Side Effects of Novantrone (mitoxantrone)

Novantrone (mitoxantrone) is a synthetic (man-made) anticancer drug used to treat secondary progressive multiple sclerosis (MS), acute nonlymphocytic leukemia, and pain related to advanced hormone-refractory prostate cancer. 

It kills cancer cells by disrupting the action of deoxyribonucleic acids (DNA) in human cells by causing abnormal cross-links and breaks in the DNA. It also interferes with ribonucleic acid (RNA) and inhibits the activity of topoisomerase II, an enzyme necessary for repairing damaged DNA.

Common side effects of Novantrone include

• nausea,
• upper respiratory tract infections,
• hair loss,
• diarrhea,
• interruption of menstruation,
• constipation, and
• inflammation of the mouth.

Serious side effects of Novantrone include

• heart failure,
• suppression of the immune system, and
• liver toxicity.

Drug interactions of Novantrone include other drugs that, like Novantrone, suppress the immune system, because it leads to severe immune suppression and an increased risk of infections. 

Novantrone should not be administered to pregnant women due to risk of severe harm to the fetus. Novantrone is excreted in breast milk and should not be used while breastfeeding.

The most common side effects of mitoxantrone are:

• nausea,
• upper respiratory tract infections,
• hair loss (alopecia),
• diarrhea,
• interruption of menstruation,
• constipation,
• inflammation of the mouth (stomatitis).

Other important side effects include

• heart failure,
• suppression of the immune system, and
• liver toxicity.

Multiple Sclerosis

Novantrone has been administered to 149 patients with multiple sclerosis in two randomized clinical trials, including 21 patients who received Novantrone in combination with corticosteroids.

In Study 1, the proportion of patients who discontinued treatment due to an adverse event was 9.7% (n = 6) in the 12 mg/m² Novantrone arm (leukopenia, depression, decreased LV function, bone pain and emesis, renal failure, and one discontinuation to prevent future complications from repeated urinary tract infections) compared to 3.1% (n = 2) in the placebo arm (hepatitis and myocardial infarction).

The following clinical adverse experiences were significantly more frequent in the Novantrone groups:

• nausea,
• alopecia,
• urinary tract infection, and
• menstrual disorders, including amenorrhea.

Table 4a summarizes clinical adverse events of all intensities occurring in ≥ 5% of patients in either dose group of Novantrone and that were numerically greater on drug than on placebo in Study 1.

The majority of these events were of mild to moderate intensity, and nausea was the only adverse event that occurred with severe intensity in more than one patient (three patients [5%] in the 12 mg/m² group). Of note, alopecia consisted of mild hair thinning.

Two of the 127 patients treated with Novantrone in Study 1 had decreased LVEF to below 50% at some point during the 2 years of treatment. An additional patient receiving 12 mg/m² did not have LVEF measured, but had another echocardiographic measure of ventricular function (fractional shortening) that led to discontinuation from the study.

Table 4a : Adverse Events of Any Intensity Occurring in ≥ 5% of Patients on Any Dose of Novantrone and That Were Numerically Greater Than in the Placebo Group Study 1

The proportion of patients experiencing any infection during Study 1 was 67% for the placebo group, 85% for the 5 mg/m² group, and 81% for the 12 mg/m² group. However, few of these infections required hospitalization:

• one placebo patient (tonsillitis),
• three 5 mg/m² patients (enteritis, urinary tract infection, viral infection), and
• four 12 mg/m² patients (tonsillitis, urinary tract infection [two], endometritis).

Table 4b summarizes laboratory abnormalities that occurred in ≥ 5% of patients in either Novantrone dose group, and that were numerically more frequent than in the placebo group.

Table 4b : Laboratory Abnormalities Occurring in ≥ 5% of Patients* on Either Dose of Novantrone and That Were More Frequent Than in the Placebo Group Study 1

There was no difference among treatment groups in the incidence or severity of hemorrhagic events.

In Study 2, Novantrone was administered once a month. Clinical adverse events most frequently reported in the Novantrone group included

• amenorrhea (53% of female patients),
• alopecia (33% of patients),
• nausea (29% of patients), and
• asthenia (24% of patients).

Tables 5a and 5b respectively summarize adverse events and laboratory abnormalities occurring in > 5% of patients in the Novantrone group and numerically more frequent than in the control group.

Table 5a : Adverse Events of Any Intensity Occurring in > 5% of Patients* in the Novantrone Group and Numerically More Frequent Than in the Control Group Study 2

Table 5b : Laboratory Abnormalities Occurring in > 5% of Patients* in the Novantrone Group and Numerically More Frequent Than in the Control Group Study 2

Leukopenia and neutropenia were reported in the N +MP group (see Table 5b).

Neutropenia occurred within 3 weeks after Novantrone administration and was always reversible. Only mild to moderate intensity infections were reported in 9 of 21 patients in the N +MP group and in 3 of 21 patients in the MP group; none of these required hospitalization.

