Version July 2025
Pentostatin should be administered under the supervision of a physician qualified and experienced in the use of cancer chemotherapeutic agents.
The use of higher doses than those specified is not recommended. Dose-limiting severe renal, liver, pulmonary, and CNS toxicities occurred in Phase 1 studies that used pentostatin at higher doses (20 to 50 mg/m2 in divided doses over 5 days) than recommended.
In a clinical investigation in patients with refractory chronic lymphocytic leukemia using pentostatin at the recommended dose in combination with fludarabine phosphate, 4 of 6 patients entered in the study had severe or fatal pulmonary toxicity. The use of pentostatin in combination with fludarabine phosphate is not recommended.
Cutaneous T-cell lymphoma, mycosis fungoides/Sezary syndrome (off-label use): IV: 4 mg/m2 once weekly for 3 weeks, then 4 mg/m2 once every 2 weeks for 6 weeks, then 4 mg/m2 once a month for a maximum of 6 months (Ref) or 3.75 to 5 mg/m2 on days 1, 2, and 3 every 3 weeks for at least 2 cycles then until disease progression or unacceptable toxicity (Ref).
Graft-versus-host disease (off-label use):
Acute graft-versus-host disease, steroid-refractory, treatment:
Initial therapy: IV: 1.5 mg/m2 days 1 to 3 and days 15 to 17 (in combination with corticosteroids) (Ref).
Steroid-refractory disease: IV: 1.5 mg/m2 daily for 3 days; may repeat after 2 weeks if needed (Ref).
Chronic graft-versus-host disease, steroid-refractory, treatment: Note: Avoid the use of pentostatin for management of pulmonary chronic graft-versus-host disease. Use caution when given in combination with mTOR inhibitors (Ref).
IV: 4 mg/m2 once every 2 weeks; discontinue after 6 months for sustained objective response, or continue every 2 to 4 weeks for up to 12 months if still improving (Ref) or 4 mg/m2 once every 2 weeks for 3 months (Ref).
Hairy cell leukemia, previously untreated or refractory: Note: Consensus guidelines suggest pentostatin may be continued until hematologic parameters have normalized and splenomegaly is no longer present on physical exam (Ref).
IV: 4 mg/m2 once every 2 weeks; continue until complete response is achieved or until 2 doses after complete response (in the absence of unacceptable toxicity); discontinue after 12 months if the best response achieved is a partial response or after 6 months if partial or complete response is not achieved (Ref).
T-cell prolymphocytic leukemia, refractory (off-label use): IV: 4 mg/m2 once weekly for 4 weeks, then 4 mg/m2 every 2 weeks until optimum response is achieved (Ref) or 4 mg/m2 once weekly for 4 weeks, then 4 mg/m2 every 2 weeks (in combination with alemtuzumab) until complete or best response or up to a total of 14 doses (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Altered kidney function prior to treatment initiation:
There are no dosage adjustments provided in the manufacturer's labeling; although not adequately studied, two patients with CrCl 50 to 60 mL/minute achieved responses when treated with 2 mg/m2/dose.
The following adjustments have also been recommended:
Indication not specified:
CrCl 46 to 60 mL/minute: Administer 70% of dose (Ref).
CrCl 31 to 45 mL/minute: Administer 60% of dose (Ref).
CrCl <30 mL/minute: Consider use of alternative drug (Ref).
Indication not specified:
CrCl ≥60 mL/minute: Administer 4 mg/m2/dose (Ref).
CrCl 40 to 59 mL/minute: Administer 3 mg/m2/dose (Ref).
CrCl 20 to 39 mL/minute: Administer 2 mg/m2/dose (Ref).
Graft-versus-host disease (off-label use):
CrCl 30 to 50 mL/minute/1.73 m2: Reduce dose by 50% (Ref).
CrCl <30 mL/minute/1.73 m2: Withhold dose (Ref).
T-cell prolymphocytic leukemia, refractory (off-label use):
CrCl ≥60 mL/minute: Administer 4 mg/m2/dose (Ref).
