Melphalan is an orally and parenterally administered nitrogen mustard-like alkylating agent used in the therapy of multiple myeloma and ovarian cancer. Melphalan therapy has been associated with low rates of serum enzyme elevations during therapy, but when used in high doses as myeloablative therapy in preparation for hematopoietic cell transplantation, it is associated with high rates of enzyme elevations and acute liver injury due to sinusoidal obstruction syndrome.
Melphalan is a phenylalanine derivative of nitrogen mustard with antineoplastic activity. Melphalan alkylates DNA at the N7 position of guanine and induces DNA inter-strand cross-linkages, resulting in the inhibition of DNA and RNA synthesis and cytotoxicity against both dividing and non-dividing tumor cells.
Melphalan Hydrochloride is a bifunctional alkylating agent and phenylalanine derivative of nitrogen mustard. Melphalan hydrochloride is converted into highly reactive ethylenimmonium intermediates that induce covalent guanine N7-N7 intra- and inter-crosslinks and alkylation of adenine N3 of DNA. This agent also alkylates RNA and protein structures. As a result RNA transcription and protein synthesis are inhibited, ultimately leading to cell growth arrest and/or death.
Mechanism of Action
Melphalan attaches alkyl groups to the N-7 position of guanine and the N-3 position of adenine, leading to the formation of mono adducts, and DNA fragmenting when repair enzymes attempt to correct the error. It can also cause DNA cross-linking from the N-7 position of one guanine to the N-7 position of another, preventing DNA strands from separating for synthesis or transcription. Finally, melphalan can induce a number of different mutations.
Melphalan, as an alkylating agent, interferes with DNA replication and transcription of RNA, and ultimately results in the disruption of nucleic acid function. Melphalan also possesses some immunosuppressive activity.
Melphalan is an antineoplastic in the class of alkylating agents and is used to treat various forms of cancer. Alkylating agents are so named because of their ability to add alkyl groups to many electronegative groups under conditions present in cells. They stop tumor growth by cross-linking guanine bases in DNA double-helix strands – directly attacking DNA. This makes the strands unable to uncoil and separate. As this is necessary for DNA replication, the cells can no longer divide. In addition, these drugs add methyl or other alkyl groups onto molecules where they do not belong which in turn inhibits their correct utilization by base pairing and causes a miscoding of DNA. Alkylating agents are cell cycle-nonspecific. Alkylating agents work by three different mechanisms all of which achieve the same end result – disruption of DNA function and cell death.
Indications
- For the palliative treatment of multiple myeloma and for the palliation of non-resectable epithelial carcinoma of the ovary. Has also been used alone or as part of various chemotherapeutic regimens as an adjunct to surgery in the treatment of breast cancer, alone or in combination regimens for palliative treatment of locally recurrent or unresectable in-transit metastatic melanoma of the extremities, as well as for the treatment of amyloidosis with prednisone.
- High-dose of Phelinun used alone or in combination with other cytotoxic medicinal products and/or total body irradiation is indicated in the treatment of: multiple myeloma, malignant lymphoma (Hodgkin, non-Hodgkin lymphoma), acute lymphoblastic, and myeloblastic leukemia, childhood neuroblastoma, ovarian cancer, mammary adenocarcinoma. Phelinun in combination with other cytotoxic medicinal products is indicated as reduced intensity conditioning (RIC) treatment prior to allogeneic hematopoietic stem cell transplantation (allo-HSCT) in malignant hematological diseases in adults. Phelinun in combination with other cytotoxic medicinal products is indicated as a conditioning regimen prior to allogeneic hematopoietic stem cell transplantation in hematological diseases in the pediatric population as Myeloablative conditioning (MAC) treatment in case of malignant hematological diseasesRIC treatment in case of non-malignant hematological diseases.
- Multiple Myeloma (MM)
- Unresectable Ovarian Cancer (Epithelial)
- Conditioning regimens for allogeneic stem cell transplantation therapy
Use in Cancer
Melphalan hydrochloride is approved to treat:
- Multiple myeloma.
- It is used for palliative treatment in patients who cannot take melphalan by mouth. This use is approved for the Alkeran and Evomela brands.
- It is used as a conditioning treatment to prepare patients for a stem cell transplant. This use is approved for the Evomela brand.
Melphalan hydrochloride is also being studied in the treatment of other types of cancer.
Contraindications
- are allergic to melphalan or any ingredients of this medication
- are allergic to chlorambucil
- are breast-feeding
- are currently receiving radiation treatment
- have cancer that has shown resistance to melphalan in the past
- have a low count of neutrophils (a type of white blood cell)
- have a low platelet count
- have received similar chemotherapy medications or radiation treatments recently
- Melphalan hypersensitivity, risk of serious hypersensitivity reactions or anaphylaxis.
- New primary malignancy.
- Anemia, bleeding, bone marrow suppression, infection, leukopenia, neutropenia, and radiation therapy, requires an experienced clinician, and thrombocytopenia.
- Extravasation.
Dosage
Strengths: 2 mg; 50 mg
Multiple Myeloma
ORAL
A typical oral dosage regimen is:
- 6 mg orally once daily; after 2 to 3 weeks therapy should be discontinued for up to 4 weeks and the blood count followed; when white blood cell and platelet counts are rising, a maintenance dose of 2 mg daily may be instituted
Alternate Oral Regimens:
- Osserman and Takatsuki have used an initial course of 10 mg/day for 7 to 10 days. They report that maximal suppression of the leukocyte and platelet counts occurs within 3 to 5 weeks and recovery within 4 to 8 weeks. Continuous oral maintenance therapy with 2 mg/day is instituted when the white blood cell count is greater than 4000 cells/mcL and the platelet count is greater than 100,000 cells/ml. The dosage is adjusted to between 1 and 3 mg/day depending on the hematological response. It is desirable to try to maintain a significant degree of bone marrow depression to keep the leukocyte count in the range of 3000 to 3500 cells/mcL.
- Hoogstraten et al have started therapy with 0.15 mg/kg/day for 7 days followed by a rest period of at least 14 days, but it may be up to 5 to 6 weeks. Maintenance therapy is started when the white blood cell and platelet counts are rising. The maintenance dose is 0.05 mg/kg/day or less and is adjusted according to the blood count.
- One study by Alexanian et al has shown that using this drug in combination with prednisone significantly improves the percentage of patients with multiple myeloma who achieve palliation. One regimen has been to administer courses of this drug at 0.25 mg/kg/day for 4 consecutive days (or, 0.2 mg/kg/day for 5 consecutive days) for a total dose of 1 mg/kg/course. These 4- to 5-day courses are then repeated every 4 to 6 weeks if the granulocyte and platelet count have returned to normal levels
IV
(when oral therapy is not appropriate):
- 16 mg/m2 as a single IV infusion over 15 to 20 minutes every 2 weeks for 4 doses; then, after adequate recovery from toxicity, at 4-week intervals
- Oral: For the palliative treatment multiple myeloma.
- IV: For the palliative treatment multiple myeloma when oral therapy is not appropriate.
