USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. Lactation Advise not to breastfeed. (8.2)Renal Impairment Closely monitor patients with moderate or severe renal impairment for toxicities. (8.6)Hepatic Impairment Closely monitor patients with severe hepatic impairment for toxicities. (8.7). Lactation Advise not to breastfeed. (8.2). Renal Impairment Closely monitor patients with moderate or severe renal impairment for toxicities. (8.6). Hepatic Impairment Closely monitor patients with severe hepatic impairment for toxicities. (8.7). 8.1 Pregnancy. Risk SummaryBased on its mechanism of action and findings in animal studies, nelarabine can cause fetal harm when administered to pregnant woman [see Clinical Pharmacology (12.1)]. Limited available data with nelarabine use in pregnant women are insufficient to determine drug-associated risk for major birth defects, miscarriage or adverse maternal or fetal outcomes. There are risks to the pregnant woman associated with untreated leukemia or lymphoma (see Clinical Considerations). In animal reproduction studies, intravenous administration of nelarabine to pregnant rabbits during the period of organogenesis resulted in teratogenicity at maternal doses below the recommended human adult dose of 1,500 mg/m2/day (see Data). Advise pregnant women of the potential risk to the fetus.The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies are 2% to 4% and 15% to 20%, respectively.Clinical ConsiderationsDisease-Associated Maternal and/or Embryo-fetal RiskThere are risks to the mother from untreated leukemia or lymphoma, including anemia, thrombocytopenia, and death.DataAnimal DataIn an embryo-fetal development study in which pregnant rabbits were administered daily doses of nelarabine during organogenesis, increased incidences of fetal malformations, anomalies, and variations were observed at doses greater than or equal to 360 mg/m2/day (8-hour IV infusion; approximately 25% of the recommended human adult dose compared on mg/m2 basis), which was the lowest dose tested. Cleft palate was seen in rabbits given 3,600 mg/m2/day (approximately 2-fold the adult dose), absent pollices (digits) in rabbits given greater than or equal to 1,200 mg/m2/day (approximately 75% of the recommended adult dose), while absent gall bladder, absent accessory lung lobes, fused or extra sternebrae, and delayed ossification was seen at all doses. Maternal body weight gain and fetal body weights were reduced in rabbits given 3,600 mg/m2/day (approximately 2-fold the adult dose), but could not account for the increased incidence of malformations seen at this or lower administered doses.. 8.2 Lactation. Risk SummaryThere are no data on the presence of nelarabine or ara-G in human or animal milk, the effect on the breastfed child, or the effect on milk production. Because of the potential for serious adverse reactions in the breastfed child from nelarabine, such as severe neurological reactions, advise women not to breastfeed during treatment with nelarabine.. 8.3 Females and Males of Reproductive Potential. Pregnancy TestingNelarabine can cause fetal harm when administered to pregnant woman [see Use in Specific Populations (8.1)]. Verify the pregnancy status of females of reproductive potential prior to starting treatment with nelarabine.ContraceptionFemalesNelarabine can cause fetal harm when administered to pregnant woman [see Warnings and Precautions (5.3), Use in Specific Populations (8.1)]. Because of the potential for genotoxicity, advise females of reproductive potential to use effective contraception during treatment with nelarabine.MalesBecause of the potential for genotoxicity, advise males (including those who have had vasectomies) with female partners of reproductive potential to use condoms during treatment with nelarabine and for months after the last dose [see Nonclinical Toxicology (13.1)].. 