Vinblastine Sulfate – Uses, Dosage, Side Effects, Interactions

Vinblastine Sulfate is the sulfate salt of vinblastine, a natural alkaloid isolated from the plant Catharanthus roseus (Madagascar periwinkle) with antineoplastic properties. Vinblastine disrupts microtubule formation and function during mitosis and interferes with glutamic acid metabolism. (NCI04)

Vinblastine sulfate appears as an anticancer drug. White to slightly yellow crystalline powder. (NTP, 1992) Antitumor alkaloid isolated from Vinca rosea. (Merck, 11th ed.)

Mechanism of action

The antitumor activity of vinblastine is thought to be due primarily to the inhibition of mitosis at metaphase through its interaction with tubulin. Vinblastine binds to the microtubular proteins of the mitotic spindle, leading to crystallization of the microtubule and mitotic arrest or cell death.

Vinblastine is a vinca alkaloid antineoplastic agent. The vinca alkaloids are structurally similar compounds comprised of 2 multi-ringed units: vindoline and catharanthine. The vinca alkaloids have become clinically useful since the discovery of their antitumor properties in 1959. Initially, extracts of the periwinkle plant (Catharanthus roseus) were investigated because of putative hypoglycemic properties but were noted to cause marrow suppression in rats and antileukemic effects in vitro. Vinblastine has some immunosuppressant effects. The vinca alkaloids are considered to be cell cycle phase-specific.

Indications

  • For treatment of breast cancer, testicular cancer, lymphomas, neuroblastoma, Hodgkin’s and non-Hodgkin’s lymphomas, mycosis fungoides, histiocytosis, and Kaposi’s sarcoma.
  • Autoimmune Hemolytic Anemia
  • Bladder Cancer, Cancer
  • Immune Thrombocytopenia (ITP)
  • Kaposi’s sarcoma
  • Letterer-Siwe disease
  • Lymphoma, Hodgkins
  • Metastatic Melanoma
  • Non-Small Cell Lung Carcinoma (NSCLC)
  • Advanced Alibert-Bazin syndrome
  • Advanced Soft Tissue Sarcoma (STS)
  • Advanced Testicular cancer
  • Histiocytic lymphoma
  • Refractory Breast cancer

Use in Cancer

Vinblastine sulfate is approved as a palliative treatment for:

  • Breast cancer has not gotten better with other treatments. It is used in adults.
  • Choriocarcinoma (a type of gestational trophoblastic disease) has not gotten better with other chemotherapy. It is used in adults.
  • Hodgkin lymphoma. It is used in adults and children with advanced diseases.
  • Kaposi sarcoma. It is used in adults.
  • Mycosis fungoides (a type of cutaneous T-cell lymphoma). It is used in adults.
  • Non-Hodgkin lymphoma (NHL) in adults.
  • Testicular germ cell tumors. It is used in adults and children with advanced diseases.

Contraindications

  • Contraindications—hypersensitivity to drug or class, bacterial infection, granulocytopenia, intrathecal use, intestinal obstruction, paralytic ileus.
  • Vinblastine sulfate is contraindicated in patients who have significant granulocytopenia, in the presence of bacterial infection. Such infections must be brought under control prior to the initiation of therapy with vinblastine sulfate.

Dosage

Strengths: 10 mg; 1 mg/mL

Usual Adult Dose

Breast Cancer

Because of the variation in the depth of the leukopenic response following therapy, the manufacturer recommends that the dose not be given more frequently than once every 7 days. The manufacturer outlines the following conservative incremental approach to dosage every 7 days for adults:

  • First dose: 3.7 mg/m2 IV
  • Second dose: 5.5 mg/m2 IV
  • Third dose: 7.4 mg/m2 IV
  • Fourth dose: 9.25 mg/m2 IV
  • Fifth dose: 11.1 mg/m2 IV
  • This progression may be followed up to a maximum dosage of 18.5 mg/m2 IV. The dose should not be increased after that dose which reduces the white cell count to approximately 3000 cells/mm3. In some adults, 3.7 mg/m2 IV may produce this leukopenia; other adults may require more than 11.1 mg/m2 IV; and, very rarely, as much as 18.5 mg/m2 IV may be necessary. For most adult patients, the weekly dose will be 5.5 to 7.4 mg/m2 IV.
  • When the dose which produces the above degree of leukopenia has been established, a dose of one increment smaller than this should be administered at weekly intervals for maintenance so the patient is receiving the maximum dose that does not cause leukopenia. Even though 7 days have elapsed, the next dose should not be given until the white cell count has returned to at least 4000/mm3. In some cases, oncolytic activity may be encountered before the leukopenic effect. When this occurs, there is no need to increase the size of subsequent doses.

Kaposi’s Sarcoma

Because of the variation in the depth of the leukopenic response following therapy, the manufacturer recommends that the dose not be given more frequently than once every 7 days. The manufacturer outlines the following conservative incremental approach to dosage every 7 days for adults:

  • First dose: 3.7 mg/m2 IV
  • Second dose: 5.5 mg/m2 IV
  • Third dose: 7.4 mg/m2 IV
  • Fourth dose: 9.25 mg/m2 IV
  • Fifth dose: 11.1 mg/m2 IV
  • This progression may be followed up to a maximum dosage of 18.5 mg/m2 IV. The dose should not be increased after that dose which reduces the white cell count to approximately 3000 cells/mm3. In some adults, 3.7 mg/m2 IV may produce this leukopenia; other adults may require more than 11.1 mg/m2 IV; and, very rarely, as much as 18.5 mg/m2 IV may be necessary. For most adult patients, the weekly dose will be 5.5 to 7.4 mg/m2 IV.
  • When the dose which produces the above degree of leukopenia has been established, a dose of one increment smaller than this should be administered at weekly intervals for maintenance so the patient is receiving the maximum dose that does not cause leukopenia. Even though 7 days have elapsed, the next dose should not be given until the white cell count has returned to at least 4000/mm3. In some cases, oncolytic activity may be encountered before the leukopenic effect. When this occurs, there is no need to increase the size of subsequent doses.

Testicular Cancer

Because of the variation in the depth of the leukopenic response following therapy, the manufacturer recommends that the dose not be given more frequently than once every 7 days. The manufacturer outlines the following conservative incremental approach to dosage every 7 days for adults:

  • First dose: 3.7 mg/m2 IV
  • Second dose: 5.5 mg/m2 IV
  • Third dose: 7.4 mg/m2 IV
  • Fourth dose: 9.25 mg/m2 IV
  • Fifth dose: 11.1 mg/m2 IV
  • This progression may be followed up to a maximum dosage of 18.5 mg/m2 IV. The dose should not be increased after that dose which reduces the white cell count to approximately 3000 cells/mm3. In some adults, 3.7 mg/m2 IV may produce this leukopenia; other adults may require more than 11.1 mg/m2 IV; and, very rarely, as much as 18.5 mg/m2 IV may be necessary. For most adult patients, the weekly dose will be 5.5 to 7.4 mg/m2 IV.
  • When the dose which produces the above degree of leukopenia has been established, a dose of one increment smaller than this should be administered at weekly intervals for maintenance so the patient is receiving the maximum dose that does not cause leukopenia. Even though 7 days have elapsed, the next dose should not be given until the white cell count has returned to at least 4000/mm3. In some cases, oncolytic activity may be encountered before leukopenic effect. When this occurs, there is no need to increase the size of subsequent doses.

Hodgkin’s Disease

Because of the variation in the depth of the leukopenic response following therapy, the manufacturer recommends that the dose not be given more frequently than once every 7 days. The manufacturer outlines the following conservative incremental approach to dosage every 7 days for adults:

  • First dose: 3.7 mg/m2 IV
  • Second dose: 5.5 mg/m2 IV
  • Third dose: 7.4 mg/m2 IV
  • Fourth dose: 9.25 mg/m2 IV
  • Fifth dose: 11.1 mg/m2 IV
  • This progression may be followed up to a maximum dosage of 18.5 mg/m2 IV. The dose should not be increased after that dose which reduces the white cell count to approximately 3000 cells/mm3. In some adults, 3.7 mg/m2 IV may produce this leukopenia; other adults may require more than 11.1 mg/m2 IV; and, very rarely, as much as 18.5 mg/m2 IV may be necessary. For most adult patients, the weekly dose will be 5.5 to 7.4 mg/m2 IV.
  • When the dose which produces the above degree of leukopenia has been established, a dose of one increment smaller than this should be administered at weekly intervals for maintenance so the patient is receiving the maximum dose that does not cause leukopenia. Even though 7 days have elapsed, the next dose should not be given until the white cell count has returned to at least 4000/mm3. In some cases, oncolytic activity may be encountered before leukopenic effect. When this occurs, there is no need to increase the size of subsequent doses.

Mycosis Fungoides

Because of the variation in the depth of the leukopenic response following therapy, the manufacturer recommends that the dose not be given more frequently than once every 7 days. The manufacturer outlines the following conservative incremental approach to dosage every 7 days for adults:

  • First dose: 3.7 mg/m2 IV
  • Second dose: 5.5 mg/m2 IV
  • Third dose: 7.4 mg/m2 IV
  • Fourth dose: 9.25 mg/m2 IV
  • Fifth dose: 11.1 mg/m2 IV
  • This progression may be followed up to a maximum dosage of 18.5 mg/m2 IV. The dose should not be increased after that dose which reduces the white cell count to approximately 3000 cells/mm3. In some adults, 3.7 mg/m2 IV may produce this leukopenia; other adults may require more than 11.1 mg/m2 IV; and, very rarely, as much as 18.5 mg/m2 IV may be necessary. For most adult patients, the weekly dose will be 5.5 to 7.4 mg/m2 IV.
  • When the dose which produces the above degree of leukopenia has been established, a dose of one increment smaller than this should be administered at weekly intervals for maintenance so the patient is receiving the maximum dose that does not cause leukopenia. Even though 7 days have elapsed, the next dose should not be given until the white cell count has returned to at least 4000/mm3. In some cases, oncolytic activity may be encountered before leukopenic effect. When this occurs, there is no need to increase the size of subsequent doses.

Choriocarcinoma

Because of the variation in the depth of the leukopenic response following therapy, the manufacturer recommends that the dose not be given more frequently than once every 7 days. The manufacturer outlines the following conservative incremental approach to dosage every 7 days for adults:

  • First dose: 3.7 mg/m2 IV
  • Second dose: 5.5 mg/m2 IV
  • Third dose: 7.4 mg/m2 IV
  • Fourth dose: 9.25 mg/m2 IV
  • Fifth dose: 11.1 mg/m2 IV
  • This progression may be followed up to a maximum dosage of 18.5 mg/m2 IV. The dose should not be increased after that dose which reduces the white cell count to approximately 3000 cells/mm3. In some adults, 3.7 mg/m2 IV may produce this leukopenia; other adults may require more than 11.1 mg/m2 IV; and, very rarely, as much as 18.5 mg/m2 IV may be necessary. For most adult patients, the weekly dose will be 5.5 to 7.4 mg/m2 IV.
  • When the dose which produces the above degree of leukopenia has been established, a dose of one increment smaller than this should be administered at weekly intervals for maintenance so the patient is receiving the maximum dose that does not cause leukopenia. Even though 7 days have elapsed, the next dose should not be given until the white cell count has returned to at least 4000/mm3. In some cases, oncolytic activity may be encountered before leukopenic effect. When this occurs, there is no need to increase the size of subsequent doses.