Ovarian Cancer
- Common regimen: 0.2 mg/kg orally daily for 5 days as a single course; courses are repeated every 4 to 5 weeks depending upon hematologic tolerance
Side Effects
The Most Common
- nausea
- vomiting
- loss of appetite or weight
- sores in the mouth and throat
- missed menstrual periods (in girls and women)
- joint, muscle, or back pain
- rash
- hives
- itching
- difficulty breathing or swallowing
- pale skin
- excessive tiredness
- fainting
- fast, irregular, or pounding heartbeat
- yellowing of the skin or eyes
- pain in the upper right part of the stomach
- dark colored urine
- unusual lumps or masses
- sores in the mouth and throat
- black, tarry, or bloody stools
- bloody vomit or vomited material that looks like coffee grounds
- unusual bruising or bleeding
- sore throat, cough, fever, or other signs of infection
More Common
- loss of appetite
- loss of menses (women)
- mild pain or irritation at injection site
- nausea and vomiting
- diarrhea
- difficulty in swallowing
- mouth ulcers or sores
- redness and/or soreness in the arm or leg
- signs of bleeding (e.g., bloody nose, blood in urine or stools, coughing blood, cuts that don’t stop bleeding, unusual bleeding or bruising, or black, tarry stools)
Rare
- signs of decreased red blood cells (anemia; e.g., pale skin, fatigue, shortness of breath, rapid heartbeat)
- signs of infection (e.g., cough, fever, chills, severe diarrhea, shortness of breath, prolonged dizziness, headache, stiff neck, weight loss, or listlessness)
- signs of liver problems (e.g., nausea, vomiting, diarrhea, loss of appetite, weight loss, yellowing of the skin or whites of the eyes, dark urine, pale stools)
- sign of lung problems (e.g., sudden or worsening shortness of breath, wheezing, tiredness, fever, painful breathing)
- signs of urinary tract infection (e.g., frequent urge to urinate, bloody or cloudy urine, pain with urination)
- skin rash or itching
- sores in the mouth or on the lips
- swelling of feet or lower legs
- symptoms of compartment syndrome (e.g., pain, pale skin, numbness, tingling, weakness, or paralysis in the limb with the infusion site)
- fast or irregular heartbeat
- symptoms of a serious allergic reaction such as hives; difficulty breathing; or swelling of the eyelids, throat, and mouth
- symptoms of an injection site reaction (e.g., severe muscle or nerve damage, pain, tenderness and inflammation, ulcers, or infection at the injection site)
Drug Interaction
| DRUG | INTERACTION |
|---|---|
| Abatacept | The risk or severity of adverse effects can be increased when Melphalan is combined with Abatacept. |
| Abciximab | The risk or severity of bleeding can be increased when Abciximab is combined with Melphalan. |
| Acenocoumarol | The risk or severity of bleeding can be increased when Acenocoumarol is combined with Melphalan. |
| Acetylsalicylic acid | The risk or severity of bleeding can be increased when Acetylsalicylic acid is combined with Melphalan. |
| Adalimumab | The risk or severity of adverse effects can be increased when Adalimumab is combined with Melphalan. |
| Adenovirus type 7 vaccine live | The risk or severity of infection can be increased when Adenovirus type 7 vaccine live is combined with Melphalan. |
| Aldesleukin | The risk or severity of adverse effects can be increased when Aldesleukin is combined with Melphalan. |
| Alefacept | The risk or severity of adverse effects can be increased when Alefacept is combined with Melphalan. |
| Alemtuzumab | The risk or severity of adverse effects can be increased when Alemtuzumab is combined with Melphalan. |
| Allogeneic processed thymus tissue | The therapeutic efficacy of Allogeneic processed thymus tissue can be decreased when used in combination with Melphalan. |
| Allopurinol | The risk or severity of adverse effects can be increased when Allopurinol is combined with Melphalan. |
| Alteplase | The risk or severity of bleeding can be increased when Alteplase is combined with Melphalan. |
| Altretamine | The risk or severity of adverse effects can be increased when Altretamine is combined with Melphalan. |
| Amsacrine | The risk or severity of adverse effects can be increased when Amsacrine is combined with Melphalan. |
| Anagrelide | The risk or severity of bleeding can be increased when Anagrelide is combined with Melphalan. |
| Anakinra | The risk or severity of adverse effects can be increased when Anakinra is combined with Melphalan. |
| Ancrod | The risk or severity of bleeding can be increased when Ancrod is combined with Melphalan. |
| Anifrolumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Anifrolumab. |
| Anistreplase | The risk or severity of bleeding can be increased when Anistreplase is combined with Melphalan. |
| Anthrax immune globulin human | The therapeutic efficacy of Anthrax immune globulin human can be decreased when used in combination with Melphalan. |
| Anthrax vaccine | The risk or severity of infection can be increased when Anthrax vaccine is combined with Melphalan. |
| Antilymphocyte immunoglobulin (horse) | The risk or severity of adverse effects can be increased when Melphalan is combined with Antilymphocyte immunoglobulin (horse). |
| Antithrombin Alfa | The risk or severity of bleeding can be increased when Antithrombin Alfa is combined with Melphalan. |
| Antithrombin III human | The risk or severity of bleeding can be increased when Antithrombin III human is combined with Melphalan. |
| Antithymocyte immunoglobulin (rabbit) | The risk or severity of adverse effects can be increased when Antithymocyte immunoglobulin (rabbit) is combined with Melphalan. |
| Apixaban | The risk or severity of bleeding can be increased when Apixaban is combined with Melphalan. |
| Apremilast | The risk or severity of adverse effects can be increased when Melphalan is combined with Apremilast. |
| Ardeparin | The risk or severity of bleeding can be increased when Ardeparin is combined with Melphalan. |
| Argatroban | The risk or severity of bleeding can be increased when Argatroban is combined with Melphalan. |
| Arsenic trioxide | The risk or severity of adverse effects can be increased when Melphalan is combined with Arsenic trioxide. |
| Articaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Articaine. |
| AstraZeneca COVID-19 Vaccine | The therapeutic efficacy of AstraZeneca COVID-19 Vaccine can be decreased when used in combination with Melphalan. |
| Azacitidine | The risk or severity of adverse effects can be increased when Azacitidine is combined with Melphalan. |
| Azathioprine | The risk or severity of adverse effects can be increased when Azathioprine is combined with Melphalan. |
| Bacillus calmette-guerin substrain connaught live antigen | The risk or severity of infection can be increased when Bacillus calmette-guerin substrain connaught live antigen is combined with Melphalan. |
| Bacillus calmette-guerin substrain russian BCG-I live antigen | The therapeutic efficacy of Bacillus calmette-guerin substrain russian BCG-I live antigen can be decreased when used in combination with Melphalan. |
| Bacillus calmette-guerin substrain tice live antigen | The risk or severity of infection can be increased when Bacillus calmette-guerin substrain tice live antigen is combined with Melphalan. |
| Baricitinib | The risk or severity of adverse effects can be increased when Melphalan is combined with Baricitinib. |
| Basiliximab | The risk or severity of adverse effects can be increased when Basiliximab is combined with Melphalan. |
| BCG vaccine | The risk or severity of infection can be increased when BCG vaccine is combined with Melphalan. |
| Beclomethasone dipropionate | The risk or severity of adverse effects can be increased when Beclomethasone dipropionate is combined with Melphalan. |
| Belatacept | The risk or severity of adverse effects can be increased when Melphalan is combined with Belatacept. |
| Belimumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Belimumab. |
| Belinostat | The risk or severity of adverse effects can be increased when Melphalan is combined with Belinostat. |