8.4 Pediatric Use. The safety and effectiveness of nelarabine for relapsed or refractory T-ALL and T-LBL has been established in pediatric patients age year and older. The effectiveness of nelarabine in pediatric patients is supported by one single-arm clinical trial, and safety has been assessed in 165 pediatric patients age year and older across multiple Phase and Phase II trials. The trial establishing efficacy included 84 patients age 21 years and younger, who had relapsed or refractory T-ALL or T-LBL. The most frequent adverse reactions of any grade occurring on treatment in this study were hematologic laboratory abnormalities. Hematologic toxicity observed in the pediatric population was higher than that seen in the adult population. [see Dosage and Administration (2.1), Adverse Reactions (6.1), Clinical Studies (14.2)]. Nervous system adverse reactions have been reported for 42% of pediatric patients across the Phase and Phase II trials. The incidence of nervous system adverse reactions was less in the pediatric population than that seen in adult patients with relapsed/refractory T-ALL/T-LBL [see Adverse Reactions (6.1)].In phase III study of nelarabine in combination with multi-agent chemotherapy as first-line therapy, there were 411 patients with T-ALL or T-LBL treated with nelarabine. The safety profile in the 357 patients age to 16 years was consistent with that seen in older patients in the study. [see Adverse Reactions (6.1)].Due to lack of long-term follow up data, determination of the impact of nelarabine on the growth and pubertal development of pediatric patients cannot be made.. 8.5 Geriatric Use. Clinical studies of nelarabine did not include sufficient numbers of patients age 65 and over to determine whether they respond differently from younger patients. In an exploratory analysis, increasing age, especially age 65 years and older, appeared to be associated with increased rates of neurologic adverse reactions. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, [see Use in Specific Populations (8.6)].. 8.6 Renal Impairment. Ara-G clearance decreased as renal function decreased [see Clinical Pharmacology (12.3)]. Because the risk of adverse reactions to this drug may be greater in patients with moderate (CLCr 30 to 50 mL/min) or severe (CLCr less than 30 mL/min) renal impairment, these patients should be closely monitored for toxicities when treated with nelarabine [see Dosage and Administration (2.3)].. 8.7 Hepatic Impairment. The influence of hepatic impairment on the pharmacokinetics of nelarabine has not been evaluated. Because the risk of adverse reactions to this drug may be greater in patients with severe hepatic impairment (total bilirubin greater than times upper limit of normal), these patients should be closely monitored for toxicities when treated with nelarabine.

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. Neurologic Adverse Reactions Severe neurologic reactions have been reported. Monitor for signs and symptoms of neurologic toxicity. (5.1)Hematologic Reactions Complete blood counts including platelets should be monitored regularly. (5.2)Embryo-Fetal Toxicity Can cause fetal harm. Advise females of reproductive potential of the potential risk to the fetus and to use effective contraception; and advise males to use condoms. (5.3, 8.1, 8.3)Effects on Ability to Drive and Use Machines Somnolence may occur. Advise patients to refrain from these activities until somnolence has resolved. (5.6). Neurologic Adverse Reactions Severe neurologic reactions have been reported. Monitor for signs and symptoms of neurologic toxicity. (5.1). Hematologic Reactions Complete blood counts including platelets should be monitored regularly. (5.2). Embryo-Fetal Toxicity Can cause fetal harm. Advise females of reproductive potential of the potential risk to the fetus and to use effective contraception; and advise males to use condoms. (5.3, 8.1, 8.3). Effects on Ability to Drive and Use Machines Somnolence may occur. Advise patients to refrain from these activities until somnolence has resolved. (5.6). 