves to grade 2 or less, resume brentuximab vedotin at reduced dosage of 0.9 mg/kg (maximum 90 mg) every 2 weeks Grade 4: Discontinue brentuximab vedotin Neutropenia Grade 3 or 4 (patient not receiving primary G-CSF prophylaxis): Administer G-CSF during subsequent cycles
Table 3: Dosage Modifications for Brentuximab Vedotin During Combination Therapy with Cyclophosphamide, Doxorubicin, and Prednisone (CHP)
Toxicity Dosage Modification Previously Untreated sALCL or Other PTCL (Initial Dosage = 1.8 mg/kg every 3 weeks) Peripheral sensory neuropathy Grade 2: Continue same dosage Grade 3: Reduce brentuximab vedotin dosage to 1.2 mg/kg (maximum 120 mg) every 3 weeks Grade 4: Discontinue brentuximab vedotin Peripheral motor neuropathy Grade 2: Reduce brentuximab vedotin dosage to 1.2 mg/kg (maximum 120 mg) every 3 weeks Grade 3 or 4: Discontinue brentuximab vedotin Neutropenia Grade 3 or 4 (patient not receiving primary G-CSF prophylaxis): Administer G-CSF during subsequent cycles
Dosing interruption and/or dosage reduction or discontinuance of brentuximab vedotin therapy may be necessary based on severity of an adverse effect as described in Tables 1, 2, and 3.
Table 1: Dosage Modifications for Toxicity of Single-agent Brentuximab Vedotin
Toxicity Dosage Modification Relapsed cHL, Consolidation Therapy for cHL, Relapsed sALCL, or Relapsed pcALCL or Mycosis Fungoides (Initial Dosage = 1.8 mg/kg every 3 weeks) Peripheral neuropathy New or worsening grade 2 or 3: Interrupt brentuximab vedotin; when toxicity resolves to grade 1 or baseline, resume at reduced dosage of 1.2 mg/kg (maximum 120 mg) every 3 weeks Grade 4: Discontinue brentuximab vedotin Neutropenia Grade 3 or 4: Interrupt brentuximab vedotin; when toxicity improves to grade 2 or less or to baseline, resume at same dosage; consider G-CSF use during subsequent cycles Recurrent grade 4 (despite G-CSF use): Consider drug discontinuance or dosage reduction (i.e., reduced brentuximab vedotin dosage of 1.2 mg/kg (maximum 120 mg) every 3 weeks)
Table 2: Dosage Modifications for Brentuximab Vedotin During Combination Therapy with Doxorubicin, Vinblastine, and Dacarbazine (AVD)
Toxicity Dosage Modification Previously Untreated cHL (Initial Dosage = 1.2 mg/kg every 2 weeks) Peripheral neuropathy Grade 2: Reduce brentuximab vedotin dosage to 0.9 mg/kg (maximum 90 mg) every 2 weeks Grade 3: Consider dosage modification of concomitant neurotoxic drugs and interrupt brentuximab vedotin; when toxicity improves to grade 2 or less, resume brentuximab vedotin at reduced dosage of 0.9 mg/kg (maximum 90 mg) every 2 weeks Grade 4: Discontinue brentuximab vedotin Neutropenia Grade 3 or 4 (patient not receiving primary G-CSF prophylaxis): Administer G-CSF during subsequent cycles
Table 3: Dosage Modifications for Brentuximab Vedotin During Combination Therapy with Cyclophosphamide, Doxorubicin, and Prednisone (CHP)
Toxicity Dosage Modification Previously Untreated sALCL or Other PTCL (Initial Dosage = 1.8 mg/kg every 3 weeks) Peripheral sensory neuropathy Grade 2: Continue same dosage Grade 3: Reduce brentuximab vedotin dosage to 1.2 mg/kg (maximum 120 mg) every 3 weeks Grade 4: Discontinue brentuximab vedotin Peripheral motor neuropathy Grade 2: Reduce brentuximab vedotin dosage to 1.2 mg/kg (maximum 120 mg) every 3 weeks Grade 3 or 4: Discontinue brentuximab vedotin Neutropenia Grade 3 or 4 (patient not receiving primary G-CSF prophylaxis): Administer G-CSF during subsequent cycles
Procedures for proper handling (e.g., use of gloves or protective clothing) and disposal of antineoplastic agents should be followed. Brentuximab vedotin is administered by IV infusion over 30 minutes. Unreconstituted brentuximab vedotin powder for injection should be stored in unopened vials at 2-8degreesC.
Unopened vials should be retained in the original package for protection from light. Prior to administration, commercially available brentuximab vedotin powder for injection must be reconstituted and diluted using proper aseptic technique. The powder is reconstituted by adding 10.5
mL of sterile water for injection to a vial labeled as containing 50 mg of the drug to provide a solution containing 5 mg/mL. The diluent should be directed toward the wall of the vial and not directly at the brentuximab vedotin cake or powder. The vial should be gently swirled and inspected visually for particulate matter and discoloration prior to dilution and administration.
The resulting solution should not be shaken. The solution should be clear to slightly opalescent, colorless, and free of visible particulates. The reconstituted brentuximab vedotin solution may be diluted immediately or stored at 2-8degreesC for use within 24 hours, and should be protected from direct sunlight until time of use.
The reconstituted solution should not be frozen. For preparation of the final diluted brentuximab vedotin solution for infusion, the required amount of reconstituted brentuximab vedotin solution should be injected into an infusion bag containing a minimum volume of 100 mL of 0.9% sodium chloride injection, 5% dextrose injection, or lactated Ringer's injection to produce a final solution with brentuximab vedotin concentration of 0.4-1.8
mg/mL. The final diluted brentuximab vedotin solution for infusion should be mixed by gentle inversion. The solution may be infused immediately or stored at 2-8degreesC and used within 24 hours following reconstitution; the solution for infusion should not be frozen and should be protected from direct sunlight until use.
Any partially used vials should be discarded. Brentuximab vedotin should not be admixed with any other drug, nor should any other drug be administered simultaneously in the same IV line with brentuximab vedotin infusion.
Unopened vials should be retained in the original package for protection from light. Prior to administration, commercially available brentuximab vedotin powder for injection must be reconstituted and diluted using proper aseptic technique. The powder is reconstituted by adding 10.5
mL of sterile water for injection to a vial labeled as containing 50 mg of the drug to provide a solution containing 5 mg/mL. The diluent should be directed toward the wall of the vial and not directly at the brentuximab vedotin cake or powder. The vial should be gently swirled and inspected visually for particulate matter and discoloration prior to dilution and administration.
The resulting solution should not be shaken. The solution should be clear to slightly opalescent, colorless, and free of visible particulates. The reconstituted brentuximab vedotin solution may be diluted immediately or stored at 2-8degreesC for use within 24 hours, and should be protected from direct sunlight until time of use.
The reconstituted solution should not be frozen. For preparation of the final diluted brentuximab vedotin solution for infusion, the required amount of reconstituted brentuximab vedotin solution should be injected into an infusion bag containing a minimum volume of 100 mL of 0.9% sodium chloride injection, 5% dextrose injection, or lactated Ringer's injection to produce a final solution with brentuximab vedotin concentration of 0.4-1.8
mg/mL. The final diluted brentuximab vedotin solution for infusion should be mixed by gentle inversion. The solution may be infused immediately or stored at 2-8degreesC and used within 24 hours following reconstitution; the solution for infusion should not be frozen and should be protected from direct sunlight until use.
Any partially used vials should be discarded. Brentuximab vedotin should not be admixed with any other drug, nor should any other drug be administered simultaneously in the same IV line with brentuximab vedotin infusion.
| DRUG LABEL | DOSING TYPE | DOSING INSTRUCTIONS |
|---|---|---|
| ADCETRIS 50 MG VIAL | Maintenance | Adults infuse 1.8 mg/kg over 30 minute(s) by intravenous route every 3 weeks |
No generic dosing information available.
The following drug interaction information is available for ADCETRIS (brentuximab vedotin):
There are 5 contraindications.
These drug combinations generally should not be dispensed or administered to the same patient. A manufacturer label warning that indicates the contraindication warrants inclusion of a drug combination in this category, regardless of clinical evidence or lack of clinical evidence to support the contraindication.
