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Carmustine: Drug information

Carmustine: Drug information
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For additional information see "Carmustine: Patient drug information" and "Carmustine: Pediatric drug information"

For abbreviations, symbols, and age group definitions show table
ALERT: US Boxed Warning
Myelosuppression (injection)

Carmustine causes suppression of marrow function (including thrombocytopenia and leukopenia), which may contribute to bleeding and overwhelming infections. Monitor blood counts weekly for at least 6 weeks after each dose. Adjust dosage based on nadir blood counts from the prior dose. Do not administer a repeat course of carmustine until blood counts recover.

Pulmonary toxicity (injection)

Carmustine causes dose-related pulmonary toxicity. Patients receiving greater than 1,400 mg/m2 cumulative dose are at significantly higher risk than those receiving less. Delayed pulmonary toxicity can occur years after treatment, and can result in death, particularly in patients treated in childhood.

Brand Names: US
  • BiCNU [DSC];
  • Gliadel Wafer
Brand Names: Canada
  • BiCNU
Pharmacologic Category
  • Antineoplastic Agent, Alkylating Agent;
  • Antineoplastic Agent, Alkylating Agent (Nitrosourea)
Dosing: Adult

Dosage guidance:

Clinical considerations: Carmustine (IV) is associated with a high emetic potential; antiemetics are recommended to prevent nausea and vomiting (Ref). Platelet counts should be >100,000/mm3, ANC >1,000/mm3, and leukocytes >4,000/mm3 prior to a repeat course. Repeat courses should not be administered more frequently than every 6 weeks. Refer to the protocol or institutional guidance for additional details of off-label dosing.

CNS tumors, primary

CNS tumors, primary:

Glioma, recurrent (off-label dose): IV: 80 mg/m2 on days 1, 2, and 3 every 8 weeks for a maximum of 6 cycles (Ref).

Glioma, malignant, newly diagnosed (off-label dose): IV: 200 mg/m2 every 8 weeks (up to a maximum cumulative dose of 1,500 mg/m2) (Ref).

Wafer implants: Note: Optimal antiseizure therapy should be initiated prior to surgery.

Glioma, newly diagnosed high-grade: Implantation (wafer): 8 wafers (7.7 mg each) implanted intracranially into the resection cavity (total dose 61.6 mg); should the size and shape not accommodate 8 wafers, the maximum number of wafers feasible (up to 8) should be placed.

Glioblastoma, recurrent: Implantation (wafer): 8 wafers (7.7 mg each) implanted intracranially into the resection cavity (total dose 61.6 mg); should the size and shape not accommodate 8 wafers, the maximum number of wafers feasible (up to 8) should be placed.

Hematopoietic cell or bone marrow transplant, autologous, conditioning regimen

Hematopoietic cell or bone marrow transplant, autologous, conditioning regimen (off-label use):

BEAM regimen: IV: 300 mg/m2 as a single dose 6 days prior to transplant (in combination with etoposide, cytarabine, and melphalan) (Ref).

BEAC regimen: IV: 300 mg/m2 as a single dose 6 days prior to transplant (in combination with etoposide, cytarabine, and cyclophosphamide) (Ref).

CBV regimen: IV: 600 mg/m2 as a single dose 3 days prior to transplant (in combination with cyclophosphamide and etoposide) (Ref).

Carmustine/thiotepa regimen (TT-BCNU regimen; primary CNS lymphoma): IV: 400 mg/m2 as a single dose 6 days prior to transplant (in combination with thiotepa) (Ref).

Hodgkin lymphoma, relapsed or refractory, salvage therapy

Hodgkin lymphoma, relapsed or refractory, salvage therapy (off-label dose): Mini-BEAM regimen: IV: 60 mg/m2 on day 1 every 4 to 6 weeks (in combination with etoposide, cytarabine, and melphalan) for 2 to 4 cycles, followed by conditioning for autologous transplant in responders (Ref).

Mycosis fungoides, early stage, topical

Mycosis fungoides, early stage, topical (off-label use/route):

Ointment (10 mg/100 grams petrolatum): Topical: Apply once daily to affected areas (Ref).

Solution (10 mg/60 mL water): Topical: Apply once daily to affected areas (Ref).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

IV: Manufacturer’s labeling: CrCl <10 mL/minute: Discontinue treatment. Do not administer to patients with compromised kidney function.

The following dosage adjustments have also been reported:

CrCl 46 to 60 mL/minute: Reduce dose to 80% of the usual dose (Ref).

CrCl 31 to 45 mL/minute: Reduce dose to 75% of the usual dose (Ref).

CrCl ≤30 mL/minute: Use is not recommended; consider use of alternative drug (Ref).

Hemodialysis: Use is not recommended (Ref).