5.1 Neurologic Adverse Reactions. Nervous system adverse reactions of any grade were reported for 223 (76%) adult patients across the Phase and Phase II trials, and Grade or higher (severe, life-threatening, or fatal) adverse reactions were reported for 55 (19%) patients following initiation of nelarabine therapy [see Adverse Reactions (6.1)]. Based on patients with complete data, the median time to onset of first event is days from start of first infusion (range: to 166), and the median duration is days (range: to 393 days).Nervous system adverse reactions of any grade were reported for 69 (42%) pediatric patients across the Phase and Phase II trials, and Grade or higher (severe, life-threatening, or fatal) adverse reactions were reported for 25 (15%) patients following initiation of nelarabine therapy [see Adverse Reactions (6.1)]. Based on patients with complete data, the median time to onset of first event is days from start of first infusion (range: to 269), and the median duration is days (range: to 82 days).Common signs and symptoms of nelarabine-related neurotoxicity include somnolence, headache, paresthesia and dysesthesia, dizziness, neuropathy (sensory and motor), cerebellar disturbances and tremor. Severe neurologic toxicity can manifest as coma, status epilepticus, craniospinal demyelination, or ascending neuropathy similar in presentation to Guillain-BarrSR syndrome.Full recovery from these adverse reactions has not always occurred with cessation of therapy with nelarabine. Patients treated previously or concurrently with intrathecal chemotherapy or previously with craniospinal irradiation may be at increased risk for neurologic adverse events.Monitor patients frequently for signs and symptoms of neurologic toxicity during and for at least 24 hours after completion of treatment with nelarabine. Discontinue nelarabine for neurologic adverse reactions of NCI CTCAE Grade or greater and provide supportive care [see Dosage and Administration (2.2), Adverse Reactions (6.1)].. 5.2 Hematologic Adverse Reactions. Leukopenia, thrombocytopenia, anemia, and neutropenia, including febrile neutropenia, have been associated with nelarabine therapy. Complete blood counts including platelets should be monitored regularly [see Dosage and Administration (2.2), Adverse Reactions (6.1)].. 5.3 Embryo-Fetal Toxicity. Based on its mechanism of action and findings in animal studies, nelarabine can cause fetal harm when administered to pregnant woman [see Clinical Pharmacology (12.1)]. In animal reproduction studies, intravenous administration of nelarabine to pregnant rabbits during the period of organogenesis resulted in teratogenicity at maternal doses below the recommended human adult dose of 1,500 mg/m2/day (see Data).Advise pregnant women of the potential risk to the fetus. Advise females of reproductive potential to use effective contraception during treatment with nelarabine. Advise males with female partners of reproductive potential to use condoms during treatment with nelarabine and for months after the last dose [see Use in Specific Populations (8.1, 8.3), Nonclinical Toxicology (13.1)]. 5.4 Tumor Lysis Syndrome. Patients receiving nelarabine should receive intravenous hydration according to standard medical practice for the management of hyperuricemia in patients at risk for tumor lysis syndrome. Consideration should be given to the use of allopurinol in patients at risk of hyperuricemia [see Dosage and Administration (2.4)].. 5.5 Vaccinations. Avoid the administration of live vaccines to immunocompromised patients.. 5.6 Effects on Ability to Drive and Use Machines. Patients treated with nelarabine may experience somnolence during and for several days after treatment [see Adverse Reactions (6.1)]. Advise patients to refrain from driving or engaging in hazardous occupations or activities until somnolence has resolved.

ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. The following clinically-significant adverse reactions are discussed in greater detail in other sections of the label:Neurologic [see Boxed Warning, Warnings and Precautions (5.1)] Hematologic [see Warnings and Precautions (5.2)] Tumor Lysis Syndrome [see Warnings and Precautions (5.4)] Effects on Ability to Drive and Use Machines [see Warnings and Precautions (5.6)] Neurologic [see Boxed Warning, Warnings and Precautions (5.1)] Hematologic [see Warnings and Precautions (5.2)] Tumor Lysis Syndrome [see Warnings and Precautions (5.4)] Effects on Ability to Drive and Use Machines [see Warnings and Precautions (5.6)] The most common (>= 20%) adverse reactions were:Adult anemia, thrombocytopenia, neutropenia, nausea, diarrhea, vomiting, constipation, fatigue, pyrexia, cough, and dyspnea (6.1)Pediatric anemia, neutropenia, thrombocytopenia, and