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blinatumomab

General

**REMS Drug**

Pronunciation:
bli-ni-too-moe-mab


Trade Name(s)

  • Blincyto

Ther. Class.
antineoplastics

Pharm. Class.
T-cell engagers

Indications

Treatment of Philadelphia chromosome-negative relapsed/refractory B-cell precursor acute lymphoblastic leukemia (ALL).

Action

Acts as a T-cell engager, binding to and activating T-cells binding them to tumor cells resulting in facilitated lysis of malignant cells.

Therapeutic Effect(s):

Depletion of B-cells, including malignant ones.

Pharmacokinetics

Absorption: IV administration results in complete bioavailability.

Distribution: Unknown.

Metabolism and Excretion: Catabolized into small peptides and amino acids.

Half-life: 2.11 hr.

TIME/ACTION PROFILE (depletion of B-cells)

ROUTEONSETPEAKDURATION
IVrapidunknownpersists during treatment free interval

Contraindication/Precautions

Contraindicated in:

  • Hypersensitivity
  • CCr <30 mL/min
  • Lactation:Discontinue blinatumomab or discontinue breastfeeding.

Use Cautiously in:

  • Geri: ↑ risk of neurologic toxicity;
  • OB: Use only if maternal benefit justifies risk to the fetus.

Adverse Reactions/Side Effects

CNS: SEIZURES, balance disorder, dizziness, encephalopathy, fatigue, headache, insomnia, aphasia, cognitive disorder, confusion, weakness

Resp: cough, dyspnea

CV: chest pain, hypotension, peripheral edema, hypertension, tachycardia

GI: PANCREATITIS, abdominal pain, ↓ appetite, constipation, diarrhea, vomiting, ↑ liver enzymes

Derm: rash

Endo: hyperglycemia

F and E: hypokalemia, hypomagnesemia, hypophosphatemia

Hemat: NEUTROPENIA, anemia, ↓ albumin, ↓ immunoglobulins, thrombocytopenia, leukocytosis, lymphopenia

MS: arthralgia, back pain, bone pain, extremity pain

Neuro: NEUROLOGIC TOXICITY, tremor

Misc: CYTOKINE RELEASE SYNDROME, FEBRILE NEUTROPENIA/INFECTIONS , HYPERSENSITIVITY REACTIONS, TUMOR LYSIS SYNDROME, chills, fever, infusion reactions

* CAPITALS indicate life-threatening.
Underline indicate most frequent.

Interactions

Drug-Drug

  • May suppress activity of CYP450 drug-metabolizing enzymes (especially first 9 days of first cycle and first two days of second cycle), careful monitoring of drugs that are substrates of CYP450, including cyclosporine and warfarin, is recommended.
  • May ↓ antibody response to and ↑ risk of adverse reactions from live-virus vaccines; do not administer live vaccines for ≥2 wk before starting therapy, during therapy, and until immune system recovers after completion of therapy.

Route/Dosage

Treatment course consists of up to two cycles for induction followed by three additional cycles (total of five cycles).

IV: (Adults and Children ≥45 kg): Cycle 1– 9 mcg/day as a continuous infusion for days 1–7, followed by 28 mcg/day as a continuous infusion for days 8–28, followed by a 2–week treatment-free interval. Subsequent cycles– 28 mcg/day as a continuous infusion for days 1–28, followed by a 2–week treatment-free interval.

IV: (Adults and Children <45 kg): Cycle 1– 5 mcg/m2 /day (not to exceed 9 mcg/day) as a continuous infusion for days 1–7, followed by 15 mcg/m2 /day (not to exceed 28 mcg/day) as a continuous infusion for days 8–28, followed by a 2–week treatment-free interval. Subsequent cycles– 15 mcg/m2 /day (not to exceed 28 mcg/day) as a continuous infusion for days 1–28, followed by a 2–week treatment-free interval.