| Belumosudil | The risk or severity of adverse effects can be increased when Melphalan is combined with Belumosudil. |
| Bemiparin | The risk or severity of bleeding can be increased when Bemiparin is combined with Melphalan. |
| Bendamustine | The risk or severity of adverse effects can be increased when Melphalan is combined with Bendamustine. |
| Bendroflumethiazide | The risk or severity of neutropenia and thrombocytopenia can be increased when Bendroflumethiazide is combined with Melphalan. |
| Benzocaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Benzocaine. |
| Benzthiazide | The risk or severity of neutropenia and thrombocytopenia can be increased when Benzthiazide is combined with Melphalan. |
| Benzyl alcohol | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Benzyl alcohol. |
| Betamethasone | The risk or severity of adverse effects can be increased when Betamethasone is combined with Melphalan. |
| Betrixaban | The risk or severity of bleeding can be increased when Betrixaban is combined with Melphalan. |
| Bexarotene | The risk or severity of adverse effects can be increased when Bexarotene is combined with Melphalan. |
| Bimekizumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Bimekizumab. |
| Bivalirudin | The risk or severity of bleeding can be increased when Bivalirudin is combined with Melphalan. |
| Bleomycin | The risk or severity of adverse effects can be increased when Bleomycin is combined with Melphalan. |
| Blinatumomab | The risk or severity of adverse effects can be increased when Melphalan is combined with Blinatumomab. |
| Bordetella pertussis toxoid antigen (formaldehyde, glutaraldehyde inactivated) | The therapeutic efficacy of Bordetella pertussis toxoid antigen (formaldehyde, glutaraldehyde inactivated) can be decreased when used in combination with Melphalan. |
| Bortezomib | The risk or severity of adverse effects can be increased when Bortezomib is combined with Melphalan. |
| Bosutinib | The risk or severity of adverse effects can be increased when Melphalan is combined with Bosutinib. |
| Brentuximab vedotin | The risk or severity of adverse effects can be increased when Melphalan is combined with Brentuximab vedotin. |
| Brodalumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Brodalumab. |
| Budesonide | The risk or severity of adverse effects can be increased when Melphalan is combined with Budesonide. |
| Bupivacaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Bupivacaine. |
| Busulfan | The risk or severity of adverse effects can be increased when Busulfan is combined with Melphalan. |
| Butacaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Butacaine. |
| Butamben | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Butamben. |
| Cabazitaxel | The risk or severity of adverse effects can be increased when Melphalan is combined with Cabazitaxel. |
| Canakinumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Canakinumab. |
| Cangrelor | The risk or severity of bleeding can be increased when Cangrelor is combined with Melphalan. |
| Capecitabine | The risk or severity of adverse effects can be increased when Melphalan is combined with Capecitabine. |
| Caplacizumab | The risk or severity of bleeding can be increased when Caplacizumab is combined with Melphalan. |
| Capsaicin | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Capsaicin. |
| Carbamazepine | The risk or severity of adverse effects can be increased when Carbamazepine is combined with Melphalan. |
| Carboplatin | The risk or severity of adverse effects can be increased when Carboplatin is combined with Melphalan. |
| Carfilzomib | The risk or severity of adverse effects can be increased when Melphalan is combined with Carfilzomib. |
| Carmustine | The risk or severity of pulmonary toxicity can be increased when Melphalan is combined with Carmustine. |
| Certolizumab pegol | The risk or severity of adverse effects can be increased when Melphalan is combined with Certolizumab pegol. |
| Chlorambucil | The risk or severity of adverse effects can be increased when Chlorambucil is combined with Melphalan. |
| Chloramphenicol | The risk or severity of adverse effects can be increased when Chloramphenicol is combined with Melphalan. |
| Chloroprocaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Chloroprocaine. |
| Chlorothiazide | The risk or severity of neutropenia and thrombocytopenia can be increased when Chlorothiazide is combined with Melphalan. |
| Ciclesonide | The risk or severity of adverse effects can be increased when Melphalan is combined with Ciclesonide. |
| Cilostazol | The risk or severity of bleeding can be increased when Cilostazol is combined with Melphalan. |
| Cinchocaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Cinchocaine. |
| Cisplatin | The risk or severity of adverse effects can be increased when Cisplatin is combined with Melphalan. |
| Cladribine | The risk or severity of adverse effects can be increased when Cladribine is combined with Melphalan. |
| Clobetasol propionate | The risk or severity of adverse effects can be increased when Clobetasol propionate is combined with Melphalan. |
| Clofarabine | The risk or severity of adverse effects can be increased when Clofarabine is combined with Melphalan. |
| Clopidogrel | The risk or severity of bleeding can be increased when Clopidogrel is combined with Melphalan. |
| Clostridium tetani toxoid antigen (formaldehyde inactivated) | The therapeutic efficacy of Clostridium tetani toxoid antigen (formaldehyde inactivated) can be decreased when used in combination with Melphalan. |
| Clozapine | The risk or severity of neutropenia can be increased when Melphalan is combined with Clozapine. |
| Cocaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Cocaine. |
| Corticotropin | The risk or severity of adverse effects can be increased when Melphalan is combined with Corticotropin. |
| Cortisone acetate | The risk or severity of adverse effects can be increased when Melphalan is combined with Cortisone acetate. |
| Corynebacterium diphtheriae toxoid antigen (formaldehyde inactivated) | The therapeutic efficacy of Corynebacterium diphtheriae toxoid antigen (formaldehyde inactivated) can be decreased when used in combination with Melphalan. |
| Cyanocobalamin | The therapeutic efficacy of Cyanocobalamin can be decreased when used in combination with Melphalan. |
| Cyclopenthiazide | The risk or severity of neutropenia and thrombocytopenia can be increased when Cyclopenthiazide is combined with Melphalan. |
| Cyclophosphamide | The risk or severity of adverse effects can be increased when Cyclophosphamide is combined with Melphalan. |
| Cyclosporine | Melphalan may increase the nephrotoxic activities of Cyclosporine. |
| Cyclothiazide | The risk or severity of neutropenia and thrombocytopenia can be increased when Cyclothiazide is combined with Melphalan. |
| Cytarabine | The risk or severity of adverse effects can be increased when Cytarabine is combined with Melphalan. |
| Dabigatran | The risk or severity of bleeding can be increased when Dabigatran is combined with Melphalan. |
| Dabigatran etexilate | The risk or severity of bleeding can be increased when Dabigatran etexilate is combined with Melphalan. |
| Dacarbazine | The risk or severity of adverse effects can be increased when Dacarbazine is combined with Melphalan. |
| Dactinomycin | The risk or severity of adverse effects can be increased when Dactinomycin is combined with Melphalan. |
| Dalteparin | The risk or severity of bleeding can be increased when Dalteparin is combined with Melphalan. |
| Danaparoid | The risk or severity of bleeding can be increased when Danaparoid is combined with Melphalan. |
| Darbepoetin alfa | The risk or severity of Thrombosis can be increased when Darbepoetin alfa is combined with Melphalan. |
| Dasatinib | The risk or severity of adverse effects can be increased when Melphalan is combined with Dasatinib. |
| Daunorubicin | The risk or severity of adverse effects can be increased when Daunorubicin is combined with Melphalan. |
| Decitabine | The risk or severity of adverse effects can be increased when Melphalan is combined with Decitabine. |
