ARRANON (nelarabine) is a pro-drug of the cytotoxic deoxyguanosine analogue, 9-β- D-arabinofuranosylguanine (ara-G). The chemical name for nelarabine is 2-amino-9-β-D arabinofuranosyl-6-methoxy-9H- purine. It has the molecular formula C11H15N5O5 and a molecular weight of 297.27. Nelarabine has the following structural formula:
Nelarabine is slightly soluble to soluble in water and melts with decomposition between 209° and 217° C. ARRANON Injection is supplied as a clear, colorless, sterile solution in glass vials. Each vial contains 250 mg of nelarabine (5 mg nelarabine per mL) and the inactive ingredient sodium chloride (4.5 mg per mL) in 50 mL Water for Injection, USP. ARRANON is intended for intravenous infusion. Hydrochloric acid and sodium hydroxide may have been used to adjust the pH. The solution pH ranges from 5.0 to 7.0.

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The following serious adverse reactions are discussed in greater detail in other sections of the label:

• Neurologic [see BOXED WARNING and WARNINGS AND PRECAUTIONS]
• Hematologic [see WARNINGS AND PRECAUTIONS]
• Hyperuricemia [see WARNINGS AND PRECAUTIONS]

Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. ARRANON was studied in 459 patients in Phase I and Phase II clinical trials. Adults The safety profile of ARRANON is based on data from 103 adult patients treated with the recommended dose and schedule in 2 studies: an adult T-cell acute lymphoblastic leukemia (T-ALL)/T-cell lymphoblastic lymphoma (T-LBL) study and an adult chronic lymphocytic leukemia study. The most common adverse reactions in adults, regardless of causality, were fatigue; gastrointestinal (GI) disorders (nausea, diarrhea, vomiting, and constipation); hematologic disorders (anemia, neutropenia, and thrombocytopenia); respiratory disorders (cough and dyspnea); nervous system disorders (somnolence and dizziness); and pyrexia. The most common adverse reactions in adults, by System Organ Class, regardless of causality, including severe or life threatening adverse reactions (NCI Common Toxicity Criteria grade 3 or grade 4) and fatal adverse reactions (grade 5) are shown in Table 1. Table 1: Most Commonly Reported ( > 5% Overall) Adverse Reactions Regardless of Causality in Adult Patients Treated with 1,500 mg/m² of ARRANON Administered Intravenously Over 2 Hours on Days 1, 3, and 5 Repeated Every 21 Days
System Organ Class
Preferred Term Percentage of Patients (N = 103) Toxicity Grade Grade 3
% Grade 4 and 5a
% All Grades
% Blood and Lymphatic System Disorders   Anemia 20 14 99   Thrombocytopenia 37 22 86   Neutropenia 14 49 81   Febrile neutropenia 9 1 12 Cardiac Disorders   Sinus tachycardia 1 0 8 Gastrointestinal Disorders   Nausea 0 0 41   Diarrhea 1 0 22   Vomiting 1 0 22   Constipation 1 0 21   Abdominal pain 1 0 9   Stomatitis 1 0 8   Abdominal distension 0 0 6 General Disorders and Administration Site Conditions   Fatigue 10 2 50   Pyrexia 5 0 23   Asthenia 0 1 17   Edema, peripheral 0 0 15   Edema 0 0 11   Pain 3 0 11   Rigors 0 0 8   Gait, abnormal 0 0 6   Chest pain 0 0 5   Non-cardiac chest pain 0 1 5 Infections   Infection 2 1 9   Pneumonia 4 1 8   Sinusitis 1 0 7 Hepatobiliary Disorders   AST increased 1 1 6 Metabolism and Nutrition Disorders   Anorexia 0 0 9   Dehydration 3 1 7   Hyperglycemia 1 0 6 Musculoskeletal and Connective Tissue Disorders   Myalgia 1 0 13   Arthralgia 1 0 9   Back pain 0 0 8   Muscular weakness 5 0 8   Pain in extremity 1 0 7 Nervous System Disorders (see Table 2) Psychiatric Disorders   Confusional state 2 0 8   Insomnia 0 0 7   Depression 1 0 6 Respiratory, Thoracic, and Mediastinal Disorders   Cough 0 0 25   Dyspnea 4 2 20   Pleural effusion 5 1 10   Epistaxis 0 0 8   Dyspnea, exertional 0 0 7   Wheezing 0 0 5 Vascular Disorders   Petechiae 2 0 12   Hypotension 1 1 8 a Five patients had a fatal adverse reaction. Fatal adverse reactions included hypotension (n = 1), respiratory arrest (n = 1), pleural effusion/pneumothorax (n = 1), pneumonia (n = 1), and cerebral hemorrhage/coma/leukoencephalopathy (n = 1). Other Adverse Events: Blurred vision was also reported in 4% of adult patients. There was a single report of biopsy confirmed progressive multifocal leukoencephalopathy in the adult patient population. Neurologic Adverse Reactions: Nervous system adverse reactions, regardless of drug relationship, were reported for 76% of adult patients across the Phase I and Phase II studies. The most common neurologic adverse reactions ( > 2%) in adult patients, regardless of causality, including all grades (NCI Common Toxicity Criteria) are shown in Table 2. Table 2: Neurologic Adverse Reactions ( > 2%) Regardless of Causality in Adult Patients Treated with 1,500 mg/m² of ARRANON Administered Intravenously Over 2 Hours on Days 1, 3, and 5 Repeated Every 21 Days
Nervous System Disorders
Preferred Term Percentage of Patients (N =103) Grade 1
% Grade 2
% Grade 3
% Grade 4
% All Grades