Availability

Lyophilized powder for injection (requires reconstitution): 35 mcg/vial (IV solution stabilizer provided with package)

Assessment

  • Monitor for signs and symptoms of cytokine release syndrome (pyrexia, fever, headache, nausea, asthenia, hypotension, ↑ AST, ↑ ALT, ↑ bilirubin) during infusion. May be similar to infusion reactions. If symptoms are Grade 3, withhold blinatumomab until resolved, then restart at 9 mcg/day for adults and 5 mcg/m2 /day for children. Escalate to 28 mcg/day for adults and 15 mcg/m2 /day in children after 7 days if toxicity does not recur. If Grade 4 symptoms occur, discontinue blinatumomab permanently.
  • Monitor for signs and symptoms of neurological toxicity (encephalopathy, convulsions, speech disorders, disturbances in consciousness, confusion, disorientation, loss of balance and coordination) during therapy. Discontinue blinatumomab permanently if more than 1 seizure occurs. If Grade 3 symptoms occur, withhold blinatumomab until no more than Grade 1 (mild) and for at least 3 days, then restart blinatumomab at 9 mcg/day for adults and 5 mcg/m2 /day for children. Escalate dose to 28 mcg/day for adults and 15 mcg/m2 /day in children after 7 days if toxicity does not recur. If toxicity occurred at 9 mcg/day for adults and 5 mcg/m2 /day for children or takes >7 days to resolve, discontinue blinatumomab permanently. If Grade 4 symptoms occur, discontinue blinatumomab permanently.
  • Assess for signs and symptoms of infection (fever, chills, sepsis, pneumonia, bacteremia, opportunistic infections, catheter site infections) during therapy. Treat with anti-infectives as needed.
  • Monitor for signs and symptoms of tumor lysis syndrome (abdominal pain and distension, dysuria, oliguria, flank pain, hematuria, anorexia, vomiting, cramps, seizures, spasms, altered consciousness) during therapy. May use prophylactic nontoxic cytoreduction and on-treatment hydration. May require temporary interruption or discontinuation.
  • Monitor for signs and symptoms of pancreatitis (severe and persistent stomach pain, with or without nausea and vomiting) during therapy.

Lab Test Considerations:

  • Verify pregnancy status prior to beginning therapy.
  • Monitor CBC periodically during therapy. May cause neutropenia. Interrupt therapy if neutropenia is prolonged.
    • Monitor ALT, AST, gamma-glutamyl transferase (GGT), and total serum bilirubin prior to starting and during therapy. If AST and ALT increase to ≥5 times the upper limit of normal or if bilirubin rises to >3 times the upper limit of normal interrupt therapy.
    • May cause hypokalemia, hypomagnesemia, hyperglycemia, and hypophosphatemia.

Potential Diagnoses

Implementation

  • Patient must be hospitalized for first 9 days of first cycle and first 2 days of second cycle. For other cycles, supervision by health care professional is recommended.
    • Premedicate adults with dexamethasone 20 mg IV and pediatrics patients with dexamethasone 5 mg/m2 1 hr prior to first dose of each cycle or when restarting infusion after interruption of 4 or more hr.
    • If an interruption due to an adverse reaction is <7 days, continue same cycle to a total of 28 days inclusive of days before and after interruption. If interruption >7 days, start a new cycle.
    • If questions occur regarding reconstitution and preparation, call 1-800-AMGEN or 1-800-772-6436.
  • Solution should be prepared in a biologic cabinet. Wear gloves, gown, and mask while handling medication. Discard IV equipment in specially designated containers.

