Version July 2025
Streptozocin should be administered under the supervision of a physician experienced in the use of cancer chemotherapeutic agents. A patient need not be hospitalized but should have access to a facility with a laboratory and supportive resources sufficient to monitor drug tolerance and to protect and maintain a patient compromised by drug toxicity. The physician must judge the possible benefit to the patient against the known toxic effects of this drug in considering the advisability of therapy with streptozocin. The physician should be familiar with the following text before making a judgment and beginning treatment.
Renal toxicity is dose-related and cumulative and may be severe or fatal. Other major toxicities are nausea and vomiting, which may be severe and at times treatment-limiting. In addition, liver dysfunction, diarrhea and hematological changes have been observed in some patients.
Streptozocin is mutagenic. When administered parenterally, it has been found to be tumorigenic or carcinogenic in some rodents.
Dosage guidance:
Safety: Ensure adequate hydration (before and after streptozocin) to reduce the risk for kidney dysfunction (Ref).
Clinical considerations : Streptozocin is associated with a high emetic potential; antiemetics are recommended to prevent nausea and vomiting (Ref).
Adrenocortical carcinoma, metastatic (off-label use): IV: 1,000 mg (or ~500 mg/m2) once daily for 5 days (cycle 1) followed by 2,000 mg (or ~1,000 mg/m2) on day 1 (subsequent cycles) every 3 weeks until disease progression or unacceptable toxicity (in combination with mitotane) (Ref).
Gastrointestinal neuroendocrine tumors (off-label use): IV: 500 mg/m2 once daily on days 1 to 5 every 10 weeks (in combination with fluorouracil); continue until disease progression or unacceptable toxicity (Ref) or 1,000 mg/m2 once every 3 weeks for 3 cycles, if no progression may continue for up to a total of 6 cycles in the absence of unacceptable toxicity (in combination with leucovorin, fluorouracil and cisplatin) (Ref).
Pancreatic neuroendocrine tumors, metastatic:
Daily schedule: IV: 500 mg/m2 once daily for 5 consecutive days every 6 weeks (in combination with either doxorubicin or fluorouracil); continue until disease progression or unacceptable toxicity (Ref).
Weekly schedule: IV: 1,000 mg/m2 once weekly; if therapeutic response not achieved after 2 weeks and no significant toxicity with the previous dose, may escalate dose to a maximum of 1,500 mg/m2 weekly (Ref).
Alternate schedules (off-label dosing): IV: 1,000 mg/m2 once every 3 weeks for up to 6 cycles (in combination with leucovorin, fluorouracil and cisplatin) (Ref) or 400 mg/m2 once daily on days 1 to 5 every 4 weeks (in combination with fluorouracil and doxorubicin) until disease progression or unacceptable toxicity (Ref) or 500 mg/m2 once daily on days 1 to 5 every 5 or 6 weeks (in combination with fluorouracil) for up to 1 year if best response is stable disease (Ref).
Thyroid carcinoma, medullary, advanced or metastatic (off-label use): IV: 500 mg/m2 once daily for 5 consecutive days every 8 weeks(in combination with doxorubicin and alternating with dacarbazine/fluorouracil) until disease progression or unacceptable toxicity, or for a total of 6 cycles if tumor response or stabilization (Ref) or 500 mg/m2 once daily for 5 days every 6 weeks (in combination with fluorouracil and alternating with fluorouracil/dacarbazine); continue until disease progression or unacceptable toxicity (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Kidney impairment prior to treatment initiation:
Altered kidney function:
There are no dosage adjustments provided in the manufacturer’s labeling; however, it is recommended to use caution and clinical judgment weighing benefit versus risk of renal toxicity in patients with preexisting kidney impairment. Adequate hydration may reduce the risk for nephrotoxicity.
The following dosing adjustments have been recommended:
eGFR 46 to 60 mL/minute: Administer 50% of usual dose (Ref).
eGFR 31 to 45 mL/minute: Use is not recommended; however, if use cannot be avoided, consider reducing dose to 25% of the original dose (Ref).
eGFR ≤30 mL/minute: Use is not recommended (Ref).
Hemodialysis: Use is not recommended (Ref).
Acute kidney impairment during treatment: Significant kidney toxicity may require dose reduction or discontinuation.
Hepatic impairment prior to treatment initiation: There are no dosage adjustments provided in the manufacturer’s labeling. However, streptozocin is rapidly hepatically metabolized; use with caution.
Acute hepatotoxicity during treatment: May require dosage reduction or discontinuation.
American Society of Clinical Oncology guidelines for appropriate systemic therapy dosing in adults with cancer with a BMI ≥30 kg/m2: 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).