% Somnolence 20 3 0 0 23 Dizziness 14 8 0 0 21 Peripheral neurologic disorders, any adverse reaction 8 12 2 0 21   Neuropathy 0 4 0 0 4   Peripheral neuropathy 2 2 1 0 5   Peripheral motor neuropathy 3 3 1 0 7   Peripheral sensory neuropathy 7 6 0 0 13 Hypoesthesia 5 10 2 0 17 Headache 11 3 1 0 15 Paresthesia 11 4 0 0 15 Ataxia 1 6 2 0 9 Depressed level of consciousness 4 1 0 1 6 Tremor 2 3 0 0 5 Amnesia 2 1 0 0 3 Dysgeusia 2 1 0 0 3 Balance disorder 1 1 0 0 2 Sensory loss 0 2 0 0 2 One patient had a fatal neurologic adverse reaction, cerebral hemorrhage/coma/leukoencephalopathy. Most nervous system adverse reactions in the adult patients were evaluated as grade 1 or 2. The additional grade 3 adverse reactions in adult patients, regardless of causality, were aphasia, convulsion, hemiparesis, and loss of consciousness, each reported in 1 patient (1%). The additional grade 4 adverse reactions, regardless of causality, were cerebral hemorrhage, coma, intracranial hemorrhage, leukoencephalopathy, and metabolic encephalopathy, each reported in one patient (1%). The other neurologic adverse reactions, regardless of causality, reported as grade 1, 2, or unknown in adult patients were abnormal coordination, burning sensation, disturbance in attention, dysarthria, hyporeflexia, neuropathic pain, nystagmus, peroneal nerve palsy, sciatica, sensory disturbance, sinus headache, and speech disorder, each reported in one patient (1%). Pediatrics The safety profile for children is based on data from 84 pediatric patients treated with the recommended dose and schedule in a T-cell acute lymphoblastic leukemia (T- ALL)/T-cell lymphoblastic lymphoma (T-LBL) treatment study. The most common adverse reactions in pediatric patients, regardless of causality, were hematologic disorders (anemia, leukopenia, neutropenia, and thrombocytopenia). Of the non- hematologic adverse reactions in pediatric patients, the most frequent adverse reactions reported were headache, increased transaminase levels, decreased blood potassium, decreased blood albumin, increased blood bilirubin, and vomiting. The most common adverse reactions in pediatric patients, by System Organ Class, regardless of causality, including severe or life threatening adverse reactions (NCI Common Toxicity Criteria grade 3 or grade 4) and fatal adverse reactions (grade 5) are shown in Table 3. Table 3: Most Commonly Reported ( > 5% Overall) Adverse Reactions Regardless of Causality in Pediatric Patients Treated with 650 mg/m² of ARRANON Administered Intravenously Over 1 Hour Daily for 5 Consecutive Days Repeated Every 21 Days
System Organ Class
Preferred Term Percentage of Patients (N = 84) Toxicity Grade Grade 3
% Grade 4 and 5a
% All Grades
% Blood and Lymphatic System Disorders   Anemia 45 10 95   Neutropenia 17 62 94   Thrombocytopenia 27 32 88   Leukopenia 14 7 38 Hepatobiliary Disorders   Transaminases increased 4 0 12   Blood albumin decreased 5 1 10   Blood bilirubin increased 7 2 10 Metabolic/Laboratory   Blood potassium decreased 4 2 11   Blood calcium decreased 1 1 8   Blood creatinine increased 0 0 6   Blood glucose decreased 4 0 6   Blood magnesium decreased 2 0 6 Nervous System Disorders (see Table 4) Gastrointestinal Disorders   Vomiting 0 0 10 General Disorders & Administration Site Conditions   Asthenia 1 0 6 Infections & Infestations   Infection 2 1 5 a Three patients had a fatal adverse reaction. Fatal adverse reactions included neutropenia and pyrexia (n = 1), status epilepticus/seizure (n = 1), and fungal pneumonia (n = 1). Neurologic Adverse Reactions: Nervous system adverse reactions, regardless of drug relationship, were reported for 42% of pediatric patients across the Phase I and Phase II studies. The most common neurologic adverse reactions ( > 2%) in pediatric patients, regardless of causality, including all grades (NCI Common Toxicity Criteria) are shown in Table 4. Table 4: Neurologic Adverse Reactions ( > 2%) Regardless of Causality in Pediatric Patients Treated with 650 mg/m² of ARRANON Administered Intravenously Over 1 Hour Daily for 5 Consecutive Days Repeated Every 21 Days
Nervous System Disorders
Preferred Term Percentage of Patients
(N = 84) Grade 1
% Grade 2
% Grade 3
% Grade 4 and 5a
% All Grades
% Headache 8 2 4 2 17 Peripheral neurologic disorders, any adverse reaction 1 4 7 0 12   Peripheral neuropathy 0 4 2 0 6   Peripheral motor neuropathy 1 0 2 0 4   Peripheral sensory neuropathy 0 0 6 0 6 Somnolence 1 4 1 1 7 Hypoesthesia 1 1 4 0 6 Seizures 0 0 0 6 6   Convulsions 0 0 0 3 4   Grand mal convulsions 0 0 0 1 1   Status epilepticus 0 0 0 1 1 Motor dysfunction 1 1 1 0 4 Nervous system disorder 1 2 0 0 4 Paresthesia 0 2 1 0 4 Tremor 1 2 0 0 4 Ataxia 1 0 1 0 2 a One (1) patient had a fatal neurologic adverse reaction, status epilepticus. The other grade 3 neurologic adverse reaction in pediatric patients, regardless of causality, was hypertonia reported in 1 patient (1%). The additional grade 4 neurologic adverse reactions, regardless of causality, were 3rd nerve paralysis, and 6th nerve paralysis, each reported in 1 patient (1%). The other neurologic adverse reactions, regardless of causality, reported as grade 1, 2, or unknown in pediatric patients were dysarthria, encephalopathy, hydrocephalus, hyporeflexia, lethargy, mental impairment, paralysis, and sensory loss, each reported in 1 patient (1%). Postmarketing Experience The following adverse reactions have been identified during post-approval use of ARRANON. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Infections and Infestations: Fatal opportunistic infections. Metabolism and Nutrition Disorders: Tumor lysis syndrome. Nervous System Disorders: Demyelination and ascending peripheral neuropathies similar in appearance to Guillain-Barre syndrome. Musculoskeletal and Connective Disorders: Rhabdomyolysis, blood creatine phosphokinase increased. Read the Arranon (nelarabine) Side Effects Center for a complete guide to possible side effectsLearn More »