leukopenia (6.1)The most common (> 10%) neurological adverse reactions were:Adult somnolence, dizziness, peripheral neurologic disorders, hypoesthesia, headache, and paresthesia (6.1)Pediatric headache and peripheral neurologic disorders (6.1)To report SUSPECTED ADVERSE REACTIONS, contact Zydus Pharmaceuticals (USA) Inc. at 1-877-993-8779 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.. Adult anemia, thrombocytopenia, neutropenia, nausea, diarrhea, vomiting, constipation, fatigue, pyrexia, cough, and dyspnea (6.1). Pediatric anemia, neutropenia, thrombocytopenia, and leukopenia (6.1). Adult somnolence, dizziness, peripheral neurologic disorders, hypoesthesia, headache, and paresthesia (6.1). Pediatric headache and peripheral neurologic disorders (6.1). 6.1 Clinical Trials Experience. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of drug cannot be directly compared with rates in the clinical trials of another drug and may not reflect the rates observed in practice.Relapsed or Refractory T-ALL and T-LBLNelarabine was studied in 459 patients in Phase and Phase II clinical trials.Adult Patient: The safety profile of nelarabine is based on data from 103 adult patients treated with the recommended dose and schedule in studies: an adult T-cell acute lymphoblastic leukemia (T-ALL)/T-cell lymphoblastic lymphoma (T-LBL) trial and an adult chronic lymphocytic leukemia trial.The most common adverse reactions in adults were fatigue; gastrointestinal (GI) disorders (nausea, diarrhea, vomiting, and constipation); hematologic disorders (anemia, neutropenia, and thrombocytopenia); respiratory disorders (cough and dyspnea); nervous system disorders (somnolence and dizziness); and pyrexia.The most common adverse reactions in adults by Body System, including severe or life-threatening adverse reactions (NCI CTCAE Grade or Grade 4) and fatal adverse reactions (Grade 5) are shown in Table 1. Table Most Commonly Reported (>= 5% Overall) Adverse Reactions in Adult Patients Treated with 1,500 mg/m2 of Nelarabine Administered Intravenously over Hours on Days 1, 3, and Repeated Every 21 Days Abbreviation: AST, aspartate transaminase.a Five patients had fatal adverse reaction. Fatal adverse reactions included hypotension(n 1), respiratory arrest (n 1), pleural effusion/pneumothorax (n 1), pneumonia (n 1), and cerebral hemorrhage/coma/leukoencephalopathy (n 1). Percentage of Patients (N 103) Body System Adverse Reaction Toxicity Grade Grade % Grades and 5a All Grades Blood and Lymphatic System Disorders Anemia 20 14 99 Thrombocytopenia 37 22 86 Neutropenia 14 49 81 Febrile neutropenia 1 12 Cardiac Disorders Sinus tachycardia 0 Gastrointestinal Disorders Nausea 0 41 Diarrhea 0 22 Vomiting 0 22 Constipation 0 21 Abdominal pain 0 Stomatitis 0 Abdominal distension 0 General Disorders and Administration Site Conditions Fatigue 10 50 Pyrexia 0 23 Asthenia 1 17 Edema, peripheral 0 15 Edema 0 11 Pain 0 11 Rigors 0 Gait, abnormal 0 Chest pain 0 Noncardiac chest pain 1 Infections Infection 1 Pneumonia 1 Sinusitis 0 Hepatobiliary Disorders AST increased 1 Metabolism and Nutrition Disorders Anorexia 0 Dehydration 1 Hyperglycemia 0 Musculoskeletal and Connective Tissue Disorders Myalgia 0 13 Arthralgia 0 Back pain 0 Muscular weakness 0 Pain in extremity 0 Nervous System Disorders (see Table 2) Psychiatric Disorders Confusional state 0 Insomnia 0 Depression 0 Respiratory, Thoracic, and Mediastinal Disorders Cough 0 25 Dyspnea 2 20 Pleural effusion 1 10 Epistaxis 0 Dyspnea, exertional 0 Wheezing 0 Vascular Disorders Petechiae 0 12 Hypotension 1 . 6.2 Postmarketing Experience. The following adverse reactions have been identified during post-approval use of nelarabine. Because these reactions are reported voluntarily from population of uncertain size, it is not always possible to reliably estimate their frequency or establish causal relationship to drug exposure.Infections and Infestations: Fatal opportunistic infections.Metabolism and Nutrition Disorders: Tumor lysis syndrome.Nervous System Disorders: Demyelination and ascending peripheral neuropathies similar in appearance to Guillain-BarrSR syndrome.Musculoskeletal and Connective Disorders: Rhabdomyolysis, blood creatine phosphokinase increased.

