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Novantrone (Mitoxantrone Hydrochloride) - Description and Clinical Pharmacology



NOVANTRONE® (mitoxantrone hydrochloride) is a synthetic antineoplastic anthracenedione for intravenous use.  The molecular formula is C22H28N4O6∙2HCl and the molecular weight is 517.41.  It is supplied as a concentrate that MUST BE DILUTED PRIOR TO INJECTION.  The concentrate is a sterile, nonpyrogenic, dark blue aqueous solution containing mitoxantrone hydrochloride equivalent to 2 mg/mL mitoxantrone free base, with sodium chloride (0.80% w/v), sodium acetate (0.005% w/v), and acetic acid (0.046% w/v) as inactive ingredients.  The solution has a pH of 3.0 to 4.5 and contains 0.14 mEq of sodium per mL.  The product does not contain preservatives.  The chemical name is 1,4-dihydroxy-5,8-bis[[2-[(2-hydroxyethyl) amino]ethyl]amino]-9,10-anthracenedione dihydrochloride and the structural formula is:


Mechanism of Action:

Mitoxantrone, a DNA-reactive agent that intercalates into deoxyribonucleic acid (DNA) through hydrogen bonding, causes crosslinks and strand breaks.  Mitoxantrone also interferes with ribonucleic acid (RNA) and is a potent inhibitor of topoisomerase II, an enzyme responsible for uncoiling and repairing damaged DNA.  It has a cytocidal effect on both proliferating and nonproliferating cultured human cells, suggesting lack of cell cycle phase specificity.

NOVANTRONE® has been shown in vitro to inhibit B cell, T cell, and macrophage proliferation and impair antigen presentation, as well as the secretion of interferon gamma, TNFα, and IL-2.


Pharmacokinetics of mitoxantrone in patients following a single intravenous administration of NOVANTRONE® can be characterized by a three-compartment model.  The mean alpha half-life of mitoxantrone is 6 to 12 minutes, the mean beta half-life is 1.1 to 3.1 hours and the mean gamma (terminal or elimination) half-life is 23 to 215 hours (median approximately 75 hours).  Pharmacokinetic studies have not been performed in humans receiving multiple daily dosing.  Distribution to tissues is extensive:  steady-state volume of distribution exceeds 1,000 L/m2.  Tissue concentrations of mitoxantrone appear to exceed those in the blood during the terminal elimination phase.  In the healthy monkey, distribution to brain, spinal cord, eye, and spinal fluid is low.

In patients administered 15-90 mg/m2 of NOVANTRONE® intravenously, there is a linear relationship between dose and the area under the concentration-time curve (AUC).

Mitoxantrone is 78% bound to plasma proteins in the observed concentration range of 26-455 ng/mL.  This binding is independent of concentration and is not affected by the presence of phenytoin, doxorubicin, methotrexate, prednisone, prednisolone, heparin, or aspirin.

Metabolism and Elimination:

Mitoxantrone is excreted in urine and feces as either unchanged drug or as inactive metabolites.  In human studies, 11% and 25% of the dose were recovered in urine and feces, respectively, as either parent drug or metabolite during the 5-day period following drug administration.  Of the material recovered in urine, 65% was unchanged drug.  The remaining 35% was composed of monocarboxylic and dicarboxylic acid derivatives and their glucuronide conjugates.  The pathways leading to the metabolism of NOVANTRONE® have not been elucidated.

Special Populations:

Gender -

The effect of gender on mitoxantrone pharmacokinetics is unknown.

Geriatric -

In elderly patients with breast cancer, the systemic mitoxantrone clearance was 21.3 L/hr/m2, compared with 28.3 L/hr/m2 and 16.2 L/hr/m2 for non-elderly patients with nasopharyngeal carcinoma and malignant lymphoma, respectively.

Pediatric -

Mitoxantrone pharmacokinetics in the pediatric population are unknown.

Race -

The effect of race on mitoxantrone pharmacokinetics is unknown.

Renal Impairment -

Mitoxantrone pharmacokinetics in patients with renal impairment are unknown.

Hepatic Impairment -

Mitoxantrone clearance is reduced by hepatic impairment.  Patients with severe hepatic dysfunction (bilirubin > 3.4 mg/dL) have an AUC more than three times greater than that of patients with normal hepatic function receiving the same dose.  Patients with multiple sclerosis who have hepatic impairment should ordinarily not be treated with NOVANTRONE®.  Other patients with hepatic impairment should be treated with caution and dosage adjustment may be required.

Drug Interactions

In vitro drug interaction studies have demonstrated that mitoxantrone did not inhibit CYP450 1A2, 2A6, 2C9, 2C19, 2D6, 2E1, and 3A4 across a broad concentration range.  The results of in vitro induction studies are inconclusive, but suggest that mitoxantrone may be a weak inducer of CYP450 2E1 activity.