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Recommended Dosage This product is for intravenous use only. The recommended duration of treatment for adult and pediatric patients has not been clearly established. In clinical trials, treatment was generally continued until there was evidence of disease progression, the patient experienced unacceptable toxicity, the patient became a candidate for bone marrow transplant, or the patient no longer continued to benefit from treatment. Adult Dosage The recommended adult dose of ARRANON is 1,500 mg/m² administered intravenously over 2 hours on days 1, 3, and 5 repeated every 21 days. ARRANON is administered undiluted. Pediatric Dosage The recommended pediatric dose of ARRANON is 650 mg/m² administered intravenously over 1 hour daily for 5 consecutive days repeated every 21 days. ARRANON is administered undiluted. Dosage Modification ARRANON administration should be discontinued for neurologic adverse reactions of NCI Common Toxicity Criteria grade 2 or greater. Dosage may be delayed for other toxicity including hematologic toxicity. [See BOXED WARNING and WARNINGS AND PRECAUTIONS] Adjustment of Dose in Special Populations ARRANON has not been studied in patients with renal or hepatic dysfunction [see Use inSpecific Populations]. No dose adjustment is recommended for patients with a creatinine clearance (CLcr) > 50 mL/min [see CLINICAL PHARMACOLOGY]. There are insufficient data to support a dose recommendation for patients with a CLcr < 50 mL/min. Prevention of Hyperuricemia Appropriate measures (e.g., hydration, urine alkalinization, and prophylaxis with allopurinol) must be taken to prevent hyperuricemia [see WARNINGS AND PRECAUTIONS]. Instructions for Handling, Preparation, and Administration Handling ARRANON is a cytotoxic agent. Caution should be used during handling and preparation. Use of gloves and other protective clothing to prevent skin contact is recommended. Proper aseptic technique should be used. Guidelines for proper handling and disposal of anticancer drugs have been published.1-4 Preparation and Administration Do not dilute ARRANON prior to administration.The appropriate dose of ARRANON is transferred into polyvinylchloride (PVC) infusion bags or glass containers and administered as a two-hour infusion in adult patients and as a one-hour infusion in pediatric patients. Prior to administration, inspect the drug product visually for particulate matter and discoloration. Stability: ARRANON Injection is stable in polyvinylchloride (PVC) infusion bags and glass containers for up to 8 hours at up to 30° C.

