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Mitotane is a derivative of the insecticide DDT and causes direct necrosis and atrophy of the adrenal cortex; it also modifies the peripheral metabolism of steroids.
Oral absorption: 35-40%
Fat-rich foods increase absorption of mitotane. Peak plasma concentrations occur 3-5 hours after a single oral dose of mitotane. Target plasma concentrations (14-20 mg/L) usually reached within 3 to 5 months.
Found in all body tissues, but primarily in fat. Slow release from fat and other tissues.
| Cross blood brain barrier? |
Mitotane: no |
| Cross blood brain barrier? | No information found |
Metabolized in the liver or other tissues. o,p’-DDA (major), o,p’-DDE (minor) and hydroxylated o,p’-DDA metabolites have been identified.
| Active metabolites | acyl chloride intermediate, o,p’-DDA, o,p’-DDE |
Bile appears to be a significant route of excretion of metabolites. Mitotane levels persist for several weeks after drug discontinuation, due to slow release from fat or other tissues.
| Urine | 10% as metabolites in 24 hours |
| Bile | 15% as metabolites in 24 hours |
| Half-life |
18 - 159 days |
- Inoperable adrenocortical carcinoma (ACC); functional and non-functional
Other Uses:
- Adjuvant treatment of adrenocortical carcinoma
Emetogenic Potential:
Extravasation Potential: Not applicable
| ORGAN SITE | SIDE EFFECT* (%) | ONSET** | |||
|---|---|---|---|---|---|
| Cardiovascular | Flushing (infrequent) | E | |||
| Hypertension (infrequent) | E | ||||
| Hypotension (orthostatic; infrequent) | E | ||||
| Dermatological | Rash (15%) | E | |||
| Gastrointestinal | Anorexia (80%) | E | |||
| Diarrhea (80%) | E | ||||
| Nausea, vomiting (80%) | E | ||||
| General | Fatigue (25%) | E D | |||
| Hematological | Myelosuppression (12%) | E | |||
| Other Prolonged bleeding time (rare) | E | ||||
| Hepatobiliary | Hepatitis (autoimmune; 7%) | E D | |||
| ↑ LFTs (>10%, rarely severe) | E | ||||
| Metabolic / Endocrine | Adrenal insufficiency (75-100%) | E | |||
| Hyperlipidemia (>10%) | E | ||||
| Hypothyroidism (rare) | E | ||||
| Other Hypouricemia, growth retardation (infrequent) Gynecomastia (> 10%) | E D | ||||
| Nervous System | Cognitive disturbance (>10%; may be severe) | E | |||
| Dizziness (15%) (including vertigo) | E D | ||||
| Dysarthria (rare) | E | ||||
| Headache (also ataxia, confusion; rare) | E | ||||
| Paresthesia (>10%) | E | ||||
| Somnolence (25%) | E | ||||
| Ophthalmic | Blurred vision (or double vision - infrequent) | E | |||
| Retinopathy (also maculopathy, infrequent) | E | ||||
| Renal | Proteinuria (infrequent) | D | |||
| Urinary | Hematuria (infrequent) | D | |||
| Hemorrhagic Cystitis (infrequent) | D | ||||
* "Incidence" may refer to an absolute value or the higher value from a reported range.
"Rare"
may refer to events with < 1% incidence, reported in post-marketing, phase 1 studies,
isolated data or anecdotal
reports.
** I = immediate (onset in hours to days)
E = early (days to weeks)
D = delayed (weeks to months)
L = late (months to years)
Mitotane's main action is adrenocortical suppression. As such, glucocorticoid replacement, and sometimes mineralocorticoid replacement therapy is required. Free cortisol and corticotropin levels should be monitored to determine the optimal dose of steroid replacement therapy; higher than usual replacement doses may be required.
If shock, severe trauma or infection occurs, mitotane should be temporarily discontinued and steroids immediately given. When mitotane is discontinued, the steroid should be tapered slowly, but may need to be continued indefinitely. Patients should use a medical alert tag or bracelet warning of adrenal suppression.