Wafer implant: There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Liver Impairment: Adult

IV: There are no dosage adjustments provided in the manufacturer’s labeling. The following recommendations have been reported:

Mild or moderate impairment: No need for dose adjustment is expected (Ref).

Severe impairment: Use is not recommended (Ref).

Wafer implant: There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Obesity: Adult

American Society of Clinical Oncology guidelines for appropriate systemic therapy dosing in adults with cancer with a BMI ≥30 kg/m2 (Note: Excludes hematopoietic cell transplantation dosing): Utilize patient's actual body weight for calculation of BSA- or weight-based dosing; manage regimen-related toxicities in the same manner as for patients with a BMI <30 kg/m2; if a dose reduction is utilized due to toxicity, may consider resumption of full, weight-based dosing (or previously tolerated dose level) with subsequent cycles only if dose escalations are allowed in the prescribing information, if contributing underlying factors (eg, hepatic or kidney impairment) are sufficiently resolved, AND if performance status has markedly improved or is considered adequate (Ref).

American Society for Blood and Marrow Transplantation practice guideline committee position statement on conditioning chemotherapy dosing in obesity: Utilize actual body weight for calculation of BSA in carmustine dosing for hematopoietic cell transplant conditioning regimens in adult patients weighing ≤120% of their ideal body weight (IBW). In patients weighing >120% IBW, utilize adjusted body weight 25% (ABW25) to calculate BSA (Ref).

ABW25: Adjusted wt (kg) = Ideal body weight (kg) + 0.25 [actual wt (kg) - ideal body weight (kg)]

Dosing: Adjustment for Toxicity: Adult

Carmustine IV:

Hematologic toxicity: Based on nadir counts with previous dose (Ref). IV:

If leukocytes ≥3,000/mm3 and platelets ≥75,000/mm3: Administer 100% of carmustine dose.

If leukocytes 2,000 to 2,999/mm3 or platelets 25,000 to 74,999/mm3: Reduce dose to 70% of usual carmustine dose.

If leukocytes <2,000/mm3 or platelets <25,000/mm3: Reduce dose to 50% of usual carmustine dose.

Pulmonary toxicity (signs/symptoms or decreased carbon monoxide diffusing capacity): Consider initiating systemic corticosteroid therapy (eg, prednisone) and consider discontinuing carmustine (Ref).

Carmustine wafer:

Intracranial hypertension (related to brain edema, inflammation, or necrosis of brain tissue surrounding resection): May require re-operation to remove wafers (or remnants) for refractory cases.

Dosing: Older Adult

Refer to adult dosing.

Dosing: Pediatric

(For additional information see "Carmustine: Pediatric drug information")

Dosage guidance:

Safety: Children are at increased risk for pulmonary toxicity due to carmustine; weigh risk versus benefit before use. Carmustine IV is associated with a moderate or high emetic potential (dose related); antiemetics are recommended to prevent nausea and vomiting (Ref). Refer to individual protocols; dosing and frequency may vary.

Hodgkin lymphoma or Non-Hodgkin lymphoma, relapsed or resistant; high-dose chemotherapy followed by autologous stem cell rescue

Hodgkin lymphoma or Non-Hodgkin lymphoma, relapsed or resistant; high-dose chemotherapy followed by autologous stem cell rescue: Limited data available:

BEAM regimen: Children and Adolescents: IV: 300 mg/m2/dose for 1 dose, refer to protocol for designated day of administration, followed by etoposide, cytarabine, and melphalan (Ref).

CBV regimen: Children and Adolescents: IV: 100 mg/m2/dose once daily for 3 days (total dose: 300 mg/m2), refer to protocol for designated day of administration, used in combination with cyclophosphamide and etoposide (Ref).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing adjustment for toxicity: Specific recommendations for pediatric patients are limited; refer to specific protocol for management in pediatric patients if available, particularly for myelosuppression (eg, leukopenia, thrombocytopenia).

Dosing: Kidney Impairment: Pediatric

IV: There are no dosage adjustments provided in the manufacturer's labeling; experience in adult patients suggests that dose should be reduced in renal impairment.

Dosing: Liver Impairment: Pediatric

IV: There are no dosage adjustments provided in the manufacturer's labeling; use with caution, dosage adjustment may be necessary.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.