CrCl 40 to 59 mL/minute: Administer 3 mg/m2/dose (Ref).
CrCl 35 to 39 mL/minute: Administer 2 mg/m2/dose (Ref).
CrCl <35 mL/minute: Withhold treatment until CrCl ≥35 mL/minute (Ref).
Acute kidney toxicity during treatment:
Elevated serum creatinine: Withhold pentostatin and determine CrCl.
There are no dosage adjustments provided in the manufacturer’s labeling.
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 (full weight) for calculation of BSA in pentostatin dosing for hematopoietic cell transplant conditioning regimens in adults (Ref).
Acute graft-versus-host disease (off-label use):
ANC <500/mm3: Withhold treatment until ANC recovery (Ref).
ANC 500 to <1,000/mm3: Reduce dose by 50% (Ref).
Chronic graft-versus-host disease (off-label use):
ANC <500/mm3, platelets <20,000/mm3, or neutropenic fever: Reduce dose by 50% (Ref).
ANC 500 to 1,000/mm3: Reduce dose by 25% (Ref).
Hairy cell leukemia:
ANC <200/mm3 (with baseline ANC >500/mm3): Temporarily interrupt treatment until ANC returns to pre-dose levels (Ref).
CNS toxicity: Withhold treatment or discontinue (Ref).
Infection, active: Interrupt treatment until infection is controlled (Ref).
Rash: Severe rashes may require treatment interruption (Ref).
Other severe adverse reactions: Withhold treatment or discontinue (Ref).
Refer to adult dosing.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
>10%:
Central nervous system: Fatigue (29% to 42%), pain (8% to 20%), chills (11% to 19%), headache (13% to 17%), central nervous system toxicity (1% to 11%)
Dermatologic: Skin rash (26% to 43%), pruritus (10% to 21%), skin changes (4% to 17%)
Gastrointestinal: Nausea (≤63%), vomiting (≤63%), diarrhea (15% to 17%), anorexia (13% to 16%), abdominal pain (4% to 16%), stomatitis (5% to 12%)
Hematologic & oncologic: Leukopenia (22% to 60%), anemia (8% to 35%), thrombocytopenia (6% to 32%)
Hepatic: Increased serum transaminases (2% to 19%)
Hypersensitivity: Hypersensitivity reaction (2% to 11%)
Infection: Infection (7% to 38%)
Neuromuscular & skeletal: Myalgia (11% to 19%), asthenia (10% to 12%)
Respiratory: Cough (17% to 20%), upper respiratory tract infection (13% to 16%), rhinitis (10% to 11%), dyspnea (8% to 11%)
Miscellaneous: Fever (42% to 46%)
1% to 10%:
Cardiovascular: Chest pain (3% to 10%), facial edema (3% to 10%), hypotension (3% to 10%), peripheral edema (3% to 10%), angina pectoris (<3%), atrioventricular block (<3%), bradycardia (<3%), cardiac arrhythmia (<3%), cardiac failure (<3%), deep vein thrombophlebitis (<3%), hypertension (<3%), pericardial effusion (<3%), phlebitis (<3%), pulmonary embolism (<3%), sinoatrial arrest (<3%), syncope (<3%), tachycardia (<3%), vasculitis (<3%), ventricular premature contractions (<3%)
Central nervous system: Anxiety (3% to 10%), confusion (3% to 10%), depression (3% to 10%), dizziness (3% to 10%), drowsiness (3% to 10%), insomnia (3% to 10%), nervousness (3% to 10%), paresthesia (3% to 10%), abnormal dreams (<3%), abnormality in thinking (<3%), amnesia (<3%), ataxia (<3%), dysarthria (<3%), emotional lability (<3%), encephalitis (<3%), hallucination (<3%), hangover effect (<3%), hostility (<3%), meningism (<3%), neuralgia (<3%), neuritis (<3%), neuropathy (<3%), neurosis (<3%), paralysis (<3%), seizure (<3%), twitching (<3%), vertigo (<3%)
