Carmustine Macure
Alkylating antineoplastic agent (nitrosourea) for brain tumors, lymphomas, and multiple myeloma
Carmustine Macure contains the active substance carmustine (also known as BCNU), a potent alkylating chemotherapy agent belonging to the nitrosourea class. It is used to treat certain brain tumors, Hodgkin lymphoma, non-Hodgkin lymphomas, and multiple myeloma. Carmustine is unique among chemotherapy agents because it readily crosses the blood-brain barrier, making it especially valuable for treating central nervous system malignancies. It is administered as a slow intravenous infusion in a hospital setting under the supervision of an oncologist experienced in chemotherapy.
Quick Facts
Key Takeaways
- Carmustine is a nitrosourea alkylating agent that crosses the blood-brain barrier, making it uniquely effective for brain tumors and CNS lymphomas.
- It causes delayed myelosuppression with blood count nadir at 4-6 weeks, requiring longer intervals between treatment cycles than most chemotherapy agents.
- Cumulative pulmonary toxicity is a serious long-term risk, with baseline and periodic pulmonary function testing recommended throughout treatment.
- Carmustine must be administered as a slow IV infusion over 1-2 hours to minimize venous irritation and injection site reactions.
- The total cumulative lifetime dose should generally not exceed 1,400 mg/m² due to the risk of irreversible bone marrow damage and pulmonary fibrosis.
What Is Carmustine Macure and What Is It Used For?
Quick Answer: Carmustine Macure is an intravenous chemotherapy drug containing carmustine (BCNU), an alkylating agent from the nitrosourea class. It is used to treat brain tumors, Hodgkin and non-Hodgkin lymphomas, and multiple myeloma, either alone or in combination with other anticancer medicines.
Carmustine Macure belongs to a group of anticancer medicines known as alkylating agents, specifically the nitrosourea subclass. The active substance, carmustine (also referred to as BCNU or 1,3-bis(2-chloroethyl)-1-nitrosourea), works by damaging the DNA of rapidly dividing cancer cells, thereby preventing them from growing and multiplying. This mechanism of action is not specific to cancer cells alone, which is why carmustine also affects healthy rapidly dividing cells, leading to the side effects discussed later in this article.
One of the most clinically significant properties of carmustine is its high lipophilicity (fat-solubility). This allows it to readily cross the blood-brain barrier, a protective membrane that prevents most substances in the bloodstream from entering the brain. Cerebrospinal fluid (CSF) concentrations of carmustine reach approximately 15-70% of simultaneous plasma levels, making it one of the few chemotherapy agents that can achieve therapeutically meaningful concentrations within the central nervous system (CNS). This property is the primary reason carmustine remains a cornerstone in the treatment of primary brain tumors.
Carmustine Macure is indicated for the treatment of the following conditions, either as a single agent or, more commonly, as part of combination chemotherapy regimens:
- Brain tumors: Including glioblastoma multiforme, brainstem glioma, medulloblastoma, astrocytoma, ependymoma, and metastatic brain tumors. Carmustine is a key component of the PCV regimen (procarbazine, lomustine, vincristine) and is also used as a single agent for recurrent gliomas.
- Hodgkin lymphoma: Carmustine is part of several established combination regimens, including the BEAM protocol (BCNU, etoposide, cytarabine, melphalan) used as a high-dose conditioning regimen before autologous stem cell transplantation.
- Non-Hodgkin lymphomas: Used in various combination regimens for both aggressive and indolent subtypes, particularly when CNS involvement is suspected or confirmed.
- Multiple myeloma: Used in combination regimens for multiple myeloma, including conditioning protocols for stem cell transplantation.
Carmustine has been in clinical use since the 1970s and remains listed on the World Health Organization (WHO) Model List of Essential Medicines, reflecting its continued importance in cancer treatment worldwide. While newer targeted therapies and immunotherapies have expanded the oncological treatment landscape, carmustine maintains an established role, particularly in settings where its ability to cross the blood-brain barrier provides a distinct therapeutic advantage.
Carmustine Macure is exclusively for use in a hospital or specialized oncology setting. It is administered by healthcare professionals experienced in cancer chemotherapy. This medicine is not available for home use or self-administration.
What Should You Know Before Taking Carmustine Macure?
Quick Answer: Carmustine should not be used in patients with severe bone marrow suppression, known hypersensitivity to carmustine or nitrosoureas, or during pregnancy and breastfeeding. Your oncologist will review your complete medical history, blood counts, and organ function before initiating treatment.
