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ALERT: U.S. Boxed Warning
The FDA-approved labeling includes a boxed warning. See Warnings/Precautions section for a concise summary of this information. For verbatim wording of the boxed warning, consult the product labeling or www.fda.gov.
Pronunciation
(strep toe ZOE sin)
Generic Available (U.S.)
No
Brand Names: U.S.
Brand Names: Canada
Pharmacologic Category
Pharmacologic Category Synonyms
Use: Labeled Indications
Treatment of metastatic islet cell carcinoma of the pancreas
Use: Unlabeled
Treatment of adrenal tumors
Pregnancy Risk Factor
D
Lactation
Enters breast milk/contraindicated
Contraindications
Pregnancy
Warnings/Precautions
Boxed warnings:
• Experienced physician: See “Other warnings/precautions” below.
• Renal toxicity: See “Concerns related to adverse effects” below.
• Systemic toxicities: See “Concerns related to adverse effects” below.
Special handling:
• Hazardous agent: Use appropriate precautions for handling and disposal.
Concerns related to adverse effects:
• Insulin release: There may be an acute release of insulin during treatment; keep syringe of D50W at bedside during administration.
• Renal toxicity: [U.S. Boxed Warning]: Renal toxicity is dose-related and cumulative and may be severe or fatal.
• Systemic toxicities: [U.S. Boxed Warning]: Other major toxicities include liver dysfunction, diarrhea, nausea, vomiting, and hematologic changes.
Other warnings/precautions:
• Experienced physician: [U.S. Boxed Warning]: Should be administered under the supervision of an experienced cancer chemotherapy physician.
• Extravasation/tissue irritation: Local tissue irritation may occur; extravasation may cause local tissue lesions and necrosis.
Adverse Reactions
>10%:
Gastrointestinal: Nausea and vomiting (100%)
Hepatic: LFTs increased
Miscellaneous: Hypoalbuminemia
Renal: BUN increased, Clcr decreased, hypophosphatemia, nephrotoxicity (25% to 75%), proteinuria, renal dysfunction (65%), renal tubular acidosis
1% to 10%:
Endocrine & metabolic: Hypoglycemia (6%)
Gastrointestinal: Diarrhea (10%)
Local: Pain at injection site
<1%: Confusion, lethargy, depression, leukopenia, thrombocytopenia, liver dysfunction, secondary malignancy
Myelosuppressive:
WBC: Mild
Platelets: Mild
Onset: 7 days
Nadir: 14 days
Recovery: 21 days
Metabolism/Transport Effects
None known.
Drug Interactions
BCG: Immunosuppressants may diminish the therapeutic effect of BCG. Risk X: Avoid combination
CloZAPine: Myelosuppressive Agents may enhance the adverse/toxic effect of CloZAPine. Specifically, the risk for agranulocytosis may be increased. Risk X: Avoid combination
Coccidioidin Skin Test: Immunosuppressants may diminish the diagnostic effect of Coccidioidin Skin Test. Risk C: Monitor therapy
Denosumab: May enhance the adverse/toxic effect of Immunosuppressants. Specifically, the risk for serious infections may be increased. Risk C: Monitor therapy
Echinacea: May diminish the therapeutic effect of Immunosuppressants. Risk D: Consider therapy modification
Herbs (Hypoglycemic Properties): May enhance the hypoglycemic effect of Hypoglycemic Agents. Risk C: Monitor therapy
Hypoglycemic Agents: May enhance the adverse/toxic effect of other Hypoglycemic Agents. Risk C: Monitor therapy
Leflunomide: Immunosuppressants may enhance the adverse/toxic effect of Leflunomide. Specifically, the risk for hematologic toxicity such as pancytopenia, agranulocytosis, and/or thrombocytopenia may be increased. Management: Consider not using a leflunomide loading dose in patients receiving other immunosuppressants. Patients receiving both leflunomide and another immunosuppressant should be monitored for bone marrow suppression at least monthly. Risk D: Consider therapy modification
Natalizumab: Immunosuppressants may enhance the adverse/toxic effect of Natalizumab. Specifically, the risk of concurrent infection may be increased. Risk X: Avoid combination
Pimecrolimus: May enhance the adverse/toxic effect of Immunosuppressants. Risk X: Avoid combination
Roflumilast: May enhance the immunosuppressive effect of Immunosuppressants. Risk D: Consider therapy modification
Sipuleucel-T: Immunosuppressants may diminish the therapeutic effect of Sipuleucel-T. Risk C: Monitor therapy
Tacrolimus (Topical): May enhance the adverse/toxic effect of Immunosuppressants. Risk X: Avoid combination
Trastuzumab: May enhance the neutropenic effect of Immunosuppressants. Risk C: Monitor therapy
Vaccines (Inactivated): Immunosuppressants may diminish the therapeutic effect of Vaccines (Inactivated). Risk C: Monitor therapy
Vaccines (Live): Immunosuppressants may enhance the adverse/toxic effect of Vaccines (Live). Vaccinial infections may develop. Immunosuppressants may diminish the therapeutic effect of Vaccines (Live). Management: Avoid use of live organism vaccines with immunosuppressants; live-attenuated vaccines should not be given for at least 3 months after immunosuppressants. Risk X: Avoid combination
Storage
Store intact vials under refrigeration. Vials are stable for 1 year at room temperature. Solution reconstituted with SWFI or NS is stable for 48 hours at room temperature and 96 hours under refrigeration. Further dilution in D5W or NS is stable for 48 hours at room temperature and 96 hours under refrigeration when protected from light. Manufacturer recommends that reconstituted solution be used within 12 hours; vial does not contain a preservative
Reconstitution
Dilute powder with 9.5 mL SWFI or NS to a concentration of 100 mg/mL.