| Defibrotide | The risk or severity of bleeding can be increased when Defibrotide is combined with Melphalan. |
| Deflazacort | The risk or severity of adverse effects can be increased when Melphalan is combined with Deflazacort. |
| Denosumab | The risk or severity of adverse effects can be increased when Denosumab is combined with Melphalan. |
| Desirudin | The risk or severity of bleeding can be increased when Desirudin is combined with Melphalan. |
| Desoximetasone | The risk or severity of adverse effects can be increased when Desoximetasone is combined with Melphalan. |
| Deucravacitinib | The risk or severity of adverse effects can be increased when Melphalan is combined with Deucravacitinib. |
| Dexamethasone | The risk or severity of adverse effects can be increased when Melphalan is combined with Dexamethasone. |
| Dexrazoxane | The risk or severity of adverse effects can be increased when Dexrazoxane is combined with Melphalan. |
| Dextran | The risk or severity of bleeding can be increased when Dextran is combined with Melphalan. |
| Dicoumarol | The risk or severity of bleeding can be increased when Dicoumarol is combined with Melphalan. |
| Difluocortolone | The risk or severity of adverse effects can be increased when Melphalan is combined with Difluocortolone. |
| Dimethyl fumarate | The risk or severity of adverse effects can be increased when Melphalan is combined with Dimethyl fumarate. |
| Dinutuximab | The risk or severity of adverse effects can be increased when Melphalan is combined with Dinutuximab. |
| Diphenhydramine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Diphenhydramine. |
| Dipyridamole | The risk or severity of bleeding can be increased when Dipyridamole is combined with Melphalan. |
| Diroximel fumarate | The risk or severity of adverse effects can be increased when Melphalan is combined with Diroximel fumarate. |
| Docetaxel | The risk or severity of adverse effects can be increased when Melphalan is combined with Docetaxel. |
| Doxorubicin | The risk or severity of adverse effects can be increased when Doxorubicin is combined with Melphalan. |
| Drotrecogin alfa | The risk or severity of bleeding can be increased when Drotrecogin alfa is combined with Melphalan. |
| Dyclonine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Dyclonine. |
| Ebola Zaire vaccine (live, attenuated) | The therapeutic efficacy of Ebola Zaire vaccine (live, attenuated) can be decreased when used in combination with Melphalan. |
| Eculizumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Eculizumab. |
| Edetic acid | The risk or severity of bleeding can be increased when Edetic acid is combined with Melphalan. |
| Edoxaban | The risk or severity of bleeding can be increased when Edoxaban is combined with Melphalan. |
| Efalizumab | The risk or severity of adverse effects can be increased when Efalizumab is combined with Melphalan. |
| Emapalumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Emapalumab. |
| Enoxaparin | The risk or severity of bleeding can be increased when Enoxaparin is combined with Melphalan. |
| Epirubicin | The risk or severity of adverse effects can be increased when Epirubicin is combined with Melphalan. |
| Epoprostenol | The risk or severity of bleeding can be increased when Epoprostenol is combined with Melphalan. |
| Eptifibatide | The risk or severity of bleeding can be increased when Eptifibatide is combined with Melphalan. |
| Eribulin | The risk or severity of adverse effects can be increased when Melphalan is combined with Eribulin. |
| Erythropoietin | The risk or severity of Thrombosis can be increased when Erythropoietin is combined with Melphalan. |
| Estramustine | The risk or severity of adverse effects can be increased when Melphalan is combined with Estramustine. |
| Etanercept | The risk or severity of adverse effects can be increased when Etanercept is combined with Melphalan. |
| Ethyl chloride | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Ethyl chloride. |
| Etidocaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Etidocaine. |
| Etoposide | The risk or severity of adverse effects can be increased when Etoposide is combined with Melphalan. |
| Everolimus | The risk or severity of adverse effects can be increased when Melphalan is combined with Everolimus. |
| Filgotinib | The risk or severity of adverse effects can be increased when Melphalan is combined with Filgotinib. |
| Fingolimod | Melphalan may increase the immunosuppressive activities of Fingolimod. |
| Floxuridine | The risk or severity of adverse effects can be increased when Floxuridine is combined with Melphalan. |
| Flucytosine | The risk or severity of adverse effects can be increased when Melphalan is combined with Flucytosine. |
| Fludarabine | The risk or severity of adverse effects can be increased when Melphalan is combined with Fludarabine. |
| Fludrocortisone | The risk or severity of adverse effects can be increased when Fludrocortisone is combined with Melphalan. |
| Fluindione | The risk or severity of bleeding can be increased when Fluindione is combined with Melphalan. |
| Flunisolide | The risk or severity of adverse effects can be increased when Flunisolide is combined with Melphalan. |
| Fluocinolone acetonide | The risk or severity of adverse effects can be increased when Fluocinolone acetonide is combined with Melphalan. |
| Fluocinonide | The risk or severity of adverse effects can be increased when Melphalan is combined with Fluocinonide. |
| Fluocortolone | The risk or severity of adverse effects can be increased when Melphalan is combined with Fluocortolone. |
| Fluorometholone | The risk or severity of adverse effects can be increased when Fluorometholone is combined with Melphalan. |
| Fluorouracil | The risk or severity of adverse effects can be increased when Fluorouracil is combined with Melphalan. |
| Flupentixol | The risk or severity of myelosuppression can be increased when Flupentixol is combined with Melphalan. |
| Fluprednisolone | The risk or severity of adverse effects can be increased when Melphalan is combined with Fluprednisolone. |
| Fluticasone | The risk or severity of adverse effects can be increased when Melphalan is combined with Fluticasone. |
| Fluticasone furoate | The risk or severity of adverse effects can be increased when Melphalan is combined with Fluticasone furoate. |
| Fluticasone propionate | The risk or severity of adverse effects can be increased when Fluticasone propionate is combined with Melphalan. |
| Fondaparinux | The risk or severity of bleeding can be increased when Fondaparinux is combined with Melphalan. |
| Gallium nitrate | The risk or severity of adverse effects can be increased when Melphalan is combined with Gallium nitrate. |
| Gemcitabine | The risk or severity of adverse effects can be increased when Gemcitabine is combined with Melphalan. |
| Gemtuzumab ozogamicin | The risk or severity of adverse effects can be increased when Gemtuzumab ozogamicin is combined with Melphalan. |
| Glatiramer | The risk or severity of adverse effects can be increased when Melphalan is combined with Glatiramer. |
| Golimumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Golimumab. |
| Guselkumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Guselkumab. |
| Haemophilus influenzae type B strain 20752 capsular polysaccharide tetanus toxoid conjugate antigen | The therapeutic efficacy of Haemophilus influenzae type B strain 20752 capsular polysaccharide tetanus toxoid conjugate antigen can be decreased when used in combination with Melphalan. |
| Heparin | The risk or severity of bleeding can be increased when Heparin is combined with Melphalan. |
| Hepatitis A Vaccine | The therapeutic efficacy of Hepatitis A Vaccine can be decreased when used in combination with Melphalan. |
| Hepatitis B Vaccine (Recombinant) | The therapeutic efficacy of Hepatitis B Vaccine (Recombinant) can be decreased when used in combination with Melphalan. |
| Human adenovirus e serotype 4 strain cl-68578 antigen | The risk or severity of infection can be increased when Human adenovirus e serotype 4 strain cl-68578 antigen is combined with Melphalan. |