Implant:

>10%:

Central nervous system: Seizure (37%; new or worsening: 20%), cerebral edema (4% to 23%), depression (16%)

Dermatologic: Skin rash (5% to 12%)

Gastrointestinal: Nausea (22%), vomiting (21%), constipation (19%)

Genitourinary: Urinary tract infection (21%)

Neuromuscular & skeletal: Weakness (22%)

Miscellaneous: Wound healing impairment (14% to 16%), fever (12%)

1% to 10%:

Cardiovascular: Chest pain (5%)

Central nervous system: Intracranial hypertension (9%), cerebral hemorrhage (6%), meningitis (4%)

Gastrointestinal: Abdominal pain (8%)

Infection: Abscess (local 6%)

Neuromuscular & skeletal: Back pain (7%)

IV: Frequency not defined:

Cardiovascular: Chest pain, flushing (with rapid infusion), occlusive arterial disease, tachycardia

Central nervous system: Brain disease, headache, seizure

Dermatologic: Alopecia, burning sensation of skin, hyperpigmentation

Gastrointestinal: Anorexia, diarrhea, nausea, vomiting

Genitourinary: Gynecomastia

Hematologic & oncologic: Acute leukemia, anemia, bone marrow dysplasia, leukemia, leukopenia (common; onset: 5 to 6 weeks; recovery: after 1 to 2 weeks), thrombocytopenia (common: onset: ~4 weeks; recovery: after 1 to 2 weeks)

Hepatic: Increased serum alkaline phosphatase, increased serum bilirubin, increased serum transaminases

Hypersensitivity: Hypersensitivity reaction

Infection: Opportunistic infection

Local: Burning sensation at injection site, erythema at injection site, pain at injection site, swelling at injection site, tissue necrosis at injection site

Ophthalmic: Blurred vision, conjunctival edema, conjunctival hemorrhage, ophthalmic signs and symptoms (loss of depth perception), suffusion of the conjunctiva (with rapid infusion)

Renal: Azotemia (progressive), nephron atrophy, renal failure

Respiratory: Interstitial pulmonary disease, pneumonitis, pulmonary fibrosis (occurring up to 17 years after treatment), pulmonary infiltrates

<1%, postmarketing, and/or case reports: Febrile neutropenia (Chopra 1993), sepsis (implant), venous thrombosis at injection site (IV)

Contraindications

IV: Hypersensitivity to carmustine or any component of the formulation.

Implant: There are no contraindications listed in the manufacturer's labeling.

Canadian labeling: Additional contraindications (not in the US labeling): IV: Hypersensitivity to other nitrosoureas; pregnancy; breastfeeding.

Warnings/Precautions

Concerns related to adverse effects:

• Bone marrow suppression: Carmustine IV causes bone marrow suppression, primarily thrombocytopenia (which may lead to bleeding) and leukopenia (which may cause infection). Hematologic toxicity is dose-limiting, may be severe, and is generally delayed and cumulative; thrombocytopenia is usually more severe than leukopenia. Myelosuppression generally occurs 4 to 6 weeks after administration; thrombocytopenia occurs at ~4 weeks and persists for 1 to 2 weeks; leukopenia occurs at 5 to 6 weeks and persists for 1 to 2 weeks. Anemia may occur (less common and less severe than leukopenia or thrombocytopenia).

• Hepatic: Reversible increases in transaminases, bilirubin, and alkaline phosphatase have been reported (rare) with the IV formulation.

• Infusion-site reactions: Rapid infusions are associated with skin flushing and conjunctiva redness (onset: <2 hours; duration ~4 hours). Carmustine is also associated with injection-site burning and local tissue reactions, including swelling, pain, erythema, and necrosis, have been reported. Monitor infusion site closely for infiltration or injection-site reactions. Avoid extravasation.

• Intracranial hypertension: Brain edema has been reported in patients with newly diagnosed glioma receiving wafer implants, including one report of intracranial mass effect unresponsive to corticosteroids that led to brain herniation. Intracranial hypertension may be related to brain edema, inflammation, or necrosis of brain tissue surrounding resection.

• Meningitis: Cases of meningitis have occurred in patients with recurrent glioma receiving wafer implants. Two cases were bacterial (one patient required removal of implants 4 days after implantation and the other developed meningitis following reoperation for recurrent tumor). Another case was determined to be chemical meningitis and resolved with corticosteroids.

• Ocular toxicity: Investigational administration (intraarterial intracarotid route [not an approved route]) has been associated with ocular toxicity.

• Pulmonary toxicity: Carmustine IV is associated with dose-related pulmonary toxicity; patients receiving cumulative doses >1,400 mg/m2 are at significantly higher risk. Delayed onset of pulmonary fibrosis may occur years after treatment (may be fatal), particularly in children. Pulmonary toxicity has occurred in children and adolescents up to 17 years after treatment; this occurred in ages 1 to 16 for the treatment of intracranial tumors; cumulative doses ranged from 770 to 1,800 mg/m2 (in combination with cranial radiotherapy). Pulmonary toxicity is characterized by pulmonary infiltrates and/or fibrosis and has been reported from 9 days to 43 months after nitrosourea treatment (including carmustine). Although pulmonary toxicity generally occurs in patients who have received prolonged treatment, pulmonary fibrosis has been reported with cumulative doses below 1,400 mg/m2. Interstitial fibrosis at lower doses has occurred (rare). In addition to high cumulative doses, other risk factors for pulmonary toxicity include history of lung disease and baseline predicted forced vital capacity (FVC) or carbon monoxide diffusing capacity (DLCO) <70%. For high-dose treatment (transplant; off-label dose), acute lung injury may occur ~1 to 3 months post transplant; advise patients to contact their transplant physician for dyspnea, cough, or fever.

