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Pentostatin: Drug information

Pentostatin: Drug information
(For additional information see "Pentostatin: Patient drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
ALERT: US Boxed Warning
Experienced physician:

Pentostatin should be administered under the supervision of a physician qualified and experienced in the use of cancer chemotherapeutic agents.

Drug toxicities:

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.

Brand Names: US
  • Nipent
Pharmacologic Category
  • Antineoplastic Agent, Antimetabolite;
  • Antineoplastic Agent, Antimetabolite (Purine Analog)
Dosing: Adult
Chronic lymphocytic leukemia

Chronic lymphocytic leukemia (off-label use):

Previously treated: IV: 4 mg/m2 once every 3 weeks (in combination with cyclophosphamide and rituximab) for 6 cycles (Lamanna 2006).

Previously untreated: IV: 2 mg/m2 once every 3 weeks (in combination with cyclophosphamide and rituximab) for 6 cycles (Kay 2007).

Cutaneous T-cell lymphoma, mycosis fungoides/Sezary syndrome

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 (Ho 1999).

Graft-versus-host disease

Graft-versus-host disease (off-label use):

Acute graft-versus-host disease, steroid-refractory:

Initial therapy: IV: 1.5 mg/m2 days 1 to 3 and days 15 to 17 (in combination with corticosteroids) (Alousi 2009).

Steroid-refractory disease: IV: 1.5 mg/m2 daily for 3 days; may repeat after 2 weeks if needed (Bolanos-Meade 2005).

Chronic graft-versus-host disease, steroid-refractory: 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 (Jacobsohn 2007; Jacobsohn 2009) or 4 mg/m2 once every 2 weeks for 3 months (Wolff 2011).

Hairy cell leukemia

Hairy cell leukemia (previously untreated or refractory): IV: 4 mg/m2 once every 2 weeks. Note: The optimal duration has not been determined; in the absence of unacceptable toxicity, may continue until complete response is achieved or until 2 doses after complete response. 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. Consensus guidelines suggest pentostatin may be continued until hematologic parameters have normalized and splenomegaly is no longer present on physical exam (Grever 2017).

T-cell large granular lymphocytic leukemia

T-cell large granular lymphocytic leukemia (off-label use; based on limited data): IV: 4 mg/m2 once every 1 to 2 weeks until maximum response is achieved (Osuji 2006) or 4 to 5 mg/m2 every 2 weeks for 8 courses (Fortune 2010) or 4 mg/m2 once a week (in combination with alemtuzumab) (Aribi 2007).

T-cell prolymphocytic leukemia, refractory

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 (Mercieca 1994) 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 (Ravandi 2009).

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

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. For renal toxicity during treatment, withhold pentostatin for elevated serum creatinine and determine CrCl.

The following adjustments have also been recommended:

Indication not specified (Kintzel 1995):

CrCl 46 to 60 mL/minute: Administer 70% of dose.

CrCl 31 to 45 mL/minute: Administer 60% of dose.

CrCl <30 mL/minute: Consider use of alternative drug.

Indication not specified (Lathia 2002):

CrCl ≥60 mL/minute: Administer 4 mg/m2/dose.

CrCl 40 to 59 mL/minute: Administer 3 mg/m2/dose.

CrCl 20 to 39 mL/minute: Administer 2 mg/m2/dose.

Chronic lymphocytic leukemia, previously treated (off-label use; Lamanna 2006): Serum creatinine >2 mg/dL or 20% above patient's baseline: Withhold treatment until serum creatinine ≤2 mg/dL or returns to baseline, or until CrCl ≥50 mL/minute.

Graft-versus-host disease (off-label use; Alousi 2009; Bolanos-Meade 2005; Jacobsohn 2007; Jacobsohn 2009; Poi 2013; Wolff 2011):

CrCl 30 to 50 mL/minute/1.73 m2: Reduce dose by 50%.

CrCl <30 mL/minute/1.73 m2: Withhold dose.

T-cell prolymphocytic leukemia, refractory (off-label use; Ravandi 2009):

CrCl ≥60 mL/minute: Administer 4 mg/m2/dose.

CrCl 40 to 59 mL/minute: Administer 3 mg/m2/dose.

CrCl 35 to 39 mL/minute: Administer 2 mg/m2/dose.

CrCl <35 mL/minute: Withhold treatment until CrCl ≥35 mL/minute.

Dosing: Hepatic Impairment: Adult

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 (ASCO [Griggs 2021]).

American Society for Blood and Marrow Transplantation practice guideline committee position statement on chemotherapy dosing in obesity: Utilize actual body weight (full weight) for calculation of BSA in pentostatin dosing for hematopoietic stem cell transplant conditioning regimens in adults (ASBMT [Bubalo 2014]).

Dosing: Adjustment for Toxicity: Adult

Acute graft-versus-host disease (off-label use):

ANC <500/mm3: Withhold treatment until ANC recovery (Alousi 2009).

ANC 500 to <1,000/mm3: Reduce dose by 50% (Alousi 2009).