Compatibility
Stable in D5W, NS.
Y-site administration: Compatible: Amifostine, etoposide phosphate, filgrastim, gemcitabine, granisetron, melphalan, ondansetron, teniposide, thiotepa, vinorelbine. Incompatible: Allopurinol, aztreonam, cefepime, piperacillin/tazobactam.
Mechanism of Action
Interferes with the normal function of DNA by alkylation and cross-linking the strands of DNA, and by possible protein modification
Pharmacodynamics/Kinetics
Duration: Disappears from serum in 4 hours
Distribution: Concentrates in liver, intestine, pancreas, and kidney
Metabolism: Rapidly hepatic
Half-life elimination: 35-40 minutes
Excretion: Urine (60% to 70% as metabolites); exhaled gases (5%); feces (1%)
Dosage
I.V. (refer to individual protocols):
Children and Adults:
Single-agent therapy: 1-1.5 g/m2 weekly for 6 weeks followed by a 4-week rest period
Combination therapy: 0.5-1 g/m2 for 5 consecutive days followed by a 4- to 6-week rest period
Dosing adjustment in renal impairment: The FDA-approved labeling does not contain dosing adjustments; however, it is recommended to use clinical judgment weighing benefit vs risk of renal toxicity in patients with pre-existing renal impairment. The following dosing adjustments have been used by some clinicians (Aronoff, 2007): Adults:
Clcr 10-50 mL/minute: Administer 75% of dose
Clcr <10 mL/minute: Administer 50% of dose
Dosing adjustment in hepatic impairment: There are no specific guidelines on dosage adjustment in patients with hepatic impairment. Streptozocin is rapidly hepatically metabolized; dose should be decreased in patients with severe liver disease.
Administration: I.V.
Administer as short (30-60 minutes) or 6-hour infusion; may be given by rapid I.V. push
Administration: I.V. Detail
pH: 3.5-4.5
Monitoring Parameters
Monitor renal function closely
Patient Education
This drug can only be given I.V.; report immediately any redness, swelling, pain, or burning at infusion site. Maintain adequate hydration unless instructed to restrict fluid intake. You will be more sensitive to infection. If you have diabetes, monitor glucose levels closely; may cause hypoglycemia. May cause nausea and vomiting; nervousness, dizziness, confusion, or lethargy; or loss of body hair (reversible when treatment is finished). Report unusual back pain, change in urinary pattern; persistent fever, chills, or sore throat; unusual bleeding; blood in urine, vomitus, or stool; chest pain, palpitations, or respiratory difficulty; or swelling of feet or lower legs.
Dental Health: Effects on Dental Treatment
No significant effects or complications reported
Dental Health: Vasoconstrictor/Local Anesthetic Precautions
No information available to require special precautions
Mental Health: Effects on Mental Status
May cause lethargy, confusion, or depression
Mental Health: Effects on Psychiatric Treatment
May cause leukopenia; use caution with clozapine and carbamazepine; renal dysfunction occurs commonly with streptozocin; will need to monitor and adjust lithium and gabapentin doses
Nursing: Physical Assessment/Monitoring
Antiemetic should be administered prior to therapy (emetic potential 100%). Infusion site should be monitored closely to prevent extravasation. Monitor for nephrotoxicity/renal dysfunction (I & O, hematuria, edema, BUN), hepatotoxicity (jaundice, fatigue, LFTs), hypoglycemia, and diarrhea (dehydration) on a regular basis. Caution patients with diabetes to monitor glucose levels closely (may precipitate hypoglycemia).
Oncology: Emetic Potential
Very high (>90%)
Oncology: Vesicant
Vesicant
Dosage Forms
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, powder for reconstitution:
Zanosar®: 1 g
References
Aronoff GR, Bennett WM, Berns JS, et al, Drug Prescribing in Renal Failure: Dosing Guidelines for Adults and Children, 5th ed. Philadelphia, PA: American College of Physicians; 2007, p 101.
Bolzan AD and Bianchi MS, “Genotoxicity of Streptozotocin,” Mutat Res, 2002, 512(2-3):121-34.
International Brand Names
Lexi-Comp.com
Last full review/revision February 2012
Content last modified February 2012
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