Lymphoma

Because of the variation in the depth of the leukopenic response following therapy, the manufacturer recommends that the dose not be given more frequently than once every 7 days. The manufacturer outlines the following conservative incremental approach to dosage every 7 days for adults:

  • First dose: 3.7 mg/m2 IV
  • Second dose: 5.5 mg/m2 IV
  • Third dose: 7.4 mg/m2 IV
  • Fourth dose: 9.25 mg/m2 IV
  • Fifth dose: 11.1 mg/m2 IV
  • This progression may be followed up to a maximum dosage of 18.5 mg/m2 IV. The dose should not be increased after that dose which reduces the white cell count to approximately 3000 cells/mm3. In some adults, 3.7 mg/m2 IV may produce this leukopenia; other adults may require more than 11.1 mg/m2 IV; and, very rarely, as much as 18.5 mg/m2 IV may be necessary. For most adult patients, the weekly dose will be 5.5 to 7.4 mg/m2 IV.
  • When the dose which produces the above degree of leukopenia has been established, a dose of one increment smaller than this should be administered at weekly intervals for maintenance so the patient is receiving the maximum dose that does not cause leukopenia. Even though 7 days have elapsed, the next dose should not be given until the white cell count has returned to at least 4000/mm3. In some cases, oncolytic activity may be encountered before leukopenic effect. When this occurs, there is no need to increase the size of subsequent doses.

Histiocytosis

Because of the variation in the depth of the leukopenic response following therapy, the manufacturer recommends that the dose not be given more frequently than once every 7 days. The manufacturer outlines the following conservative incremental approach to dosage every 7 days for adults:

  • First dose: 3.7 mg/m2 IV
  • Second dose: 5.5 mg/m2 IV
  • Third dose: 7.4 mg/m2 IV
  • Fourth dose: 9.25 mg/m2 IV
  • Fifth dose: 11.1 mg/m2 IV
  • This progression may be followed up to a maximum dosage of 18.5 mg/m2 IV. The dose should not be increased after that dose which reduces the white cell count to approximately 3000 cells/mm3. In some adults, 3.7 mg/m2 IV may produce this leukopenia; other adults may require more than 11.1 mg/m2 IV; and, very rarely, as much as 18.5 mg/m2 IV may be necessary. For most adult patients, the weekly dose will be 5.5 to 7.4 mg/m2 IV.
  • When the dose which produces the above degree of leukopenia has been established, a dose of one increment smaller than this should be administered at weekly intervals for maintenance so the patient is receiving the maximum dose that does not cause leukopenia. Even though 7 days have elapsed, the next dose should not be given until the white cell count has returned to at least 4000/mm3. In some cases, oncolytic activity may be encountered before leukopenic effect. When this occurs, there is no need to increase the size of subsequent doses.

Usual Pediatric Dose

Testicular Cancer

Initial doses of this drug in pediatric patients varies depending on the schedule used and whether it is administered as a single agent or incorporated within a chemotherapeutic regimen:

  • As a single agent for Letterer-Siwe disease (histiocytosis X), the initial dose is 6.5 mg/m2 IV
  • When used in combination with other chemotherapeutic agents for Hodgkin’s disease, the initial dose is 6 mg/m2 IV
  • For testicular germ cell carcinomas, the initial dose is 3 mg/m2 IV in a combination regimen
  • Dose modifications should be guided by hematologic tolerance.

Hodgkin’s Disease

Initial doses of this drug in pediatric patients varies depending on the schedule used and whether it is administered as a single agent or incorporated within a chemotherapeutic regimen:

  • As a single agent for Letterer-Siwe disease (histiocytosis X), the initial dose is 6.5 mg/m2 IV
  • When used in combination with other chemotherapeutic agents for Hodgkin’s disease, the initial dose is 6 mg/m2 IV
  • For testicular germ cell carcinomas, the initial dose is 3 mg/m2 IV in a combination regimen
  • Dose modifications should be guided by hematologic tolerance.

Histiocytosis

Initial doses of this drug in pediatric patients varies depending on the schedule used and whether it is administered as a single agent or incorporated within a chemotherapeutic regimen:

  • As a single agent for Letterer-Siwe disease (histiocytosis X), the initial dose is 6.5 mg/m2 IV
  • When used in combination with other chemotherapeutic agents for Hodgkin’s disease, the initial dose is 6 mg/m2 IV
  • For testicular germ cell carcinomas, the initial dose is 3 mg/m2 IV in a combination regimen
  • Dose modifications should be guided by hematologic tolerance.