Pharmacokinetic studies of the interaction of NOVANTRONE® with concomitantly administered medications in humans have not been performed.  The pathways leading to the metabolism of NOVANTRONE® have not been elucidated.  To date, post-marketing experience has not revealed any significant drug interactions in patients who have received NOVANTRONE® for treatment of cancer.  Information on drug interactions in patients with multiple sclerosis is limited.


Multiple Sclerosis:

The safety and efficacy of NOVANTRONE® in multiple sclerosis were assessed in two randomized, multicenter clinical studies.

One randomized, controlled study (Study 1) was conducted in patients with secondary progressive or progressive relapsing multiple sclerosis.  Patients in this study demonstrated significant neurological disability based on the Kurtzke Expanded Disability Status Scale (EDSS).  The EDSS is an ordinal scale with 0.5 point increments ranging from 0.0 to 10.0 (increasing score indicates worsening) and based largely on ambulatory impairment in its middle range (EDSS 4.5 to 7.5 points).  Patients in this study had experienced a mean deterioration in EDSS of about 1.6 points over the 18 months prior to enrollment.

Patients were randomized to receive placebo, 5 mg/m2 NOVANTRONE®, or 12 mg/m2 NOVANTRONE® administered IV every 3 months for 2 years.  High-dose methylprednisolone was administered to treat relapses.  The intent-to-treat analysis cohort consisted of 188 patients; 149 completed the 2-year study.  Patients were evaluated every 3 months, and clinical outcome was determined after 24 months.  In addition, a subset of patients was assessed with magnetic resonance imaging (MRI) at baseline, Month 12, and Month 24.  Neurologic assessments and MRI reviews were performed by evaluators blinded to study drug and clinical outcome, although the diagnosis of relapse and the decision to treat relapses with steroids were made by unblinded treating physicians.  A multivariate analysis of five clinical variables (EDSS, Ambulation Index [AI], number of relapses requiring treatment with steroids, months to first relapse needing treatment with steroids, and Standard Neurological Status [SNS]) was used to determine primary efficacy.  The AI is an ordinal scale ranging from 0 to 9 in one point increments to define progressive ambulatory impairment.  The SNS provides an overall measure of neurologic impairment and disability, with scores ranging from 0 (normal neurologic examination) to 99 (worst possible score).

Results of Study 1 are summarized in Table 1.

Table 1: Efficacy Results at Month 24: Study 1
Treatment Groupsp-value
Primary EndpointsPlacebo (N = 64)5 mg/m2 (N = 64)12 mg/m2 (N = 60)
NR = not reached within 24 months; MRI = magnetic resonance imaging.
* Wei-Lachin test.
** Month 24 value minus baseline.
‡ A subset of 110 patients was selected for MRI analysis.  MRI results were not available for all patients at all time points.
Primary efficacy multivariate analysis*---< 0.0001
Primary clinical variables analyzed:     
EDSS change** (mean)0.23– 0.23– 0.130.0194
Ambulation Index change** (mean)0.770.410.300.0306
Mean number of relapses per patient requiring corticosteroid treatment (adjusted for discontinuation)1.200.730.400.0002
Months to first relapse requiring corticosteroid treatment (median [1st quartile])14.2 [6.7]NR [6.9]NR [20.4]0.0004
Standard Neurological Status change** (mean)0.77– 0.38– 1.070.0269
No. of patients with new Gd-enhancing lesions5/32 (16%)4/37 (11%)0/310.022
Change in number of T2-weighted lesions, mean (n)**1.94 (32)0.68 (34)0.29 (28)0.027

A second randomized, controlled study (Study 2) evaluated NOVANTRONE® in combination with methylprednisolone (MP) and was conducted in patients with secondary progressive or worsening relapsing-remitting multiple sclerosis who had residual neurological deficit between relapses.  All patients had experienced at least two relapses with sequelae or neurological deterioration within the previous 12 months.  The average deterioration in EDSS was 2.2 points during the previous 12 months.  During the screening period, patients were treated with two monthly doses of 1 g of IV MP and underwent monthly MRI scans.  Only patients who developed at least one new Gd-enhancing MRI lesion during the 2-month screening period were eligible for randomization.  A total of 42 evaluable patients received monthly treatments of 1 g of IV MP alone (n = 21) or ~12 mg/m2 of IV NOVANTRONE® plus 1 g of IV MP (n = 21) (NOV + MP) for 6 months.  Patients were evaluated monthly, and study outcome was determined after 6 months.  The primary measure of effectiveness in this study was a comparison of the proportion of patients in each treatment group who developed no new Gd-enhancing MRI lesions at 6 months; these MRIs were assessed by a blinded panel.  Additional outcomes were measured, including EDSS and number of relapses, but all clinical measures in this trial were assessed by an unblinded treating physician.  Five patients, all in the MP alone arm, failed to complete the study due to lack of efficacy.

