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Melphalan – Oral (Alkeran®, L-PAM)

OncoLink Team
Last Modified: January 7, 2016

Pronounced: MEL-fa-lan
Classification: Alkylating Agent

About Melphalan

Melphalan exerts its anti-cancer affect by a process called alkylation. Alkylation damages the DNA of cells, which prevents them from dividing, and causes them to die. Since cancer cells, in general, divide faster and with less error correcting than healthy cells, cancer cells are more sensitive to this damage. In this way, Melphalan slows or stops the growth of cancer cells in your body.

How to Take Melphalan

Melphalan is given orally (by mouth) in the form of a tablet, taken on an empty stomach (1 hour before or 2 hours after a meal). The dosage and schedule is determined by the person's size and type of cancer.

Storage and Handling of Oral Melphalan

Store your medication in the original, labeled container, and in the refrigerator (unless otherwise directed by your healthcare provider or pharmacist). This medication should not be stored in a pillbox. Keep containers out of reach of children and pets.

If a caregiver prepares your dose for you, they should consider wearing gloves or pour the pills directly from their container into the cap, a small cup, or directly into your hand. They should avoid touching the pills. They should always wash their hands before and after giving you the medication. Pregnant or nursing women should not prepare the dose for you. Ask your oncology team where to return any unused medication for disposal. Do not flush down the toilet or throw in the trash.

Where do I get this medication?

Oral melphalan is available through some retail pharmacies and specialty pharmacies.  Your oncology team will work with your prescription drug plan to identify an in-network pharmacy for distribution of this medication. 

Insurance Information

This medication may be covered under your prescription drug plan. Patient assistance may be available to qualifying individuals without prescription drug coverage. Co-pay cards, which reduce the patient’s co-pay responsibility for eligible commercially (non-government sponsored) insured patients, are also offered by the manufacturer. Co-pay assistance from private third party foundations may be available. Your care team can help you access these resources, if they are available.

This medication is covered under Medicare part B for Medicare recipients. Make sure your pharmacist knows to process this prescription through your Medicare part B and NOT part D.

Possible Side Effects of Melphalan

There are a number of things you can do to manage the side effects of melphalan. Talk to your doctor or nurse about these recommendations. They can help you decide what will work best for you. These are some of the most common side effects:

Nausea and/or Vomiting

Talk to your doctor or nurse so they can prescribe medications to help you manage nausea and vomiting. In addition, dietary changes may help. Avoid things that may worsen the symptoms, such as heavy or greasy/fatty, spicy or acidic foods (lemons, tomatoes, oranges). Try antacids, (e.g. milk of magnesia, calcium tablets such as Tums), saltines, or ginger ale to lessen symptoms.

Call your doctor or nurse if you are unable to keep fluids down for more than 12 hours or if you feel lightheaded or dizzy at any time.

Diarrhea

Your oncology team can recommend medications to relieve diarrhea. Also, try eating low-fiber, bland foods, such as white rice and boiled or baked chicken. Avoid raw fruits, vegetables, whole grain breads, cereals and seeds. Soluble fiber is found in some foods and absorbs fluid, which can help relieve diarrhea. Foods high in soluble fiber include: applesauce, bananas (ripe), canned fruit, orange sections, boiled potatoes, white rice, products made with white flour, oatmeal, cream of rice, cream of wheat, and farina. Drink 8-10 glasses on non-alcoholic, un-caffeinated fluid a day to prevent dehydration.

Low White Blood Cell Count (Leukopenia or Neutropenia)

White blood cells (WBC) are important for fighting infection. While receiving treatment, your WBC count can drop, putting you at a higher risk of getting an infection. You should let your doctor or nurse know right away if you have a fever (temperature greater than 100.4), sore throat or cold, shortness of breath, cough, burning with urination, or a sore that doesn't heal.

Tips to preventing infection:

  • Washing hands, both yours and your visitors, is the best way to prevent the spread of infection.
  • Avoid large crowds and people who are sick (i.e.: those who have a cold, fever or cough or live with someone with these symptoms).
  • When working in your yard, wear protective clothing including long pants and gloves.
  • Do not handle pet waste.
  • Keep all cuts or scratches clean.
  • Shower or bath daily and perform frequent mouth care.
  • Do not cut cuticles or ingrown nails. You may wear nail polish, but not fake nails.
  • Ask your doctor or nurse before scheduling dental appointments or procedures.
  • Ask your doctor or nurse before you, or someone you live with, has any vaccinations.

Low Red Blood Cell Count (Anemia)

Your red blood cells are responsible for carrying oxygen to the tissues in your body. When the red cell count is low, you may feel tired or weak. You should let your doctor or nurse know if you experience any shortness of breath, difficulty breathing or pain in your chest. If the count gets too low, you may receive a blood transfusion.