| Drug Interaction | Drug Names |
|---|---|
| Efalizumab; Natalizumab/Immunosuppressives; Immunomodulators SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient. MECHANISM OF ACTION: Natalizumab,(1-3) efalizumab,(4) immunosuppressives, and immunomodulators all suppress the immune system. CLINICAL EFFECTS: Concurrent use of natalizumab(1-3) or efalizumab(4) with immunosuppressives or immunomodulators may result in an increased risk of infections, including progressive multifocal leukoencephalopathy (PML), an opportunistic infection caused by the JC virus (JCV). PREDISPOSING FACTORS: Previous JCV infection, longer duration of natalizumab treatment - especially if greater than 2 years, and prior or concomitant treatment with immunosuppressant medication are all independent risk factors which increase the risk for PML.(1,5) The FDA has estimated PML incidence stratified by risk factors: If anti-JCV antibody positive, no prior immunosuppressant use and natalizumab treatment less than 25 months, incidence <1/1,000. If anti-JCV antibody positive, history of prior immunosuppressant use and natalizumab treatment less than 25 months, incidence 2/1,000 If anti-JCV antibody positive, no prior immunosuppressant use and natalizumab treatment 25-48 months, incidence 4/1,000 If anti-JCV antibody positive, history of prior immunosuppressant use and natalizumab treatment 25-48 months, incidence 11/1,000. PATIENT MANAGEMENT: The US manufacturer of natalizumab states patients with Crohn's disease should not receive concurrent immunosuppressants, with the exception of limited overlap of corticosteroids, due to the increased risk for PML. For new natalizumab patients currently receiving chronic oral corticosteroids for Crohn's Disease, begin corticosteroid taper when therapeutic response to natalizumab has occurred. If corticosteroids cannot be discontinued within six months of starting natalizumab, discontinue natalizumab.(3) The US manufacturer of natalizumab states that natalizumab should not ordinarily be used in multiple sclerosis patients receiving immunosuppressants or immunomodulators due to the increased risk for PML. Immunosuppressives include, but are not limited to azathioprine, cyclophosphamide, cyclosporine, mercaptopurine, methotrexate, mitoxantrone, mycophenolate, and corticosteroids.(3,6) The UK manufacturer of natalizumab states that concurrent use with immunosuppressives or antineoplastic agents is contraindicated.(1) The Canadian manufacturer of natalizumab states that natalizumab should not be used with immunosuppressive or immunomodulatory agents.(2) The US manufacturer of certolizumab states that concurrent therapy with natalizumab is not recommended.(7) DISCUSSION: Progressive multifocal leukoencephalopathy has been reported in patients receiving concurrent natalizumab were recently or concomitantly taking immunomodulators or immunosuppressants.(1-5,8,9) In a retrospective cohort study of multiple sclerosis patients newly initiated on a disease-modifying therapy, use of high-efficacy agents (alemtuzumab, natalizumab, or ocrelizumab) resulted in the same risk of overall infections as moderate-efficacy agents, but there was an elevated risk of serious infections (adjusted hazard ratio [aHR] = 1.24, 95% confidence interval (CI) = 1.06-1.44) and UTIs (aHR = 1.21, 95% CI = 1.14-1.30).(10) |
TYSABRI |
| Live Vaccines; Live BCG/Selected Immunosuppressive Agents SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient. MECHANISM OF ACTION: A variety of disease modifying agents suppress the immune system. Immunocompromised patients may be at increased risk for uninhibited replication after administration of live, attenuated vaccines or intravesicular BCG. Immune response to vaccines may be decreased during periods of immunocompromise.(1) CLINICAL EFFECTS: The expected serum antibody response may not be obtained and/or the vaccine may result in illness.(1) After instillation of intravesicular BCG, immunosuppression may interfere with local immune response, or increase the severity of mycobacterial infection following inadvertent systemic exposure.(2) PREDISPOSING FACTORS: Immunosuppressive diseases (e.g. hematologic malignancies, HIV disease), treatments (e.g. radiation) and drugs may all increase the magnitude of immunodeficiency. PATIENT MANAGEMENT: The Centers for Disease Control(CDC) Advisory Committee on Immunization Practices (ACIP) states that live-virus and live, attenuated vaccines should not be administered to patients who are immunocompromised. The magnitude of immunocompromise and associated risks should be determined by a physician.(1) For patients scheduled to receive chemotherapy, vaccination should ideally precede the initiation of chemotherapy by 14 days. Patients vaccinated while on immunosuppressive therapy or in the 2 weeks prior to starting therapy should be considered unimmunized and should be revaccinated at least 3 months after discontinuation of therapy.(1) Patients who receive anti-B cell therapies should not receive live vaccines for at least 6 months after such therapies due to a prolonged duration of immunosuppression. An exception is the Zoster vaccine, which can be given at least 1 month after receipt of anti-B cell therapies.(1) The US manufacturer of abatacept states live vaccines should not be given during or for up to 3 months after discontinuation of abatacept.(2) The US manufacturer of live BCG for intravesicular treatment of bladder cancer states use is contraindicated in immunosuppressed patients.(3) The US manufacturer of daclizumab states live vaccines are not recommended during and for up to 4 months after discontinuation of treatment.(4) The US manufacturer of guselkumab states that live vaccines should be avoided during treatment with guselkumab.(5) The US manufacturer of inebilizumab-cdon states that live vaccines are not recommended during treatment and after discontinuation until B-cell repletion. Administer all live vaccinations at least 4 weeks prior to initiation of inebilizumab-cdon.(6) The US manufacturer of ocrelizumab states that live vaccines are not recommended during treatment and until B-cell repletion occurs after discontinuation of therapy. Administer all live vaccines at least 4 weeks prior to initiation of ocrelizumab.(7) The US manufacturer of ozanimod states that live vaccines should be avoided during and for up to 3 months after discontinuation of ozanimod.(8) The US manufacturer of siponimod states that live vaccines are not recommended during treatment and for up to 4 weeks after discontinuation of treatment.(9) The US manufacturer of ustekinumab states BCG vaccines should not be given in the year prior to, during, or the year after ustekinumab therapy.(10) The US manufacturer of satralizumab-mwge states that live vaccines are not recommended during treatment and should be administered at least four weeks prior to initiation of satralizumab-mwge.(11) The US manufacturer of ublituximab-xiiy states that live vaccines are not recommended during treatment and until B-cell recovery. Live vaccines should be administered at least 4 weeks prior to initiation of ublituximab-xiiy.(12) The US manufacturer of etrasimod states that live vaccines should be avoided during and for 5 weeks after treatment. Live vaccines should be administered at least 4 weeks prior to initiation of etrasimod.(13) The US manufacturer of emapalumab-lzsg states that live vaccines should not be administered to patients receiving emapalumab-lzsg and for at least 4 weeks after the last dose of emapalumab-lzsg. The safety of immunization with live vaccines during or following emapalumab-lzsg therapy has not been studied.(14) DISCUSSION: Killed or inactivated vaccines do not pose a danger to immunocompromised patients.(1) Patients with a history of leukemia who are in remission and have not received chemotherapy for at least 3 months are not considered to be immunocompromised.(1) |
ACAM2000 (NATIONAL STOCKPILE), ADENOVIRUS TYPE 4, ADENOVIRUS TYPE 4 AND TYPE 7, ADENOVIRUS TYPE 7, BCG (TICE STRAIN), BCG VACCINE (TICE STRAIN), DENGVAXIA, ERVEBO (NATIONAL STOCKPILE), FLUMIST TRIVALENT 2024-2025, IXCHIQ, M-M-R II VACCINE, PRIORIX, PROQUAD, ROTARIX, ROTATEQ, STAMARIL, VARIVAX VACCINE, VAXCHORA ACTIVE COMPONENT, VAXCHORA VACCINE, VIVOTIF, YF-VAX |
| Bleomycin/Brentuximab SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient. MECHANISM OF ACTION: The exact mechanism is unknown. CLINICAL EFFECTS: Concurrent use of brentuximab with bleomycin-based chemotherapy regimens may result in non-infectious pulmonary toxicity.(1,2) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Concurrent use of brentuximab with bleomycin-based chemotherapy regimens is contraindicated.(1,2) In patients who have received concurrent therapy, monitor for signs of pulmonary toxicity, including cough and dyspnea. Patients with symptoms of pulmonary toxicity may respond to corticosteroid therapy.(1,2) DISCUSSION: In a clinical trial that compared the use of brentuximab with Adriamycin (doxorubicin), bleomycin, vinblastine, and dacarbazine (ABVD) to the use of brentuximab with Adriamycin (doxorubicin), vinblastine, and dacarbazine (AVD), 40% of patients receiving brentuximab with ABVD experienced pulmonary toxicity. No patients receiving brentuximab with AVD have experienced pulmonary toxicity to date. Historical controls suggest a frequency of pulmonary toxicity of 10-25% in bleomycin-based regimens.(1) |
BLEOMYCIN SULFATE |
| Talimogene laherparepvec/Selected Immunosuppressants SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient. MECHANISM OF ACTION: Talimogene laherparepvec is a live, attenuated herpes simplex virus.(1) CLINICAL EFFECTS: Concurrent use of talimogene laherparepvec in patients receiving immunosuppressive therapy may cause a life-threatening disseminated herpetic infection.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Talimogene laherparepvec is contraindicated in immunosuppressed patients.(1) The magnitude of immunocompromise and associated risks due to immunosuppressant drugs should be determined by a physician. DISCUSSION: Concurrent use of talimogene laherparepvec in patients receiving immunosuppressive therapy may cause a life-threatening disseminated herpetic infection.(1) |
IMLYGIC |
| Nadofaragene Firadenovec/Selected Immunosuppressants SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient. MECHANISM OF ACTION: Nadofaragene firadenovec may contain low levels of replication-competent adenovirus.(1) CLINICAL EFFECTS: Concurrent use of nadofaragene firadenovec in patients receiving immunosuppressive therapy may cause disseminated adenovirus infection.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Individuals who are immunosuppressed or immune-deficient should not receive nadofaragene firadenovec.(1) DISCUSSION: Nadofaragene firadenovec is a non-replicating adenoviral vector-based gene therapy but may contain low levels of replication-competent adenovirus. Immunocompromised persons, including those receiving immunosuppressant therapy, may be at risk for disseminated adenovirus infection.(1) |
ADSTILADRIN |
There are 18 severe interactions.
These drug interactions can produce serious consequences in most patients. Actions required for severe interactions include, but are not limited to, discontinuing one or both agents, adjusting dosage, altering administration scheduling, and providing additional patient monitoring. Review the full interaction monograph for more information.