The results of this trial are displayed in Table 2.

Table 2: Efficacy Results: Study 2
Primary Endpoint MP alone (N = 21) NOV + MP (N = 21) p-value
MP = methylprednisolone
NOV + MP = NOVANTRONE® plus methylprednisolone.
* Results at Month 6, not including data for 5 withdrawals in the MP alone group.
Patients (%) without new Gd-enhancing lesions on MRIs (primary endpoint)*5 (31%)19 (90%)0.001
Secondary Endpoints    
EDSS change (Month 6 minus baseline)* (mean)-0.1-1.10.013
Annualized relapse rate (mean per patient)
Patients (%) without relapses7 (33%)14 (67%)0.031

Advanced Hormone-Refractory Prostate Cancer

A multicenter Phase 2 trial of NOVANTRONE® and low-dose prednisone (N + P) was conducted in 27 symptomatic patients with hormone-refractory prostate cancer.  Using NPCP (National Prostate Cancer Project) criteria for disease response, there was one partial responder and 12 patients with stable disease.  However, nine patients or 33% achieved a palliative response defined on the basis of reduction in analgesic use or pain intensity.

These findings led to the initiation of a randomized multicenter trial (CCI-NOV22) comparing the effectiveness of (N + P) to low-dose prednisone alone (P).  Eligible patients were required to have metastatic or locally advanced disease that had progressed on standard hormonal therapy, a castrate serum testosterone level, and at least mild pain at study entry.  NOVANTRONE® was administered at a dose of 12 mg/m2 by short IV infusion every 3 weeks.  Prednisone was administered orally at a dose of 5 mg twice a day.  Patients randomized to the prednisone arm were crossed over to the N + P arm if they progressed or if they were not improved after a minimum of 6 weeks of therapy with prednisone alone.

A total of 161 patients were randomized, 80 to the N + P arm and 81 to the P arm.  The median NOVANTRONE® dose administered was 12 mg/m2 per cycle.  The median cumulative NOVANTRONE® dose administered was 73 mg/m2 (range of 12 to 212 mg/m2).

A primary palliative response (defined as a 2-point decrease in pain intensity in a 6-point pain scale, associated with stable analgesic use, and lasting a minimum of 6 weeks) was achieved in 29% of patients randomized to N + P compared to 12% of patients randomized to P alone (p = 0.011).  Two responders left the study after meeting primary response criterion for two consecutive cycles.  For the purposes of this analysis, these two patients were assigned a response duration of zero days.  A secondary palliative response was defined as a 50% or greater decrease in analgesic use, associated with stable pain intensity, and lasting a minimum of 6 weeks.  An overall palliative response (defined as primary plus secondary responses) was achieved in 38% of patients randomized to N + P compared to 21% of patients randomized to P (p = 0.025).

The median duration of primary palliative response for patients randomized to N + P was 7.6 months compared to 2.1 months for patients randomized to P alone (p = 0.0009).  The median duration of overall palliative response for patients randomized to N + P was 5.6 months compared to 1.9 months for patients randomized to P alone (p = 0.0004).

Time to progression was defined as a 1-point increase in pain intensity, or a > 25% increase in analgesic use, or evidence of disease progression on radiographic studies, or requirement for radiotherapy.  The median time to progression for all patients randomized to N + P was 4.4 months compared to 2.3 months for all patients randomized to P alone (p = 0.0001).  Median time to death was 11.3 months for all patients on the N + P arm compared to 10.8 months for all patients on P alone (p = 0.2324).

Forty-eight patients on the P arm crossed over to receive N + P.  Of these, thirty patients had progressed on P, while 18 had stable disease on P.  The median cycle of crossover was 5 cycles (range of 2 to 16 cycles).  Time trends for pain intensity prior to crossover were significantly worse for patients who crossed over than for those who remained on P alone (p = 0.012).  Nine patients (19%) demonstrated a palliative response on N + P after crossover.  The median time to death for patients who crossed over to N + P was 12.7 months.

The clinical significance of a fall in prostate-specific antigen (PSA) concentrations after chemotherapy is unclear.  On the CCI-NOV22 trial, a PSA fall of 50% or greater for two consecutive follow-up assessments after baseline was reported in 33% of all patients randomized to the N + P arm and 9% of all patients randomized to the P arm.  These findings should be interpreted with caution since PSA responses were not defined prospectively.  A number of patients were inevaluable for response, and there was an imbalance between treatment arms in the numbers of evaluable patients.  In addition, PSA reduction did not correlate precisely with palliative response, the primary efficacy endpoint of this study.  For example, among the 26 evaluable patients randomized to the N + P arm who had a ≥ 50% reduction in PSA, only 13 had a primary palliative response.  Also, among 42 evaluable patients on this arm who did not have this reduction in PSA, 8 nonetheless had a primary palliative response.