Gastrointestinal toxicity occurs in 80% of patients and is reversible when the dose is reduced.
Skin rashes are usually transient and not dose-related.
Adverse CNS effects occur in 40% of patients, especially when levels are > 20 mg/L, and are manifested as lethargy, somnolence, dizziness, depression, irritability, confusion and tremors. More rare CNS side effects, consisting of speech difficulty, memory loss, ataxia and hallucinations, have been reported. Long-term use may cause brain damage or functional impairment.
Behavioral and neurological assessments should be performed periodically when continuous mitotane exceeds 2 years, especially when plasma levels are greater than 20 mg/L.
Refer to protocol by which patient is being treated. Ideally, treatment should be started while the patient is hospitalized, and after debulking surgery has been performed (if applicable). Steroid replacement therapy may be required (e.g. glucocorticoid - cortisone acetate 25 mg qam and 12.5 mg qpm ±fludrocortisone (Florinef®) 0.1 mg daily for mineralocorticoid deficiency causing orthostatic hypotension).
If shock, severe trauma or infection occurs, mitotane should be temporarily discontinued and steroids immediately given. When mitotane is discontinued, the steroid should be tapered slowly, but may need to be continued indefinitely. Patients should use medical alert tag or bracelet warning of adrenal suppression.
Oral: start at 2-6 g/day, in 3 or 4 divided doses, and then titrate (at 2 week intervals) up to 8-10 g /day. Maximum tolerated dose may vary from 2-16 g/day. Dose may be increased based on clinical response and patient tolerance.
Highest doses used in studies were 18-19 g/day. If available, mitotane levels should be monitored regularly to keep levels between 14-20 mg/L. Severe neurotoxicity may occur with levels > 20mg/L.
Mitotane has a long half life an accumulates in fat. Dose adjustments may not result in immediate improvement in drug related effects.
|
Toxicity / Event
|
Dose
|
|
Severe trauma, stress or infection
|
Interrupt; start steroids
|
|
Myelosuppression
|
No dose adjustment required
|
|
Adrenal insufficiency
|
Use corticosteroid supplementation
|
|
Mild to moderate GI, skin or CNS toxicity
|
Decrease dose* or hold, depending on severity
|
| Mitotane levels > 20 mg/L | Hold and monitor levels; restart when levels within therapeutic range |
|
Grade 3 related non-hematologic toxicity
|
Hold, consider dose reduction*
|
|
Grade 4 related non-hematologic toxicity
|
Discontinue
|
- Oral self-administration; drug available by outpatient prescription.
- Swallow tablets whole; do not crush or chew.
- May be taken with or without food with a glass of water. Timing of the dose relative to meals must be consistent. Administration with a high fat meal enhances absorption.
- Consider steroid replacement.
- Patients should use medical alert tag or bracelet warning of adrenal suppression.
- Patients who have a hypersensitivity to this drug or any of its components
- Mitotane should be discontinued after severe shock, trauma or infection, and exogenous steroids administered
- Large metastatic ACC tumours should be removed before starting mitotane, to minimize tumour infarction and hemorrhage due to the rapid action of the drug.
- Use with caution in patients with liver disease other than metastatic ACC.
- Prolonged bleeding time has been reported - Caution in patients undergoing invasive procedures
- Caution is required when driving or operating machinery. Avoid concurrent administration of other CNS depressants.
- Caution in obese patients and patients with rapid weight loss
-
Teratogenicity:
Unknown
Mitotane is not recommended for use in pregnancy; adverse pregnancy outcomes have been observed after drug exposure. Adequate contraception should be used by both sexes during treatment, and for as long as mitotane levels are detectable, or for at least 6 months after the last dose (the long half-life of mitotane must be considered). -
Excretion into breast milk:
Probable
Breastfeeding is not recommended until mitotane levels are not detectable (or at least 6 months after last dose). -
Fertility effects:
Unknown
Effects on fertility have not be established; however, related compounds such as DDT are known to adversely affect fertility, pregnancy and development.