Dermatologic: Diaphoresis (8% to 10%), urticaria (3% to 10%), xeroderma (3% to 10%), cellulitis (6%), furunculosis (4%), acne vulgaris (<3%), alopecia (<3%), eczema (<3%), skin photosensitivity (<3%)
Endocrine & metabolic: Amenorrhea (<3%), decreased libido (<3%), hypercalcemia (<3%), hyponatremia (<3%), gout (<3%), loss of libido (<3%)
Gastrointestinal: Dyspepsia (3% to 10%), flatulence (3% to 10%), gingivitis (3% to 10%), constipation (<3%), dysgeusia (<3%), dysphagia (<3%), glossitis (<3%), intestinal obstruction (<3%), oral candidiasis (2%)
Genitourinary: Urinary tract infection (3%), impotence (<3%), lump in breast (<3%)
Hematologic & oncologic: Agranulocytosis (3% to 10%), hemorrhage (3% to 10%), acute leukemia (<3%), aplastic anemia (<3%), hemolytic anemia (<3%), neoplasm (<3%), petechial rash (<3%)
Infection: Herpes zoster infection (8%), viral infection (8%), bacterial infection (5%), herpes simplex infection (4%), sepsis (3%), abscess (2%)
Neuromuscular & skeletal: Arthralgia (3% to 6%), arthritis (<3%), hyperkinetic muscle activity (<3%), osteomyelitis (1%)
Ophthalmic: Conjunctivitis (4%), amblyopia (<3%), disease of the lacrimal apparatus (<3%), nonreactive pupils (<3%), photophobia (<3%), retinopathy (<3%), visual disturbance (<3%), watery eyes (<3%), xerophthalmia (<3%)
Otic: Deafness (<3%), labyrinthitis (<3%), otalgia (<3%), tinnitus (<3%)
Renal: Increased serum creatinine (3% to 10%), nephrolithiasis (<3%), renal disease (<3%), renal failure syndrome (<3%), renal function abnormality (<3%), renal insufficiency (<3%)
Respiratory: Pharyngitis (8% to 10%), sinusitis (6%), pneumonia (5%), asthma (3% to 10%), bronchitis (3%), bronchospasm (<3%), flu-like symptoms (<3%), laryngeal edema (<3%)
<1%: Fungal skin infection, uveitis, vision loss
Frequency not defined:
Hematologic & oncologic: Bone marrow depression, neutropenia
Hepatic: Hepatotoxicity
Renal: Nephrotoxicity
Respiratory: Pulmonary toxicity
Postmarketing: Acute respiratory failure, autoimmune thrombocytopenia, exfoliative dermatitis, febrile neutropenia, hemolytic-uremic syndrome, pulmonary edema, thrombotic thrombocytopenic purpura
Hypersensitivity to pentostatin or any component of the formulation.
Concerns related to adverse effects:
• Bone marrow suppression: Myelosuppression may occur, primarily in the early treatment courses. Neutropenia may worsen during initial courses for the treatment of hairy cell leukemia. If severe neutropenia persists beyond early cycles, evaluate for disease status (including bone marrow examination).
• CNS toxicity: Severe CNS toxicities have occurred with doses higher than recommended; do not exceed the recommended dose.
• Dermatologic toxicity: Severe rashes may occur and may worsen with therapy continuation.
• Hepatotoxicity: Severe liver toxicities have occurred with doses higher than recommended; do not exceed the recommended dose. May cause elevations (usually reversible) in LFTs.
• Kidney toxicity: Severe kidney toxicities have occurred with doses higher than recommended; do not exceed the recommended dose. Serum creatinine elevations occurring at recommended doses are usually minor and reversible.
• Pulmonary toxicity: Severe pulmonary toxicities have occurred with doses higher than recommended; do not exceed the recommended dose. Concomitant use with fludarabine has resulted in serious or fatal pulmonary toxicity; the use of pentostatin in combination with fludarabine is not recommended.