Chronic graft-versus-host disease (off-label use):

ANC <500/mm3, platelets <20,000/mm3, or neutropenic fever: Reduce dose by 50% (Jacobsohn 2007; Jacobsohn 2009; Wolff 2011).

ANC 500 to 1,000/mm3: Reduce dose by 25% (Jacobsohn 2007; Wolff 2011).

Hairy cell leukemia:

ANC <200/mm3 (with baseline ANC >500/mm3): Temporarily interrupt treatment until ANC returns to pre-dose levels.

CNS toxicity: Withhold treatment or discontinue.

Infection, active: Interrupt treatment until infection is controlled.

Rash: Severe rashes may require treatment interruption or discontinuation.

Other severe adverse reactions: Withhold treatment or discontinue.

Dosing: Older Adult

Refer to adult dosing.

Adverse Reactions

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

Contraindications

Hypersensitivity to pentostatin or any component of the formulation

Warnings/Precautions

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). Monitor blood counts during treatment (more frequently in the initial cycles).

• CNS toxicity: [US Boxed Warning]: Severe CNS toxicities have occurred with doses higher than recommended; do not exceed the recommended dose. Withhold treatment or discontinue for CNS toxicity.

• Dermatologic toxicity: Severe rashes may occur and may worsen with therapy continuation; may require treatment interruption or discontinuation.

• Hepatotoxicity: [US Boxed Warning]: Severe liver toxicities have occurred with doses higher than recommended; do not exceed the recommended dose. May cause elevations (usually reversible) in liver function tests.

• Pulmonary toxicity: [US Boxed Warning]: 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.

• Renal toxicity: [US Boxed Warning]: Severe renal 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. Withhold treatment for elevated serum creatinine and determine creatinine clearance. May require dosage adjustment or therapy discontinuation.

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 (Grever 2017). Use in patients with infections only if the potential benefit justifies the potential risk.

• Renal impairment: Use with caution in patients with renal dysfunction (CrCl <60 mL/minute); the terminal half-life is prolonged; may require dosage adjustment.

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.

Dosage Forms: US

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

Solution Reconstituted, Intravenous:

Nipent: 10 mg (1 ea)

Generic Equivalent Available: US

No

Pricing: US

Solution (reconstituted) (Nipent Intravenous)

10 mg (per each): $3,219.58

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.

Administration: Adult

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 Drugs Handling Considerations

Hazardous agent (NIOSH 2016 [group 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 2016; USP-NF 2020).

Use: Labeled Indications

Hairy cell leukemia: 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).

Use: Off-Label: Adult

Chronic lymphocytic leukemia; 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

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

Pentostatin may be confused with pentamidine, pentosan

High alert medication:

This medication is in a class the Institute for Safe Medication Practices (ISMP) includes among its list of drug classes which have a heightened risk of causing significant patient harm when used in error.

International issues:

Nipent [US, Canada, and multiple international markets] may be confused with Nipin brand name for nifedipine [Italy, Singapore]

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 Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

5-Aminosalicylic Acid Derivatives: May enhance the myelosuppressive effect of Myelosuppressive Agents. Risk C: Monitor therapy

Abrocitinib: May enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

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

Baricitinib: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Baricitinib. Risk X: Avoid combination

BCG (Intravesical): Myelosuppressive Agents may diminish the therapeutic effect of BCG (Intravesical). Risk X: Avoid combination

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

Brincidofovir: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Brincidofovir. Risk C: Monitor therapy

Brivudine: May enhance the adverse/toxic effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

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

Chloramphenicol (Ophthalmic): May enhance the adverse/toxic effect of Myelosuppressive Agents. Risk C: Monitor therapy

Chloramphenicol (Systemic): Myelosuppressive Agents may enhance the myelosuppressive effect of Chloramphenicol (Systemic). Risk X: Avoid combination

Cladribine: May enhance the myelosuppressive effect of Myelosuppressive Agents. Risk X: Avoid combination

Cladribine: Agents that Undergo Intracellular Phosphorylation may diminish the therapeutic effect of Cladribine. Risk X: Avoid combination

Cladribine: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Cladribine. Risk X: Avoid combination

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

Coccidioides immitis Skin Test: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the diagnostic effect of Coccidioides immitis Skin Test. 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 (Adenovirus Vector): Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of COVID-19 Vaccine (Adenovirus Vector). Management: Administer a 2nd dose using an mRNA COVID-19 vaccine (at least 4 weeks after the primary vaccine dose) and a bivalent booster dose (at least 2 months after the additional mRNA dose or any other boosters). Risk D: Consider therapy modification

COVID-19 Vaccine (Inactivated Virus): Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of COVID-19 Vaccine (Inactivated Virus). Risk C: Monitor therapy

COVID-19 Vaccine (mRNA): Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect 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 diminish the therapeutic effect of COVID-19 Vaccine (Subunit). Risk C: Monitor therapy

COVID-19 Vaccine (Virus-like Particles): Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of COVID-19 Vaccine (Virus-like Particles). Risk C: Monitor therapy

Deferiprone: Myelosuppressive Agents may enhance the neutropenic effect 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 enhance the adverse/toxic effect of Dengue Tetravalent Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Dengue Tetravalent Vaccine (Live). Risk X: Avoid combination