Low Platelet Count (Thrombocytopenia)

Platelets help your blood clot, so when the count is low you are at a higher risk of bleeding. Let your doctor or nurse know if you have any excess bruising or bleeding, including nose bleeds, bleeding gums or blood in your urine or stool. If the platelet count becomes too low, you may receive a transfusion of platelets.

  • Do not use a razor (an electric razor is fine).
  • Avoid contact sports and activities that can result in injury or bleeding.
  • Do not take aspirin (salicylic acid), non-steroidal, anti-inflammatory medications (NSAIDs) such as Motrin®, Aleve®, Advil®, etc. as these can all increase the risk of bleeding. Unless your healthcare team tells you otherwise, you may take acetaminophen (Tylenol).
  • Do not floss or use toothpicks and use a soft-bristle toothbrush to brush your teeth.

Fatigue

Fatigue is very common during cancer treatment and is an overwhelming feeling of exhaustion that is not usually relieved by rest. While on cancer treatment, and for a period after, you may need to adjust your schedule to manage fatigue. Plan times to rest during the day and conserve energy for more important activities. Exercise can help combat fatigue; a simple daily walk with a friend can help.  Talk to your healthcare team for helpful tips on dealing with this side effect.

Mouth Ulcers (Sores)

Certain cancer treatments can cause sores or soreness in your mouth and/or throat. Notify your doctor or nurse if your mouth, tongue, inside of your cheek or throat becomes white, ulcerated or painful. Performing regular mouth care can help prevent or manage mouth sores. If mouth sores become painful, your doctor or nurse can recommend a pain reliever.

  • Brush with a soft-bristle toothbrush or cotton swab twice a day.
  • Avoid mouthwashes that contain alcohol. A baking soda and/or salt warm water mouth rinse (2 level teaspoons of baking soda or 1 level teaspoon salt in an eight ounce glass of warm water) is recommended 4 times daily.
  • If your mouth becomes dry, eat moist foods, drink plenty of fluids (6-8 glasses), and suck on sugarless hard candy.
  • Avoid smoking and chewing tobacco, drinking alcoholic beverages and citrus juices.

Loss or Thinning of Scalp and Body Hair (Alopecia)

Your hair may become thin, brittle, or may fall out. This typically begins two to three weeks after treatment starts. This hair loss can be all body hair, including pubic, underarm, legs/arms, eyelashes, and nose hairs. The use of scarves, wigs, hats and hairpieces may help. Hair generally starts to regrow soon after treatment is completed. Remember your hair helps keep you warm in cold weather, so a hat is particularly important in cold weather or to protect you from the sun.

Allergic Reactions

In some cases, patients can have an allergic reaction to this medication. Signs of a reaction can include: shortness of breath or difficulty breathing, chest pain, rash, flushing or itching or a decrease in blood pressure. If you notice any changes in how you feel during the infusion, notify your care team immediately.

Rash 

Some patients may develop a rash, very dry or itchy skin. Use an alcohol free moisturizer on your skin and lips; avoid moisturizers with perfumes or scents. Your doctor or nurse can recommend a topical medication if itching is bothersome. If your skin does crack or bleed, be sure to keep the area clean to avoid infection. Be sure to notify your healthcare provider of any rash that develops, as this can be a sign of allergic reaction. They can give you more tips on caring for your skin.

Lung Changes

This medication may cause lung problems, including pulmonary fibrosis (a scarring and stiffening of the lung tissue) and pneumonitis (swelling of the lungs). These problems can develop during, or months to years after, treatment. Call your healthcare provider right away if you have shortness of breath, cough, fever, wheezing or difficulty breathing.

Liver Toxicity

This medication can cause liver toxicity, which your doctor may monitor for using blood tests called liver function tests. Notify your healthcare provider if you notice yellowing of the skin or eyes, your urine appears dark or brown or pain in your abdomen, as these can be signs of liver toxicity.

Radiation Recall

Radiation recall is when the administration of a medication causes a skin reaction that looks like a sunburn (redness, swelling, soreness, peeling skin) in areas where radiation was previously given. Notify your oncology team if you notice this side effect. Treatment can include topical steroid ointments and a delay in your next chemotherapy dose.

Secondary Malignancies

There is a very low risk of developing leukemia or other type of cancer due to treatment with this medication, which can occur many years after treatment. 

Sexual & Reproductive Concerns

This drug may affect your reproductive system, resulting in the menstrual cycle or sperm production becoming irregular or stopping permanently. Women may experience menopausal effects including hot flashes and vaginal dryness. In addition, the desire for sex may decrease during treatment.

Exposure of an unborn child to this medication could cause birth defects, so you should not become pregnant or father a child while on this medication.  Effective birth control is necessary during treatment, even if your menstrual cycle stops or you believe you are not producing sperm. You may want to consider sperm banking or egg harvesting if you may wish to have a child in the future. Discuss these options with your oncology team. You should not breastfeed while on this medication.

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