Vincristine

Vincristine is a semisynthetic natural product with a well-characterized action mech-

anism that involves the disruption of the microtubules and the subsequent cell death
by apoptosis [5].

From: Epigenetic Cancer Therapy, 2015

Related terms:

Neoplasm, Cyclophosphamide, Chemotherapy, Prednisone, Cisplatin, Etoposide,

Mutation, Doxorubicin, Toxicity

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Cancer chemotherapy
Jane M Dobson, ... Anne E Peaston, in Small Animal Clinical Pharmacology (Second
Edition), 2008

Clinical applications
Vincristine is widely used in veterinary oncology. Almost all combination chemother-
apy protocols for canine, feline and ferret lymphoma incorporate vincristine into the
drug cycle. Remission can be induced with vincristine-containing protocols in cases
of chronic lymphocytic leukemia and acute lymphoblastic leukemia. Single-agent
vincristine is the treatment of choice for transmissible venereal tumor and results in
a durable complete remission in over 90% of cases. Vincristine is a component of the
VAC protocol (vincristine, doxorubicin (Adriamycin®), cyclophosphamide), which has
shown some efficacy against soft tissue sarcomas, including hemangiosarcoma.

Vincristine and prednisone have also been shown to increase the platelet count
in patients with immune-mediated thrombocytopenia compared to treatment with
prednisone alone. Following administration of vincristine, a mild transient decrease
occurs in platelet count followed by a peak platelet count 8 days after drug admin-
istration to normal dogs. Platelets formed following administration of vincristine
showed normal aggregation in vitro. Similarly, clot retraction and buccal mucosal
bleeding time were normal in vincristine-treated dogs. Vincristine is not believed to
have major effects on wound healing.

Formulations and dose rates

Vincristine must be stored at 2–8°C to maintain potency and will degrade if exposed
to light.

DOGS
•0.5–0.75 mg/m2 IV bolus, once weekly or according to protocol being used•Doses
as low as 0.02 mg/kg have been used to stimulate platelet production

CATS
•0.025 mg/kg or 0.5 mg/m2 IV bolus, once weekly or according to protocol being
used

FERRETS
•0.75 mg/m2 IV bolus

Vincristine should never be administered intrathecally.

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BIOSYNTHETIC PRODUCTS FOR

ANTICANCER DRUG DESIGN AND
TREATMENT: THE BRYOSTATINS
George R. Pettit, ... Fiona Hogan, in Anticancer Drug Development, 2002

7. Bryostatin with Vincristine

Vincristine augments the antitumor effect of byostatin (Al-Katib et al., 1993b; Mo-
hammad et al., 1994b, 1994c). Exposure of WSU-DLCL2 cells to bryostatin prior to
treatment with vincristine enhances apoptosis (Mohammad et al., 1995a). Bryostatin
given 24 h before vincristine or melphalan resulted in the highest tumor growth
inhibition, tumor growth delay, and tumor cell kill. Two of five mice receiving
the bryostatin/vincristine combination were free of tumors more than 200 days
after treatment. Whether bryostatin acts as a differentiating agent or as a direct
anti-Waldenström's macroglobulinemia tumor agent remains unclear (Mohammad
et al., 1994a).

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Respiratory Toxicology
K.Y. Yoneda, C.E. Cross, in Comprehensive Toxicology, 2010

8.24.8.2.1 Vincristine
Vincristine is a vinca alkaloid used primarily in the treatment of leukemias, lym-
phomas, neuroblastoma, and sarcomas. Pulmonary toxicity has been well described
when vincristine is used in combination with other chemotherapeutic agents. How-
ever, it is not generally believed to be the major contributing factor. A retrospective
review of 207 patients with non-Hodgkin’s lymphoma treated with three different
vincristine-containing regimens suggests that most likely methotrexate, but po-
tentially also leucovorin and/or bleomycin, was the cause of pulmonary toxicity,
not vincristine (Shapiro et al. 1991). When vincristine is used in combination with
bleomycin, doxorubicin, cyclophosphamide, procarbazine, prednisone, and gemc-
itabine, 30% of 27 patients experienced serious pulmonary toxicity believed to be
due to an interaction between bleomycin and gemcitabine. Neither radiation nor
vincristine was believed to be a contributing factor (Macann et al. 2008). A large
randomized controlled trial of 402 patients with small cell lung cancer, treated
with either a combination of ifosfamide, carboplatin, etoposide, and vincristine or
standard chemotherapy not including vincristine, revealed no cases of reported
pulmonary toxicity (Thatcher et al. 2005b).