Contraindications
Carmustine Macure must not be administered in the following circumstances:
- Known hypersensitivity to carmustine, other nitrosoureas, or any of the excipients in the formulation.
- Severe bone marrow suppression (myelosuppression), as carmustine will further suppress blood cell production and may lead to life-threatening infections or bleeding.
- Pregnancy and breastfeeding: Carmustine is classified as a teratogen and is expected to cause harm to the unborn child based on its mechanism of action and animal data.
- Severe hepatic impairment: As carmustine is metabolized in the liver, severe liver dysfunction may lead to unpredictable drug levels and increased toxicity.
- Severe renal impairment: Impaired renal function may reduce clearance of carmustine metabolites, increasing the risk of toxicity.
Warnings and Precautions
Before and during treatment with carmustine, your medical team will carefully monitor several aspects of your health. The following warnings apply to all patients receiving this medicine:
Carmustine causes delayed and cumulative bone marrow suppression. The nadir (lowest point) for platelets typically occurs at 4-5 weeks and for white blood cells at 5-6 weeks after administration. Blood counts must be monitored weekly for at least 6 weeks after each dose. The next treatment cycle should not be given until blood counts have adequately recovered.
- Pulmonary toxicity: Carmustine can cause lung damage (pulmonary fibrosis) that may be delayed, progressive, and potentially fatal. The risk increases with cumulative doses exceeding 1,400 mg/m² but can occur at lower doses. Baseline and periodic pulmonary function tests (including DLCO) are recommended. Patients with a baseline forced vital capacity (FVC) or DLCO below 70% of predicted are at particular risk.
- Hepatotoxicity: Reversible elevations in liver enzymes (transaminases, alkaline phosphatase, bilirubin) have been reported. Liver function should be monitored before and during treatment.
- Renal toxicity: Progressive renal impairment including decreased kidney size, progressive azotemia, and renal failure has been reported with large cumulative doses.
- Secondary malignancies: As with other alkylating agents, there is an increased risk of developing secondary cancers, particularly acute leukemia and myelodysplastic syndrome, following treatment with carmustine.
- Infusion-site reactions: Carmustine is a vesicant and can cause severe tissue damage if extravasation occurs. The infusion site must be carefully monitored throughout administration.
- Fertility: Carmustine may cause irreversible infertility in both men and women. Discussion of fertility preservation options should occur before treatment initiation.
Pregnancy and Breastfeeding
Carmustine is contraindicated during pregnancy. Based on its mechanism of action as a DNA-alkylating agent and data from animal reproductive studies, carmustine is expected to cause fetal harm when administered to pregnant women. Women of childbearing potential must use highly effective contraception during treatment and for at least 6 months after the last dose. Male patients should use effective contraception during treatment and for at least 3 months after the last dose.
It is not known whether carmustine or its metabolites are excreted in human breast milk. However, given the potential for serious adverse reactions in breastfed infants, breastfeeding is contraindicated during carmustine treatment and for at least 7 days after the final dose. Women should be advised to discontinue breastfeeding prior to initiating therapy.
Both male and female patients should be counseled about the potential risk of permanent infertility and be offered fertility preservation options (such as sperm banking or egg freezing) before starting treatment. The gonadotoxic effects of carmustine are dose-dependent and cumulative.
How Does Carmustine Macure Interact with Other Drugs?
Quick Answer: Carmustine can interact with several medications, including phenytoin, cimetidine, digoxin, and other myelosuppressive agents. Live vaccines are contraindicated during treatment. Always inform your oncologist about all medications you are taking.