Mitotane has a long half life and drug interactions are therefore possible for many weeks after the last dose.
| AGENT | EFFECT | MECHANISM | MANAGEMENT |
|---|---|---|---|
| Measurement of urinary adrenal steroids | false negative for cortisol secretion rate | Mitotane increases extra-adrenal metabolism of cortisol so less is excreted in urine | Obtain both urine and plasma levels of cortisol |
| Drug metabolized by CYP3A4 (barbituates, phenytoin, corticosteroids) | ↑ metabolism of these drugs | Mitotane induces hepatic microsomal enzyme oxidation system | Monitor pharmacological effects up to 6 months after last mitotane dose; adjust dose of glucocorticoid replacement, barbiturate or phenytoin as needed |
| CNS depressants | Enhanced CNS depression | Additive | Caution |
| Spironolactone | Blocks effects of mitotane | Uncertain | Avoid |
| Thyroid function test | ↓ in serum protein-bound iodine | Mitotane binds thyroxine-binding globulin | Resin triiodothyronine uptake tests are not affected. Free thyroxine concentrations apparently remain in the normal range |
| Warfarin | ↓ pharmacological response to warfarin | Enhanced metabolism of warfarin by hepatic microsomal enzyme oxidation system | Monitor prothrombin times and adjust warfarin dose prn whenever mitotane dose is started, changed or stopped<div style="page-break-before: always"></div> |
| ↑ Hormone binding proteins (HBPs) | may effect interpretation of hormone assays | ↑ HBPs | Caution |
| Testosterone replacement | ↓ effectiveness | ↓ conversion to 5-alpha dihydrotestosterone via mitotane inhibition of 5-alpha reductase | Consider the use of 5-alpha reduced androgens for mitotane-induced male hyogonadism |
| Monitor Type | Monitor Frequency |
|---|---|
Observe for adrenal insufficiency |
|
| Clinical CNS evaluation especially with long-term usage | |
| Regular clinical assessment of GI and skin toxicity, adrenal insufficiency, opthalmic and CNS effects |
Grade toxicity using the current NCI-CTCAE (Common Terminology Criteria for Adverse Events) version
| Monitor Type | Monitor Frequency |
|---|---|
| Urine test | periodic |
| Neurological assessments | Baseline and regular |
| Serum cortisol levels | Baseline and periodic |
| CBC | Baseline and regular |
| Liver function tests | Baseline and as clinically indicated |
| If mitotane plasma level testing is available and clinically necessary, consider levels q2 weeks after starting treatment, after each dose adjustment, in hepatic/renal impairment, obese patients or patients with recent weight loss; every 1 week monitoring if a high starting dose has been used. Monitor levels regularly (e.g. monthly) after reaching maintenance dose especially with toxicity and in obese patients. If treatment is interrupted, monitor levels q2 months. |
Baudin E, Pellegriti G, Bonnay M, et al. Impact of monitoring plasma 1,1- dichlorodiphenildichloroethane (o,p'-DDD) levels on the treatment of patients with adrenocortical carcinoma. Cancer 2001;92: 1385–92.
Chortis V, Taylor AE, Schneider P, et al. Mitotane therapy in adrenocortical cancer induces CYP3A4 and inhibits 5-Reductase, explaining the need for personalized glucocorticoid and androgen replacement. J Clin Endocrinol Metab 2013;98(1):161–71.
Mitotane, AHFS Drug Information. Accessed on April 22, 2013 from http://www.ahfsdruginformation.com
Product Monograph: Lysodren® (mitotane). Bristol-Myers Squibb Canada, November 7, 2013.
Terzolo M, Pia A, Berruti A, et al. Low-dose monitored mitotane treatment achieves the therapeutic range with manageable side effects in patients with adrenocortical cancer. J Clin Endocrinol Metab 2000;85:2234–38.
June 2019 Updated emetic risk category.
Refer to the New Drug Funding Program or Ontario Public Drug Programs websites for the most up-to-date public funding information.
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