| Drug Interaction | Drug Names |
|---|---|
| Deferiprone/Selected Myelosuppressive Agents SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Concurrent use of deferiprone with other drugs known to be associated with neutropenia or agranulocytosis may increase the frequency or risk for severe toxicity.(1) CLINICAL EFFECTS: Concurrent use of deferiprone and myelosuppressive agents may result in severe neutropenia or agranulocytosis, which may be fatal. PREDISPOSING FACTORS: Agranulocytosis may be less common in patients receiving deferiprone for thalassemia, and more common in patients treated for other systemic iron overload conditions (e.g. myelodysplastic syndromes, sickle cell disease).(2,3) Inadequate monitoring appears to increase the risk for severe outcomes. Manufacturer post market surveillance found that in all fatal cases of agranulocytosis reported between 1999 and 2005, data on weekly white blood count (WBC) monitoring was missing. In three fatal cases, deferiprone was continued for two to seven days after the detection of neutropenia or agranulocytosis.(2) PATIENT MANAGEMENT: If possible, discontinue one of the drugs associated with risk for neutropenia or agranulocytosis. If alternative therapy is not available, documentation and adherence to the deferiprone monitoring protocol is essential. Baseline absolute neutrophil count (ANC) must be at least 1,500/uL prior to starting deferiprone. Monitor ANC weekly during therapy. If infection develops, interrupt deferiprone therapy and monitor ANC more frequently. If ANC is less than 1,500/uL but greater than 500/uL, discontinue deferiprone and any other drugs possibly associated with neutropenia. Initiate ANC and platelet counts daily until recovery (i.e. ANC at least 1,500/uL). If ANC is less than 500/uL, discontinue deferiprone, evaluate patient and hospitalize if appropriate. Do not resume deferiprone unless potential benefits outweigh potential risks.(1) DISCUSSION: Drugs linked to this monograph have an FDA Boxed Warning for risk of neutropenia, agranulocytosis, or pancytopenia, or have > 5% risk for neutropenia and/or warnings describing risk for myelosuppression in manufacturer prescribing information.(1-25) In pooled clinical studies submitted to the FDA, 6.1% of deferiprone patients met criteria for neutropenia and 1.7% of patients developed agranulocytosis.(1) The time to onset of agranulocytosis was highly variable with a range of 65 days to 9.2 years (median, 161 days).(3) |
DEFERIPRONE, DEFERIPRONE (3 TIMES A DAY), FERRIPROX, FERRIPROX (2 TIMES A DAY), FERRIPROX (3 TIMES A DAY) |
| Tofacitinib/Immunosuppressives; Immunomodulators SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Concurrent use of tofacitinib and azathioprine, other biologic disease-modifying antirheumatic drugs (DMARDs), or potent immunosuppressants may result in additive or synergistic effects on the immune system.(1) CLINICAL EFFECTS: Concurrent use of tofacitinib and azathioprine, other biologic DMARDs, or potent immunosuppressants use may increase the risk of serious infections.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Tofacitinib should not be used concurrently with azathioprine, other biologic DMARDs, or cyclosporine.(1) Patient should be monitored for decreases in lymphocytes and neutrophils. Therapy should be adjusted based on the indication. - For all indications: If absolute neutrophil count (ANC) or lymphocyte count is less than 500 cells/mm3, discontinue tofacitinib. - For rheumatoid arthritis or psoriatic arthritis and absolute neutrophil count (ANC) 500 to 1000 cells/mm3: interrupt dosing. When ANC is greater than 1000 cells/mm3, resume Xeljanz 5 mg twice daily or Xeljanz XR 11 mg once daily. - For ulcerative colitis and ANC 500 to 1000 cells/mm3: -If taking Xeljanz 10 mg twice daily, decrease to 5 mg twice daily. When ANC is greater than 1000 cells/mm3, increase to 10 mg twice daily based on clinical response. -If taking Xeljanz 5 mg twice daily, interrupt dosing. When ANC is greater than 1000 cells/mm3, resume 5 mg twice daily. -If taking Xeljanz XR 22 mg once daily, decrease to 11 mg once daily. When ANC is greater than 1000 cells/mm3, increase to 22 mg once daily based on clinical response. -If taking Xeljanz XR 11 mg once daily, interrupt dosing. When ANC is greater than 1000 cells/mm3, resume 11 mg once daily. - For polyarticular course juvenile idiopathic arthritis (pcJIA) and ANC 500 to 1000 cells/mm3: interrupt dosing until ANC is greater than 1000 cells/mm3.(1) DISCUSSION: Concurrent use of tofacitinib and azathioprine, other biologic DMARDs, or potent immunosuppressants may increase the risk of infection.(1) |
TOFACITINIB CITRATE, XELJANZ, XELJANZ XR |
| Clozapine/Selected Myelosuppressive Agents SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Clozapine and other myelosuppressive agents may be associated with neutropenia or agranulocytosis.(2) CLINICAL EFFECTS: Moderate neutropenia, even if due to combination therapy, may require abrupt discontinuation of clozapine resulting in decompensation of the patient's psychiatric disorder (e.g. schizophrenia). The disease treated by the myelosuppressive agent may be compromised if myelosuppression requires dose reduction, delay, or discontinuation of the myelosuppressive agent. Undetected severe neutropenia or agranulocytosis may be fatal. PREDISPOSING FACTORS: Low white blood counts prior to initiation of the myelosuppressive agent may increase risk for clinically significant neutropenia. PATIENT MANAGEMENT: If a patient stabilized on clozapine therapy requires treatment with a myelosuppressive agent, the clozapine prescriber should consult with prescriber of the myelosuppressive agent (e.g. oncologist) to discuss treatment and monitoring options.(2) More frequent ANC monitoring or treatment alternatives secondary to neutropenic episodes may need to be considered. Clozapine is only available through a restricted distribution system which requires documentation of the absolute neutrophil count (ANC) prior to dispensing.(1-2) For most clozapine patients, clozapine treatment must be interrupted for a suspected clozapine-induced ANC < 1000 cells/microliter. For patients with benign ethnic neutropenia (BEN), treatment must be interrupted for suspected clozapine-induced neutropenia < 500 cells/microliter.(2) DISCUSSION: Clozapine is only available through a restricted distribution system which requires documentation of the ANC prior to dispensing.(1) Agents linked to this interaction generally have > 5% risk for neutropenia and/or warnings describing risk for myelosuppression in manufacturer prescribing information.(3-26) |
CLOZAPINE, CLOZAPINE ODT, CLOZARIL, VERSACLOZ |
| Selected Multiple Sclerosis Agents/Immunosuppressants; Immunomodulators SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Ocrelizumab or ofatumumab in combination with immunosuppressives and immune-modulators all suppress the immune system.(1,2) CLINICAL EFFECTS: Concurrent use of ocrelizumab or ofatumumab with immunosuppressive or immune-modulating agents may result in an increased risk of serious infections, such as disseminated herpetic infection or progressive multifocal leukoencephalopathy (PML), an opportunistic infection caused by the JC virus (JCV).(1,2) PREDISPOSING FACTORS: Incomplete washout of previously prescribed immunosuppressive or immune-modulating medications. PATIENT MANAGEMENT: The ocrelizumab US prescribing information states: - Ocrelizumab and other immune-modulating or immunosuppressive therapies, (including immunosuppressant doses of corticosteroids) are expected to increase the risk of immunosuppression, and the risk of additive immune system effects must be considered if these therapies are coadministered with ocrelizumab. When switching from drugs with prolonged immune effects, such as daclizumab, fingolimod, natalizumab, teriflunomide, or mitoxantrone, the duration and mode of action of these drugs must be considered to avoid unintended additive immunosuppressive effects when initiating ocrelizumab.(1) The ofatumumab US prescribing information states: - Ofatumumab and other immunosuppressive therapies (including systemic corticosteroids) may have the potential for increased immunosuppressive effects and increase the risk of infection. When switching between therapies, the duration and mechanism of action of each therapy should be considered due to the potential for additive immunosuppressive effects. Ofatumumab for MS therapy has not been studied in combination with other MS agents that suppress the immune system.(2) DISCUSSION: Fatal disseminated herpes zoster and herpes simplex infections and cases of progressive multifocal leukoencephalopathy (PML) have been reported in patients who previously received immunomodulators or immunosuppressants.(1,2) In a retrospective cohort study of multiple sclerosis patients newly initiated on a disease-modifying therapy, use of high-efficacy agents (alemtuzumab, natalizumab, or ocrelizumab) resulted in the same risk of overall infections as moderate-efficacy agents, but there was an elevated risk of serious infections (adjusted hazard ratio [aHR] = 1.24, 95% confidence interval (CI) = 1.06-1.44) and UTIs (aHR = 1.21, 95% CI = 1.14-1.30).(3) |
KESIMPTA PEN, OCREVUS, OCREVUS ZUNOVO |
| Upadacitinib/Immunosuppressives; Immunomodulators SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Upadacitinib, immunosuppressives, and immunomodulators all suppress the immune system. CLINICAL EFFECTS: Concurrent use of upadacitinib with immunosuppressives or immunomodulators may result in an increased risk of serious infections. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The US manufacturer of upadacitinib states that concurrent use of upadacitinib with immunosuppressives or immunomodulators is not recommended. DISCUSSION: Serious infections have been reported in patients receiving upadacitinib. Reported infections included pneumonia, cellulitis, tuberculosis, multidermatomal herpes zoster, oral/esophageal candidiasis, cryptococcosis. Reports of viral reactivation, including herpes virus reactivation and hepatitis B reactivation, were reported in clinical studies with upadacitinib.(1) |
RINVOQ, RINVOQ LQ |
| Inebilizumab/Immunosuppressives; Immunomodulators SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Inebilizumab, immunosuppressives, and immunomodulators all suppress the immune system.(1) CLINICAL EFFECTS: Concurrent use of inebilizumab with immunosuppressive or immunomodulating agents may result in myelosuppression including neutropenia resulting in an increased risk for serious infections.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The US manufacturer of inebilizumab states that the concurrent use of inebilizumab with immunosuppressive agents, including systemic corticosteroids, may increase the risk of infection. If concurrent therapy is warranted, consider the risk of additive immune suppression and monitor based on prescribing information for both agents.(1) DISCUSSION: Inebilizumab has not been studied in combination with other immunosuppressants. If concurrent therapy is warranted, consider the potential for increased immunosuppressive risks from both agents. The most common infections reported by inebilizumab treated patients in the randomized and open-label clinical trial periods included urinary tract infections (20%), nasopharyngitis (13%), upper respiratory tract infections (8%), and influenza (7%). Although there been no cases of Hepatitis B virus reactivation or progressive multifocal leukoencephalopathy reported in patients taking inebilizumab, these infections have been observed in patients taking other B-cell-depleting antibodies.(1) |
UPLIZNA |
| Baricitinib/Immunosuppressives; Immunomodulators SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Concurrent use of baricitinib with other biologic disease-modifying antirheumatic drugs (DMARDs) or potent immunosuppressants such as azathioprine or cyclosporine may result in additive or synergistic effects on the immune system. CLINICAL EFFECTS: Concurrent use of baricitinib with other biologic DMARDs or potent immunosuppressants such as azathioprine or cyclosporine may increase the risk of serious infections.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The US manufacturer of baricitinib states that concurrent use of baricitinib with biologic DMARDs or potent immunosuppressants is not recommended.(1) DISCUSSION: Most patients who developed serious infections while being treated with baricitinib were on concomitant immunosuppressants like methotrexate and corticosteroids. The combination of baricitinib with other biologic DMARDs has not been studied.(1) |
OLUMIANT |
| Leflunomide; Teriflunomide/Selected Immunosuppressants SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Concurrent use of leflunomide or teriflunomide and potent immunosuppressants may result in additive or synergistic effects on the immune system.(1,2) Leflunomide is a prodrug and is converted to its active metabolite teriflunomide.(1) CLINICAL EFFECTS: Concurrent use of leflunomide or teriflunomide with immunosuppressants may result in an increased risk of serious infections, including opportunistic infections, especially Pneumocystis jiroveci pneumonia, tuberculosis (including extra-pulmonary tuberculosis), and aspergillosis. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: If leflunomide or teriflunomide is used concurrently with immunosuppressive agents, chronic CBC monitoring should be performed more frequently, every month instead of every 6 to 8 weeks. If bone marrow suppression or a serious infection occurs, leflunomide or teriflunomide should be stopped and rapid drug elimination procedure should be performed.(1,2) DISCUSSION: Pancytopenia, agranulocytosis and thrombocytopenia have been reported in patients receiving leflunomide or teriflunomide alone, but most frequently in patients taking concurrent immunosuppressants.(1,2) Severe and potentially fatal infections, including sepsis, have been reported in patients receiving leflunomide or teriflunomide, especially Pneumocystis jiroveci pneumonia and aspergillosis. Tuberculosis has also been reported.(1,2) |
ARAVA, AUBAGIO, LEFLUNICLO, LEFLUNOMIDE, TERIFLUNOMIDE |
