Dactinomycin (Monograph)

Brand name: Cosmegen
Drug class: Antineoplastic Agents
VA class: AN200
CAS number: 50-76-0

Introduction

Antineoplastic agent; an actinomycin antibiotic produced by Streptomyces parvullus.¹⁰⁰

Uses for Dactinomycin

Wilms’ Tumor

In children with Wilms’ tumor, used in combination regimens (e.g., with vincristine with or without doxorubicin) as an adjunct to surgery with or without radiation therapy.^{100 101 103} The best combination or sequential therapy to achieve maximum response and duration of survival has not been established and comparative efficacy is continually being evaluated.^{100 103}

Generally should not be administered concomitantly with radiation therapy in the treatment of Wilms’ tumor.^{100 103} (See Toxicity Potentiation with Concomitant Radiation Therapy under Cautions.)

Rhabdomyosarcoma

Component of various chemotherapeutic regimens as an adjunct to surgery with or without radiation therapy; however, the best combination or sequential therapy to achieve maximum response and duration of survival has not been established and comparative efficacy is continually being evaluated.^{100 101 103 104}

Ewing’s Sarcoma

Has been used in combination chemotherapy for treatment of Ewing’s sarcoma;¹⁰⁰ however, other regimens currently are preferred.^{101 105}

Trophoblastic Neoplasms

Treatment (alone or as a component of various chemotherapeutic regimens) of trophoblastic neoplasms (choriocarcinoma, chorioadenoma destruens) in women.^{100 101 106}

Dactinomycin alone is generally reserved for patients whose tumors develop resistance or do not respond to methotrexate or in patients with impaired hepatic or renal function with increased risk of methotrexate toxicity.¹⁰⁶

Combination therapy with methotrexate and cyclophosphamide (MAC regimen) has been used for treatment of metastatic gestational trophoblastic tumors that are refractory to single-drug therapy.^{101 106}

Combination therapy with etoposide, methotrexate, cyclophosphamide, and vincristine (EMA-CO) is commonly used in patients with poor-prognosis metastatic gestational trophoblastic tumors.^{101 106}

Testicular Cancer

Used in combination with vinblastine, bleomycin, cyclophosphamide, and cisplatin (VAB-6) for the treatment of advanced nonseminomatous testicular carcinoma.^{100 107} The best combination or sequential therapy has not been established and comparative efficacy is continually being evaluated.¹⁰⁷

Solid Tumors

Used alone or in combination with other chemotherapeutic agents by regional isolation perfusion as an adjunct to surgery or as palliative therapy alone in the treatment of locally recurrent or locoregional solid tumors (sarcomas, carcinomas, and adenocarcinomas).¹⁰⁰

Ovarian Germ Cell Tumors

Component of alternative chemotherapeutic regimens for ovarian germ cell tumors^{† [off-label]}.^{101 102}

Dactinomycin Dosage and Administration

General

• Consult specialized references for procedures for proper handling and disposal of antineoplastics.¹⁰⁰

Administration

IV Administration

For solution and drug compatibility information, see Compatibility under Stability.

Administer by IV infusion (preferred) or IV injection.¹⁰⁰ May also be adminstered by regional isolation perfusion.¹⁰⁰

Do not administer IM, sub-Q, or orally.¹⁰⁰

Avoid extravasation; extremely irritating to tissues.¹⁰⁰ Pain and burning or stinging sensation during IV administration may be a symptom, but extravasation may occur without these symptoms and even when blood returns well on aspiration of the infusion needle.¹⁰⁰ If manifestations of extravasation occur, immediately stop administration and restart at another site; apply ice intermittently to affected area for 15 minutes 4 times daily for 3 days. ¹⁰⁰ Because of the progressive nature of extravasation reactions, close observation and plastic surgery consultation recommended.¹⁰⁰ Blistering, ulceration, and/or persistent pain are indications for wide excision surgery, followed by split-thickness skin grafting.¹⁰⁰ (See Local Effects under Cautions.)

Prepare and handle cautiously (by trained nonpregnant personnel); use protective equipment (e.g., latex gloves, protective eyewear) and wash hands after removal of latex gloves.¹⁰⁰ Avoid exposure by inhalation or by direct contact of the skin or mucous membranes.¹⁰⁰ If drug powder or solution comes in contact with skin or mucosa, immediately irrigate affected area with water for ≥15 minutes; flush affected eye(s) with water or saline for ≥15 minutes and obtain prompt ophthalmologic consultation.¹⁰⁰ Remove contaminated clothing and shoes; destroy clothing and and thoroughly clean shoes before reuse.¹⁰⁰ (See Toxicity and Adequate Patient Monitoring under Cautions.)