IV Administration

  • Continuous Infusion: Do not flush line, especially when changing bags or at completion of infusion; may result in excess or overdose. Aseptically add 270 mL of 0.9% NaCl polyolefin, PVC non-di-ethylhexylphalate (non-DEHP), or ethyl vinyl acetate (EVA) bag.
    • Add 5.5 mL IV solution stabilizer to IV bag. Stabilizer is used to coat prefilled IV bag; do not use for reconstitution. Gently mix; avoid foaming. Discard remaining stabilizer.
    • Entire volume of admixed blinatumomab will be more than 240 mL volume administered to patient to account for priming and ensure patient received full dose. Remove air from infusion bag. Add or remove 0.9% NaCl from bag if needed to adjust volume to 265 to 275 mL.
    • Reconstitute blinatumomab, using 3 mL preservative-free Sterile Water for Injection/vial for a concentration of 12.5 mg/mL. Direct solution toward side of vial; gently swirl to avoid foaming. Do not shake. Solution should be clear to opalescent; do not infuse solutions that are discolored or contain a precipitate. Vials are stable at room temperature for 4 hr or 24 hr if refrigerated. Patients weighing ≥45 kg: For 9 mcg/day infused over 24 hr at a rate of 10 mL/hr, transfer 0.83 mL of reconstituted solution into IV bag. For 9 mcg/day infused over 48 hr at a rate of 5 mL/hr, transfer 1.7 mL of reconstituted solution into IV bag. For 28 mcg/day infused over 24 hr at a rate of 10 mL/hr, transfer 2.6 mL of reconstituted solution into IV bag. For 28 mcg/day infused over 48 hr at a rate of 5 mL/hr, transfer 5.2 mL of reconstituted solution (2.7 mL from one vial and 2.5 mL from a second vial) into IV bag. Patients weighing <45 kg:See package insert for volumes to add to IV bag for 5 mcg/m2 /day dose. Diluted solution is stable for 48 hr at room temperature or for 8 days if refrigerated. May also be infused over 7 days; not recommended for patients weighing <22 kg. See manufacturer's directions for preparation of 7–day infusion.
  • Rate: Infuse via programmable, lockable, non-elastomeric infusion pump with an alarm. Infuse 240 mL over 24 or 48 hr based on pharmacy label, at a rate of 10 mL/hr for 24 hr or 5 mL/hr for 48 hr. Use tubing that is sterile, non-pyrogenic, low protein-binding, with a 0.2 micron in-line filter. Ensure tubing is compatible with infusion pump. If using a multilumen catheter, infuse blinatumomab through a dedicated lumen.

Patient/Family Teaching

  • Explain schedule for blinatumomab administration. Instruct patient to read Medication Guide before starting therapy and before each cycle in case of changes.
  • Instruct patient in how to keep area around IV catheter clean to reduce infections. Advise patient not to change settings of infusion pump.
  • May cause seizures and loss of consciousness. Caution patient to avoid driving or other activities requiring alertness until response from medication is known.
  • Advise patient to notify health care professional immediately if signs and symptoms of cytokine release syndrome (fever, tiredness or weakness, dizziness, headache, low BP, nausea, vomiting, chills, facial swelling, wheezing or difficulty breathing, rash) or neurological problems (seizures, difficulty speaking or slurred speech, loss of consciousness, confusion, disorientation, loss of balance) occur or if side effects occur that are bothersome or persistent.
  • Caution patient to avoid receiving live vaccines for 2 wks before and during, and until immune recovery following last cycle of blinatumomab therapy.
  • Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult health care professional before taking other Rx, OTC, or herbal products.
  • Rep: Advise female patient to use effective contraception and avoid breastfeeding during and for at least 48 hrs after last dose.

Evaluation/Desired Outcomes

Decrease in progression of Philadelphia chromosome-negative relapsed/refractory B-cell precursor acute lymphoblastic leukemia (ALL).

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Citation

Quiring, Courtney, et al. "Blinatumomab." Davis's Drug Guide, 16th ed., F.A. Davis Company, 2019. Nursing Central, nursing.unboundmedicine.com/nursingcentral/view/Davis-Drug-Guide/110159/all/blinatumomab.
Quiring C, Sanoski CA, Vallerand AH. Blinatumomab. Davis's Drug Guide. 16th ed. F.A. Davis Company; 2019. https://nursing.unboundmedicine.com/nursingcentral/view/Davis-Drug-Guide/110159/all/blinatumomab. Accessed April 23, 2019.
Quiring, C., Sanoski, C. A., & Vallerand, A. H. (2019). Blinatumomab. In Davis's Drug Guide. Available from https://nursing.unboundmedicine.com/nursingcentral/view/Davis-Drug-Guide/110159/all/blinatumomab
Quiring C, Sanoski CA, Vallerand AH. Blinatumomab [Internet]. In: Davis's Drug Guide. F.A. Davis Company; 2019. [cited 2019 April 23]. Available from: https://nursing.unboundmedicine.com/nursingcentral/view/Davis-Drug-Guide/110159/all/blinatumomab.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - blinatumomab ID - 110159 A1 - Quiring,Courtney, AU - Sanoski,Cynthia A, AU - Vallerand,April Hazard, BT - Davis's Drug Guide UR - https://nursing.unboundmedicine.com/nursingcentral/view/Davis-Drug-Guide/110159/all/blinatumomab PB - F.A. Davis Company ET - 16 DB - Nursing Central DP - Unbound Medicine ER -