| Ponesimod/Immunosuppressives; Immunomodulators SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Ponesimod in combination with immunosuppressives and immune-modulators all suppress the immune system.(1) CLINICAL EFFECTS: Concurrent use of ponesimod with immunosuppressive or immune-modulating agents may result in an increased risk of serious infections, such as disseminated herpetic infection, cryptococcal infection, or progressive multifocal leukoencephalopathy (PML), an opportunistic infection caused by the JC virus (JCV).(1) PREDISPOSING FACTORS: Incomplete washout of previously prescribed immunosuppressive or immune-modulating medications. PATIENT MANAGEMENT: The ponesimod US prescribing information states ponesimod has not been studied in combination with anti-neoplastic, immune-modulating, or immunosuppressive therapies. Caution should be used during concomitant administration because of the risk of additive immune effects during therapy and in the weeks following administration. When switching from drugs with prolonged immune effects, the half-life and mode of action of these drugs must be considered in order to avoid unintended additive immunosuppressive effects. Initiating treatment with ponesimod after alemtuzumab is not recommended. However, ponesimod can generally be started immediately after discontinuation of beta interferon or glatiramer acetate.(1) DISCUSSION: Fatal disseminated herpes zoster and herpes simplex infections, cryptococcal meningitis, disseminated cryptococcal infections, and cases of progressive multifocal leukoencephalopathy (PML) have been reported in patients who previously received immunomodulators or immunosuppressants.(1) |
PONVORY |
| Sodium Iodide I 131/Myelosuppressives; Immunomodulators SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Sodium iodide I 131 can cause depression of the hematopoetic system. Myelosuppressives and immunomodulators also suppress the immune system.(1) CLINICAL EFFECTS: Concurrent use of sodium iodide I 131 with agents that cause bone marrow depression, including myelosuppressives or immunomodulators, may result in an enhanced risk of hematologic disorders, including anemia, blood dyscrasias, bone marrow depression, leukopenia, and thrombocytopenia. Bone marrow depression may increase the risk of serious infections and bleeding.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The US manufacturer of sodium iodide I 131 states that concurrent use with bone marrow depressants may enhance the depression of the hematopoetic system caused by large doses of sodium iodide I 131.(1) Sodium iodide I 131 causes a dose-dependent bone marrow suppression, including neutropenia or thrombocytopenia, in the 3 to 5 weeks following administration. Patients may be at increased risk of infections or bleeding during this time. Monitor complete blood counts within one month of therapy. If results indicate leukopenia or thrombocytopenia, dosimetry should be used to determine a safe sodium iodide I 131 activity.(1) DISCUSSION: Hematologic disorders including death have been reported with sodium iodide I 131. The most common hematologic disorders reported include anemia, blood dyscrasias, bone marrow depression, leukopenia, and thrombocytopenia.(1) |
HICON, SODIUM IODIDE I-131 |
| Fingolimod/Immunosuppressives; Immunomodulators SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Fingolimod in combination with immunosuppressives and immune-modulators all suppress the immune system.(1-3) CLINICAL EFFECTS: Concurrent use of fingolimod with immunosuppressive or immune-modulating agents may result in an increased risk of serious infections, such as disseminated herpetic infection or progressive multifocal leukoencephalopathy (PML), an opportunistic infection caused by the JC virus (JCV).(1-3) PREDISPOSING FACTORS: Incomplete washout of previously prescribed immunosuppressive or immune-modulating medications. PATIENT MANAGEMENT: Recommendations for fingolimod regarding this interaction differ between regulatory approving agencies. The fingolimod US prescribing information states: - Antineoplastic, immune-modulating, or immunosuppressive therapies, (including corticosteroids) are expected to increase the risk of immunosuppression, and the risk of additive immune system effects must be considered if these therapies are coadministered with fingolimod. When switching from drugs with prolonged immune effects, such as natalizumab, teriflunomide or mitoxantrone, the duration and mode of action of these drugs must be considered to avoid unintended additive immunosuppressive effects when initiating fingolimod.(1) The fingolimod Canadian prescribing information states: - Concurrent use with immunosuppressive or immunomodulatory agents is contraindicated due to the risk of additive immune system effects. However, co-administration of a short course of corticosteroids (up to 5 days) did not increase the overall rate of infection in patients participating Phase III clinical trials.(2) The fingolimod UK specific product characteristics states: - Fingolimod is contraindicated in patients currently receiving immunosuppressive therapies or those immunocompromised by prior therapies. When switching patients from another disease modifying therapy to Gilenya, the half-life and mode of action of the other therapy must be considered in order to avoid an additive immune effect whilst at the same time minimizing the risk of disease activation.(3) DISCUSSION: Fatal disseminated herpes zoster and herpes simplex infections and cases of progressive multifocal leukoencephalopathy (PML) have been reported in patients who previously received immunomodulators or immunosuppressants.(1-3) |
FINGOLIMOD, GILENYA, TASCENSO ODT |
| Ozanimod/Immunosuppressives; Immunomodulators SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Ozanimod in combination with immunosuppressives and immune-modulators all suppress the immune system.(1) CLINICAL EFFECTS: Concurrent use of ozanimod with immunosuppressive or immune-modulating agents may result in an increased risk of serious infections, such as disseminated herpetic infection or progressive multifocal leukoencephalopathy (PML), an opportunistic infection caused by the JC virus (JCV).(1) PREDISPOSING FACTORS: Incomplete washout of previously prescribed immunosuppressive or immune-modulating medications. PATIENT MANAGEMENT: The ozanimod US prescribing information state this information regarding this interaction: -Ozanimod has not been studied in combination with anti-neoplastic, immune-modulating, or immunosuppressive therapies. Caution should be used during concomitant administration because of the risk of additive immune effects during therapy and in the week following administration. When switching from drugs with prolonged immune effects, the half-life and mode of action of these drugs must be considered in order to avoid unintended additive immunosuppressive effects. Initiating treatment with ozanimod after alemtuzumab is not recommended. However, ozanimod can generally be started immediately after discontinuation of beta interferon or glatiramer acetate.(1) DISCUSSION: Fatal disseminated herpes zoster and herpes simplex infections and cases of progressive multifocal leukoencephalopathy (PML) have been reported in patients who previously received immunomodulators or immunosuppressants.(1) |
ZEPOSIA |
| Siponimod/Immunosuppressives; Immunomodulators SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Siponimod in combination with immunosuppressives and immune-modulators all suppress the immune system.(1) CLINICAL EFFECTS: Concurrent use of siponimod with immunosuppressive or immune-modulating agents may result in an increased risk of serious infections, such as disseminated herpetic infection or progressive multifocal leukoencephalopathy (PML), an opportunistic infection caused by the JC virus (JCV).(1) PREDISPOSING FACTORS: Incomplete washout of previously prescribed immunosuppressive or immune-modulating medications. PATIENT MANAGEMENT: The siponimod US prescribing information state this information regarding this interaction: -Siponimod has not been studied in combination with anti-neoplastic, immune-modulating, or immunosuppressive therapies. Caution should be used during concomitant administration because of the risk of additive immune effects during therapy and in the week following administration. When switching from drugs with prolonged immune effects, the half-life and mode of action of these drugs must be considered in order to avoid unintended additive immunosuppressive effects. Initiating treatment with siponimod after alemtuzumab is not recommended. However, siponimod can generally be started immediately after discontinuation of beta interferon or glatiramer acetate.(1) DISCUSSION: Fatal disseminated herpes zoster and herpes simplex infections and cases of progressive multifocal leukoencephalopathy (PML) have been reported in patients who previously received immunomodulators or immunosuppressants.(1) |
MAYZENT |
| Cladribine/Immunosuppressives; Immunomodulators SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Cladribine in combination with immunosuppressives and immune-modulators all suppress the immune system.(1-2) CLINICAL EFFECTS: Concurrent use of cladribine with immunosuppressive or immune-modulating agents may result in an increased risk of serious infections, such as disseminated herpetic infection or progressive multifocal leukoencephalopathy (PML), an opportunistic infection caused by the JC virus (JCV).(1-2) PREDISPOSING FACTORS: Incomplete washout of previously prescribed immunosuppressive or immune-modulating medications. PATIENT MANAGEMENT: Recommendations for cladribine regarding this interaction differ between regulatory approving agencies. The cladribine US prescribing information states: -Concomitant use with myelosuppressive or other immunosuppressive drugs is not recommended. Acute short-term therapy with corticosteroids can be administered. In patients who have previously been treated with immunomodulatory or immunosuppressive drugs, consider potential additive effect, the mode of action, and duration of effect of the other drugs prior to initiation of cladribine.(1) The cladribine Canadian prescribing information states: -Use of cladribine in immunocompromised patients is contraindicated because of a risk of additive effects on the immune system. Acute short-term therapy with corticosteroids can be administered during cladribine treatment.(2) DISCUSSION: Fatal disseminated herpes zoster and herpes simplex infections and cases of progressive multifocal leukoencephalopathy (PML) have been reported in patients who previously received immunomodulators or immunosuppressants.(1-2) |
CLADRIBINE, MAVENCLAD |
| Anifrolumab/Biologic Therapies SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Concurrent use of anifrolumab with other biologic therapies may result in additive or synergistic effects on the immune system.(1) CLINICAL EFFECTS: Concurrent use of anifrolumab with other biologic therapies may increase the risk of serious infections.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The concurrent use of anifrolumab with other biologic therapies is not recommended.(1) DISCUSSION: The combination of anifrolumab with other biologic therapies has not been studied and is not recommended.(1) |
SAPHNELO |
| Ritlecitinib/Immunosuppressives; Immunomodulators SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Ritlecitinib, immunosuppressives, and immunomodulators all suppress the immune system. CLINICAL EFFECTS: Concurrent use of ritlecitinib with immunosuppressives or immunomodulators may result in an increased risk of serious infections. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The US manufacturer of ritlecitinib states that concurrent use of ritlecitinib with other JAK inhibitors, biologic immunomodulators, cyclosporine or other potent immunosuppressants is not recommended.(1) DISCUSSION: Serious infections have been reported in patients receiving ritlecitinib. Reported infections included appendicitis, COVID-19 infection (including pneumonia), and sepsis. Reports of viral reactivation, including herpes virus reactivation was reported in clinical studies with ritlecitinib.(1) |
LITFULO |
| Etrasimod/Immunosuppressives; Immunomodulators SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Etrasimod causes reversible sequestration of lymphocytes in lymphoid tissues, resulting in a mean 55% decrease in peripheral blood lymphocyte count at 52 weeks.(1) Other immunosuppressives and immune-modulators also suppress the immune system. CLINICAL EFFECTS: Concurrent use of etrasimod with immunosuppressive or immune-modulating agents may result in an increased risk of serious and fatal infections, such as disseminated herpetic infection, cryptococcal infection, or progressive multifocal leukoencephalopathy (PML).(1) PREDISPOSING FACTORS: Incomplete washout of previously prescribed immunosuppressive or immune-modulating medications increases the risk of adverse effects. PATIENT MANAGEMENT: The etrasimod US prescribing information states etrasimod has not been studied in combination with anti-neoplastic, immune-modulating, or immunosuppressive therapies. Concomitant administration of these therapies with etrasimod should be avoided because of the risk of additive immune effects during therapy and in the weeks following administration. Etrasimod's effect on peripheral lymphocytes may persist for up to 5 weeks after discontinuation.(1) When switching from drugs with prolonged immune effects, the half-life and mode of action of these drugs must be considered in order to avoid unintended additive immunosuppressive effects.(1) DISCUSSION: Fatal disseminated herpes zoster and herpes simplex infections, cryptococcal meningitis, disseminated cryptococcal infections, and cases of progressive multifocal leukoencephalopathy (PML) have been reported in patients treated with other sphingosine-1 phosphate receptor modulators.(1) |
VELSIPITY |
| Ropeginterferon alfa-2b/Slt Immunosuppress; Immunomodulator SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Ropeginterferon alfa-2b and immunosuppressives both suppress the immune system. CLINICAL EFFECTS: Concurrent use of ropeginterferon alfa-2b with immunosuppressives may result in an increased risk of serious infections. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Avoid concurrent use of myelosuppressive agents.(1-2) If concurrent use cannot be avoided, monitor for effects of excessive immunosuppression. DISCUSSION: In clinical trials, 20% of patients experienced leukopenia. Interferon alfa products may cause fatal or life-threatening infections.(1-2) |
BESREMI |
There are 6 moderate interactions.