| Hydrochlorothiazide | The risk or severity of neutropenia and thrombocytopenia can be increased when Hydrochlorothiazide is combined with Melphalan. |
| Hydrocortisone acetate | The risk or severity of adverse effects can be increased when Melphalan is combined with Hydrocortisone acetate. |
| Hydrocortisone butyrate | The risk or severity of adverse effects can be increased when Melphalan is combined with Hydrocortisone butyrate. |
| Hydrocortisone succinate | The risk or severity of adverse effects can be increased when Melphalan is combined with Hydrocortisone succinate. |
| Hydroflumethiazide | The risk or severity of neutropenia and thrombocytopenia can be increased when Hydroflumethiazide is combined with Melphalan. |
| Hydroxychloroquine | The risk or severity of adverse effects can be increased when Melphalan is combined with Hydroxychloroquine. |
| Hydroxyurea | The risk or severity of adverse effects can be increased when Hydroxyurea is combined with Melphalan. |
| Ibritumomab tiuxetan | The risk or severity of adverse effects can be increased when Ibritumomab tiuxetan is combined with Melphalan. |
| Ibrutinib | The risk or severity of adverse effects can be increased when Melphalan is combined with Ibrutinib. |
| Icosapent ethyl | The risk or severity of bleeding can be increased when Icosapent ethyl is combined with Melphalan. |
| Idarubicin | The risk or severity of adverse effects can be increased when Melphalan is combined with Idarubicin. |
| Idelalisib | The risk or severity of adverse effects can be increased when Melphalan is combined with Idelalisib. |
| Ifosfamide | The risk or severity of adverse effects can be increased when Melphalan is combined with Ifosfamide. |
| Iloprost | The risk or severity of bleeding can be increased when Iloprost is combined with Melphalan. |
| Imatinib | The risk or severity of adverse effects can be increased when Imatinib is combined with Melphalan. |
| Indomethacin | The risk or severity of adverse effects can be increased when Indomethacin is combined with Melphalan. |
| Inebilizumab | The risk or severity of infection can be increased when Melphalan is combined with Inebilizumab. |
| Infliximab | The risk or severity of adverse effects can be increased when Infliximab is combined with Melphalan. |
| rinotecan | The risk or severity of adverse effects can be increased when Irinotecan is combined with Melphalan. |
| Ixabepilone | The risk or severity of adverse effects can be increased when Melphalan is combined with Ixabepilone. |
| Ixekizumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Ixekizumab. |
| Janssen COVID-19 Vaccine | The therapeutic efficacy of Janssen COVID-19 Vaccine can be decreased when used in combination with Melphalan. |
| Japanese encephalitis virus strain sa 14-14-2 antigen (formaldehyde inactivated) | The therapeutic efficacy of Japanese encephalitis virus strain sa 14-14-2 antigen (formaldehyde inactivated) can be decreased when used in combination with Melphalan. |
| Leflunomide | The risk or severity of adverse effects can be increased when Melphalan is combined with Leflunomide. |
| Lenalidomide | The risk or severity of adverse effects can be increased when Lenalidomide is combined with Melphalan. |
| Lepirudin | The risk or severity of bleeding can be increased when Lepirudin is combined with Melphalan. |
| Levobupivacaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Levobupivacaine. |
| Lidocaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Lidocaine. |
| Linezolid | The risk or severity of adverse effects can be increased when Linezolid is combined with Melphalan. |
| Lipegfilgrastim | Melphalan may increase the myelosuppressive activities of Lipegfilgrastim. |
| Lomustine | The risk or severity of adverse effects can be increased when Melphalan is combined with Lomustine. |
| Lopinavir | The serum concentration of Melphalan can be increased when it is combined with Lopinavir. |
| Magnesium | The serum concentration of Magnesium can be decreased when it is combined with Melphalan. |
| Measles virus vaccine live attenuated | The therapeutic efficacy of Measles virus vaccine live attenuated can be decreased when used in combination with Melphalan. |
| Mechlorethamine | The risk or severity of adverse effects can be increased when Mechlorethamine is combined with Melphalan. |
| Meloxicam | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Meloxicam. |
| Meningococcal (groups A, C, Y and W-135) oligosaccharide diphtheria CRM197 conjugate vaccine | The therapeutic efficacy of Meningococcal (groups A, C, Y and W-135) oligosaccharide diphtheria CRM197 conjugate vaccine can be decreased when used in combination with Melphalan. |
| Mepivacaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Mepivacaine. |
| Mepolizumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Mepolizumab. |
| Meprednisone | The risk or severity of adverse effects can be increased when Melphalan is combined with Meprednisone. |
| Mercaptopurine | The risk or severity of adverse effects can be increased when Mercaptopurine is combined with Melphalan. |
| Metamizole | The risk or severity of myelosuppression can be increased when Metamizole is combined with Melphalan. |
| Methimazole | The risk or severity of adverse effects can be increased when Methimazole is combined with Melphalan. |
| Methotrexate | The risk or severity of adverse effects can be increased when Methotrexate is combined with Melphalan. |
| Methoxy polyethylene glycol-epoetin beta | The risk or severity of Thrombosis can be increased when Methoxy polyethylene glycol-epoetin beta is combined with Melphalan. |
| Methylprednisolone | The risk or severity of adverse effects can be increased when Methylprednisolone is combined with Melphalan. |
| Mitomycin | The risk or severity of adverse effects can be increased when Mitomycin is combined with Melphalan. |
| Mitoxantrone | The risk or severity of adverse effects can be increased when Melphalan is combined with Mitoxantrone. |
| Moderna COVID-19 Vaccine | The therapeutic efficacy of Moderna COVID-19 Vaccine can be decreased when used in combination with Melphalan. |
| Modified vaccinia ankara | The therapeutic efficacy of Modified vaccinia ankara can be decreased when used in combination with Melphalan. |
| Mometasone furoate | The risk or severity of adverse effects can be increased when Melphalan is combined with Mometasone furoate. |
| Monomethyl fumarate | The risk or severity of adverse effects can be increased when Melphalan is combined with Monomethyl fumarate. |
| Mosunetuzumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Mosunetuzumab. |
| Mumps virus strain B level jeryl lynn live antigen | The therapeutic efficacy of Mumps virus strain B level jeryl lynn live antigen can be decreased when used in combination with Melphalan. |
| Muromonab | The risk or severity of adverse effects can be increased when Muromonab is combined with Melphalan. |
| Mycophenolate mofetil | The risk or severity of adverse effects can be increased when Mycophenolate mofetil is combined with Melphalan. |
| Mycophenolic acid | The risk or severity of adverse effects can be increased when Mycophenolic acid is combined with Melphalan. |
| Nadroparin | The risk or severity of bleeding can be increased when Nadroparin is combined with Melphalan. |
| Nalidixic acid | The risk or severity of gastrointestinal bleeding can be increased when Nalidixic acid is combined with Melphalan. |
| Natalizumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Natalizumab. |
| Nelarabine | The risk or severity of adverse effects can be increased when Melphalan is combined with Nelarabine. |
| Nilotinib | The risk or severity of adverse effects can be increased when Melphalan is combined with Nilotinib. |
| Nimesulide | The risk or severity of bleeding can be increased when Nimesulide is combined with Melphalan. |
| Nuvaxovid | The therapeutic efficacy of Nuvaxovid can be decreased when used in combination with Melphalan. |
| Obinutuzumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Obinutuzumab. |