Side effects

Most Common 

  • Most people do not experience all of the vinblastine side effects listed.
  • Vinblastine’s side effects are often predictable in terms of their onset and duration.
  • Vinblastine’s side effects should improve after treatment is complete.
  • Vinblastine’s side effects are usually quite manageable. There are many options to help minimize or prevent the side effects of vinblastine.
  • Low blood counts. Your white and red blood cells and platelets may temporarily decrease. This can put you at increased risk for infection, anemia and/or bleeding.
  • Injection site reactions
  • Fatigue, and weakness
  • Nausea and vomiting – usually moderate and occur within the first 24 hours of treatment
  • Poor appetite
  • Peripheral neuropathy (numbness in your fingers and toes) may occur with repeated doses. This should be reported to your healthcare provider.
  • Constipation may occur within 1-3 days after your treatment, and is sometimes accompanied by abdominal cramping. It is important to keep your bowels moving regularly.

More Common 

  • Diarrhea
  • Fever
  • Hair loss may occur, but your hair will most likely grow back when the treatments are completed. This usually begins 2-3 weeks after each treatment.
  • Hearing loss
  • Mouth sores
  • Taste changes, metallic taste
  • Headache
  • Depression
  • Jaw pain, bone pain, tumor pain
  • High blood pressure (hypertension)
  • Tiredness
  • Shortness of breath, myalgias (muscle pain), and arthralgias (joint pain) may occur infrequently

Rare

  • temporary mental depression,
  • paresthesias,
  • loss of deep tendon reflexes,
  • headache,
  • convulsions,
  • psychoses;
  • dysfunction of the autonomic nervous system, with marked constipation,
  • paralytic ileus,
  • urinary retention,
  • bilateral pain and tenderness of the parotid glands associated
  • dryness of the mouth, sinus tachycardia;
  • nausea, vomiting,
  • anorexia,
  • diarrhea;
  • loss of hair,
  • vesicular mucositis of the mouth, and
  • dermatitis. (NTP, 1992)

Drug Interactions

Pregnancy and Lactation

Pregnancy category D 

Vinblastine Sulfate During Pregnancy or Breastfeeding. Vinblastine Sulfate is not recommended for use during pregnancy. It may harm the fetus. If you become pregnant or think you may be pregnant, tell your doctor immediately. It is unknown if this drug passes into breast milk.
Most sources consider breastfeeding to be contraindicated during maternal antineoplastic drug therapy.[1] It is probably impractical to resume breastfeeding after vinblastine therapy because of the drug’s long half-life. Chemotherapy may adversely affect the normal microbiome and chemical makeup of breast milk.[2] Women who receive chemotherapy during pregnancy are more likely to have difficulty nursing their infant.

Lactation

Most sources consider breastfeeding to be contraindicated during maternal antineoplastic drug therapy.[1] It is probably impractical to resume breastfeeding after vinblastine therapy because of the drug’s long half-life. Chemotherapy may adversely affect the normal microbiome and chemical makeup of breast milk.[2] Women who receive chemotherapy during pregnancy are more likely to have difficulty nursing their infant.

What special precautions should I follow?

Before receiving vinblastine,

  • tell your doctor and pharmacist if you are allergic to vinblastine, any other medications, or any of the ingredients in vinblastine injection. 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: aprepitant (Emend), certain antifungals such as itraconazole (Sporanox) and ketoconazole (Nizoral); clarithromycin (Biaxin, in Prevpac); erythromycin (E.E.S., E-Mycin, others); HIV protease inhibitors including indinavir (Crixivan), nelfinavir (Viracept), and ritonavir (Norvir, in Kaletra); phenytoin (Dilantin), tolterodine (Detrol, Detrol LA). Your doctor may need to change the doses of your medications or monitor you carefully for side effects. Tell your doctor and pharmacist about all the medications you are taking so they can check whether any of your medications may increase the risk that you will develop hearing problems during your treatment with vinblastine.
  • tell your doctor if you have an infection. Your doctor will want to treat your infection before you receive a vinblastine injection.
  • tell your doctor if you have or have ever had heart or blood vessel disease, including varicose veins (swelling, redness, or pain in a vein in your arms or legs), or lung or liver disease.
  • you should know that vinblastine may interfere with the normal menstrual cycle (period) in women and may temporarily or permanently stop sperm production in men. Tell your doctor if you are pregnant, plan to become pregnant, or are breastfeeding. You should not become pregnant or breast-feed while you are receiving vinblastine injections. If you become pregnant while receiving a vinblastine injection, call your doctor. Vinblastine may harm the fetus.