Investigators at Cancer and Leukemia Group B (CALGB) conducted a Phase 3 comparative trial of NOVANTRONE® plus hydrocortisone (N + H) versus hydrocortisone alone (H) in patients with hormone-refractory prostate cancer (CALGB 9182).  Eligible patients were required to have metastatic disease that had progressed despite at least one hormonal therapy.  Progression at study entry was defined on the basis of progressive symptoms, increases in measurable or osseous disease, or rising PSA levels.  NOVANTRONE® was administered intravenously at a dose of 14 mg/m2 every 21 days and hydrocortisone was administered orally at a daily dose of 40 mg.  A total of 242 subjects were randomized, 119 to the N + H arm and 123 to the H arm.  There were no differences in survival between the two arms, with a median of 11.1 months in the N + H arm and 12 months in the H arm (p = 0.3298).

Using NPCP criteria for response, partial responses were achieved in 10 patients (8.4%) randomized to the N + H arm compared with 2 patients (1.6%) randomized to the H arm (p = 0.018).  The median time to progression, defined by NPCP criteria, for patients randomized to the N + H arm was 7.3 months compared to 4.1 months for patients randomized to H alone (p = 0.0654).

Approximately 60% of patients on each arm required analgesics at baseline.  Analgesic use was measured in this study using a 5-point scale.  The best percent change from baseline in mean analgesic use was -17% for 61 patients with available data on the N + H arm, compared with +17% for 61 patients on H alone (p = 0.014).  A time trend analysis for analgesic use in individual patients also showed a trend favoring the N + H arm over H alone but was not statistically significant.

Pain intensity was measured using the Symptom Distress Scale (SDS) Pain Item 2 (a 5-point scale).  The best percent change from baseline in mean pain intensity was -14% for 37 patients with available data on the N + H arm, compared with +8% for 38 patients on H alone (p = 0.057).  A time trend analysis for pain intensity in individual patients showed no difference between treatment arms.

Acute Nonlymphocytic Leukemia:

In two large randomized multicenter trials, remission induction therapy for acute nonlymphocytic leukemia (ANLL) with NOVANTRONE® 12 mg/m2 daily for 3 days as a 10-minute intravenous infusion and cytarabine 100 mg/m2 for 7 days given as a continuous 24-hour infusion was compared with daunorubicin 45 mg/m2 daily by intravenous infusion for 3 days plus the same dose and schedule of cytarabine used with NOVANTRONE®.  Patients who had an incomplete antileukemic response received a second induction course in which NOVANTRONE® or daunorubicin was administered for 2 days and cytarabine for 5 days using the same daily dosage schedule.  Response rates and median survival information for both the U.S. and international multicenter trials are given in Table 3:

Table 3: Response Rates, Time to Response, and Survival in U.S. and International Trials
Trial% CompleteResponse (CR)Median Time to CR (days)Survival (days)
NOV = NOVANTRONE® + cytarabine
DAUN  =  daunorubicin + cytarabine
U.S.63 (62/98)53 (54/102)3542312237
International50 (56/112)51 (62/123)3642192230

In these studies, two consolidation courses were administered to complete responders on each arm.  Consolidation therapy consisted of the same drug and daily dosage used for remission induction, but only 5 days of cytarabine and 2 days of NOVANTRONE® or daunorubicin were given.  The first consolidation course was administered 6 weeks after the start of the final induction course if the patient achieved a complete remission.  The second consolidation course was generally administered 4 weeks later.  Full hematologic recovery was necessary for patients to receive consolidation therapy.  For the U.S. trial, median granulocyte nadirs for patients receiving NOVANTRONE® + cytarabine for consolidation courses 1 and 2 were 10/mm3 for both courses, and for those patients receiving daunorubicin + cytarabine nadirs were 170/mm3 and 260/mm3, respectively.  Median platelet nadirs for patients who received NOVANTRONE® + cytarabine for consolidation courses 1 and 2 were 17,000/mm3 and 14,000/mm3, respectively, and were 33,000/mm3 and 22,000/mm3 in courses 1 and 2 for those patients who received daunorubicin + cytarabine.  The benefit of consolidation therapy in ANLL patients who achieve a complete remission remains controversial.  However, in the only well-controlled prospective, randomized multicenter trials with NOVANTRONE® in ANLL, consolidation therapy was given to all patients who achieved a complete remission.  During consolidation in the U.S. study, two myelosuppression-related deaths occurred on the NOVANTRONE® arm and one on the daunorubicin arm.  However, in the international study there were eight deaths on the NOVANTRONE® arm during consolidation which were related to the myelosuppression and none on the daunorubicin arm where less myelosuppression occurred.

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