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Liposomes
Dawn N. Waterhouse, ... Murray S. Webb, in Methods in Enzymology, 2005

Abstract
Vincristine is a dimeric Catharanthus alkaloid derived from the Madagascan peri-
winkle that acts by binding to tubulin and blocking metaphase in actively dividing
cells. While vincristine is widely used in the treatment of a number of human
carcinomas, its use is associated with dose-limiting neurotoxicity, manifested mainly
as peripheral neuropathy. It is known that the therapeutic activity of vincristine can be
significantly enhanced after its encapsulation in appropriately designed liposomal
systems. Enhanced efficacy is also associated with a slight decrease in drug
toxicity. Thus, the therapeutic index of vincristine can be enhanced significantly
through the use of a liposomal delivery system. Vincristine may be encapsulat-
ed into liposomes of varying lipid composition by several techniques, including
passive loading, pH gradient loading, and ionophore-assisted loading. However,
most research has focused on the encapsulation of vincristine in response to a
transbilayer pH gradient, which actively concentrates the drug within the aqueous
interior of the liposome. This chapter details the preparation and evaluation of
liposomal vincristine. Specifically, we elaborate on the components (choice of lipids,
molar proportions, etc.), methods (preparation of liposomes, drug loading methods,
etc.), critical design features (size, surface charge, etc.), and key biological endpoints
(circulation lifetime, bioavailability, efficacy measurements) important to the
development of a formulation of vincristine with enhanced therapeutic properties.

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Neurological Complications of Onco-

logical Therapy
Michelle Monje, Patrick Y. Wen, in Handbook of Neuro-Oncology NeuroImaging,
2008

Vincristine
Vincristine is a vinca alkaloid that disrupts microtubules and is used to treat many
cancers including leukemia, lymphoma, sarcomas and brain tumors. It causes an
axonal neuropathy affecting both sensory and motor fibers in almost all patients.
Small sensory fibers are particularly affected. Clinical manifestations include f-
ingertip and foot parasthesias, muscle cramps, foot and wrist drop and sensory loss
of varying degrees. Focal neuropathies and cranial neuropathies are also possible.
In addition to the sensory and motor neuropathy, vincristine commonly causes
an autonomic neuropathy, characterized by gastrointestinal, urinary and/or sexual
dysfunction. Rarely, vincristine causes the syndrome of inappropriate anti-diuretic
hormone (SIADH), resulting in hyponatremia leading to metabolic encephalopathy
and seizures.

Vincristine should never be administered intrathecally and accidental administration

of vincristine into the CSF produces a rapidly ascending myelopathy, coma and death
[9,127].
Other vinca alkloids such as vinblastine and vinorlbine are associated with a lower
incidence of neuropathies.

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Neurologic Complications of Oncolog-

ic Therapy
Isabel Arrillaga-Romany, ... Patrick Y. Wen, in Handbook of Neuro-Oncology Neu-
roimaging (Second Edition), 2016

Vincristine
Vincristine is a vinca alkaloid that disrupts microtubules and is used to treat many
cancers including leukemia, lymphoma, sarcomas, and brain tumors. It causes an
axonal neuropathy affecting both sensory and motor fibers in almost all patients.225
Small sensory fibers are particularly affected. Clinical manifestations include f-
ingertip and foot paresthesias, muscle cramps, foot and wrist drop, and sensory loss
of varying degrees. Focal neuropathies and cranial neuropathies are also possible.
Patient with hereditary neuropathies (such as Charcot-Marie-Tooth),226,227 or on
concurrent inhibitors of CYP3A4 (such as antifungals),228,229 or hematopoietic colony
stimulating factors230 are particularly vulnerable this neuropathy.

In addition to the sensory and motor neuropathy, vincristine commonly causes

an autonomic neuropathy, characterized by gastrointestinal, urinary, and/or sexual
dysfunction.231 Focal cranial nerve neuropathies, most commonly involving the
oculomotor nerve, can also occur.232 Rarely, vincristine causes the syndrome of inap-
propriate antidiuretic hormone, resulting in hyponatremia leading to metabolic en-
cephalopathy and seizures.233 Vincristine should never be administered intrathecally
and accidental administration of vincristine into the cerebrospinal fluid produces a
rapidly ascending myelopathy, coma, and death.234 Other vinca alkaloids such as
vinblastine and vinorlbine are associated with a lower incidence of neuropathies.

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Autonomic Dysfunction: Drug-In-

duced
A.L. Tonkin, in Encyclopedia of Neuroscience, 2009
Vinca alkaloids
Vincristine and vinblastine are used in the chemotherapy of hematological ma-
lignancies such as lymphomas and leukemias. Vincristine, and to a lesser extent,
vinblastine, frequently cause a dose-dependent peripheral sensory neuropathy due
to axonal degeneration, which is common at cumulative doses over 40 mg. Motor
symptoms are rare but autonomic involvement occurs in more than a third of
patients, usually manifest as orthostatic hypotension, constipation, paralytic ileus,
erectile dysfunction, and urinary retention. Most of the neurological symptoms are
reversible after months or years but in some cases are irreversible.