Administer desired dose directly into any suitable vein or preferably into tubing or sidearm of a freely flowing IV infusion to reduce the risk of severe local reactions.¹⁰⁰ (See Local Effects under Cautions.)

Following injection, flush vein with the running IV solution for 2–5 minutes and/or inject 5–10 mL of IV solution into sidearm to flush any remaining drug from the tubing.^a

For direct IV injection, withdraw dose from the vial with one sterile needle and use another sterile needle for injection into vein.¹⁰⁰

Do not use an inline cellulose ester membrane filter during administration.^a

Reconstitution

Use strict aseptic technique since drug product contains no preservative.¹⁰⁰

Reconstitute vial containing 500 mcg of dactinomycin powder with 1.1 mL of sterile water for injection without preservatives, to provide a solution containing 500 mcg/mL.¹⁰⁰

Do not use diluents with preservatives (benzyl alcohol or parabens) which may cause precipitation.¹⁰⁰

Dilution

Reconstituted solution may be added to IV infusions of 0.5% dextrose or 0.9% sodium chloride injection.¹⁰⁰

Rate of Administration

For direct IV injection, administer desired dose over a few minutes directly into any suitable vein.^a

Regional Isolation Perfusion

Techniques for administration by regional isolation perfusion may vary; consult specialized references.¹⁰⁰

Administration Risks

Possible systemic and local adverse effects associated with drug that escapes into systemic circulation (e.g., myelosuppression, increased susceptibility to infection, impaired wound healing, ulceration of GI mucosa, absorption of toxic products accompanying extensive tumor destruction, edema of extremity, soft tissue damage, venous thrombosis).¹⁰⁰ (See Major Toxicities under Cautions.)

Dosage

Calculate dosage carefully before administration of each dose.¹⁰⁰

Base dosage on the clinical and hematologic response, patient tolerance, and other chemotherapy or irradiation being used.¹⁰⁰

Base dosage on body surface area in obese or edematous patients.¹⁰⁰

Consult published protocols for dosages in combination regimens and method and sequence of administration.¹⁰⁰

Pediatric Patients

Wilms’ Tumor

IV

Children >6 months of age: 15 mcg/kg daily for 5 days administered in various combinations and schedules with other chemotherapeutic agents.¹⁰⁰

Rhabdomyosarcoma

IV

Children >6 months of age: 15 mcg/kg daily for 5 days administered in various combinations and schedules with other chemotherapeutic agents.¹⁰⁰

Ewing’s Sarcoma

IV

Children >6 months of age: 15 mcg/kg daily for 5 days administered in various combinations and schedules with other chemotherapeutic agents.¹⁰⁰

Adults

Trophoblastic Neoplasms

Monotherapy

IV

12 mcg/kg daily for 5 days.¹⁰⁰

Combination Therapy

IV

500 mcg on days 1 and 2 as part of a combination regimen with etoposide, methotrexate, folinic acid, vincristine, cyclophosphamide, and cisplatin.^{100 110}

Testicular Cancer

IV

1000 mcg/m² on day 1 as part of a combination regimen with cyclophosphamide, bleomycin, vinblastine, and cisplatin.¹⁰⁰

Solid Tumors

IV (Regional Isolation Perfusion)

Dosage by regional isolation perfusion may vary; consult specialized references.¹⁰⁰

Pelvis or lower extremity: Usual dose is 50 mcg/kg.¹⁰⁰

Upper extremity: Usual dose is 35 mcg/kg.¹⁰⁰

Consider dosage reduction in obese patients or those who have received prior chemotherapy or irradiation.¹⁰⁰

Prescribing Limits

Pediatric Patients

IV

Maximum 15 mcg/kg daily or 400–600 mcg/m² IV daily for 5 days for each 2-week course of therapy.¹⁰⁰

Adults

IV

Maximum 15 mcg/kg daily or 400–600 mcg/m² IV daily for 5 days for each 2-week course.¹⁰⁰

Special Populations

Hepatic Impairment

No specific dosage recommendations at this time.¹⁰⁰

Renal Impairment

No specific dosage recommendations at this time.¹⁰⁰

Geriatric Patients

Start at lower end of dosage range because of age-related decreases in hepatic, renal, or cardiac function and concomitant disease and drug therapy.¹⁰⁰

Cautions for Dactinomycin

Contraindications

• Current or recent infection with chickenpox or herpes zoster.¹⁰⁰ (See Immunosuppression under Cautions.)