• Renal: Renal failure, progressive azotemia, and decreased kidney size have been reported.

• Secondary malignancies: Long-term IV use is associated with the development of secondary malignancies (acute leukemias and bone marrow dysplasias).

• Seizures: Seizures occurred in patients who received carmustine wafer implants, including new or worsening (treatment-emergent) seizures. Just over half of treatment-emergent seizures occurred within 5 days of surgery; the median onset of first new or worsened post-operative seizure was 4 days.

• Wound healing impairment: Impaired neurosurgical wound healing, including wound dehiscence, delayed healing, and subdural, subgaleal, or wound effusions may occur with carmustine wafer implant treatment; cerebrospinal fluid leaks have also been reported.

Special populations:

• Pediatric: Children are at higher risk of delayed pulmonary toxicity with the IV formulation.

Dosage form specific issues:

• Injection: Diluent may contain ethanol or propylene glycol (formulation-dependent; refer to manufacturer's labeling).

• Wafer: Monitor closely for known craniotomy-related complications (seizure, intracranial infection, abnormal wound healing, brain edema). Wafer migration may occur; avoid communication between the resection cavity and the ventricular system to prevent wafer migration; communications larger than the wafer should be closed prior to implantation; wafer migration into the ventricular system may cause obstructive hydrocephalus.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Solution Reconstituted, Intravenous:

BiCNU: 100 mg (1 ea [DSC]) [contains alcohol, usp]

Generic: 50 mg (1 ea [DSC]); 100 mg (1 ea); 300 mg (1 ea [DSC])

Solution Reconstituted, Intravenous [preservative free]:

Generic: 100 mg (1 ea)

Wafer, Implant:

Gliadel Wafer: 7.7 mg (8 ea) [contains polifeprosan 20]

Generic Equivalent Available: US

May be product dependent

Pricing: US

Solution (reconstituted) (Carmustine Intravenous)

100 mg (per each): $421.20 - $2,142.88

Wafer (Gliadel Wafer Implant)

7.7 mg (per each): $6,335.99

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution Reconstituted, Intravenous:

BiCNU: 100 mg (1 ea) [contains alcohol, usp]

Generic: 100 mg (1 ea)

Administration: Adult

Carmustine (IV) is associated with a high emetic potential; antiemetics are recommended to prevent nausea and vomiting (Ref).

Injection: Infuse slowly over at least 2 hours (infusions <2 hours may lead to injection site pain or burning); infuse through a free-flowing saline or dextrose infusion, or administer through a central catheter to alleviate venous pain/irritation. Do not exceed a rate of 1.66 mg/m2/minute.

Irritant; infiltration may result in local pain, erythema, swelling, burning and skin necrosis; the alcohol-based diluent may be an irritant, especially with high doses. Avoid extravasation. Monitor infusion site.

High-dose carmustine (transplant dose; off-label use): Infuse over a least 2 hours to avoid excessive flushing, agitation, and hypotension; was infused over 1 hour in some trials (Ref). High-dose carmustine may be fatal if not followed by stem cell rescue. Monitor vital signs frequently during infusion; patients should be supine during infusion and may require the Trendelenburg position, fluid support, and vasopressor support.

Implant: Double glove before handling; outer gloves should be discarded as chemotherapy waste after handling wafers. Any wafer or remnant that is removed upon repeat surgery should be discarded as chemotherapy waste. The outer surface of the external foil pouch is not sterile. Open pouch gently; avoid pressure on the wafers to prevent breakage. Wafers that are broken in half may be used, however, wafers broken into more than 2 pieces should be discarded in a biohazard container. Slight overlapping of wafers during placement is acceptable. Oxidized regenerated cellulose (Surgicel) may be placed over the wafer to secure; irrigate cavity prior to closure.

Topical (off-label use): Wear gloves during application. Apply solution with brush or gauze pads; ointment and solution should be applied to involved areas only; avoid contact with eyes/orifices (Ref).

Administration: Pediatric

Parenteral: IV: Infuse over 2 hours at a rate not to exceed 1.66 mg/m2/minute; infusions <2 hours may lead to injection-site pain or burning. Infuse through a free-flowing NS or D5W infusion, or administer through a central catheter to alleviate venous pain/irritation.

High-dose carmustine: Infuse over at least 2 hours at a rate not to exceed 1.66 mg/m2/minute to avoid excessive flushing, agitation, and hypotension. Monitor vital signs frequently during infusion; patients should be supine during infusion and may require the Trendelenburg position, fluid support, and vasopressor support.