The clinician should assess the patient’s characteristics and take action as needed. Actions required for moderate interactions include, but are not limited to, discontinuing one or both agents, adjusting dosage, altering administration.
| Drug Interaction | Drug Names |
|---|---|
| Ustekinumab/Immunosuppressives; Immunomodulators SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Ustekinumab, immunosuppressives, and immunomodulators all suppress the immune system.(1) CLINICAL EFFECTS: Concurrent use of ustekinumab with immunosuppressive or immunomodulating agents may result in an increased risk for serious infections.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The US manufacturer of ustekinumab recommends caution because the concurrent use of ustekinumab with immunosuppressive agents may increase the risk of infection. If concurrent therapy is warranted, consider the risk of additive immune suppression and monitor based on prescribing information for both agents.(1) DISCUSSION: Ustekinumab has not been studied in combination with other immunosuppressants in psoriasis studies. In psoriatic arthritis studies, concomitant methotrexate use did not appear to influence the safety or efficacy of ustekinumab. In Crohn's disease and ulcerative colitis studies, concomitant use of immunosuppressants or corticosteroids did not appear to influence the safety or efficacy of ustekinumab. If concurrent therapy is warranted, consider the potential for increased immunosuppressive risks from both agents.(1) The most common infections reported by ustekinumab treated patients in the clinical trial periods included nasopharyngitis(8%) and upper respiratory tract infection(5%). Serious bacterial, mycobacterial, fungal, and viral infections were observed in patients receiving ustekinumab. Cases of interstitial pneumonia, eosinophilic pneumonia, and cryptogenic organizing pneumonia resulting in respiratory failure or prolonged hospitalization have been reported in patients receiving ustekinumab.(1) |
OTULFI, PYZCHIVA, SELARSDI, STELARA, STEQEYMA, USTEKINUMAB, USTEKINUMAB-AEKN, USTEKINUMAB-TTWE, WEZLANA, YESINTEK |
| COVID-19 Vaccines/Immunosuppressives; Immunomodulators SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Immunosuppressants and immunomodulators may prevent the immune system from properly responding to the COVID-19 vaccine.(1,2) CLINICAL EFFECTS: Administration of a COVID-19 vaccine with immunosuppressants or immunomodulators may interfere with vaccine-induced immune response and impair the efficacy of the vaccine. However, patients should be offered and given a COVID-19 vaccine even if the use and timing of immunosuppressive agents cannot be adjusted.(1,2) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: In an effort to optimize COVID-19 vaccine response, the American College of Rheumatology (ACR) published conditional recommendations for administration of COVID-19 vaccines with immunosuppressants and immunomodulators.(1) The CDC also provides clinical considerations for COVID-19 vaccination in patients on immunosuppressants.(2) The CDC states that all immunocompromised patients over 6 months of age should receive at least 1 dose of COVID-19 vaccine if eligible. See the CDC's Interim Clinical Considerations for Use of COVID-19 Vaccines for specific recommendations based on age, vaccination history, and vaccine manufacturer.(2) The ACR states that in general, immunosuppressants and immunomodulators should be held for 1-2 weeks after each vaccine dose. See below for specific recommendations for certain agents.(1) The CDC advises planning for vaccination at least 2 weeks before starting or resuming immunosuppressive therapy.(2) Patients should be offered and given a COVID-19 vaccine even if the use and timing of immunosuppressive agents cannot be adjusted.(1,2) B-cell depleting agents, including rituximab: The ACR recommends consulting with the rheumatologist to determine optimal timing of COVID-19 vaccination. Measuring CD19 B cells may be considered to determine need for a booster vaccine dose. If B cell levels are not measured, a supplemental vaccine dose 2-4 weeks before the next scheduled dose of rituximab is recommended.(1) The CDC states that the utility of B-cell quantification to guide clinical care is not known and is not recommended. Patients who receive B-cell depleting therapy should receive COVID-19 vaccines about 4 weeks before the next scheduled dose. For patients who received 1 or more doses of COVID-19 vaccine during treatment with B-cell-depleting therapies that were administered over a limited period (e.g., as part of a treatment regimen for certain malignancies), revaccination may be considered. The suggested interval to start revaccination is about 6 months after completion of the B-cell-depleting therapy.(2) Abatacept: - Subcutaneous abatacept should be withheld for 1-2 weeks after each vaccine dose, as disease activity allows. - For intravenous abatacept, time administration so that vaccination will occur 1 week before the next abatacept infusion.(1) Cyclophosphamide: When feasible, administer cyclophosphamide one week after each COVID-19 vaccine dose.(1) Recipients of hematopoietic cell transplant or CAR-T-cell therapy who received one or more doses of COVID-19 vaccine prior to or during treatment should undergo revaccination following the current CDC recommendations for unvaccinated patients. Revaccination should start at least 3 months (12 weeks) after transplant or CAR-T-cell therapy.(2) TNF-alpha inhibitors and cytokine inhibitors: The ACR was not able to reach consensus on whether to modify dosing or timing of these agents with COVID-19 vaccination.(1) The CDC includes these agents in their general recommendation to hold therapy for at least 2 weeks following vaccination.(2) DISCUSSION: The ACR convened a COVID-19 Vaccine Guidance Task Force to provide guidance on optimal use of COVID-19 vaccines in rheumatology patients. These recommendations are based on limited clinical evidence of COVID-19 vaccines in patients without rheumatic and musculoskeletal disorders and evidence of other vaccines in this patient population.(1) The ACR recommendation for rituximab is based on studies of humoral immunity following receipt of other vaccines. These studies have uncertain generalizability to vaccination against COVID-19, as it is unknown if efficacy is attributable to induction of host T cells versus B cell (antibody-based) immunity.(1) The ACR recommendation for mycophenolate is based on preexisting data of mycophenolate on non-COVID-19 vaccine immunogenicity. Emerging data suggests that mycophenolate may impair SARS-CoV-2 vaccine response in rheumatic and musculoskeletal disease and transplant patients.(1) The ACR recommendation for methotrexate is based on data from influenza vaccines and pneumococcal vaccines with methotrexate.(1) The ACR recommendation for JAK inhibitors is based on concerns related to the effects of JAK inhibitors on interferon signaling that may result in a diminished vaccine response.(1) The ACR recommendation for subcutaneous abatacept is based on several studies suggesting a negative effect of abatacept on vaccine immunogenicity. The first vaccine dose primes naive T cells, naive T cell priming is inhibited by CTLA-4, and abatacept is a CTLA-4Ig construct. CTLA-4 should not inhibit boosts of already primed T cells at the time of the second vaccine dose.(1) |
COMIRNATY 2024-2025, MODERNA COVID 24-25(6M-11Y)EUA, NOVAVAX COVID 2024-2025 (EUA), PFIZER COVID 2024-25(5-11Y)EUA, PFIZER COVID 2024-25(6M-4Y)EUA, SPIKEVAX 2024-2025 |
| Sarilumab/Immunosuppressives; Immunomodulators SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Sarilumab, immunosuppressives, and immunomodulators all suppress the immune system.(1) CLINICAL EFFECTS: Concurrent use of sarilumab with immunosuppressive or immunomodulating agents may result in an increased risk for serious infections.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The US manufacturer of sarilumab recommends caution because the concurrent use of sarilumab with immunosuppressive agents may increase the risk of infection. If concurrent therapy is warranted, consider the risk of additive immune suppression and monitor based on prescribing information for both agents.(1) DISCUSSION: Sarilumab was studied as monotherapy and in combination with methotrexate or conventional disease modifying antirheumatic drugs (DMARDs) in rheumatoid arthritis studies. Sarilumab has not been studied with biological DMARDs and concurrent use should be avoided. If concurrent therapy is warranted, consider the potential for increased immunosuppressive risks from both agents.(1) The most common infections reported by sarilumab treated patients in the clinical trial periods included pneumonia and cellulitis. Serious bacterial, mycobacterial, fungal, and viral infections were observed in patients receiving sarilumab. Cases of tuberculosis, candidiasis, and pneumocystis with sarilumab have been reported.(1) |
KEVZARA |
| Ublituximab/Immunosuppressives; Immunomodulators SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Ublituximab, immunosuppressives, and immunomodulators all suppress the immune system.(1) CLINICAL EFFECTS: Concurrent use of ublituximab with immunosuppressive or immunomodulating agents may result in an increased risk for serious infections.(1) PREDISPOSING FACTORS: Incomplete washout of previously prescribed immunosuppressive or immune-modulating medications. PATIENT MANAGEMENT: The US manufacturer of ublituximab recommends caution because the concurrent use of ublituximab with immunomodulating or immunosuppressive agents, including immunosuppressant doses of corticosteroids, may increase the risk of infection.(1) If concurrent therapy is warranted, consider the risk of additive immune suppression and monitor based on prescribing information for both agents. When switching from agents with immune effects, the half-life and mechanism of action of these drugs must be taken into consideration in order to prevent additive immunosuppressive effects.(1) DISCUSSION: The most common infections reported by ublituximab-treated patients in the clinical trial periods included upper respiratory tract infections and urinary tract infections. Serious, including life-threatening or fatal, bacterial and viral infections were observed in patients receiving ublituximab.(1) Serious and/or fatal bacterial, fungal, and new or reactivated viral infections have been associated with other anti-CD20 B-cell depleting therapies. There were no cases of progressive multifocal leukoencephalopathy (PML) reported during the clinical trials; however, there have been reports of PML during or following completion of other anti-CD20 B-cell depleting therapies.(1) |
BRIUMVI |
| Belimumab/Biologic Therapies SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Concurrent use of belimumab with other biologic therapies may result in additive or synergistic effects on the immune system.(1) CLINICAL EFFECTS: Concurrent use of belimumab with other biologic therapies may increase the risk of serious infections.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The concurrent use of belimumab with other biologic therapies should be approached with caution.(1) DISCUSSION: In a randomized, double-blind, placebo-controlled trial, more patients who received belimumab and rituximab experienced serious adverse events, serious infections, and post-injection systemic reactions (22.2%, 9%, and 13.2%, respectively) than patients who received belimumab with placebo (13.9%, 2.8%, 9.7%) or standard therapy (19.7%, 5.3%, 5.3%).(1) The combination of belimumab with other biologic therapies has not been studied and should be used cautiously.(1) |
BENLYSTA |
| Tocilizumab/Immunosuppressives; Immunomodulators SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Tocilizumab, immunosuppressives, and immunomodulators all suppress the immune system.(1) CLINICAL EFFECTS: Concurrent use of tocilizumab with immunosuppressive or immunomodulating agents may result in an increased risk for serious infections.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The US manufacturer of tocilizumab recommends caution because the concurrent use of tocilizumab with immunosuppressive agents may increase the risk of infection. If concurrent therapy is warranted, consider the risk of additive immune suppression and monitor based on prescribing information for both agents.(1) DISCUSSION: Tocilizumab was studied as monotherapy and in combination with methotrexate, non-biologic DMARDs or corticosteroids, depending on the indication. Tocilizumab has not been studied with biological DMARDs and concurrent use should be avoided. If concurrent therapy is warranted, consider the potential for increased immunosuppressive risks from both agents.(1) The most common infections reported by tocilizumab treated patients in the clinical trial periods included pneumonia, urinary tract infection, cellulitis, herpes zoster, gastroenteritis, diverticulitis, sepsis and bacterial arthritis. Serious bacterial, mycobacterial, fungal, and viral infections were observed in patients receiving tocilizumab. Cases of tuberculosis, cryptococcus, aspergillosis, candidiasis, and pneumocystosis have been reported.(1) |
ACTEMRA, ACTEMRA ACTPEN, TOFIDENCE, TYENNE, TYENNE AUTOINJECTOR |
The following contraindication information is available for ADCETRIS (brentuximab vedotin):
Drug contraindication overview.