• Known hypersensitivity to dactinomycin or any ingredient in the formulation.¹⁰⁰

Warnings/Precautions

Warnings

Carcinogenic Effects

Secondary malignancies (e.g., leukemias) reported in patients receiving dactinomycin in combination with radiation therapy.¹⁰⁰ Long-term observation for occurrence of secondary malignancy is necessary in patients receiving combined modality treatment for cancer.¹⁰⁰

Fetal/Neonatal Morbidity and Mortality

May cause fetal harm; teratogenicity and embryotoxicity demonstrated in animals.¹⁰⁰ Avoid pregnancy during therapy.¹⁰⁰ If used during pregnancy or if patient becomes pregnant, apprise of potential fetal hazard.¹⁰⁰

Immunosuppression

Do not administer at or near the time of infection with chickenpox or herpes zoster.¹⁰⁰ Risk of severe and possibly fatal generalized disease.¹⁰⁰

Concurrent administration of live virus vaccines not recommended.¹⁰⁰

Sensitivity Reactions

Hypersensitivity Reactions

Possible serious hypersensitivity reactions, including anaphylaxis. ¹⁰⁰

Major Toxicities

Hematologic Effects

Risk of dose-limiting myelosuppression, manifested primarily by leukopenia and thrombocytopenia; anemia, pancytopenia, reticulopenia, agranulocytosis, and aplastic anemia also may occur.^{100 a}

Leukocyte and platelet nadirs generally occur 14–21 days following completion of a course of therapy.^a Leukocyte and platelet counts usually return to normal levels within 21–25 days.¹⁰⁰

Monitor hematologic function frequently.¹⁰⁰ If severe myelosuppression develops, discontinue therapy until blood counts return to an acceptable level;¹⁰⁰ administer supportive therapy, anti-infectives for complicating infections, and blood product transfusions as indicated.^a

Use with extreme caution in patients with impaired bone marrow function.^a

GI Effects

Nausea and vomiting; generally occur within hours of administration and last up to 24 hours.^{100 a} Antiemetics may be effective in preventing or treating nausea and vomiting.^{100 a}

Risk of stomatitis or diarrhea; if stomatitis or diarrhea develops, discontinue therapy until symptoms resolve. ¹⁰⁰

Hepatic Effects

Potentially fatal hepatic failure and hepatic veno-occlusive disease reported.¹⁰⁰ Veno-occlusive disease may be associated with intravascular clotting disorder and multiorgan failure and may be fatal, particularly in children <4 years of age.¹⁰⁰

Abnormal liver function tests, ascites, hepatomegaly, and hepatitis reported.¹⁰⁰

Local Effects

Extravasation may produce severe local tissue damage, necrosis, cellulitis, phlebitis, and inflammation; contracture of the arms reported.^{100 a} Follow precautions to avoid extravasation.¹⁰⁰ (See IV Administration under Dosage and Administration.)

Epidermolysis, erythema, and edema, sometimes severe, reported with regional limb perfusion.¹⁰⁰

General Precautions

Toxicity and Adequate Patient Monitoring

Highly toxic drug with a low therapeutic index; therapeutic response is not likely to occur without some evidence of toxicity.^{100 a} Handle and administer cautiously; administer only under the supervision of qualified clinician experienced in the use of cancer chemotherapy agents.¹⁰⁰ (See IV Administration under Dosage and Administration.)

