The role of arsenic in cancer treatment
Many patients question whether or not TRISENOX
® (arsenic trioxide)
injection is toxic because it contains arsenic. While TRISENOX is a form of arsenic
known as "arsenic trioxide," it is manufactured under carefully controlled conditions,
prepared with the highest quality standards, and has been found to be safe and effective
when used appropriately by doctors and nurses experienced in the treatment of cancer.
1
Arsenic trioxide is routinely used to treat certain leukemia patients. Like other cancer medicines,
arsenic kills cancer cells, and the federal government approved TRISENOX as a cancer
medicine because it has proven to be safe and effective in patients with relapsed or refractory APL.
1-3
Although some people may automatically think of arsenic as a toxic chemical, it
is actually a naturally occurring substance that has been used in medicine for over
2,000 years. For example, arsenic was used to fight the plague in the middle ages,
and it was one of the first drugs used to treat a certain type of leukemia back
in the 1800s. Doctors in Asia have used arsenic for hundreds of years for many different
medical problems.
As with all medicines, the dose of arsenic is important. Many cancer drugs would
be hazardous if used in the wrong amounts or in the wrong way, and arsenic is no
different. The dose of arsenic in TRISENOX is given over time
at a carefully measured rate. When used at the right dose and given in the right
way, TRISENOX is a safe and effective cancer treatment for relapsed or refractory APL.
>> Click here for frequently asked questions
about therapy with TRISENOX.
TRISENOX is indicated for induction of remission and consolidation in patients with APL who
are refractory to, or have relapsed from, retinoid and anthracycline chemotherapy, and whose
APL is characterized by the presence of the t(15;17) translocation or PML/RAR-alpha gene expression.
Serious adverse events, grade 3 or 4, were common. Those events attributable to TRISENOX in the Phase 2
study of 40 patients with refractory or relapsed APL included APL differentiation syndrome (n=3), hyperleukocytosis (n=3), QTc
interval prolongation (n=16), atrial dysrhythmias (n=2), hyperglycemia (n=2), and torsades de pointes (n=1).
In addition to QT interval prolongation, the most common drug-related side effects included leukocytosis, gastrointestinal events (nausea, vomiting, diarrhea, and abdominal pain), fatigue, swelling, hyperglycemia (an abnormal increased content of sugar in the blood), shortness of breath, cough, rash or itching, headache, and dizziness. Have your doctor review side effects with you.
In clinical trials, most patients taking TRISENOX experienced some drug-related toxicity, most commonly leukocytosis, gastrointestinal (nausea, vomiting, diarrhea, and abdominal pain), fatigue, edema, hyperglycemia, dyspnea, cough, rash or itching, headache, and dizziness. These adverse effects have not been observed to be permanent or irreversible, nor do they usually require interruption of therapy.
It is important to call your doctor if you experience any treatment side effects.
WARNING
Experienced Physician and Institution:
TRISENOX® (arsenic trioxide) injection should be administered under the supervision
of a physician who is experienced in the management of patients with acute leukemia.
APL Differentiation Syndrome:
Some patients with APL treated with TRISENOX have experienced symptoms similar to a syndrome called
the retinoic-acid-acute promyelocytic leukemia (RA-APL) or APL differentiation syndrome, characterized
by fever, dyspnea, weight gain, pulmonary infiltrates and pleural or pericardial effusions, with or
without leukocytosis. This syndrome can be fatal. The management of the syndrome has not been fully
studied, but high-dose steroids have been used at the first suspicion of the APL differentiation
syndrome and appear to mitigate signs and symptoms. At the first signs that could suggest the syndrome
(unexplained fever, dyspnea and/or weight gain, abnormal chest auscultatory findings or radiographic
abnormalities), high-dose steroids (dexamethasone 10 mg intravenously BID) should be immediately
initiated, irrespective of the leukocyte count, and continued for at least 3 days or longer until
signs and symptoms have abated. The majority of patients do not require termination of TRISENOX therapy
during treatment of the APL differentiation syndrome.
ECG Abnormalities:
Arsenic trioxide can cause QT interval prolongation and complete atrioventricular block. QT prolongation can
lead to a torsade de pointes-type ventricular arrhythmia, which can be fatal. The risk of torsade de pointes
is related to the extent of QT prolongation, concomitant administration of QT prolonging drugs, a history of
torsade de pointes, pre-existing QT interval prolongation, congestive heart failure, administration of
potassium-wasting diuretics, or other conditions that result in hypokalemia or hypomagnesemia. One patient
(also receiving amphotericin B) had torsade de pointes during induction therapy for relapsed APL with arsenic
trioxide.
ECG and Electrolyte Monitoring Recommendations:
Prior to initiating therapy with TRISENOX, a 12-lead ECG should be performed and serum electrolytes (potassium,
calcium, and magnesium) and creatinine should be assessed; pre-existing electrolyte abnormalities should be
corrected and, if possible, drugs that are known to prolong the QT interval should be discontinued. For QTc
greater than 500 msec, corrective measures should be completed and the QTc reassessed with serial ECGs prior
to considering using TRISENOX. During therapy with TRISENOX, potassium concentrations should be kept above 4 mEq/L
and magnesium concentrations should be kept above 1.8 mg/dL. Patients who reach an absolute QT interval value > 500
msec should be reassessed and immediate action should be taken to correct concomitant risk factors, if any, while
the risk/benefit of continuing versus suspending TRISENOX therapy should be considered. If syncope, rapid or irregular
heartbeat develops, the patient should be hospitalized for monitoring, serum electrolytes should be assessed, TRISENOX
therapy should be temporarily discontinued until the QTc interval regresses to below 460 msec, electrolyte abnormalities
are corrected, and the syncope and irregular heartbeat cease. There are no data on the effect of TRISENOX on the QTc
interval during the infusion.
1. TRISENOX® (arsenic trioxide) Injection [current approved prescribing information]. Frazer, PA: Cephalon, Inc.
2. Soignet SL, Frankel SR, Douer D, et al. United States multicenter study of arsenic
trioxide in relapsed acute promyelocytic leukemia. J Clin Oncol. 2001;19:3852-3860.
3. Soignet SL, Maslak P, Wang Z-G, et al. Complete remission after treatment of
acute promyelocytic leukemia with arsenic trioxide. N Engl J Med. 1998;339:1341-1348.