| Ocrelizumab | Ocrelizumab may increase the immunosuppressive activities of Melphalan. |
| Ofatumumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Ofatumumab. |
| Olaparib | The risk or severity of adverse effects can be increased when Melphalan is combined with Olaparib. |
| Oxaliplatin | The risk or severity of adverse effects can be increased when Oxaliplatin is combined with Melphalan. |
| Oxetacaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Oxetacaine. |
| Oxybuprocaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Oxybuprocaine. |
| Ozanimod | The risk or severity of adverse effects can be increased when Melphalan is combined with Ozanimod. |
| Paclitaxel | The risk or severity of adverse effects can be increased when Melphalan is combined with Paclitaxel. |
| Palbociclib | The risk or severity of adverse effects can be increased when Melphalan is combined with Palbociclib. |
| Palifermin | The therapeutic efficacy of Palifermin can be decreased when used in combination with Melphalan. |
| Panobinostat | The risk or severity of adverse effects can be increased when Melphalan is combined with Panobinostat. |
| Parnaparin | The risk or severity of bleeding can be increased when Parnaparin is combined with Melphalan. |
| Pazopanib | The risk or severity of adverse effects can be increased when Melphalan is combined with Pazopanib. |
| Pegaspargase | The risk or severity of adverse effects can be increased when Pegaspargase is combined with Melphalan. |
| Pegcetacoplan | The risk or severity of adverse effects can be increased when Melphalan is combined with Pegcetacoplan. |
| Peginesatide | The risk or severity of Thrombosis can be increased when Peginesatide is combined with Melphalan. |
| Peginterferon alfa-2a | The risk or severity of adverse effects can be increased when Peginterferon alfa-2a is combined with Melphalan. |
| Peginterferon alfa-2b | The risk or severity of adverse effects can be increased when Peginterferon alfa-2b is combined with Melphalan. |
| Peginterferon beta-1a | The risk or severity of adverse effects can be increased when Melphalan is combined with Peginterferon beta-1a. |
| Pemetrexed | The risk or severity of adverse effects can be increased when Pemetrexed is combined with Melphalan. |
| Penicillamine | The risk or severity of adverse effects can be increased when Penicillamine is combined with Melphalan. |
| Pentosan polysulfate | The risk or severity of bleeding can be increased when Pentosan polysulfate is combined with Melphalan. |
| Pentostatin | The risk or severity of adverse effects can be increased when Pentostatin is combined with Melphalan. |
| Pentoxifylline | The risk or severity of bleeding can be increased when Pentoxifylline is combined with Melphalan. |
| Pertussis vaccine | The therapeutic efficacy of Pertussis vaccine can be decreased when used in combination with Melphalan. |
| Phenindione | The risk or severity of bleeding can be increased when Phenindione is combined with Melphalan. |
| Phenol | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Phenol. |
| Phenprocoumon | The risk or severity of bleeding can be increased when Phenprocoumon is combined with Melphalan. |
| Phenylalanine | The risk or severity of adverse effects can be increased when Phenylalanine is combined with Melphalan. |
| Pimecrolimus | The risk or severity of adverse effects can be increased when Pimecrolimus is combined with Melphalan. |
| Pirfenidone | The risk or severity of adverse effects can be increased when Melphalan is combined with Pirfenidone. |
| Polythiazide | The risk or severity of neutropenia and thrombocytopenia can be increased when Polythiazide is combined with Melphalan. |
| Pomalidomide | The risk or severity of adverse effects can be increased when Melphalan is combined with Pomalidomide. |
| Ponatinib | The risk or severity of adverse effects can be increased when Melphalan is combined with Ponatinib. |
| Pralatrexate | The risk or severity of adverse effects can be increased when Melphalan is combined with Pralatrexate. |
| Pramocaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Pramocaine. |
| Prasugrel | The risk or severity of bleeding can be increased when Prasugrel is combined with Melphalan. |
| Prednisolone | The risk or severity of adverse effects can be increased when Prednisolone is combined with Melphalan. |
| Prednisone | The risk or severity of adverse effects can be increased when Prednisone is combined with Melphalan. |
| Prilocaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Prilocaine. |
| Procaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Procaine. |
| Procarbazine | The risk or severity of adverse effects can be increased when Melphalan is combined with Procarbazine. |
| Proparacaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Proparacaine. |
| Propoxycaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Propoxycaine. |
| Propylthiouracil | The risk or severity of adverse effects can be increased when Propylthiouracil is combined with Melphalan. |
| Protein C | The risk or severity of bleeding can be increased when Protein C is combined with Melphalan. |
| Protein S human | The risk or severity of bleeding can be increased when Protein S human is combined with Melphalan. |
| Rabies immune globulin, human | The therapeutic efficacy of Rabies immune globulin, human can be decreased when used in combination with Melphalan. |
| Rabies virus inactivated antigen, A | The therapeutic efficacy of Rabies virus inactivated antigen, A can be decreased when used in combination with Melphalan. |
| Rabies virus inactivated antigen, B | The therapeutic efficacy of Rabies virus inactivated antigen, B can be decreased when used in combination with Melphalan. |
| Raltitrexed | The risk or severity of adverse effects can be increased when Raltitrexed is combined with Melphalan. |
| Ravulizumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Ravulizumab. |
| Reteplase | The risk or severity of bleeding can be increased when Reteplase is combined with Melphalan. |
| Reviparin | The risk or severity of bleeding can be increased when Reviparin is combined with Melphalan. |
| Rilonacept | The risk or severity of adverse effects can be increased when Melphalan is combined with Rilonacept. |
| Risankizumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Risankizumab. |
| Rituximab | The risk or severity of adverse effects can be increased when Rituximab is combined with Melphalan. |
| Rivaroxaban | The risk or severity of bleeding can be increased when Rivaroxaban is combined with Melphalan. |
| Roflumilast | Roflumilast may increase the immunosuppressive activities of Melphalan. |
| Ropeginterferon alfa-2b | The risk or severity of adverse effects can be increased when Melphalan is combined with Ropeginterferon alfa-2b. |
| Ropivacaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Ropivacaine. |
| Rotavirus vaccine | The therapeutic efficacy of Rotavirus vaccine can be decreased when used in combination with Melphalan. |
| Rubella virus vaccine | The risk or severity of infection can be increased when Rubella virus vaccine is combined with Melphalan. |
| Ruxolitinib | The risk or severity of adverse effects can be increased when Melphalan is combined with Ruxolitinib. |
| Sarilumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Sarilumab. |
| Satralizumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Satralizumab. |
| Secukinumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Secukinumab. |
| Siltuximab | The risk or severity of adverse effects can be increased when Melphalan is combined with Siltuximab. |
| Siponimod | The risk or severity of adverse effects can be increased when Melphalan is combined with Siponimod. |
| Sipuleucel-T | The therapeutic efficacy of Sipuleucel-T can be decreased when used in combination with Melphalan. |
| Sirolimus | The risk or severity of adverse effects can be increased when Sirolimus is combined with Melphalan. |
| Smallpox (Vaccinia) Vaccine, Live | The therapeutic efficacy of Smallpox (Vaccinia) Vaccine, Live can be decreased when used in combination with Melphalan. |