Hazardous Drugs Handling Considerations

Hazardous agent (NIOSH 2024 [table 1]).

Use appropriate precautions for receiving, handling, storage, preparation, dispensing, transporting, administration, and disposal. Follow NIOSH and USP 800 recommendations and institution-specific policies/procedures for appropriate containment strategy (NIOSH 2023; NIOSH 2024; USP-NF 2020).

Use: Labeled Indications

Central nervous system tumors:

Injection: Palliative treatment of brain tumors including glioblastoma, brainstem glioma, medulloblastoma, astrocytoma, ependymoma, and metastatic brain tumors.

Wafer (implant): Treatment of newly diagnosed high-grade glioma (as an adjunct to surgery and radiation); treatment of recurrent glioblastoma (as adjunct to surgery).

Hodgkin lymphoma, relapsed/refractory: Injection: Palliative treatment (secondary) of Hodgkin lymphoma (in combination with other antineoplastics) that has relapsed with or was refractory to primary therapy.

Use: Off-Label: Adult

Hematopoietic cell or bone marrow transplant, autologous, conditioning regimen; Mycosis fungoides, early stage (topical)

Medication Safety Issues
Sound-alike/look-alike issues:

Carmustine may be confused with bendamustine, lomustine

High alert medication:

The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drug classes (chemotherapeutic agent, parenteral and oral) which have a heightened risk of causing significant patient harm when used in error (High-Alert Medications in Acute Care, Community/Ambulatory Care, and Long-Term Care Settings).

Metabolism/Transport Effects

None known.

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.

5-Aminosalicylic Acid Derivatives: May increase myelosuppressive effects of Myelosuppressive Agents. Risk C: Monitor

Abrocitinib: May increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid

Antithymocyte Globulin (Equine): Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Antithymocyte Globulin (Equine). Specifically, these effects may be unmasked if the dose of cytotoxic chemotherapy is reduced. Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Antithymocyte Globulin (Equine). Specifically, infections may occur with greater severity and/or atypical presentations. Risk C: Monitor

Antithyroid Agents: Myelosuppressive Agents may increase neutropenic effects of Antithyroid Agents. Risk C: Monitor

Baricitinib: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Baricitinib. Risk X: Avoid

BCG Products: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of BCG Products. Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of BCG Products. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid

Brincidofovir: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Brincidofovir. Risk C: Monitor

Brivudine: May increase adverse/toxic effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid

Chikungunya Vaccine (Live): Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Chikungunya Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Chikungunya Vaccine (Live). Risk X: Avoid

Chloramphenicol (Ophthalmic): May increase adverse/toxic effects of Myelosuppressive Agents. Risk C: Monitor

Chloramphenicol (Systemic): Myelosuppressive Agents may increase myelosuppressive effects of Chloramphenicol (Systemic). Risk X: Avoid

Cimetidine: May increase myelosuppressive effects of Carmustine. Management: Consider alternatives to cimetidine in patients receiving carmustine. If the combination cannot be avoided, monitor for enhanced carmustine myelotoxicity. Risk D: Consider Therapy Modification

Cladribine: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Cladribine. Risk X: Avoid

CloZAPine: Myelosuppressive Agents may increase adverse/toxic effects of CloZAPine. Specifically, the risk for neutropenia may be increased. Risk C: Monitor

Coccidioides immitis Skin Test: Coadministration of Immunosuppressants (Cytotoxic Chemotherapy) and Coccidioides immitis Skin Test may alter diagnostic results. Management: Consider discontinuing cytotoxic chemotherapy several weeks prior to coccidioides immitis skin antigen testing to increase the likelihood of accurate diagnostic results. Risk D: Consider Therapy Modification

COVID-19 Vaccine (Inactivated Virus): Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of COVID-19 Vaccine (Inactivated Virus). Risk C: Monitor

COVID-19 Vaccine (mRNA): Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of COVID-19 Vaccine (mRNA). Management: Give a 3-dose primary series for all patients aged 6 months and older taking immunosuppressive medications or therapies. Booster doses are recommended for certain age groups. See CDC guidance for details. Risk D: Consider Therapy Modification

COVID-19 Vaccine (Subunit): Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of COVID-19 Vaccine (Subunit). Risk C: Monitor

Deferiprone: Myelosuppressive Agents may increase neutropenic effects of Deferiprone. Management: Avoid the concomitant use of deferiprone and myelosuppressive agents whenever possible. If this combination cannot be avoided, monitor the absolute neutrophil count more closely. Risk D: Consider Therapy Modification

Dengue Tetravalent Vaccine (Live): Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Dengue Tetravalent Vaccine (Live). Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Dengue Tetravalent Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid

Denosumab: May increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Management: Consider the risk of serious infections versus the potential benefits of coadministration of denosumab and cytotoxic chemotherapy. If combined, monitor patients for signs/symptoms of serious infections. Risk D: Consider Therapy Modification

Deucravacitinib: May increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid

Etrasimod: May increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid

Fexinidazole: Myelosuppressive Agents may increase myelosuppressive effects of Fexinidazole. Risk X: Avoid

Filgotinib: May increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid

Fosphenytoin-Phenytoin: Carmustine may decrease serum concentration of Fosphenytoin-Phenytoin. Management: Consider alternatives to fosphenytoin-phenytoin in carmustine treated patients. If combined, monitor closely for reduced phenytoin concentrations and increase fosphenytoin-phenytoin doses as needed. Risk D: Consider Therapy Modification

Inebilizumab: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Inebilizumab. Risk C: Monitor

Influenza Virus Vaccines: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Influenza Virus Vaccines. Management: Administer influenza vaccines at least 2 weeks prior to initiating chemotherapy if possible. If vaccination occurs less than 2 weeks prior to or during chemotherapy, revaccinate at least 3 months after therapy discontinued if immune competence restored. Risk D: Consider Therapy Modification

Leflunomide: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Leflunomide. Management: Increase the frequency of chronic monitoring of platelet, white blood cell count, and hemoglobin or hematocrit to monthly, instead of every 6 to 8 weeks, if leflunomide is coadministered with immunosuppressive agents, such as cytotoxic chemotherapy. Risk D: Consider Therapy Modification

Lenograstim: Antineoplastic Agents may decrease therapeutic effects of Lenograstim. Management: Avoid the use of lenograstim 24 hours before until 24 hours after the completion of myelosuppressive cytotoxic chemotherapy. Risk D: Consider Therapy Modification

Linezolid: May increase myelosuppressive effects of Myelosuppressive Agents. Risk C: Monitor

Lipegfilgrastim: Antineoplastic Agents may decrease therapeutic effects of Lipegfilgrastim. Management: Avoid concomitant use of lipegfilgrastim and myelosuppressive cytotoxic chemotherapy. Lipegfilgrastim should be administered at least 24 hours after the completion of myelosuppressive cytotoxic chemotherapy. Risk D: Consider Therapy Modification

Melphalan: May increase adverse/toxic effects of Carmustine. Specifically, melphalan may sensitize patients to carmustine lung toxicity. Risk C: Monitor

Mumps- Rubella- or Varicella-Containing Live Vaccines: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Mumps- Rubella- or Varicella-Containing Live Vaccines. Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid

Nadofaragene Firadenovec: Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Nadofaragene Firadenovec. Specifically, the risk of disseminated adenovirus infection may be increased. Risk X: Avoid

Natalizumab: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Natalizumab. Risk X: Avoid

Ocrelizumab: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Ocrelizumab. Risk C: Monitor

Ofatumumab: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Ofatumumab. Risk C: Monitor

Olaparib: Myelosuppressive Agents may increase myelosuppressive effects of Olaparib. Risk C: Monitor

Palifermin: May increase adverse/toxic effects of Antineoplastic Agents. Specifically, the duration and severity of oral mucositis may be increased. Management: Do not administer palifermin within 24 hours before, during infusion of, or within 24 hours after administration of myelotoxic chemotherapy. Risk D: Consider Therapy Modification

PHENobarbital: May decrease serum concentration of Carmustine. Management: Consider alternatives to phenobarbital when using carmustine. If combined, monitor for reduced carmustine efficacy. Risk D: Consider Therapy Modification

Pidotimod: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Pidotimod. Risk C: Monitor

Pimecrolimus: May increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid

Piperacillin: May increase hypokalemic effects of Antineoplastic Agents. Risk C: Monitor

Pneumococcal Vaccines: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Pneumococcal Vaccines. Risk C: Monitor

Poliovirus Vaccine (Live/Trivalent/Oral): Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Poliovirus Vaccine (Live/Trivalent/Oral). Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Poliovirus Vaccine (Live/Trivalent/Oral). Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid

Polymethylmethacrylate: Immunosuppressants (Cytotoxic Chemotherapy) may increase hypersensitivity effects of Polymethylmethacrylate. Management: Use caution when considering use of bovine collagen-containing implants such as the polymethylmethacrylate-based Bellafill brand implant in patients who are receiving immunosuppressants. Consider use of additional skin tests prior to administration. Risk D: Consider Therapy Modification

Primidone: May decrease serum concentration of Carmustine. Management: Consider alternatives to primidone when using carmustine. If combined, monitor for reduced carmustine efficacy. Risk D: Consider Therapy Modification

Promazine: May increase myelosuppressive effects of Myelosuppressive Agents. Risk C: Monitor