Drug interactions with carmustine are clinically important and must be carefully managed by your healthcare team. Because carmustine is typically administered in a hospital setting under close medical supervision, your oncologist and pharmacist will review all concurrent medications before each treatment cycle. The following interactions are the most significant:
Major Interactions
| Drug | Interaction | Clinical Significance |
|---|---|---|
| Live vaccines | Carmustine-induced immunosuppression may lead to uncontrolled vaccine virus replication | Contraindicated. No live vaccines during treatment or for at least 3-6 months after completion. |
| Phenytoin | Carmustine may reduce phenytoin absorption and serum levels | Monitor phenytoin levels closely. Dose adjustment may be required. Risk of breakthrough seizures. |
| Cimetidine | May enhance carmustine myelotoxicity by inhibiting its metabolism | Avoid concurrent use. Consider alternative H2 antagonists or proton pump inhibitors. |
| Other myelosuppressive agents | Additive bone marrow suppression with other chemotherapy, radiation, or immunosuppressants | Expected in combination regimens. Requires careful dose scheduling and monitoring. |
| Melphalan | Increased risk of severe pulmonary toxicity when used in combination | Close pulmonary monitoring required. Used together in some stem cell transplant conditioning regimens. |
Minor Interactions
| Drug | Interaction | Clinical Significance |
|---|---|---|
| Digoxin | Carmustine may reduce digoxin absorption | Monitor digoxin levels. Dose adjustment may be needed. |
| Corticosteroids (e.g., dexamethasone) | Often co-administered; may mask signs of infection | Monitor for occult infections during combined use. |
| Anticoagulants (e.g., warfarin) | Carmustine-induced thrombocytopenia increases bleeding risk | Monitor platelet counts and INR closely. Adjust anticoagulant dosing as needed. |
It is essential to inform your oncology team about all medications you are currently taking, including over-the-counter medicines, herbal supplements, and vitamins. Some herbal products, particularly those with antiplatelet or anticoagulant properties (such as ginkgo biloba, garlic supplements, or fish oil in high doses), may increase the risk of bleeding when combined with carmustine-induced thrombocytopenia.
What Is the Correct Dosage of Carmustine Macure?
Quick Answer: The typical single-agent dose is 150-200 mg/m² given intravenously every 6 weeks. The dose is often divided over 2 consecutive days. Dosing is calculated based on body surface area and adjusted according to blood count recovery and organ function.
Carmustine dosing is highly individualized based on the patient's body surface area (BSA), the specific treatment protocol being followed, the patient's overall health status, organ function, and response to previous cycles. The following dosing guidelines are general recommendations; your oncologist will determine the exact dose appropriate for your specific situation.
Adults
Single-Agent Therapy
The recommended dose as a single agent is 150-200 mg/m² administered intravenously every 6 weeks. This dose is usually divided equally over 2 consecutive days (75-100 mg/m²/day for 2 days). The infusion should be given slowly over 1-2 hours. The 6-week interval between cycles is necessary due to the delayed myelosuppressive effects of carmustine.
Combination Chemotherapy
When used in combination regimens, the dose of carmustine is typically reduced. Common protocols include:
- BEAM regimen (for stem cell transplant conditioning): Carmustine 300 mg/m² on day -6 as a single dose, combined with etoposide, cytarabine, and melphalan.
- Other combinations: Doses typically range from 80-150 mg/m² depending on the specific protocol and other agents used.
| Nadir After Prior Dose | Leukocytes (/mm³) | Platelets (/mm³) | Dose Adjustment |
|---|---|---|---|
| Adequate recovery | > 4,000 | > 100,000 | 100% of planned dose |
| Mild suppression | 3,000-3,999 | 75,000-99,999 | 100% of planned dose |
| Moderate suppression | 2,000-2,999 | 25,000-74,999 | Reduce to 70% of planned dose |
| Severe suppression | < 2,000 | < 25,000 | Reduce to 50% of planned dose |
Children
The use of carmustine in pediatric patients follows similar principles as in adults, with dosing based on body surface area. Pediatric oncologists determine the appropriate dose within the context of specific treatment protocols for childhood brain tumors and lymphomas. Due to the delayed myelosuppressive effects and risk of long-term pulmonary toxicity, careful monitoring is essential in the pediatric population. Children may be more susceptible to certain long-term adverse effects, including growth impairment and secondary malignancies.
Elderly
There are no specific dose adjustments recommended solely on the basis of age. However, elderly patients frequently have decreased renal function and reduced bone marrow reserve, which should be taken into account when determining the dose. Initial dosing at the lower end of the recommended range is prudent, and close monitoring of blood counts and organ function is essential. Elderly patients may also be at increased risk of pulmonary toxicity.
Missed Dose
Because carmustine is administered in a hospital setting by healthcare professionals according to a strict treatment schedule, missed doses are uncommon. If a scheduled treatment must be delayed (typically due to inadequate blood count recovery), your oncologist will determine the appropriate time to resume treatment. Do not attempt to compensate for a delayed treatment by increasing the dose.
Overdose
Overdose with carmustine can result in life-threatening myelosuppression, severe gastrointestinal toxicity, hepatotoxicity, and multi-organ failure. There is no specific antidote for carmustine overdose. Management is supportive, including aggressive blood product support (platelet and red cell transfusions), granulocyte colony-stimulating factor (G-CSF), broad-spectrum antibiotics for neutropenic fever, and intensive care monitoring. Because of the delayed onset of myelosuppression, patients who have received an overdose must be monitored for an extended period (at least 6-8 weeks) even if they initially appear well.