| Sodium citrate | The risk or severity of bleeding can be increased when Sodium citrate is combined with Melphalan. |
| Sorafenib | The risk or severity of adverse effects can be increased when Sorafenib is combined with Melphalan. |
| Spesolimab | The risk or severity of adverse effects can be increased when Melphalan is combined with Spesolimab. |
| Streptokinase | The risk or severity of bleeding can be increased when Streptokinase is combined with Melphalan. |
| Streptozocin | The risk or severity of adverse effects can be increased when Streptozocin is combined with Melphalan. |
| Sulfamethoxazole | The risk or severity of myelosuppression can be increased when Sulfamethoxazole is combined with Melphalan. |
| Sulfasalazine | The risk or severity of adverse effects can be increased when Sulfasalazine is combined with Melphalan. |
| Sulfinpyrazone | The risk or severity of bleeding can be increased when Sulfinpyrazone is combined with Melphalan. |
| Sulodexide | The risk or severity of bleeding can be increased when Sulodexide is combined with Melphalan. |
| Sunitinib | The risk or severity of adverse effects can be increased when Melphalan is combined with Sunitinib. |
| Tacrolimus | Tacrolimus may increase the immunosuppressive activities of Melphalan. |
| Tedizolid phosphate | The risk or severity of myelosuppression can be increased when Melphalan is combined with Tedizolid phosphate. |
| Temozolomide | The risk or severity of adverse effects can be increased when Temozolomide is combined with Melphalan. |
| Temsirolimus | The risk or severity of adverse effects can be increased when Melphalan is combined with Temsirolimus. |
| Tenecteplase | The risk or severity of bleeding can be increased when Tenecteplase is combined with Melphalan. |
| Teniposide | The risk or severity of adverse effects can be increased when Teniposide is combined with Melphalan. |
| Teprotumumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Teprotumumab. |
| Teriflunomide | The risk or severity of adverse effects can be increased when Melphalan is combined with Teriflunomide. |
| Tetracaine | The risk or severity of methemoglobinemia can be increased when Melphalan is combined with Tetracaine. |
| Thalidomide | The risk or severity of adverse effects can be increased when Thalidomide is combined with Melphalan. |
| Thiotepa | The risk or severity of adverse effects can be increased when Melphalan is combined with Thiotepa. |
| Ticagrelor | The risk or severity of bleeding can be increased when Ticagrelor is combined with Melphalan. |
| Tick-borne encephalitis vaccine (whole virus, inactivated) | The therapeutic efficacy of Tick-borne encephalitis vaccine (whole virus, inactivated) can be decreased when used in combination with Melphalan. |
| Ticlopidine | The risk or severity of bleeding can be increased when Ticlopidine is combined with Melphalan. |
| Tinzaparin | The risk or severity of bleeding can be increased when Tinzaparin is combined with Melphalan. |
| Tioguanine | The risk or severity of adverse effects can be increased when Tioguanine is combined with Melphalan. |
| Tirofiban | The risk or severity of bleeding can be increased when Tirofiban is combined with Melphalan. |
| Tixocortol | The risk or severity of adverse effects can be increased when Melphalan is combined with Tixocortol. |
| Tocilizumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Tocilizumab. |
| Tofacitinib | Melphalan may increase the immunosuppressive activities of Tofacitinib. |
| Topotecan | The risk or severity of adverse effects can be increased when Topotecan is combined with Melphalan. |
| Tositumomab | The risk or severity of adverse effects can be increased when Tositumomab is combined with Melphalan. |
| Trabectedin | The risk or severity of adverse effects can be increased when Melphalan is combined with Trabectedin. |
| Trastuzumab | Trastuzumab may increase the neutropenic activities of Melphalan. |
| Trastuzumab emtansine | The risk or severity of adverse effects can be increased when Melphalan is combined with Trastuzumab emtansine. |
| Tretinoin | The risk or severity of adverse effects can be increased when Tretinoin is combined with Melphalan. |
| Triamcinolone | The risk or severity of adverse effects can be increased when Triamcinolone is combined with Melphalan. |
| Trichlormethiazide | The risk or severity of neutropenia and thrombocytopenia can be increased when Trichlormethiazide is combined with Melphalan. |
| Trifluridine | The risk or severity of adverse effects can be increased when Trifluridine is combined with Melphalan. |
| Triflusal | The risk or severity of bleeding can be increased when Triflusal is combined with Melphalan. |
| Trilostane | The risk or severity of adverse effects can be increased when Melphalan is combined with Trilostane. |
| Typhoid vaccine | The therapeutic efficacy of Typhoid vaccine can be decreased when used in combination with Melphalan. |
| Typhoid Vaccine Live | The risk or severity of infection can be increased when Typhoid Vaccine Live is combined with Melphalan. |
| Typhoid Vi polysaccharide vaccine | The therapeutic efficacy of Typhoid Vi polysaccharide vaccine can be decreased when used in combination with Melphalan. |
| Upadacitinib | The risk or severity of adverse effects can be increased when Melphalan is combined with Upadacitinib. |
| Urokinase | The risk or severity of bleeding can be increased when Urokinase is combined with Melphalan. |
| Varicella zoster vaccine (live/attenuated) | The risk or severity of infection can be increased when Varicella zoster vaccine (live/attenuated) is combined with Melphalan. |
| Varicella zoster vaccine (recombinant) | The therapeutic efficacy of Varicella zoster vaccine (recombinant) can be decreased when used in combination with Melphalan. |
| Vedolizumab | The risk or severity of adverse effects can be increased when Melphalan is combined with Vedolizumab. |
| Vibrio cholerae CVD 103-HgR strain live antigen | The therapeutic efficacy of Vibrio cholerae CVD 103-HgR strain live antigen can be decreased when used in combination with Melphalan. |
| Vilanterol | The risk or severity of adverse effects can be increased when Melphalan is combined with Vilanterol. |
| Vinblastine | The risk or severity of adverse effects can be increased when Vinblastine is combined with Melphalan. |
| Vincristine | The risk or severity of adverse effects can be increased when Vincristine is combined with Melphalan. |
| Vindesine | The risk or severity of adverse effects can be increased when Vindesine is combined with Melphalan. |
| Vinorelbine | The risk or severity of adverse effects can be increased when Vinorelbine is combined with Melphalan. |
| Voclosporin | The risk or severity of adverse effects can be increased when Melphalan is combined with Voclosporin. |
| Vorapaxar | The risk or severity of bleeding can be increased when Vorapaxar is combined with Melphalan. |
| Vorinostat | The risk or severity of adverse effects can be increased when Melphalan is combined with Vorinostat. |
| Warfarin | The risk or severity of bleeding can be increased when Warfarin is combined with Melphalan. |
| Ximelagatran | The risk or severity of bleeding can be increased when Ximelagatran is combined with Melphalan. |
| Yellow fever vaccine | The risk or severity of infection can be increased when Yellow fever vaccine is combined with Melphalan. |
Pregnancy and Lactation
Pregnancy
There is a possibility of birth defects if either the man or the woman is taking melphalan at the time of conception, or if it is taken during pregnancy. Effective birth control should be practiced while using this medication. There may be an increased risk of blood clots for women using hormonal birth control while taking melphalan. Talk to your doctor about alternative options. Men who are taking this medication should not father a child during treatment and for 6 months after treatment is completed.
This medication should not be used during pregnancy unless the benefits outweigh the risks. If you become pregnant while taking this medication, contact your doctor immediately.