BOXED WARNING SECTION.

WARNING: NEUROLOGIC ADVERSE REACTIONS. Severe neurologic adverse reactions have been reported with the use of nelarabine. These adverse reactions have included altered mental states including severe somnolence, central nervous system effects including convulsions, and peripheral neuropathy ranging from numbness and paresthesias to motor weakness and paralysis. There have also been reports of adverse reactions associated with demyelination, and ascending peripheral neuropathies similar in appearance to Guillain-BarrSR syndrome [see Warnings and Precautions (5.1)].Full recovery from these adverse reactions has not always occurred with cessation of therapy with nelarabine. Monitor frequently for signs and symptoms of neurologic toxicity during treatment with nelarabine. Discontinue nelarabine for neurologic adverse reactions of NCI Common Toxicity Criteria for Adverse Events (CTCAE) Grade or greater [see Warnings and Precautions (5.1)].. WARNING: NEUROLOGIC ADVERSE REACTIONSSee full prescribing information for complete boxed warning.Severe neurologic adverse reactions have been reported with the use of nelarabine. These adverse reactions have included altered mental states including severe somnolence, central nervous system effects including convulsions, and peripheral neuropathy ranging from numbness and paresthesias to motor weakness and paralysis. There have also been reports of adverse reactions associated with demyelination, and ascending peripheral neuropathies similar in appearance to Guillain-BarrSR syndrome. (5.1)Full recovery from these adverse reactions has not always occurred with cessation of therapy with nelarabine. Monitor frequently for signs and symptoms of neurologic toxicity. Discontinue nelarabine for neurologic adverse reactions of NCI Common Toxicity Criteria for Adverse Events (CTCAE) Grade or greater. (5.1).

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. Nelarabine is prodrug of the deoxyguanosine analogue 9--D-arabinofuranosylguanine (ara-G), nucleoside metabolic inhibitor. Nelarabine is demethylated by adenosine deaminase (ADA) to ara-G, mono-phosphorylated by deoxyguanosine kinase and deoxycytidine kinase, and subsequently converted to the active 5-triphosphate, ara-GTP. Accumulation of ara-GTP in leukemic blasts allows for incorporation into deoxyribonucleic acid (DNA), leading to inhibition of DNA synthesis and cell death. Other mechanisms may contribute to the cytotoxic and systemic toxicity of nelarabine.. 12.3 Pharmacokinetics. Absorption: Following intravenous administration of nelarabine to adult patients with refractory leukemia or lymphoma, plasma ara-G Cmax values generally occurred at the end of the nelarabine infusion and were generally higher than nelarabine Cmax values, suggesting rapid and extensive conversion of nelarabine to ara-G. Mean plasma nelarabine and ara-G Cmax values were 5.0 +- 3.0 mcg/mL and 31.4 +- 5.6 mcg/mL, respectively, after 1,500 mg/m2 nelarabine dose infused over hours in adult patients. The area under the concentration- time curve (AUC) of ara-G is 37 times higher than that for nelarabine on day after nelarabine IV infusion of 1,500 mg/m2 dose (162 +- 49 mcg.h/mL versus 4.4 +- 2.2 mcg.h/mL, respectively). Comparable Cmax and AUC values were obtained for nelarabine between days and at the nelarabine adult dosage of 1,500 mg/m2, indicating that nelarabine does not accumulate after multiple-dosing. There are not enough ara-G data to make comparison between day and day 5. After nelarabine adult dose of 1,500 mg/m2, intracellular Cmax for ara-GTP appeared within to 25 hours on day 1. Exposure (AUC) to intracellular ara-GTP was 532 times higher than that for nelarabine and 14 times higher than that for ara-G (2,339 +- 