Bone marrow suppression: May require dosage reduction or discontinuation.
Refer to adult dosing. Select dose cautiously, beginning at the lower end of dosing range.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
Frequency not defined.
Endocrine & metabolic: Decreased glucose tolerance, glycosuria, hyperglycemia, hypoalbuminemia, hypoglycemia, hypophosphatemia, increased lactate dehydrogenase
Gastrointestinal: Diarrhea, nausea, vomiting
Genitourinary: Anuria, azotemia, nephrotoxicity, proteinuria
Hepatic: Increased serum transaminases
Local: Injection site reaction (includes burning sensation at injection site, erythema at injection site, inflammation at injection site, irritation at injection site, swelling at injection site, tenderness at injection site)
Renal: Increased blood urea nitrogen, increased serum creatinine, renal insufficiency, renal tubular acidosis
<1%, postmarketing, and/or case reports: Anemia, bone marrow depression (nadir: 2 to 3 weeks), confusion, depression, diabetes insipidus, hepatic insufficiency, lethargy, leukopenia, metastases, thrombocytopenia
There are no contraindications listed in the manufacturer's labeling.
Concerns related to adverse effects:
• Bone marrow suppression: Hematologic toxicity has been observed. Bone marrow suppression is rare and often involves mild anemia; however, fatal toxicity has occurred with reductions in leucocyte and platelet counts.
• CNS effects: May cause confusion, lethargy or depression; caution patients about performing tasks that require mental alertness (eg, operating machinery or driving).
• Extravasation/tissue irritation: Streptozocin is an irritant with vesicant-like properties. Avoid extravasation. Local tissue irritation or inflammation (burning, edema, erythema, tenderness) may occur, but usually resolves within a few days.
• Gastrointestinal events: Diarrhea and severe nausea and vomiting have been observed.
• Glucose intolerance: Mild to moderate glucose intolerance may occur; generally is reversible. Insulin shock with hypoglycemia has been observed.
• Hepatotoxicity: Liver dysfunction has been observed. Hepatotoxicity may be characterized by elevated transaminases and LDH, or by hypoalbuminemia.
• Kidney toxicity: Kidney toxicity is dose-related and cumulative; may be severe or fatal. Azotemia, anuria, hypophosphatemia, glycosuria, and renal tubular acidosis have been reported. Mild proteinuria is an early sign of renal toxicity. Avoid use in combination with other nephrotoxic medications.
• Secondary malignancy: Streptozocin is mutagenic; parenteral use is tumorigenic and carcinogenic in animals.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution Reconstituted, Intravenous:
Zanosar: 1 g (1 ea [DSC])
No
Solution (reconstituted) (Zanosar Intravenous)
1 g (per each): $419.08
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.
IV: Administer as either a rapid IV injection or as short or prolonged infusion.
Streptozocin is associated with a high emetic potential; antiemetics are recommended to prevent nausea and vomiting (Ref).
Irritant with vesicant-like properties; ensure proper needle or catheter placement prior to and during infusion; avoid extravasation.
Extravasation management: If extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in place); gently aspirate extravasated solution (do NOT flush the line); remove needle/cannula; elevate extremity.
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).
Pancreatic neuroendocrine tumors, metastatic: Treatment of symptomatic or progressive metastatic islet cell carcinoma of the pancreas (functional and nonfunctional).
Adrenocortical carcinoma, metastatic; Gastrointestinal neuroendocrine tumors; Thyroid carcinoma, medullary, advanced or metastatic
Streptozocin may be confused with streptomycin
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).
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.
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
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
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
Piperacillin: May increase hypokalemic effects of Antineoplastic Agents. Risk C: Monitor
Adverse events have been observed in animal reproduction studies.
It is not known if streptozocin is present in breast milk.
Due to the potential for serious adverse reactions in the breastfed infant, breastfeeding is not recommended.
CBC with differential (weekly); blood glucose; renal function tests, including BUN, serum creatinine, and serial urinalysis, and serum electrolytes (at baseline, weekly during, and for 4 weeks after treatment); 24-hour urine collection if proteinuria is detected on urinalysis; liver function tests (weekly). Monitor infusion site.
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.
Streptozocin inhibits DNA synthesis by alkylation and cross-linking the strands of DNA, and by possible protein modification; cell cycle nonspecific.
Onset: 1,500 mg/m2 once weekly: Onset of response: 17 days; median time to maximum response: 35 days.
Distribution: Concentrates in liver, kidney, and pancreatic beta cells.
Metabolism: Rapid; primarily hepatic.
Half-life elimination: <1 hour (Perry 2012).
Excretion: Urine (primarily; up to 20% as parent drug and metabolites).