There was no difference among treatment groups in the incidence or severity of hemorrhagic events. There were no withdrawals from Study 2 for safety reasons.

Leukemia

• Novantrone has been studied in approximately 600 patients with acute nonlymphocytic leukemia (ANLL).
• Table 6 represents the adverse reaction experience in the large U.S. comparative study of mitoxantrone + cytarabine vs daunorubicin + cytarabine.
• Experience in the large international study was similar.
• A much wider experience in a variety of other tumor types revealed no additional important reactions other than cardiomyopathy.
• It should be appreciated that the listed adverse reaction categories include overlapping clinical symptoms related to the same condition, e.g., dyspnea, cough and pneumonia.
• In addition, the listed adverse reactions cannot all necessarily be attributed to chemotherapy as it is often impossible to distinguish effects of the drug and effects of the underlying disease.
• It is clear, however, that the combination of Novantrone + cytarabine was responsible for nausea and vomiting, alopecia, mucositis/stomatitis, and myelosuppression.
• Table 6 summarizes adverse reactions occurring in patients treated with Novantrone + cytarabine in comparison with those who received daunorubicin + cytarabine for therapy of ANLL in a large multicenter randomized prospective U.S. trial.
• Adverse reactions are presented as major categories and selected examples of clinically significant subcategories.

Table 6 : Adverse Events Occurring in ANLL Patients Receiving Novantrone or Daunorubicin

Hormone-Refractory Prostate Cancer

Detailed safety information is available for a total of 353 patients with hormone-refractory prostate cancer treated with Novantrone, including 274 patients who received Novantrone in combination with corticosteroids.

Table 7 summarizes adverse reactions of all grades occurring in ≥ 5% of patients in Trial CCI-NOV22.

Table 7 : Adverse Events of Any Intensity Occurring in ≥ 5% of Patients Trial CCI-NOV22

No nonhematologic adverse events of Grade 3/4 were seen in > 5% of patients.

Table 8 summarizes adverse events of all grades occurring in ≥ 5% of patients in Trial CALGB 9182.

Table 8 : Adverse Events of Any Intensity Occurring in ≥ 5 % of Patients Trial CALGB 9182

General

Allergic Reaction

Hypotension, urticaria, dyspnea, and rashes have been reported occasionally. Anaphylaxis/anaphylactoid reactions have been reported rarely.

Cutaneous

Extravasation at the infusion site has been reported, which may result in erythema, swelling, pain, burning, and/or blue discoloration of the skin. Extravasation can result in tissue necrosis with resultant need for debridement and skin grafting. Phlebitis has also been reported at the site of the infusion.

Hematologic

Topoisomerase II inhibitors, including Novantrone, in combination with other antineoplastic agents or alone, have been associated with the development of acute leukemia.

Leukemia

Myelosuppression is rapid in onset and is consistent with the requirement to produce significant marrow hypoplasia in order to achieve a response in acute leukemia. The incidences of infection and bleeding seen in the U.S. trial are consistent with those reported for other standard induction regimens.

Hormone-Refractory Prostate Cancer

In a randomized study where dose escalation was required for neutrophil counts greater than 1000/mm³, Grade 4 neutropenia (ANC < 500 /mm³) was observed in 54% of patients treated with Novantrone + low-dose prednisone.

In a separate randomized trial where patients were treated with 14 mg/m², Grade 4 neutropenia in 23% of patients treated with Novantrone + hydrocortisone was observed.

Neutropenic fever/infection occurred in 11% and 10% of patients receiving Novantrone + corticosteroids, respectively, on the two trials.

Platelets < 50,000/mm³ were noted in 4% and 3% of patients receiving Novantrone + corticosteroids on these trials, and there was one patient death on Novantrone + hydrocortisone due to intracranial hemorrhage after a fall.

Gastrointestinal

Nausea and vomiting occurred acutely in most patients and may have contributed to reports of dehydration, but were generally mild to moderate and could be controlled through the use of antiemetics. Stomatitis/mucositis occurred within 1 week of therapy.

Cardiovascular

Congestive heart failure, tachycardia, EKG changes including arrhythmias, chest pain, and asymptomatic decreases in left ventricular ejection fraction have occurred.

Pulmonary

Interstitial pneumonitis has been reported in cancer patients receiving combination chemotherapy that included Novantrone.

Mitoxantrone and its metabolites are excreted in bile and urine, but it is not known whether the metabolic or excretory pathways are saturable, may be inhibited or induced, or if mitoxantrone and its metabolites undergo enterohepatic circulation.

To date, post-marketing experience has not revealed any significant drug interactions in patients who have received Novantrone for treatment of cancer. Information on drug interactions in patients with multiple sclerosis is limited.

Following concurrent administration of Novantrone with corticosteroids, no evidence of drug interactions has been observed.