What Are the Side Effects of Carmustine Macure?
Quick Answer: The most common side effects include bone marrow suppression (affecting blood cell counts), nausea and vomiting, and injection site reactions. Serious long-term risks include pulmonary fibrosis and secondary malignancies. Side effects are generally dose-dependent and cumulative.
Like all chemotherapy medicines, carmustine can cause side effects, although not everybody gets all of them. The severity and frequency of side effects are generally related to the dose administered and the cumulative total dose received over the course of treatment. Your oncology team will provide supportive care measures to help manage many of these side effects. It is important to report any new or worsening symptoms to your healthcare team promptly.
Very Common (affects more than 1 in 10 patients)
Reported in > 10% of treated patients
- Myelosuppression: Decreased white blood cells (leukopenia), decreased platelets (thrombocytopenia), and decreased red blood cells (anemia). This is the dose-limiting toxicity and occurs in virtually all patients. Nadir typically at 4-6 weeks.
- Nausea and vomiting: Usually occurs within 2-4 hours of infusion and may last 4-6 hours. Modern antiemetic regimens can significantly reduce this.
- Infusion-site reactions: Pain, burning, and venous irritation at the injection site are common. Phlebitis and thrombophlebitis may occur.
- Flushing: Facial flushing during and immediately after infusion is common and usually transient.
- Fatigue: General tiredness and weakness, often related to myelosuppression and the overall metabolic burden of chemotherapy.
Common (affects 1 to 10 in 100 patients)
Reported in 1-10% of treated patients
- Pulmonary toxicity: Including pulmonary infiltrates and fibrosis. Risk increases with cumulative doses exceeding 1,400 mg/m². May present as cough, dyspnea, or abnormal chest imaging.
- Hepatotoxicity: Elevated liver enzymes (AST, ALT, alkaline phosphatase, bilirubin). Usually reversible but may occasionally be severe.
- Stomatitis: Inflammation and sores in the mouth and throat, making eating and swallowing painful.
- Diarrhea: Loose or frequent stools, which may lead to dehydration if not managed.
- Alopecia: Hair loss, which is usually temporary. Hair typically regrows after treatment completion.
- Skin hyperpigmentation: Darkening of the skin, particularly at the infusion site or in sun-exposed areas.
Uncommon (affects 1 to 10 in 1,000 patients)
Reported in 0.1-1% of treated patients
- Renal toxicity: Decreased kidney function, progressive azotemia, and reduced kidney size. More common with cumulative dosing.
- Ocular toxicity: Conjunctival suffusion, blurred vision, and retinal hemorrhage have been reported, particularly with arterial infusion routes.
- Neurotoxicity: Encephalopathy, confusion, and ataxia, particularly with high doses or when combined with other neurotoxic agents.
- Gynecomastia: Breast enlargement in male patients.
Rare (affects fewer than 1 in 1,000 patients)
Reported in < 0.1% of treated patients
- Secondary malignancies: Acute leukemia and myelodysplastic syndrome may develop months to years after treatment. The risk is increased with prolonged therapy and combination with other alkylating agents or radiation.
- Veno-occlusive disease (VOD): Hepatic veno-occlusive disease, particularly in the context of high-dose conditioning regimens.
- Severe allergic reactions: Anaphylaxis-like reactions, though extremely rare, have been reported.
- Cardiac toxicity: Cardiac arrhythmias and hypotension during rapid infusion.
Contact your medical team or seek emergency care immediately if you experience: fever above 38°C (100.4°F) during treatment (may indicate neutropenic fever), unusual bleeding or bruising, severe shortness of breath or persistent cough, signs of infection (sore throat, mouth sores, burning during urination), or severe abdominal pain. Neutropenic fever is a medical emergency requiring immediate evaluation and intravenous antibiotics.
How Should You Store Carmustine Macure?
Quick Answer: Carmustine Macure must be stored in a refrigerator (2-8°C) and protected from light. The reconstituted solution should be used promptly and is stable for a limited time at room temperature. In practice, storage and preparation are handled entirely by hospital pharmacy staff.
Carmustine Macure is a hospital-only medicine, and all storage, preparation, and handling are performed by trained pharmacy and nursing staff in accordance with institutional protocols for cytotoxic agents. Patients do not need to handle or store this medicine themselves. Nevertheless, the following storage requirements apply:
- Unopened vials: Store in a refrigerator at 2-8°C (36-46°F). Protect from light by keeping vials in the outer carton until ready for use.