When to contact your doctor or health care provider:

  • Severe constipation, unrelieved by laxative use
  • Nausea (interferes with the ability to eat and is unrelieved with prescribed medications)
  • 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
  • Blood in the urine
  • Pain or burning with urination
  • Extreme fatigue (unable to carry on self-care activities) Mouth sores (painful redness, swelling or ulcers)

Always inform your healthcare provider if you experience any unusual symptoms.

Precautions:

  • Before starting vinblastine 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 receive any kind of immunization or vaccination without your doctor’s approval while taking vinblastine.
  • Inform your healthcare professional if you are pregnant or may be pregnant prior to starting this treatment. Pregnancy category D (vinblastine 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 vinblastine. 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

  • Apply a warm compress if you have any pain, redness, or swelling at the IV site, and notify your doctor.
  • Keep your bowels moving. Your healthcare provider may prescribe a stool softener to help prevent constipation that may be caused by this medicine.
  • If you experience diarrhea of greater than 4-6 stools per day, contact your healthcare provider and increase your fluid intake.
  • Drink at least 2 to 3 quarts of fluid every 24 hours, unless you were told to restrict your fluid intake, and maintain good nutrition. This will decrease your chances of being constipated, and prevent dehydration.
  • You may be at risk of infection so try to avoid crowds or people with colds, and report fever or any other signs of infection immediately to your healthcare provider.
  • Wash your hands often.
  • Use an electric razor and soft toothbrush to minimize bleeding.
  • Avoid contact sports or activities that could cause injury.
  • Avoid sun exposure. Wear SPF 30 (or higher) sunblock and protective clothing.
  • To reduce nausea, take anti-nausea medications as prescribed by your doctor, and eat small, frequent meals.
  • Follow the regimen of anti-diarrhea medication as prescribed by your health care professional.
  • Eat foods that may help reduce diarrhea
  • To help treat/prevent mouth sores, use a soft toothbrush, and rinse at least three times a day with 1/2 to 1 teaspoon of baking soda and/or salt in 8 ounces of water.
  • In general, drinking alcoholic beverages should be minimized or avoided. You should discuss this with your doctor.
  • Get plenty of rest
  • Maintain good nutrition
  • Remain active as you are able. Gentle exercise is encouraged such as daily walks
  • Use caution when driving or engaging in tasks that require alertness until a response to the drug is known.
  • 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