Disease-related concerns:
• Infections: Preexisting infections may worsen with pentostatin treatment; if possible, infections should be resolved prior to pentostatin treatment initiation. Temporarily withhold pentostatin for active infection during therapy. Guidelines from the Hairy Cell Leukemia Society suggest that pentostatin has been used in patients with an active infection (HCLF [Grever 2017]). Use in patients with infections only if the potential benefit justifies the potential risk.
Concurrent drug therapy issues:
• Drug-drug interactions: Concurrent use with fludarabine has resulted in severe or fatal pulmonary toxicity and is not recommended. Fatal pulmonary edema and hypotension have been reported in patients treated with pentostatin in combination with carmustine, etoposide, or high-dose cyclophosphamide as part of a myeloablative regimen for bone marrow transplant.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Solution Reconstituted, Intravenous:
Nipent: 10 mg (1 ea)
No
Solution (reconstituted) (Nipent Intravenous)
10 mg (per each): $3,541.54
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IV: Administer IV over 20 to 30 minutes or as a bolus infusion. Hydrate with 500 to 1,000 mL fluid prior to infusion and 500 mL after infusion.
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).
Hairy cell leukemia, previously untreated or refractory: Treatment (as a single agent) of untreated and interferon alfa-refractory hairy cell leukemia in patients with active disease (clinically significant anemia, neutropenia, thrombocytopenia, or disease-related symptoms).
Cutaneous T-cell lymphomas, mycosis fungoides/Sezary syndrome; Graft-versus-host disease, acute, treatment; Graft-versus-host disease, chronic, steroid-refractory, treatment; T-cell large granular lymphocytic leukemia; T-cell prolymphocytic leukemia, refractory
Pentostatin may be confused with pentamidine, pentosan
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).
Nipent [US, Canada, and multiple international markets] may be confused with Nipin brand name for nifedipine [Italy, Singapore]
None known.
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
Cladribine: Agents that Undergo Intracellular Phosphorylation may decrease therapeutic effects of Cladribine. Risk X: Avoid
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
Fludarabine: Pentostatin may increase adverse/toxic effects of Fludarabine. Specifically, the risk of fatal pulmonary toxicity may be increased. Risk X: Avoid
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
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
Nelarabine: Pentostatin may decrease active metabolite exposure of Nelarabine. 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
Pegademase Bovine: May decrease therapeutic effects of Pentostatin. Pentostatin may decrease therapeutic effects of Pegademase Bovine. Risk C: Monitor
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
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
Patients who could become pregnant should avoid becoming pregnant during treatment.
Based on the mechanism of action and on findings from animal reproduction studies, in utero exposure to pentostatin may cause fetal harm.
It is not known if pentostatin is present in breast milk.
Due to the potential for serious adverse reactions in the breastfed infant, a decision should be made to discontinue pentostatin or breastfeeding, taking into account the importance of treatment to the mother.
CBC with differential and platelet count (prior to each dose; more frequently during initial cycles), peripheral blood smears (periodically for hairy cells and to assess treatment response), liver function, serum uric acid, renal function (serum creatinine and/or CrCl at baseline, and serum creatinine prior to each dose), bone marrow evaluation. Monitor for signs/symptoms of infection or of pulmonary, CNS, and/or dermatologic toxicity.
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.
Pentostatin is a purine antimetabolite that inhibits adenosine deaminase, preventing the deamination of adenosine to inosine. Accumulation of deoxyadenosine (dAdo) and deoxyadenosine 5′-triphosphate (dATP) results in a reduction of purine metabolism which blocks DNA synthesis and leads to cell death.
Distribution: Vd: IV: 20 L/m2 (Lathia 2002).
Protein binding: ~4%.
Half-life elimination: Terminal: 5.7 hours; Kidney impairment (CrCl <50 mL/minute): 18 hours (range: 11 to 23 hours [Lathia 2002]).
Excretion: Urine (~90%).
Clearance: Adults: 68 mL/minute/m2 (mean).
Kidney function impairment: Pentostatin’s half-life is extended in patients with CrCl <50 mL/minute.