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Administration of nelarabine in combination with adenosine deaminase inhibitors, such as pentostatin, is not recommended [see CLINICAL PHARMACOLOGY]. Read the Arranon Drug Interactions Center for a complete guide to possible interactions Learn More »

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ARRANON® is indicated for the treatment of patients with T-cell acute lymphoblastic leukemia and T-cell lymphoblastic lymphoma whose disease has not responded to or has relapsed following treatment with at least two chemotherapy regimens. This use is based on the induction of complete responses. Randomized trials demonstrating increased survival or other clinical benefit have not been conducted.

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None. Last reviewed on RxList: 2/15/2012
This monograph has been modified to include the generic and brand name in many instances.

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There is no known antidote for overdoses of ARRANON. It is anticipated that overdosage would result in severe neurotoxicity (possibly including paralysis, coma), myelosuppression, and potentially death. In the event of overdose, supportive care consistent with good clinical practice should be provided. Nelarabine has been administered in clinical trials up to a dose of 2,900 mg/m² on days 1, 3, and 5 to 2 adult patients. At a dose of 2,200 mg/m² given on days 1, 3, and 5 every 21 days, 2 patients developed a significant grade 3 ascending sensory neuropathy. MRI evaluations of the 2 patients demonstrated findings consistent with a demyelinating process in the cervical spine.

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Dosage Forms And Strengths 250 mg/50 mL (5 mg/mL) vial Storage And Handling ARRANON Injection is supplied as a clear, colorless, sterile solution in Type I, clear glass vials with a gray butyl rubber (latex-free) stopper and a red snap-off aluminum seal. Each vial contains 250 mg of nelarabine (5 mg nelarabine per mL) and the inactive ingredient sodium chloride (4.5 mg per mL) in 50 mL Water for Injection, USP. Vials are available in the following carton size: NDC 0007-4401-06 (package of 6) Store at 25° C (77° F); excursions permitted to 15° to 30° C (59° to 86° F) [see USP Controlled Room Temperature]. REFERENCES 1. Preventing Occupational Exposures to Antineoplastic and Other Hazardous Drugs in Health Care Settings. NIOSH Alert 2004-165. 2. OSHA Technical Manual, TED 1-0.15A, Section VI: Chapter 2. Controlling Occupational Exposure to Hazardous Drugs. OSHA, 1999. http://www.osha.gov/dts/osta/otm/otm vi/otm vi 2.html 3. American Society of Health-System Pharmacists. ASHP Guidelines on Handling Hazardous Drugs. Am JHealth-Syst Pharm. 2006;63:1172-1193. 4. Polovich M, White JM, Kelleher LO (eds.) 2005. Chemotherapy and Biotherapy Guidelines and Recommendations for Practice. (2nded) Pittsburgh, PA: Oncology Nursing Society. GlaxoSmithKline, Research Triangle Park, NC 27709. December 2011 Last reviewed on RxList: 2/15/2012
This monograph has been modified to include the generic and brand name in many instances.