Concomitant use with bleomycin. (See Respiratory Effects under Warnings/Precautions: Other Warnings and Precautions, in Cautions.)
Concomitant use with bleomycin. (See Respiratory Effects under Warnings/Precautions: Other Warnings and Precautions, in Cautions.)
There are 4 contraindications.
Absolute contraindication.
| Contraindication List |
|---|
| Child-pugh class B hepatic impairment |
| Child-pugh class C hepatic impairment |
| Lactation |
| Progressive multifocal leukoencephalopathy |
There are 8 severe contraindications.
Adequate patient monitoring is recommended for safer drug use.
| Severe List |
|---|
| Child-pugh class A hepatic impairment |
| Chronic kidney disease stage 4 (severe) GFR 15-29 ml/min |
| Chronic kidney disease stage 5 (failure) GFr<15 ml/min |
| Disease of liver |
| Interstitial lung disease |
| Neutropenic disorder |
| Peripheral neuropathy |
| Pregnancy |
There are 5 moderate contraindications.
Clinically significant contraindication, where the condition can be managed or treated before the drug may be given safely.
| Moderate List |
|---|
| Anemia |
| Hyperglycemia |
| Infection |
| Kidney disease with likely reduction in glomerular filtration rate (GFr) |
| Thrombocytopenic disorder |
The following adverse reaction information is available for ADCETRIS (brentuximab vedotin):
Adverse reaction overview.
Adverse effects reported in 10% or more of patients with previously untreated stage III or IV cHL receiving brentuximab vedotin in combination with AVD in the ECHELON-1 study include anemia, neutropenia, peripheral sensory neuropathy, constipation, vomiting, fatigue, diarrhea, pyrexia, abdominal pain, decreased weight, stomatitis, febrile neutropenia, bone pain, insomnia, decreased appetite, back pain, rash, dyspnea, peripheral motor neuropathy, and elevated concentrations of alanine aminotransferase (ALT). Adverse effects reported in 10% or more of patients with cHL at high risk for relapse or progression following autologous stem cell transplantation receiving brentuximab vedotin consolidation therapy in the AETHERA study include neutropenia, peripheral sensory neuropathy, thrombocytopenia, anemia, upper respiratory tract infection, fatigue, peripheral motor neuropathy, nausea, cough, diarrhea, decreased weight, pyrexia, arthralgia, vomiting, abdominal pain, constipation, dyspnea, decreased appetite, pruritus, headache, muscle spasms, myalgia, and chills. Adverse effects reported in 10% or more of patients with relapsed cHL receiving brentuximab vedotin as a single agent include neutropenia, peripheral sensory neuropathy, fatigue, upper respiratory tract infection, nausea, diarrhea, anemia, pyrexia, thrombocytopenia, rash, abdominal pain, vomiting, arthralgia/myalgia, headache, pruritus, constipation, cough, peripheral motor neuropathy, back pain, insomnia, alopecia, chills, dyspnea, night sweats, anxiety, decreased appetite, dizziness, lymphadenopathy, oropharyngeal pain, and extremity pain.
Adverse effects reported in 10% or more of patients with previously untreated CD30-positive PTCL receiving brentuximab vedotin in combination with CHP in the ECHELON-2 study include anemia, neutropenia, peripheral neuropathy, lymphopenia, nausea, diarrhea, fatigue/asthenia, mucositis, constipation, alopecia, pyrexia, vomiting, febrile neutropenia, abdominal pain, decreased appetite, thrombocytopenia, rash, edema, dyspnea, headache, upper respiratory tract infection, cough, dizziness, hypokalemia, decreased weight, insomnia, and myalgia. Adverse effects reported in 10% or more of patients with relapsed sALCL receiving brentuximab vedotin as a single agent include neutropenia, peripheral sensory neuropathy, anemia, fatigue, nausea, pyrexia, rash, diarrhea, pain, constipation, dyspnea, pruritus, cough, vomiting, decreased appetite, dizziness, headache, insomnia, myalgia, peripheral edema, thrombocytopenia, alopecia, decreased weight, chills, upper respiratory tract infection, back pain, dry skin, extremity pain, lymphadenopathy, and muscle spasms. Adverse effects reported in 10% or more of patients with relapsed pcALCL or CD30-positive mycosis fungoides receiving brentuximab vedotin as a single agent in the ALCANZA study include anemia, peripheral sensory neuropathy, nausea, diarrhea, fatigue/asthenia, neutropenia, pruritus, pyrexia, vomiting, alopecia, decreased appetite, thrombocytopenia, arthralgia, myalgia, dyspnea, peripheral edema, and rash.
Adverse effects reported in 10% or more of patients with previously untreated stage III or IV cHL receiving brentuximab vedotin in combination with AVD in the ECHELON-1 study include anemia, neutropenia, peripheral sensory neuropathy, constipation, vomiting, fatigue, diarrhea, pyrexia, abdominal pain, decreased weight, stomatitis, febrile neutropenia, bone pain, insomnia, decreased appetite, back pain, rash, dyspnea, peripheral motor neuropathy, and elevated concentrations of alanine aminotransferase (ALT). Adverse effects reported in 10% or more of patients with cHL at high risk for relapse or progression following autologous stem cell transplantation receiving brentuximab vedotin consolidation therapy in the AETHERA study include neutropenia, peripheral sensory neuropathy, thrombocytopenia, anemia, upper respiratory tract infection, fatigue, peripheral motor neuropathy, nausea, cough, diarrhea, decreased weight, pyrexia, arthralgia, vomiting, abdominal pain, constipation, dyspnea, decreased appetite, pruritus, headache, muscle spasms, myalgia, and chills. Adverse effects reported in 10% or more of patients with relapsed cHL receiving brentuximab vedotin as a single agent include neutropenia, peripheral sensory neuropathy, fatigue, upper respiratory tract infection, nausea, diarrhea, anemia, pyrexia, thrombocytopenia, rash, abdominal pain, vomiting, arthralgia/myalgia, headache, pruritus, constipation, cough, peripheral motor neuropathy, back pain, insomnia, alopecia, chills, dyspnea, night sweats, anxiety, decreased appetite, dizziness, lymphadenopathy, oropharyngeal pain, and extremity pain.
Adverse effects reported in 10% or more of patients with previously untreated CD30-positive PTCL receiving brentuximab vedotin in combination with CHP in the ECHELON-2 study include anemia, neutropenia, peripheral neuropathy, lymphopenia, nausea, diarrhea, fatigue/asthenia, mucositis, constipation, alopecia, pyrexia, vomiting, febrile neutropenia, abdominal pain, decreased appetite, thrombocytopenia, rash, edema, dyspnea, headache, upper respiratory tract infection, cough, dizziness, hypokalemia, decreased weight, insomnia, and myalgia. Adverse effects reported in 10% or more of patients with relapsed sALCL receiving brentuximab vedotin as a single agent include neutropenia, peripheral sensory neuropathy, anemia, fatigue, nausea, pyrexia, rash, diarrhea, pain, constipation, dyspnea, pruritus, cough, vomiting, decreased appetite, dizziness, headache, insomnia, myalgia, peripheral edema, thrombocytopenia, alopecia, decreased weight, chills, upper respiratory tract infection, back pain, dry skin, extremity pain, lymphadenopathy, and muscle spasms. Adverse effects reported in 10% or more of patients with relapsed pcALCL or CD30-positive mycosis fungoides receiving brentuximab vedotin as a single agent in the ALCANZA study include anemia, peripheral sensory neuropathy, nausea, diarrhea, fatigue/asthenia, neutropenia, pruritus, pyrexia, vomiting, alopecia, decreased appetite, thrombocytopenia, arthralgia, myalgia, dyspnea, peripheral edema, and rash.