Rabies Vaccine: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Rabies Vaccine. Management: Complete rabies vaccination at least 2 weeks before initiation of immunosuppressant therapy if possible. If combined, check for rabies antibody titers, and if vaccination is for post exposure prophylaxis, administer a 5th dose of the vaccine. Risk D: Consider Therapy Modification

Ritlecitinib: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Ritlecitinib. Risk X: Avoid

Ropeginterferon Alfa-2b: Myelosuppressive Agents may increase myelosuppressive effects of Ropeginterferon Alfa-2b. Management: Avoid coadministration of ropeginterferon alfa-2b and other myelosuppressive agents. If this combination cannot be avoided, monitor patients for excessive myelosuppressive effects. Risk D: Consider Therapy Modification

Ruxolitinib (Topical): Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Ruxolitinib (Topical). Risk X: Avoid

Sipuleucel-T: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Sipuleucel-T. Management: Consider reducing the dose or discontinuing the use of immunosuppressants, such as cytotoxic chemotherapy, prior to initiating sipuleucel-T therapy. Risk D: Consider Therapy Modification

Sphingosine 1-Phosphate (S1P) Receptor Modulators: May increase immunosuppressive effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk C: Monitor

Tacrolimus (Topical): Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Tacrolimus (Topical). Risk X: Avoid

Talimogene Laherparepvec: Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Talimogene Laherparepvec. Specifically, the risk of infection from the live, attenuated herpes simplex virus contained in talimogene laherparepvec may be increased. Risk X: Avoid

Tertomotide: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Tertomotide. Risk X: Avoid

Tofacitinib: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Tofacitinib. Risk X: Avoid

Typhoid Vaccine: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Typhoid Vaccine. Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Typhoid Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid

Ublituximab: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Ublituximab. Risk C: Monitor

Upadacitinib: Immunosuppressants (Cytotoxic Chemotherapy) may increase immunosuppressive effects of Upadacitinib. Risk X: Avoid

Vaccines (Live): Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Vaccines (Live). Specifically, the risk of vaccine-associated infection may be increased. Vaccines (Live) may decrease therapeutic effects of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid

Vaccines (Non-Live/Inactivated/Non-Replicating): Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Vaccines (Non-Live/Inactivated/Non-Replicating). Management: Give non-live/inactivated/non-replicating vaccines at least 2 weeks prior to starting chemotherapy when possible. Patients vaccinated less than 14 days before or during chemotherapy should be revaccinated at least 3 months after therapy is complete. Risk D: Consider Therapy Modification

Yellow Fever Vaccine: Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Yellow Fever Vaccine. Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Yellow Fever Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Risk X: Avoid

Zoster Vaccine (Live/Attenuated): Immunosuppressants (Cytotoxic Chemotherapy) may increase adverse/toxic effects of Zoster Vaccine (Live/Attenuated). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may decrease therapeutic effects of Zoster Vaccine (Live/Attenuated). Risk X: Avoid

Reproductive Considerations

Evaluate pregnancy status prior to therapy. Patients who could become pregnant should use highly effective contraceptives during and for at least 6 months following treatment with carmustine. Patients with partners who could become pregnant should use highly effective contraceptives during and for at least 3 months following treatment with carmustine. Carmustine may impair male fertility; advise males of potential risk of infertility.

Pregnancy Considerations

Based on the mechanism of action, and data from animal reproduction studies, in utero exposure to carmustine may cause fetal harm. Outcome information related to the use of carmustine in pregnancy is limited (NTP 2013).

Breastfeeding Considerations

It is not known if carmustine is present in breast milk.

Due to the potential for serious adverse reactions in the breastfed infant, the manufacturer recommends breastfeeding be discontinued during treatment with the injection and for at least 7 days after implantation of the wafer.

Monitoring Parameters

Verify pregnancy status prior to therapy in patients who could become pregnant.

Injection: CBC with differential and platelet count (weekly for at least 6 weeks after each dose), pulmonary function tests (FVC, DLCO; at baseline and frequently during treatment), LFTs (transaminases and bilirubin; periodically during treatment), renal function tests (periodically). Monitor BP and vital signs during administration. Monitor infusion site for possible infiltration or injection-site reactions. Monitor for signs/symptoms of pulmonary toxicity and for development of secondary malignancies.

Wafer: Monitor postoperatively for seizures, impaired neurosurgical wound healing, and signs/symptoms of meningitis, CNS infection, and obstructive hydrocephalus; monitor closely for intracranial hypertension related to brain edema, inflammation, or necrosis of brain tissue surrounding resection.

The American Society of Clinical Oncology hepatitis B virus (HBV) screening and management provisional clinical opinion (ASCO [Hwang 2020]) recommends HBV screening with hepatitis B surface antigen, hepatitis B core antibody, total Ig or IgG, and antibody to hepatitis B surface antigen prior to beginning (or at the beginning of) systemic anticancer therapy; do not delay treatment for screening/results. Detection of chronic or past HBV infection requires a risk assessment to determine antiviral prophylaxis requirements, monitoring, and follow-up.