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A Worldwide Yearly Survey of New Data

in Adverse Drug Reactions
Dayna S. McManus, in Side Effects of Drugs Annual, 2016

Vincristine
Vincristine, a chemotherapeutic agent, in combination with azole antifungals, has
shown to increase adverse drug reactions. The most common adverse reactions
that have been reported include gastrointestinal toxicity, peripheral neuropathy,
electrolyte abnormalities, cranial neuropathy and seizures. These increased adverse
events are thought to be related to the azole antifungal's inhibition of the cytochrome
P450 (CYP) which results in inhibition of the metabolism of vincristine and therefore
an increase in adverse effects. A retrospective study of 68 children with acute
lymphoblastic leukemia (ALL) who received vincristine and azole antifungals was
conducted. Patients were divided into different groups depending on the antifungal
agent they received. The control group who just received vincristine had 44 patients,
the itraconazole group at 44 patients, the fluconazole group had 42 patients and
the voriconazole group had 6 patients. Overall there were significantly more
adverse drug events in the itraconazole group and the voriconazole group compared
to the fluconazole and control group (P < 0.05). There was no major difference
between fluconazole and the control group. This is likely because fluconazole does
not inhibit CYP3A4 as significantly the other azole antifungal agents. The side
effects seen were similar to what has been reported before with gastrointestinal
toxicity and peripheral neuropathy being the most common side effects. Therefore,
when utilizing vincristine in this patient population fluconazole appears to be the
safest azole antifungal to utilize for treatment and or prophylaxis of fungal infections
[35c].

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Gliomas
L.Burt Nabors, ... Wolfgang Grisold, in Handbook of Clinical Neurology, 2016

Clinical applications and indications

Vincristine is primarily utilized in the treatment of low-grade gliomas and anaplastic
oligodendrogliomas as a part of the three-drug regimen PCV. Randomized con-
trolled studies in anaplastic oligodendroglioma administered PCV in either a neoad-
juvant or adjuvant fashion around radiation therapy for patients newly diagnosed
with anaplastic oligodendrogliomas and in both situations a survival advantage
existed for patients (Cairncross et al., 2013; van den Bent et al., 2013). Vincristine
is used in the treatment of medulloblastoma as a part of a multimodality and
multiagent approach (Packer et al., 1994, 1999; Rood et al., 2004).

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Neurologic Complications of
Chemotherapy
Patrick Y. Wen, in Office Practice of Neurology (Second Edition), 2003

Vinca Alkaloids.
Vincristine is a vinca alkaloid used to treat many cancers including leukemia, lym-
phomas, sarcomas, and brain tumors. Its main toxicity is an axonal neuropathy
resulting from disruption of the microtubules within axons and interference with
axonal transport. The neuropathy involves both sensory and motor fibers, although
small sensory fibers are especially affected. Almost all patients have some degree
of neuropathy, which is the dose-limiting toxicity. The earliest symptoms usually
are paresthesias in the fingertips and feet. Muscle cramps are also quite common.
These symptoms may occur after several weeks of treatment or even after the drug
has been discontinued and progress for several months before improving. Children
tend to recover more quickly than adults. Initially objective sensory findings tend
to be minor compared with the symptoms, but loss of ankle jerks is common.
 Occasionally there may be profound weakness, with bilateral foot drop and wrist
drop, and loss of all sensory modalities. This occurs especially in older patients who
are cachectic, patients who have received prior radiation to the peripheral nerves,
or those who have preexisting neurologic diseases such as Charcot-Marie-Tooth
neuropathy. Vincristine may also cause focal neuropathies.

Neurophysiologic studies show a primarily axonal neuropathy. Although there are

anecdotal reports that glutamine may help some patients with vincristine neuropa-
thy, there is generally no effective treatment.

Autonomic neuropathy is common in patients receiving vincristine. Colicky abdom-

inal pain and constipation occur in almost 50% of patients, and rarely paralytic
ileus may result. All patients receiving vincristine should receive prophylactic stool
softeners and laxatives. Less commonly, patients may develop impotence, postural
hypotension, and atonic bladders.

Vincristine occasionally may cause cranial neuropathies. The most common nerve
to be involved is the occulomotor nerve, resulting in ptosis and ophthalmoplegia.
Other nerves that may be involved include recurrent laryngeal nerve, optic nerve,
facial nerve, and auditory nerve. Vincristine may also cause retinal damage and night
blindness. Some patients may experience jaw pain and parotid pain.

Rarely, vincristine may cause SIADH, resulting in hyponatremia, confusion, and

seizures. CNS complications unrelated to SIADH may also occur. These include
seizures, encephalopathy, transient cortical blindness, ataxia, athetosis, and parkin-
sonism.

The related vinca alkaloids vindesine and vinblastine have less neurotoxicity. This
may be related to differences in lipid solubility, plasma clearance and terminal
half-life, and different sensitivities of axoplasmic transport. Vinorelbine is a semisyn-
thetic analogue of vinblastine that is being increasingly used for patients with breast
and lung cancer. Like vincristine, vinorelbine inhibits microtubule assembly but has
less affinity for neural tissue and therefore was predicted to be less neurotoxic.
Vinorelbine use is associated with mild paresthesias in about 20% of patients. Severe
neuropathy is rare but appears to be more common in patients treated previously
with paclitaxel.

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