There are 34 severe adverse reactions.
| More Frequent | Less Frequent |
|---|---|
|
Anemia Neutropenic disorder Thrombocytopenic disorder |
Infection Interstitial pneumonitis Maculopapular rash Peripheral motor neuropathy Pneumonia Pyelonephritis |
| Rare/Very Rare |
|---|
|
Abnormal hepatic function tests Acute pancreatitis Acute respiratory distress syndrome Anaphylaxis DRESS syndrome Enterocolitis Gastrointestinal hemorrhage Gastrointestinal obstruction Gastrointestinal perforation Gastrointestinal ulcer Hepatitis Hepatocellular damage Hyperbilirubinemia Hyperglycemia Ileus Ketoacidosis Neutropenic colitis Pneumothorax Progressive multifocal leukoencephalopathy Pulmonary thromboembolism Septic shock Stevens-johnson syndrome Supraventricular arrhythmias Toxic epidermal necrolysis Tumor lysis syndrome |
There are 40 less severe adverse reactions.
| More Frequent | Less Frequent |
|---|---|
|
Acute abdominal pain Alopecia Arthralgia Back pain Chills Constipation Cough Diarrhea Dyspnea Fatigue Fever Insomnia Lymphopenia Muscle spasm Musculoskeletal pain Myalgia Nausea Pain Peripheral sensory neuropathy Pruritus of skin Skin rash Sore throat Upper respiratory infection Vomiting |
Anorexia Bone pain Dizziness Headache disorder Hypersensitivity drug reaction Hypokalemia Night sweats Pain in oropharynx Peripheral edema Stomatitis Symptoms of anxiety Urinary tract infection Weight loss |
| Rare/Very Rare |
|---|
|
Dehydration Hyponatremia Paresthesia |
The following precautions are available for ADCETRIS (brentuximab vedotin):
Safety and efficacy of brentuximab vedotin have not been established in pediatric patients.
Contraindicated
Severe Precaution
Management or Monitoring Precaution
Contraindicated
| None |
Severe Precaution
| None |
Management or Monitoring Precaution
| None |
Brentuximab vedotin may cause fetal harm if administered to pregnant women based on animal findings. (See Fetal/Neonatal Morbidity and Mortality under Warnings/Precautions: Other Warnings and Precautions, in Cautions.)
It is not known whether brentuximab vedotin is distributed into milk in humans; because of the potential for serious adverse reactions to brentuximab vedotin in nursing infants, women should be advised to discontinue nursing during brentuximab vedotin therapy. The effects of the drug on nursing infants or on the production of milk are unknown.
The ECHELON-1 study did not include sufficient numbers of patients 65 years of age and older to determine whether geriatric patients with previously untreated stage III or IV cHL receiving brentuximab vedotin in combination with AVD respond differently than younger adults; however, febrile neutropenia occurred more frequently in geriatric patients (39 versus 17%). In the ECHELON-2 study, 31% of patients with previously untreated CD30-positive PTCL receiving brentuximab vedotin in combination with CHP were 65 years of age or older. Grade 3 or greater adverse effects (74 versus 62%) and serious adverse effects (49 versus 33%) occurred more frequently in geriatric patients compared with younger adults.
In this study, geriatric patients were at greater risk for developing febrile neutropenia compared with younger adults (29 versus 14%). Clinical studies evaluating single-agent brentuximab vedotin for relapsed cHL, cHL following autologous stem cell transplantation, and relapsed systemic anaplastic large cell lymphoma (sALCL) did not include sufficient numbers of patients 65 years of age and older to determine whether geriatric patients respond differently than younger adults. In the ALCANZA study, 42% of patients with relapsed primary cutaneous ALCL (pcALCL) or CD30-positive mycosis fungoides receiving single-agent brentuximab vedotin were 65 years of age or older. No overall differences in safety and efficacy were observed between these geriatric patients and younger adults.
In this study, geriatric patients were at greater risk for developing febrile neutropenia compared with younger adults (29 versus 14%). Clinical studies evaluating single-agent brentuximab vedotin for relapsed cHL, cHL following autologous stem cell transplantation, and relapsed systemic anaplastic large cell lymphoma (sALCL) did not include sufficient numbers of patients 65 years of age and older to determine whether geriatric patients respond differently than younger adults. In the ALCANZA study, 42% of patients with relapsed primary cutaneous ALCL (pcALCL) or CD30-positive mycosis fungoides receiving single-agent brentuximab vedotin were 65 years of age or older. No overall differences in safety and efficacy were observed between these geriatric patients and younger adults.
The following prioritized warning is available for ADCETRIS (brentuximab vedotin):
WARNING: Rarely, a serious (sometimes fatal) brain infection (Progressive Multifocal Leukoencephalopathy-PML) has occurred in people receiving this medication. Get medical help right away if you develop any signs of PML, including changes in mood, unusual behavior, confusion, difficulty concentrating, changes in vision/speech/walking, decreased strength or weakness on one side of the body.
WARNING: Rarely, a serious (sometimes fatal) brain infection (Progressive Multifocal Leukoencephalopathy-PML) has occurred in people receiving this medication. Get medical help right away if you develop any signs of PML, including changes in mood, unusual behavior, confusion, difficulty concentrating, changes in vision/speech/walking, decreased strength or weakness on one side of the body.
The following icd codes are available for ADCETRIS (brentuximab vedotin)'s list of indications:
| Cd30-positive mycosis fungoides | |
| C84.0 | Mycosis fungoides |
| C84.00 | Mycosis fungoides, unspecified site |
| C84.01 | Mycosis fungoides, lymph nodes of head, face, and neck |
| C84.02 | Mycosis fungoides, intrathoracic lymph nodes |
| C84.03 | Mycosis fungoides, intra-abdominal lymph nodes |
| C84.04 | Mycosis fungoides, lymph nodes of axilla and upper limb |
| C84.05 | Mycosis fungoides, lymph nodes of inguinal region and lower limb |
| C84.06 | Mycosis fungoides, intrapelvic lymph nodes |
| C84.07 | Mycosis fungoides, spleen |
| C84.08 | Mycosis fungoides, lymph nodes of multiple sites |
| C84.09 | Mycosis fungoides, extranodal and solid organ sites |
| Hodgkin's lymphoma | |
| C81 | Hodgkin lymphoma |
| C81.0 | Nodular lymphocyte predominant hodgkin lymphoma |
| C81.00 | Nodular lymphocyte predominant hodgkin lymphoma, unspecified site |
| C81.01 | Nodular lymphocyte predominant hodgkin lymphoma, lymph nodes of head, face, and neck |
| C81.02 | Nodular lymphocyte predominant hodgkin lymphoma, intrathoracic lymph nodes |
| C81.03 | Nodular lymphocyte predominant hodgkin lymphoma, intra-abdominal lymph nodes |
| C81.04 | Nodular lymphocyte predominant hodgkin lymphoma, lymph nodes of axilla and upper limb |
| C81.05 | Nodular lymphocyte predominant hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
| C81.06 | Nodular lymphocyte predominant hodgkin lymphoma, intrapelvic lymph nodes |
| C81.07 | Nodular lymphocyte predominant hodgkin lymphoma, spleen |
| C81.08 | Nodular lymphocyte predominant hodgkin lymphoma, lymph nodes of multiple sites |
| C81.09 | Nodular lymphocyte predominant hodgkin lymphoma, extranodal and solid organ sites |
| C81.1 | Nodular sclerosis hodgkin lymphoma |
| C81.10 | Nodular sclerosis hodgkin lymphoma, unspecified site |
| C81.11 | Nodular sclerosis hodgkin lymphoma, lymph nodes of head, face, and neck |
| C81.12 | Nodular sclerosis hodgkin lymphoma, intrathoracic lymph nodes |
| C81.13 | Nodular sclerosis hodgkin lymphoma, intra-abdominal lymph nodes |
| C81.14 | Nodular sclerosis hodgkin lymphoma, lymph nodes of axilla and upper limb |
| C81.15 | Nodular sclerosis hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
| C81.16 | Nodular sclerosis hodgkin lymphoma, intrapelvic lymph nodes |
| C81.17 | Nodular sclerosis hodgkin lymphoma, spleen |
| C81.18 | Nodular sclerosis hodgkin lymphoma, lymph nodes of multiple sites |
| C81.19 | Nodular sclerosis hodgkin lymphoma, extranodal and solid organ sites |
| C81.2 | Mixed cellularity hodgkin lymphoma |
| C81.20 | Mixed cellularity hodgkin lymphoma, unspecified site |
| C81.21 | Mixed cellularity hodgkin lymphoma, lymph nodes of head, face, and neck |
| C81.22 | Mixed cellularity hodgkin lymphoma, intrathoracic lymph nodes |
| C81.23 | Mixed cellularity hodgkin lymphoma, intra-abdominal lymph nodes |
| C81.24 | Mixed cellularity hodgkin lymphoma, lymph nodes of axilla and upper limb |
| C81.25 | Mixed cellularity hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
| C81.26 | Mixed cellularity hodgkin lymphoma, intrapelvic lymph nodes |
| C81.27 | Mixed cellularity hodgkin lymphoma, spleen |
| C81.28 | Mixed cellularity hodgkin lymphoma, lymph nodes of multiple sites |
| C81.29 | Mixed cellularity hodgkin lymphoma, extranodal and solid organ sites |
| C81.3 | Lymphocyte depleted hodgkin lymphoma |
| C81.30 | Lymphocyte depleted hodgkin lymphoma, unspecified site |
| C81.31 | Lymphocyte depleted hodgkin lymphoma, lymph nodes of head, face, and neck |
| C81.32 | Lymphocyte depleted hodgkin lymphoma, intrathoracic lymph nodes |
| C81.33 | Lymphocyte depleted hodgkin lymphoma, intra-abdominal lymph nodes |