- Reconstituted solution: After reconstitution with the supplied diluent (absolute ethanol), the solution should be further diluted with 0.9% sodium chloride or 5% dextrose and used within the timeframe specified by the manufacturer, typically within 8 hours at room temperature or 24 hours if refrigerated.
- Physical appearance: The reconstituted solution should be clear and colorless to pale yellow. Do not use if the solution is discolored, cloudy, or contains particulate matter.
- Disposal: Any unused medicine or waste material should be disposed of in accordance with local requirements for cytotoxic waste. Carmustine is classified as a hazardous pharmaceutical waste.
- Handling precautions: All personnel involved in the preparation and administration of carmustine must wear appropriate personal protective equipment (gloves, gown, eye protection) and follow institutional guidelines for the safe handling of cytotoxic agents.
Keep this medicine out of the sight and reach of children. Do not use this medicine after the expiry date which is stated on the carton and vial label. The expiry date refers to the last day of that month.
What Does Carmustine Macure Contain?
Quick Answer: Each vial contains 100 mg of carmustine as the active substance, supplied with a diluent vial containing absolute ethanol for reconstitution. The powder is then further diluted in standard intravenous fluids before administration.
Carmustine Macure is supplied as a powder and solvent for concentrate for solution for infusion. Each treatment pack consists of:
- Active substance: Carmustine 100 mg per vial (as a lyophilized powder).
- Solvent for reconstitution: Absolute ethanol (dehydrated alcohol) provided in a separate vial. This is used as the first step in the reconstitution process.
After reconstitution with the ethanol diluent, the concentrate is further diluted with 500 mL of 0.9% sodium chloride solution or 5% dextrose (glucose) solution to produce the final infusion solution. The ethanol content of the final diluted solution is relatively low but should be considered in patients with alcohol intolerance or those receiving medications that interact with alcohol (such as metronidazole or disulfiram).
Carmustine is a member of the nitrosourea chemical class. Its chemical name is 1,3-bis(2-chloroethyl)-1-nitrosourea. The molecular formula is C5H9Cl2N3O2 and its molecular weight is approximately 214.05 g/mol. Carmustine is a bifunctional alkylating agent that forms both interstrand and intrastrand DNA cross-links, as well as DNA-protein cross-links, which are responsible for its cytotoxic activity.
The product does not contain preservatives, and each vial is intended for single use only. Any remaining solution after preparation of the required dose must be discarded as cytotoxic waste.
Frequently Asked Questions About Carmustine Macure
Medical References
All information in this article is based on the following peer-reviewed medical sources and international guidelines:
- European Medicines Agency (EMA). Carmustine – Summary of Product Characteristics. EMA Product Information Database. Available at: www.ema.europa.eu
- World Health Organization (WHO). WHO Model List of Essential Medicines – 23rd List, 2023. Geneva: World Health Organization. Available at: WHO Essential Medicines
- National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Central Nervous System Cancers, Version 2.2024.
- Weller M, van den Bent M, Preusser M, et al. EANO guidelines on the diagnosis and treatment of diffuse gliomas of adulthood. Nature Reviews Clinical Oncology. 2021;18(3):170-186. doi:10.1038/s41571-020-00447-z
- British National Formulary (BNF). Carmustine monograph. National Institute for Health and Care Excellence (NICE). Available at: bnf.nice.org.uk
- Aronin PA, Mahaley MS Jr, Rudnick SA, et al. Prediction of BCNU pulmonary toxicity in patients with malignant gliomas. New England Journal of Medicine. 1980;303(4):183-188.
- European Society for Medical Oncology (ESMO). Clinical Practice Guidelines: Brain Tumours, 2023. Available at: www.esmo.org/guidelines
- U.S. Food and Drug Administration (FDA). Carmustine – Prescribing Information. Available at: www.fda.gov
About Our Medical Editorial Team
This article has been written and reviewed by qualified medical professionals to ensure clinical accuracy and adherence to current treatment guidelines.
📚 Peer Review Process
All medical content is reviewed by at least two licensed specialist physicians before publication.
🔍 Fact-Checking
All medical claims are verified against peer-reviewed sources and international guidelines.
🔄 Update Frequency
Content is reviewed and updated at least every 12 months or when new research emerges.
✏ Corrections Policy
Any errors are corrected immediately with transparent changelog. Read more
Medical Editorial Board: iMedic has an independent medical editorial board consisting of specialist physicians in oncology, hematology, pharmacology, and internal medicine.