Closely observe patient and frequently assess bone marrow, hepatic, and renal function.¹⁰⁰

Toxicity Potentiation with Concomitant Radiation Therapy

Appears to potentiate effects of radiation therapy.¹⁰⁰ Severe reactions possible if high doses of both dactinomycin and radiation are used or if patient is especially sensitive to such combination therapy.¹⁰⁰

Increased incidence of GI toxicity (e.g., severe oropharyngeal mucositis) and myelosuppression reported.¹⁰⁰

Erythema at the site of irradiation may occur early in normal skin and buccal and pharyngeal mucosa and may be followed rapidly by hyperpigmentation and/or edema, desquamation, vesiculation, and rarely necrosis.^{100 a}

Possible reactivation of radiation effects (e.g., erythema) in previously irradiated tissues.¹⁰⁰

Hepatomegaly, elevated serum AST concentrations, and ascites reported in the first 2 months after radiation therapy in patients with right-sided Wilms’ tumor; administer dactinomycin with particular caution in the first 2 months after radiation therapy.^{100 a} Do not administer concomitantly with radiation therapy for treatment of Wilms’ tumor unless benefit outweighs risk.^{100 103}

Specific Populations

Pregnancy

Category D.¹⁰⁰ (See Fetal/Neonatal Morbidity and Mortality under Cautions.)

Lactation

Not known whether dactinomycin is distributed into human milk.¹⁰⁰ Discontinue nursing or the drug.¹⁰⁰

Pediatric Use

Increased incidence of adverse effects in infants; use only in infants older than 6–12 months of age.¹⁰⁰

Increased incidence of fatal veno-occlusive disease in children <4 years of age.¹⁰⁰ (See Hepatic Effects under Cautions.)

Geriatric Use

Insufficient experience in patients ≥65 years of age to determine whether geriatric patients respond differently than younger adults; consider the greater frequency of decreased hepatic, renal, and/or cardiac function and of concomitant disease and drug therapy observed in the elderly.¹⁰⁰

Possible increased incidence of myelosuppression compared with younger adults.¹⁰⁰

Common Adverse Effects

With IV therapy, myelosuppression, nausea, vomiting, anorexia, abdominal pain, diarrhea, GI ulceration, dysphagia, stomatitis, alopecia, rash, malaise, fatigue, lethargy, liver function test abnormalities, hepatitis, growth retardation, fever, infection, myalgia.¹⁰⁰

With regional isolation perfusion, edema of involved extremity, regional soft tissue damage, myelosuppression, infection, impaired wound healing.¹⁰⁰

Drug Interactions

No formal drug interaction studies to date.¹⁰⁰

Specific Drugs, Therapies, and Laboratory Tests

Dactinomycin Pharmacokinetics

Absorption

Bioavailability

Poorly absorbed from the GI tract.^a

Distribution

Extent

Rapidly distributed into tissues, with highest concentrations in bone marrow and nucleated cells (i.e., granulocytes, lymphocytes).^{a 100} Does not cross the blood-brain barrier.^{100 a}

Appears to cross placenta; not known whether distributed into milk.^{a 100}

Elimination

Metabolism

Minimally metabolized.¹⁰⁰

Elimination Route

Excreted in urine and feces; excreted in urine primarily as unchanged drug.^{a 100}

Half-life

Biphasic; terminal half-life is approximately 36 hours.^{100 a}

Stability

Storage

Parenteral

Powder for Injection

25°C (may be exposed to 15–30°C).¹⁰⁰ Protect from light and humidity; discard any unused portion.¹⁰⁰

Compatibility

Parenteral

Manufacturer states that dactinomycin should not be mixed with diluents containing preservatives (benzyl alcohol or parabens); precipitation reported.¹⁰⁰

Solution CompatibilityHID

Drug Compatibility

Actions

• Mechanism(s) of antineoplastic action not fully understood; appears to inhibit DNA-dependent RNA synthesis by forming a complex with DNA by intercalating with guanine residues and impairing the template activity of DNA.^{100 a}

• Also inhibits protein and DNA synthesis, but less extensively and at higher concentrations of dactinomycin than are needed to inhibit RNA synthesis.^a

• Cytotoxicity precludes use as an anti-infective agent.^{a 100}

Advice to Patients

• Risk of alopecia, nausea, vomiting, myelosuppression, and hepatotoxicity.¹⁰⁰

• Importance of patients informing clinicians immediately if any stinging or burning occurs at IV injection site during administration.¹⁰⁰

• Importance of women informing clinicians immediately if they are or plan to become pregnant or plan to breast-feed; necessity for clinicians to advise women to avoid pregnancy during therapy and advise pregnant women of risk to the fetus.¹⁰⁰

• Importance of patients informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses.¹⁰⁰

• Importance of informing patients of other important precautionary information.¹⁰⁰ (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

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