Denosumab: May enhance the immunosuppressive effect 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 enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

Dipyrone: May enhance the adverse/toxic effect of Myelosuppressive Agents. Specifically, the risk for agranulocytosis and pancytopenia may be increased Risk X: Avoid combination

Etrasimod: May enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

Fexinidazole: Myelosuppressive Agents may enhance the myelosuppressive effect of Fexinidazole. Risk X: Avoid combination

Filgotinib: May enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

Fludarabine: Pentostatin may enhance the adverse/toxic effect of Fludarabine. Specifically, the risk of fatal pulmonary toxicity may be increased. Risk X: Avoid combination

Inebilizumab: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Inebilizumab. Risk C: Monitor therapy

Influenza Virus Vaccines: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect 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 enhance the immunosuppressive effect 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 diminish the therapeutic effect 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

Lipegfilgrastim: Antineoplastic Agents may diminish the therapeutic effect 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 enhance the adverse/toxic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination

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

Natalizumab: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Natalizumab. Risk X: Avoid combination

Nelarabine: Pentostatin may decrease serum concentrations of the active metabolite(s) of Nelarabine. Risk X: Avoid combination

Ocrelizumab: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Ocrelizumab. Risk C: Monitor therapy

Ofatumumab: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Ofatumumab. Risk C: Monitor therapy

Olaparib: Myelosuppressive Agents may enhance the myelosuppressive effect of Olaparib. Risk C: Monitor therapy

Palifermin: May enhance the adverse/toxic effect 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 diminish the therapeutic effect of Pentostatin. Pentostatin may diminish the therapeutic effect of Pegademase Bovine. Risk C: Monitor therapy

Pidotimod: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Pidotimod. Risk C: Monitor therapy

Pimecrolimus: May enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk X: Avoid combination

Pneumococcal Vaccines: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Pneumococcal Vaccines. Risk C: Monitor therapy

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

Polymethylmethacrylate: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the potential for allergic or hypersensitivity reactions to 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 enhance the myelosuppressive effect of Myelosuppressive Agents. Risk C: Monitor therapy

Rabies Vaccine: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect 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 enhance the immunosuppressive effect of Ritlecitinib. Risk X: Avoid combination

Ropeginterferon Alfa-2b: Myelosuppressive Agents may enhance the myelosuppressive effect 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 enhance the immunosuppressive effect of Ruxolitinib (Topical). Risk X: Avoid combination

Sipuleucel-T: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect 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 Modulator: May enhance the immunosuppressive effect of Immunosuppressants (Cytotoxic Chemotherapy). Risk C: Monitor therapy

Tacrolimus (Topical): Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Tacrolimus (Topical). Risk X: Avoid combination

Talimogene Laherparepvec: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the adverse/toxic effect 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 combination

Tertomotide: Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Tertomotide. Risk X: Avoid combination

Tofacitinib: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Tofacitinib. Risk X: Avoid combination

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

Ublituximab: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Ublituximab. Risk C: Monitor therapy

Upadacitinib: Immunosuppressants (Cytotoxic Chemotherapy) may enhance the immunosuppressive effect of Upadacitinib. Risk X: Avoid combination

Vaccines (Inactivated/Non-Replicating): Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Vaccines (Inactivated/Non-Replicating). Management: Give inactivated vaccines at least 2 weeks prior to initiation of chemotherapy when possible. Patients vaccinated less than 14 days before initiating or during chemotherapy should be revaccinated at least 3 months after therapy is complete. Risk D: Consider therapy modification

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

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

Reproductive Considerations

Females of reproductive potential should avoid becoming pregnant during treatment.

Pregnancy Considerations

Based on the mechanism of action and on findings from animal reproduction studies, in utero exposure to pentostatin may cause fetal harm.

Breastfeeding Considerations

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.

Monitoring Parameters

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 pulmonary, CNS, and 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.

Mechanism of Action

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.

Pharmacokinetics (Adult Data Unless Noted)

Distribution: Vd: IV: 20 L/m2 (Lathia 2002).

Protein binding: ~4%.

Half-life elimination: Terminal: 5.7 hours; Renal impairment (CrCl <50 mL/minute): 18 hours (range: 11 to 23 hours [Lathia 2002]).

Excretion: Urine (~90%).

Clearance: Adults: 68 mL/minute/m2 (mean).

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

  • (AR) Argentina: Nipent;
  • (EE) Estonia: Nipent;
  • (ES) Spain: Nipent;
  • (FR) France: Nipent;
  • (GB) United Kingdom: Nipent;
  • (GR) Greece: Nipent;
  • (IT) Italy: Nipent;
  • (JP) Japan: Coforin | Coforin yamakawa;
  • (KR) Korea, Republic of: Nipent;
  • (LT) Lithuania: Nipent;
  • (LV) Latvia: Nipent;
  • (NL) Netherlands: Nipent;
  • (NZ) New Zealand: Nipent;
  • (PL) Poland: Nipent;
  • (PR) Puerto Rico: Nipent;
  • (PT) Portugal: Nipent
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