| C81.34 | Lymphocyte depleted hodgkin lymphoma, lymph nodes of axilla and upper limb |
| C81.35 | Lymphocyte depleted hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
| C81.36 | Lymphocyte depleted hodgkin lymphoma, intrapelvic lymph nodes |
| C81.37 | Lymphocyte depleted hodgkin lymphoma, spleen |
| C81.38 | Lymphocyte depleted hodgkin lymphoma, lymph nodes of multiple sites |
| C81.39 | Lymphocyte depleted hodgkin lymphoma, extranodal and solid organ sites |
| C81.4 | Lymphocyte-rich hodgkin lymphoma |
| C81.40 | Lymphocyte-rich hodgkin lymphoma, unspecified site |
| C81.41 | Lymphocyte-rich hodgkin lymphoma, lymph nodes of head, face, and neck |
| C81.42 | Lymphocyte-rich hodgkin lymphoma, intrathoracic lymph nodes |
| C81.43 | Lymphocyte-rich hodgkin lymphoma, intra-abdominal lymph nodes |
| C81.44 | Lymphocyte-rich hodgkin lymphoma, lymph nodes of axilla and upper limb |
| C81.45 | Lymphocyte-rich hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
| C81.46 | Lymphocyte-rich hodgkin lymphoma, intrapelvic lymph nodes |
| C81.47 | Lymphocyte-rich hodgkin lymphoma, spleen |
| C81.48 | Lymphocyte-rich hodgkin lymphoma, lymph nodes of multiple sites |
| C81.49 | Lymphocyte-rich hodgkin lymphoma, extranodal and solid organ sites |
| C81.7 | Other hodgkin lymphoma |
| C81.70 | Other hodgkin lymphoma, unspecified site |
| C81.71 | Other hodgkin lymphoma, lymph nodes of head, face, and neck |
| C81.72 | Other hodgkin lymphoma, intrathoracic lymph nodes |
| C81.73 | Other hodgkin lymphoma, intra-abdominal lymph nodes |
| C81.74 | Other hodgkin lymphoma, lymph nodes of axilla and upper limb |
| C81.75 | Other hodgkin lymphoma, lymph nodes of inguinal region and lower limb |
| C81.76 | Other hodgkin lymphoma, intrapelvic lymph nodes |
| C81.77 | Other hodgkin lymphoma, spleen |
| C81.78 | Other hodgkin lymphoma, lymph nodes of multiple sites |
| C81.79 | Other hodgkin lymphoma, extranodal and solid organ sites |
| C81.9 | Hodgkin lymphoma, unspecified |
| C81.90 | Hodgkin lymphoma, unspecified, unspecified site |
| C81.91 | Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck |
| C81.92 | Hodgkin lymphoma, unspecified, intrathoracic lymph nodes |
| C81.93 | Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes |
| C81.94 | Hodgkin lymphoma, unspecified, lymph nodes of axilla and upper limb |
| C81.95 | Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb |
| C81.96 | Hodgkin lymphoma, unspecified, intrapelvic lymph nodes |
| C81.97 | Hodgkin lymphoma, unspecified, spleen |
| C81.98 | Hodgkin lymphoma, unspecified, lymph nodes of multiple sites |
| C81.99 | Hodgkin lymphoma, unspecified, extranodal and solid organ sites |
| Peripheral t-cell lymphoma | |
| C84.4 | Peripheral t-cell lymphoma, not elsewhere classified |
| C84.40 | Peripheral t-cell lymphoma, not elsewhere classified, unspecified site |
| C84.41 | Peripheral t-cell lymphoma, not elsewhere classified, lymph nodes of head, face, and neck |
| C84.42 | Peripheral t-cell lymphoma, not elsewhere classified, intrathoracic lymph nodes |
| C84.43 | Peripheral t-cell lymphoma, not elsewhere classified, intra-abdominal lymph nodes |
| C84.44 | Peripheral t-cell lymphoma, not elsewhere classified, lymph nodes of axilla and upper limb |
| C84.45 | Peripheral t-cell lymphoma, not elsewhere classified, lymph nodes of inguinal region and lower limb |
| C84.46 | Peripheral t-cell lymphoma, not elsewhere classified, intrapelvic lymph nodes |
| C84.47 | Peripheral t-cell lymphoma, not elsewhere classified, spleen |
| C84.48 | Peripheral t-cell lymphoma, not elsewhere classified, lymph nodes of multiple sites |
| C84.49 | Peripheral t-cell lymphoma, not elsewhere classified, extranodal and solid organ sites |
| C84.6 | Anaplastic large cell lymphoma, ALk-positive |
| C84.60 | Anaplastic large cell lymphoma, ALk-positive, unspecified site |
| C84.61 | Anaplastic large cell lymphoma, ALk-positive, lymph nodes of head, face, and neck |
| C84.62 | Anaplastic large cell lymphoma, ALk-positive, intrathoracic lymph nodes |
| C84.63 | Anaplastic large cell lymphoma, ALk-positive, intra-abdominal lymph nodes |
| C84.64 | Anaplastic large cell lymphoma, ALk-positive, lymph nodes of axilla and upper limb |
| C84.65 | Anaplastic large cell lymphoma, ALk-positive, lymph nodes of inguinal region and lower limb |
| C84.66 | Anaplastic large cell lymphoma, ALk-positive, intrapelvic lymph nodes |
| C84.67 | Anaplastic large cell lymphoma, ALk-positive, spleen |
| C84.68 | Anaplastic large cell lymphoma, ALk-positive, lymph nodes of multiple sites |
| C84.69 | Anaplastic large cell lymphoma, ALk-positive, extranodal and solid organ sites |
| C84.7 | Anaplastic large cell lymphoma, ALk-negative |
| C84.70 | Anaplastic large cell lymphoma, ALk-negative, unspecified site |
| C84.71 | Anaplastic large cell lymphoma, ALk-negative, lymph nodes of head, face, and neck |
| C84.72 | Anaplastic large cell lymphoma, ALk-negative, intrathoracic lymph nodes |
| C84.73 | Anaplastic large cell lymphoma, ALk-negative, intra-abdominal lymph nodes |
| C84.74 | Anaplastic large cell lymphoma, ALk-negative, lymph nodes of axilla and upper limb |
| C84.75 | Anaplastic large cell lymphoma, ALk-negative, lymph nodes of inguinal region and lower limb |
| C84.76 | Anaplastic large cell lymphoma, ALk-negative, intrapelvic lymph nodes |
| C84.77 | Anaplastic large cell lymphoma, ALk-negative, spleen |
| C84.78 | Anaplastic large cell lymphoma, ALk-negative, lymph nodes of multiple sites |
| C84.79 | Anaplastic large cell lymphoma, ALk-negative, extranodal and solid organ sites |
| C84.7A | Anaplastic large cell lymphoma, ALk-negative, breast |
| C84.9 | Mature t/Nk-cell lymphomas, unspecified |
| C84.90 | Mature t/Nk-cell lymphomas, unspecified, unspecified site |
| C84.91 | Mature t/Nk-cell lymphomas, unspecified, lymph nodes of head, face, and neck |
| C84.92 | Mature t/Nk-cell lymphomas, unspecified, intrathoracic lymph nodes |
| C84.93 | Mature t/Nk-cell lymphomas, unspecified, intra-abdominal lymph nodes |
| C84.94 | Mature t/Nk-cell lymphomas, unspecified, lymph nodes of axilla and upper limb |
| C84.95 | Mature t/Nk-cell lymphomas, unspecified, lymph nodes of inguinal region and lower limb |
| C84.96 | Mature t/Nk-cell lymphomas, unspecified, intrapelvic lymph nodes |
| C84.97 | Mature t/Nk-cell lymphomas, unspecified, spleen |
| C84.98 | Mature t/Nk-cell lymphomas, unspecified, lymph nodes of multiple sites |
| C84.99 | Mature t/Nk-cell lymphomas, unspecified, extranodal and solid organ sites |
| C86.00 | Extranodal Nk/t-cell lymphoma, nasal type not having achieved remission |
| C86.2 | Enteropathy-type (intestinal) t-cell lymphoma |
| C86.5 | Angioimmunoblastic t-cell lymphoma |
| C91.5 | Adult t-cell lymphoma/leukemia (HTLv-1-associated) |
| C91.50 | Adult t-cell lymphoma/leukemia (HTLv-1-associated) not having achieved remission |
| C91.51 | Adult t-cell lymphoma/leukemia (HTLv-1-associated), in remission |
| C91.52 | Adult t-cell lymphoma/leukemia (HTLv-1-associated), in relapse |
| Primary cutaneous anaplastic large cell lymphoma | |
| C86.6 | Primary cutaneous Cd30-positive t-cell proliferations |
| C86.60 | Primary cutaneous Cd30-positive t-cell proliferations not having achieved remission |
| Systemic anaplastic large cell lymphoma | |
| C84.6 | Anaplastic large cell lymphoma, ALk-positive |
| C84.60 | Anaplastic large cell lymphoma, ALk-positive, unspecified site |
| C84.61 | Anaplastic large cell lymphoma, ALk-positive, lymph nodes of head, face, and neck |
| C84.62 | Anaplastic large cell lymphoma, ALk-positive, intrathoracic lymph nodes |
| C84.63 | Anaplastic large cell lymphoma, ALk-positive, intra-abdominal lymph nodes |
| C84.64 | Anaplastic large cell lymphoma, ALk-positive, lymph nodes of axilla and upper limb |
| C84.65 | Anaplastic large cell lymphoma, ALk-positive, lymph nodes of inguinal region and lower limb |
| C84.66 | Anaplastic large cell lymphoma, ALk-positive, intrapelvic lymph nodes |
| C84.67 | Anaplastic large cell lymphoma, ALk-positive, spleen |
| C84.68 | Anaplastic large cell lymphoma, ALk-positive, lymph nodes of multiple sites |
| C84.69 | Anaplastic large cell lymphoma, ALk-positive, extranodal and solid organ sites |
| C84.7 | Anaplastic large cell lymphoma, ALk-negative |
| C84.70 | Anaplastic large cell lymphoma, ALk-negative, unspecified site |
| C84.71 | Anaplastic large cell lymphoma, ALk-negative, lymph nodes of head, face, and neck |
| C84.72 | Anaplastic large cell lymphoma, ALk-negative, intrathoracic lymph nodes |
| C84.73 | Anaplastic large cell lymphoma, ALk-negative, intra-abdominal lymph nodes |
| C84.74 | Anaplastic large cell lymphoma, ALk-negative, lymph nodes of axilla and upper limb |
| C84.75 | Anaplastic large cell lymphoma, ALk-negative, lymph nodes of inguinal region and lower limb |
| C84.76 | Anaplastic large cell lymphoma, ALk-negative, intrapelvic lymph nodes |
| C84.77 | Anaplastic large cell lymphoma, ALk-negative, spleen |
| C84.78 | Anaplastic large cell lymphoma, ALk-negative, lymph nodes of multiple sites |
| C84.79 | Anaplastic large cell lymphoma, ALk-negative, extranodal and solid organ sites |
| C84.7A | Anaplastic large cell lymphoma, ALk-negative, breast |
Formulary Reference Tool