2,628 mcg.h/mL versus 4.4 +- 2.2 mcg.h/mL and 162 +- 49 mcg.h/mL, respectively). Because the intracellular levels of ara-GTP were so prolonged, its elimination half-life could not be accurately estimated.Distribution: Nelarabine and ara-G are extensively distributed throughout the body. For nelarabine, VSS values were 197 +- 216 L/m2 in adult patients. For ara-G, VSS/F values were 50 +- 24 L/m2 in adult patients.Nelarabine and ara-G are not substantially bound to human plasma proteins (< 25%) in vitro, and binding is independent of nelarabine or ara-G concentrations up to 600 uM.Metabolism: The principal route of metabolism for nelarabine is O-demethylation by adenosine deaminase to form ara-G, which undergoes hydrolysis to form guanine. In addition, some nelarabine is hydrolyzed to form methylguanine, which is O-demethylated to form guanine. Guanine is N-deaminated to form xanthine, which is further oxidized to yield uric acid.Excretion: Nelarabine and ara-G are partially eliminated by the kidneys. Mean urinary excretion of nelarabine and ara-G was 6.6 +- 4.7% and 27 +- 15% of the administered dose, respectively, in 28 adult patients over the 24 hours after nelarabine infusion on day 1. Renal clearance averaged 24 +- 23 L/h for nelarabine and 6.2 +- 5.0 L/h for ara-G in 21 adult patients. Combined Phase pharmacokinetic data at nelarabine doses of 199 to 2,900 mg/m2 (n 66 adult patients) indicate that the mean clearance (CL) of nelarabine is 197 +- 189 L/h/m2 on day 1. The apparent clearance of ara-G (CL/F) is 10.5 +- 4.5 L/h/m2 on day 1. Nelarabine and ara-G are rapidly eliminated from plasma with mean half-life of 18 minutes and 3.2 hours, respectively, in adult patients.Pediatrics: No pharmacokinetic data are available in pediatric patients at the once-daily 650 mg/m2 nelarabine dosage. Combined Phase pharmacokinetic data at nelarabine doses of 104 to 2,900 mg/m2 indicate that the mean clearance (CL) of nelarabine is about 30% higher in pediatric patients than in adult patients (259 +- 409 L/h/m2 versus 197 +- 189 L/h/m2, respectively) (n 66 adults, = 22 pediatric patients) on day 1. The apparent clearance of ara-G (CL/F) is comparable between the two groups (10.5 +- 4.5 L/h/m2 in adult patients and 11.3 +- 4.2 L/h/m2 in pediatric patients) on day 1. Nelarabine and ara-G are extensively distributed throughout the body. For nelarabine, VSS values were 213 +- 358 L/m2 in pediatric patients. For ara-G, VSS/F values were 33 +- 9.3 L/m2 in pediatric patients. Nelarabine and ara-G are rapidly eliminated from plasma in pediatric patients, with half-life of 13 minutes and hours, respectively.Effect of Age: Age has no effect on the pharmacokinetics of nelarabine or ara-G in adults. Decreased renal function, which is more common in the elderly, may reduce ara-G clearance [see Use in Specific Populations (8.5)].Effect of Gender: Gender has no effect on nelarabine or ara-G pharmacokinetics.Effect of Race: In general, nelarabine mean clearance and volume of distribution values tend to be higher in whites (n 63) than in blacks (by about 10%) (n 15). The opposite is true for ara-G; mean apparent clearance and volume of distribution values tend to be lower in whites than in blacks (by about 15% to 20%). No differences in safety or effectiveness were observed between these groups.Effect of Renal Impairment: The pharmacokinetics of nelarabine and ara-G have not been specifically studied in renally impaired or hemodialyzed patients. Nelarabine is excreted by the kidney to small extent (5% to 10% of the administered dose). Ara-G is excreted by the kidney to greater extent (20% to 30% of the administered nelarabine dose). In the combined Phase trials, patients were categorized into groups: normal with CLCr greater than 80 