  1. https://pubchem.ncbi.nlm.nih.gov/compound/Vinblastine-sulfate
  2. https://pubchem.ncbi.nlm.nih.gov/compound/Vinblastine-sulfate-salt
  3. https://pubchem.ncbi.nlm.nih.gov/compound/Vincaleukoblastine-sulfate
  4. https://medlineplus.gov/druginfo/meds/a682848.html
  5. https://go.drugbank.com/drugs/DB00570
  6. https://www.drugs.com/monograph/vinblastine.html
  7. https://www.cancer.gov/about-cancer/treatment/drugs/vinblastinesulfate
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  22. FDA/SPL Indexing Data
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    Unless otherwise noted, the contents of the FDA website (www.fda.gov), both text and graphics, are not copyrighted. They are in the public domain and may be republished, reprinted and otherwise used freely by anyone without the need to obtain permission from FDA. Credit to the U.S. Food and Drug Administration as the source is appreciated but not required.
    https://www.fda.gov/about-fda/about-website/website-policies#linking
    N00W22YO2B
    https://www.fda.gov/ForIndustry/DataStandards/SubstanceRegistrationSystem-UniqueIngredientIdentifierUNII/
  23. International Agency for Research on Cancer (IARC)
    LICENSE
    Materials made available by IARC/WHO enjoy copyright protection under the Berne Convention for the Protection of Literature and Artistic Works, under other international conventions, and under national laws on copyright and neighbouring rights. IARC exercises copyright over its Materials to make sure that they are used in accordance with the Agency’s principles. All rights are reserved.
    https://publications.iarc.fr/Terms-Of-Use
    Vinblastine sulfate
    https://monographs.iarc.who.int/list-of-classifications
    IARC Classification
    https://www.iarc.fr/
  24. MassBank of North America (MoNA)
    LICENSE
    The content of the MoNA database is licensed under CC BY 4.0.
    https://mona.fiehnlab.ucdavis.edu/documentation/license
    VINBLASTINE SULFATE
    https://mona.fiehnlab.ucdavis.edu/spectra/browse?query=compound.metaData%3Dq%3D%27name%3D%3D%22InChIKey%22%20and%20value%3D%3D%22KDQAABAKXDWYSZ-PNYVAJAMSA-N%22%27
  25. National Drug Code (NDC) Directory
    LICENSE
    Unless otherwise noted, the contents of the FDA website (www.fda.gov), both text and graphics, are not copyrighted. They are in the public domain and may be republished, reprinted and otherwise used freely by anyone without the need to obtain permission from FDA. Credit to the U.S. Food and Drug Administration as the source is appreciated but not required.
    https://www.fda.gov/about-fda/about-website/website-policies#linking
    VINBLASTINE SULFATE
    https://www.fda.gov/drugs/drug-approvals-and-databases/national-drug-code-directory
  26. NCI Cancer Drugs
    LICENSE
    https://www.cancer.gov/policies/copyright-reuse
    Vinblastine Sulfate
    https://www.cancer.gov/about-cancer/treatment/drugs/vinblastinesulfate
  27. NLM RxNorm Terminology
    LICENSE
    The RxNorm Terminology is created by the National Library of Medicine (NLM) and is in the public domain and may be republished, reprinted and otherwise used freely by anyone without the need to obtain permission from NLM. Credit to the U.S. National Library of Medicine as the source is appreciated but not required. The full RxNorm dataset requires a free license.
    https://www.nlm.nih.gov/research/umls/rxnorm/docs/termsofservice.html
    https://rxnav.nlm.nih.gov/id/rxnorm/11199
  28. PubChem
    https://pubchem.ncbi.nlm.nih.gov
  29. Springer Nature
    https://pubchem.ncbi.nlm.nih.gov/substance/?source=15745&sourceid=64072649-101309878
  30. Wikidata
    LICENSE
    CCZero
    https://creativecommons.org/publicdomain/zero/1.0/
    vinblastine sulfate
    https://www.wikidata.org/wiki/Q27077057
  31. Medical Subject Headings (MeSH)
    LICENSE
    Works produced by the U.S. government are not subject to copyright protection in the United States. Any such works found on National Library of Medicine (NLM) Web sites may be freely used or reproduced without permission in the U.S.
    https://www.nlm.nih.gov/copyright.html
    Vinblastine
    https://www.ncbi.nlm.nih.gov/mesh/68014747
    MeSH Tree
    http://www.nlm.nih.gov/mesh/meshhome.html
    Tubulin Modulators
    https://www.ncbi.nlm.nih.gov/mesh/68050257
    Antineoplastic Agents, Phytogenic
    https://www.ncbi.nlm.nih.gov/mesh/68000972
  32. UN Globally Harmonized System of Classification and Labelling of Chemicals (GHS)
    GHS Classification Tree
    http://www.unece.org/trans/danger/publi/ghs/ghs_welcome_e.html
  33. NORMAN Suspect List Exchange
    LICENSE
    Data: CC-BY 4.0; Code (hosted by ECI, LCSB): Artistic-2.0
    https://creativecommons.org/licenses/by/4.0/
    NORMAN Suspect List Exchange Classification
    https://www.norman-network.com/nds/SLE/
  34. PATENTSCOPE (WIPO)
    SID 388325377
    https://pubchem.ncbi.nlm.nih.gov/substance/388325377