Breast-feeding
It is not known if this medication passes into breast milk. If you are a breastfeeding mother and are taking melphalan, it may affect your baby. Talk to your doctor about whether you should continue breastfeeding. Patients should avoid breastfeeding during melphalan therapy because of the potential for serious adverse reactions in nursing children from melphalan. It is not known if melphalan is excreted into human milk. Do not resume breastfeeding until 1 week after the last melphalan dose.
Warnings for this medication?
Before you begin using a medication, be sure to inform your doctor of any medical conditions or allergies you may have, any medications you are taking, whether you are pregnant or breastfeeding, and any other significant facts about your health. These factors may affect how you should use this medication.
Anemia: Melphalan may cause low levels of red blood cells. If you experience symptoms of reduced red blood cell count (anemia) such as shortness of breath, feeling unusually tired, or pale skin, contact your doctor as soon as possible.
Bleeding: This medication can reduce the number of platelet cells in the blood. Platelets help the blood to clot, and a shortage could make you bleed more easily. Tell your doctor of any signs that your blood is not clotting as quickly. Such symptoms may include black and tarry stools, blood in the urine, easy bruising, or cuts that won’t stop bleeding.
Blood clots: There may be an increased risk of blood clots in the legs or lungs when melphalan is used in combination with certain other medications. If you are at increased risk of blood clots, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed.
Fertility: Sterility may occur with the use of melphalan.
Gout: This medication may cause high levels of uric acid in the blood, making gout more likely to occur.
Infection and vaccines: As well as killing cancer cells, this medication can reduce the number of cells that fight infection in the body (white blood cells). Avoid contact with people with contagious infections and tell your doctor if you begin to notice the signs of an infection such as fever or chills. Also tell your doctor if you have been vaccinated, or are planning to be vaccinated with a live vaccine.
Kidney problems: Kidney disease or reduced kidney function may cause this medication to build up in the body, increasing the risk of side effects. If you have kidney problems, discuss with your doctor how this medication may affect your medical condition, how your medical condition may affect the dosing and effectiveness of this medication, and whether any special monitoring is needed.
Lung problems: In rare cases, melphalan can cause lung problems (pulmonary fibrosis, permanent scarring of the lungs or interstitial pneumonitis, inflammation of the lungs) that, in some cases, can be fatal. If you experience any difficulty breathing, wheezing, fever, shortness of breath, cough, or coughing up of blood, accompanied by weakness and weight loss while taking melphalan, tell your doctor immediately.
Secondary cancer: When used for long periods of time, this medication can increase the risk of developing leukemia. If you have any concerns, talk to your doctor about the risks and benefits of using this medication.
Children: The safety and effectiveness of this medication have not been established for children.
What special precautions should I follow?
Before taking melphalan,
- tell your doctor and pharmacist if you are allergic to melphalan, any other medications, or any of the ingredients in melphalan tablets. Ask your pharmacist for a list of the ingredients.
- tell your doctor and pharmacist what other prescription and nonprescription medications, vitamins, nutritional supplements, and herbal products you are taking or plan to take. Be sure to mention any of the following: carmustine (BICNU, BCNU), cimetidine (Tagamet), cisplatin (Platinol AQ), cyclosporine (Sandimmune, Gengraf, Neoral), or interferon alfa (Intron A, Infergen, Alferon N).
- tell your doctor if you have taken melphalan before, but your cancer did not respond to the medication. Your doctor will probably tell you not to take melphalan.
- tell your doctor if you have received radiation therapy or other chemotherapy recently or if you have or have ever had kidney disease.
- you should know that melphalan may interfere with the normal menstrual cycle (period) in women and may temporarily or permanently stop sperm production in men. Melphalan may cause infertility (difficulty becoming pregnant); however, you should not assume that you cannot get pregnant or that you cannot get someone else pregnant. Women who are pregnant or breastfeeding should tell their doctors before they begin taking this drug. You should not plan to have children while receiving chemotherapy or for a while after treatments. (Talk to your doctor for further details.) Use a reliable method of birth control to prevent pregnancy. Melphalan may harm the fetus.
- do not have any vaccinations without talking to your doctor.
When to contact your doctor or health care provider:
Seek emergency help immediately and notify your healthcare provider, it you experience the following symptoms:
- Shortness of breath, wheezing, difficulty breathing, closing up of the throat, swelling of facial features, hives (possible allergic reaction).
Contact your healthcare provider immediately, day or night, if you should experience any of the following symptoms:
- Fever of 100.4° F (38° C) or higher, chills (possible signs of infection)
The following symptoms require medical attention but are not an emergency. Contact your healthcare provider within 24 hours of noticing any of the following:
- Nausea (interferes with the ability to eat and is unrelieved with prescribed medication)
- Vomiting (vomiting more than 4-5 times in a 24-hour period)
- Diarrhea (4-6 episodes in a 24-hour period)
- Unusual bleeding or bruising
- Black or tarry stools, or blood in your stools or urine
- Extreme fatigue (unable to carry on self-care activities)
- Mouth sores (painful redness, swelling, or ulcers)
- Yellowing of the skin or eyes. Signs of infection such as redness or swelling, pain in swallowing, coughing up mucous, or painful urination.
Always inform your healthcare provider if you experience any unusual symptoms.
Precautions:
- Before starting melphalan treatment, make sure you tell your doctor about any other medications you are taking (including prescription, over-the-counter, vitamins, herbal remedies, etc.). Do not take aspirin, or products containing aspirin unless your doctor specifically permits this.
- Do not receive any kind of immunization or vaccination without your doctor’s approval while taking melphalan.
- Inform your healthcare professional if you are pregnant or may be pregnant prior to starting this treatment. Pregnancy category D (melphalan may be hazardous to the fetus. Women who are pregnant or become pregnant must be advised of the potential hazard to the fetus).
- For both men and women: Do not conceive a child (get pregnant) while taking melphalan. Barrier methods of contraception, such as condoms, are recommended. Discuss with your doctor when you may safely become pregnant or conceive a child after therapy.
- Do not breastfeed while taking this medication.
Self-Care Tips:
- If taking melphalan pills take them on an empty stomach 1 hour before or 2 hours after meals.
- Drink at least two to three quarts of fluid every 24 hours, unless you are instructed otherwise.
- You may be at risk of infection so try to avoid crowds or people with colds and those not feeling well, and report fever or any other signs of infection immediately to your healthcare provider.
- Wash your hands often.
- To help treat/prevent mouth sores, use a soft toothbrush, and rinse three times a day with 1/2 to 1 teaspoon of baking soda and/or 1/2 to 1 teaspoon of salt mixed with 8 ounces of water.
- Use an electric razor and a soft toothbrush to minimize bleeding.
- Avoid contact sports or activities that could cause injury.
- This medication when taken as pills causes little nausea. But if you should experience nausea, take anti-nausea medications as prescribed by your doctor, and eat small frequent meals. Sucking on lozenges and chewing gum may also help.
- Avoid sun exposure. Wear SPF 15 (or higher) sunblock and protective clothing.
- In general, drinking alcoholic beverages should be kept to a minimum or avoided completely. You should discuss this with your doctor.
- Get plenty of rest.
- Maintain good nutrition.
- If you experience symptoms or side effects, be sure to discuss them with your healthcare team. They can prescribe medications and/or offer other suggestions that are effective in managing such problems.
References