mL/min (n 67), mild with CLCr 50 to 80 mL/min (n 15), and moderate with CLCr less than 50 mL/min (n 3). The mean apparent clearance (CL/F) of ara-G was about 15% and 40% lower in patients with mild and moderate renal impairment, respectively, than in patients with normal renal function [see Use in Specific Populations (8.6), Dosage and Administration (2.3)]. No differences in safety or effectiveness were observed.Effect of Hepatic Impairment: The influence of hepatic impairment on the pharmacokinetics of nelarabine has not been evaluated [see Use in Specific Populations (8.7)].Drug Interactions: Cytochrome P450: Nelarabine and ara-G did not significantly inhibit the activities of the human hepatic cytochrome P450 isoenzymes 1A2, 2A6, 2B6, 2C8, 2C9, 2C19, 2D6, or 3A4 in vitro at concentrations of nelarabine and ara-G up to 100 uM.Fludarabine: Administration of fludarabine 30 mg/m2 as 30-minute infusion hours before 1,200-mg/m2 infusion of nelarabine did not affect the pharmacokinetics of nelarabine, ara-G, or ara-GTP in 12 patients with refractory leukemia.Pentostatin: There is in vitro evidence that pentostatin is strong inhibitor of adenosine deaminase. Inhibition of adenosine deaminase may result in reduction in the conversion of the prodrug nelarabine to its active moiety and consequently in reduction in efficacy of nelarabine and/or change in adverse reaction profile of either drug [see Drug Interactions (7)].

CLINICAL STUDIES SECTION.

14 CLINICAL STUDIES. 14.1 Adult Clinical Trial in Relapsed or Refractory T-ALL and T-LBL. The safety and efficacy of nelarabine in adult patients were studied in clinical trial which included 39 treated patients, 28 who had T-ALL or T-LBL that had relapsed following or was refractory to at least two prior induction regimens. 1,500-mg/m2 dose of nelarabine was administered intravenously over hours on Days 1, 3, and repeated every 21 days. Patients who experienced signs or symptoms of Grade or greater neurologic toxicity on therapy were to be discontinued from further therapy with nelarabine. Seventeen patients had diagnosis of T-ALL and 11 had diagnosis of T-LBL. For patients with >= prior inductions, the age range was 16 to 65 years (mean: 34 years) and most patients were male (82%) and Caucasian (61%). Patients with central nervous system (CNS) disease were not eligible.Complete response (CR) in this trial was defined as bone marrow blast counts <= 5%, no other evidence of disease, and full recovery of peripheral blood counts. Complete response without complete hematologic recovery (CR) was also assessed. The results of the trial for patients who had received >= prior inductions are shown in Table 5. Table Efficacy Results in Adult Patients With >= Prior Inductions Treated With 1,500 mg/m2 of Nelarabine Administered Intravenously Over Hours on Days 1, 3, and Repeated Every 21 Days Abbreviations: CR, complete response; CI, confidence interval; CR, complete response without hematologic recovery.a Does not include patient who was transplanted (duration of response was 156+ weeks). = 28 CR plus CR (n) [95% CI] 21% (6) [8%, 41%] CR (n) [95% CI] 18% (5) [6%, 37%] CR (n) [95% CI] 4% (1) [0%, 18%] Duration of CR plus CR (range in weeks)a to 195+ Median overall survival (weeks) [95% CI] 20.6 weeks [10.4, 36.4] The mean number of days on therapy was 56 days (range of 10 to 136 days). Time to CR plus CR ranged from 2.9 to 11.7 weeks.. 