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Neurologic Adverse Reactions Neurotoxicity is the dose-limiting toxicity of nelarabine. Patients undergoing therapy with ARRANON should be closely observed for signs and symptoms of neurologic toxicity [see BOXED WARNING and DOSAGE AND ADMINISTRATION]. Common signs and symptoms of nelarabine-related neurotoxicity include somnolence, confusion, convulsions, ataxia, paresthesias, and hypoesthesia. Severe neurologic toxicity can manifest as coma, status epilepticus, craniospinal demyelination, or ascending neuropathy similar in presentation to Guillain-Barre syndrome. Patients treated previously or concurrently with intrathecal chemotherapy or previously with craniospinal irradiation may be at increased risk for neurologic adverse events. Hematologic Adverse Reactions Leukopenia, thrombocytopenia, anemia, and neutropenia, including febrile neutropenia have been associated with nelarabine therapy. Complete blood counts including platelets should be monitored regularly [see DOSAGE AND ADMINISTRATION and ADVERSE REACTIONS]. Pregnancy Pregnancy Category D ARRANON can cause fetal harm when administered to a pregnant woman. Nelarabine administered during the period of organogenesis caused increased incidences of fetal malformations, anomalies, and variations in rabbits (see Use In Specific Populations]. There are no adequate and well-controlled studies of ARRANON in pregnant women. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus. Women of child-bearing potential should be advised to avoid becoming pregnant while receiving treatment with ARRANON. Hyperuricemia Patients receiving ARRANON should receive intravenous hydration according to standard medical practice for the management of hyperuricemia in patients at risk for tumor lysis syndrome. Consideration should be given to the use of allopurinol in patients at risk of hyperuricemia [see DOSAGE AND ADMINISTRATION]. Vaccinations Administration of live vaccines to immunocompromised patients should be avoided. Patient Counseling Information Patient labeling is provided as a tear-off leaflet at the end of this full prescribing information. However, inform the patients of the following:

• Since patients receiving nelarabine therapy may experience somnolence, they should be cautioned about operating hazardous machinery, including automobiles.
• Patients should be instructed to contact their physician if they experience new or worsening symptoms of peripheral neuropathy (see BOXED WARNING, WARNINGS AND PRECAUTIONS, and DOSAGE AND ADMINISTRATION]. These signs and symptoms include: tingling or numbness in fingers, hands, toes, or feet; difficulty with the fine motor coordination tasks such as buttoning clothing; unsteadiness while walking; weakness arising from a low chair; weakness in climbing stairs; increased tripping while walking over uneven surfaces.
• Patients should be instructed that seizures have been known to occur in patients who receive nelarabine. If a seizure occurs, the physician administering ARRANON should be promptly informed.
• Patients who develop fever or signs of infection while on therapy should notify their physician promptly.
• Patients should be advised to use effective contraceptive measures to prevent pregnancy and to avoid breast-feeding during treatment with ARRANON.

Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenicity testing of nelarabine has not been done. However, nelarabine was mutagenic when tested in vitro in L5178Y/TK mouse lymphoma cells with and without metabolic activation. No studies have been conducted in animals to assess genotoxic potential or effects on fertility. The effect on human fertility is unknown. Use In Specific Populations Pregnancy Pregnancy Category D [see WARNINGS AND PRECAUTIONS] ARRANON can cause fetal harm when administered to a pregnant woman. Nelarabine administered to rabbits during the period of organogenesis caused increased incidences of fetal malformations, anomalies, and variations at doses > 360 mg/m² /day (8-hour IV infusion; approximately V the adult dose compared on a mg/m² basis), which was the lowest dose tested. Cleft palate was seen in rabbits given 3,600 mg/m² /day (approximately 2-fold the adult dose), absent pollices (digits) in rabbits given > 1,200 mg/m /day (approximately % the adult dose), while absent gall bladder, absent accessory lung lobes, fused or extra sternebrae and delayed ossification was seen at all doses. Maternal body weight gain and fetal body weights were reduced in rabbits given 3,600 mg/m² /day (approximately 2-fold the adult dose), but could not account for the increased incidence of malformations seen at this or lower administered doses. There are no adequate and well-controlled studies of ARRANON in pregnant women. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus. Women of child-bearing potential should be advised to avoid becoming pregnant while receiving treatment with ARRANON. Nursing Mothers It is not known whether nelarabine or ara-G are excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from ARRANON, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother. Pediatric Use The safety and effectiveness of ARRANON has been established in pediatric patients [see DOSAGE AND ADMINISTRATION and Clinical Studies]. Geriatric Use Clinical studies of ARRANON did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from younger patients. In an exploratory analysis, increasing age, especially age 65 years and older, appeared to be associated with increased rates of neurologic adverse reactions. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function. Renal Impairment Ara-G clearance decreased as renal function decreased [see CLINICAL PHARMACOLOGY]. Because the risk of adverse reactions to this drug may be greater in patients with moderate (CLcr 30 to 50 mL/min) or severe (CLcr < 30 mL/min) renal impairment, these patients should be closely monitored for toxicities when treated with ARRANON [see DOSAGE AND ADMINISTRATION]. Hepatic Impairment The influence of hepatic impairment on the pharmacokinetics of nelarabine has not been evaluated. Because the risk of adverse reactions to this drug may be greater in patients with severe hepatic impairment (total bilirubin > 3 times upper limit of normal), these patients should be closely monitored for toxicities when treated with ARRANON. Last reviewed on RxList: 2/15/2012
This monograph has been modified to include the generic and brand name in many instances.

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