Mechanism of Action

Carmustine interferes with the normal function of DNA and RNA by alkylation and cross-linking the strands of DNA and RNA, and by possible protein modification; may also inhibit enzyme processes by carbamylation of amino acids in protein.

Pharmacokinetics (Adult Data Unless Noted)

Absorption: Wafer: Systemic absorption measurable for ~24 hours after insertion

Distribution: IV: 3.3 L/kg; readily crosses blood-brain barrier producing CSF levels ≥50% of blood plasma levels; highly lipid soluble

Metabolism: Rapidly hepatic; forms active metabolites

Half-life elimination: IV: 15 to 75 minutes

Time to peak: Wafer: Systemic: ~3 hours after insertion

Excretion: IV: Urine (~60% to 70%) within 96 hours; lungs (~10% as CO2)

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AR) Argentina: Bicnu | Bodacler | Consium;
  • (AT) Austria: Bcnu | Carmubris | Carmustin obvius | Carmustin waymade;
  • (AU) Australia: Bicnu | Carmustine Juno | Carmustine lupin | Carmustine medsurge | Gliadel | Gliadel wafer;
  • (BE) Belgium: Nitrumon;
  • (BG) Bulgaria: Bcnu | Carmustine Obvius;
  • (BR) Brazil: Becenum | Gliadel | Nibisnu;
  • (CL) Chile: Bodacler | Carmustina;
  • (CO) Colombia: Bicnu | Carm spal p | Carmustina;
  • (CZ) Czech Republic: Bicnu | Carmustine accord | Carmustine Obvius | Carmustine tillomed | Carmustine Waymade | Carmustine zentiva;
  • (DE) Germany: Carmubris | Carmustin accord | Carmustin ratiopharm | Carmustin waymade | Carmustine Obvius | Gliadel;
  • (EC) Ecuador: Bicnu;
  • (EE) Estonia: Bicnu | Carmubris | Carmustine accord | Caroma | Carustine;
  • (ES) Spain: Bicnu | Carmustina accord | Carmustina obvius | Carmustina teva | Gliadel;
  • (FI) Finland: Becenun | Carmustine accord | Carmustine macure | Carmustine Obvius;
  • (FR) France: Bicnu | Carmustine accord | Carmustine Obvius | Gliadel;
  • (GB) United Kingdom: Carmustine Obvius | Gliadel;
  • (GR) Greece: Bicnu | Carmubris | Carmustine/tillomed | Gliadel;
  • (HK) Hong Kong: Gliadel;
  • (HU) Hungary: Bicnu | Carmustine Obvius | Carmustine zentiva;
  • (IE) Ireland: Bicnu | Gliadel;
  • (IN) India: Consium;
  • (IT) Italy: Bicnu | Carmustina | Carmustina waymade | Carmustine Obvius;
  • (JP) Japan: Gliadel;
  • (KR) Korea, Republic of: Bicnu;
  • (LT) Lithuania: Bicnu | Carmustine zentiva | Consium;
  • (LU) Luxembourg: Nitrumon;
  • (LV) Latvia: Bicnu | Carmustine Obvius;
  • (MX) Mexico: Bicnu | Gliadel;
  • (MY) Malaysia: Carmuther | Carustine | Gliadel wafer;
  • (NL) Netherlands: Carmustine accord | Carmustine Obvius | Carmustine teva | Carmustine tillomed;
  • (NO) Norway: Becenun | Bicnu | Carmubris | Carmustine macure | Carmustine Obvius;
  • (NZ) New Zealand: Bicnu;
  • (PE) Peru: Bicnu | Carmustina;
  • (PH) Philippines: Bicnu;
  • (PL) Poland: Bicnu | Carmubris | Carmustine Obvius | Carmustine zentiva | Carmuther;
  • (PR) Puerto Rico: Bicnu | Gliadel;
  • (PT) Portugal: Bicnu | Carmustina obvius | Carmustina teva | Gliadel;
  • (RU) Russian Federation: Bicnu;
  • (SA) Saudi Arabia: Bicnu;
  • (SE) Sweden: Becenun | Carmustine accord | Carmustine macure | Carmustine Obvius;
  • (SI) Slovenia: Bcnu | Carmubris | Karmustin teva;
  • (SK) Slovakia: Carmustine Obvius | Carmustine zentiva;
  • (TN) Tunisia: Bicnu | Carustine;
  • (TR) Turkey: Bicnu;
  • (TW) Taiwan: Bicnu | Carmuther | Gliadel wafer;
  • (UY) Uruguay: Bicnu | Carmustina fu;
  • (ZA) South Africa: Carmubris | Carmuther | Gliadel
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