14.2 Pediatric Clinical Trial in Relapsed or Refractory T-ALL and T-LBL. The safety and efficacy of nelarabine in pediatric patients were studied in clinical trial which included patients age 21 years and younger, who had relapsed or refractory T-ALL or T-LBL. Eighty-four (84) patients, 39 of whom had received two or more prior induction regimens, were treated with 650 mg/m2/day of nelarabine administered intravenously over hour daily for consecutive days repeated every 21 days (see Table 6). Patients who experienced signs or symptoms of Grade or greater neurologic toxicity on therapy were to be discontinued from further therapy with nelarabine. Table Pediatric Clinical Trial Patient Allocation Abbreviations: T-ALL, T-cell acute lymphoblastic leukemia; T-LBL, T-cell lymphoblastic lymphoma. Patient Population Patients treated at 650 mg/m2/day 5 days, every 21 days. 84 Patients with T-ALL or T-LBL with two or more prior induction treated at 650 mg/m2/day 5 days, every 21 days. 39 Patients with T-ALL or T-LBL with one prior induction treated at 650 mg/m2/day 5 days, every 21 days. 31 The 84 patients ranged in age from 2.5 to 21.7 years (overall mean: 11.9 years), 52% were to 12 years of age and most were male (74%) and Caucasian (62%). The majority (77%) of patients had diagnosis of T-ALL.Complete response (CR) in this trial was defined as bone marrow blast counts <= 5%, no other evidence of disease, and full recovery of peripheral blood counts. Complete response without full hematologic recovery (CR) was also assessed as meaningful outcome in this trial. Duration of response is reported from date of response to date of relapse, and may include subsequent stem cell transplant. Efficacy results are presented in Table 7. Table Efficacy Results in Patients Age 21 Years and Younger at Diagnosis With >= Prior Inductions Treated With 650 mg/m2 of Nelarabine Administered Intravenously Over Hour Daily for Consecutive Days Repeated Every 21 Days Abbreviations: CR, complete response; CI, confidence interval; CR, complete response without hematologic recovery.a Does not include patients who were transplanted or had subsequent systemic chemotherapy (duration of response in these patients was 4.7 to 42.1 weeks). = 39 CR plus CR (n) [95% CI] 23% (9) [11%, 39%] CR (n) [95% CI] 13% (5) [4%, 27%] CR (n) [95% CI] 10% (4) [3%, 24%] Duration of CR plus CR (range in weeks)a 3.3 to 9.3 Median overall survival (weeks) [95% CI] 13.1 [8.7, 17.4] The mean number of days on therapy was 46 days (range: to 129 days). Median time to CR plus CR was 3.4 weeks (95% CI: 3.0, 3.7).

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION. Adult Dose 1,500 mg/m administered intravenously over hours on Days 1, 3, and repeated every 21 days. (2.1)Pediatric Dose 650 mg/m administered intravenously over hour daily for consecutive days repeated every 21 days. (2.1)Discontinue treatment for neurologic reactions greater than or equal to Grade 2. (2.2)Dosage may be delayed for hematologic reactions. (2.2)Take measures to prevent hyperuricemia. (2.4). Adult Dose 1,500 mg/m administered intravenously over hours on Days 1, 3, and repeated every 21 days. (2.1). Pediatric Dose 650 mg/m administered intravenously over hour daily for consecutive days repeated every 21 days. (2.1). Discontinue treatment for neurologic reactions greater than or equal to Grade 2. (2.2). Dosage may be delayed for hematologic reactions. (2.2). Take measures to prevent hyperuricemia. (2.4). 2.1 Recommended Dosage. This product is for intravenous use only.Adult Dosage: The recommended adult dose of nelarabine injection is 1,500 mg/m administered intravenously over hours on Days 1, 3, and repeated every 21 days. Administer nelarabine injection undiluted.Pediatric Dosage: The recommended pediatric dose of nelarabine injection is 650 mg/m administered intravenously over hour daily for consecutive days repeated every 21 days. Administer nelarabine injection undiluted.The recommended duration of treatment for adult and pediatric patients has not been clearly established. In clinical trials, treatment was generally continued until there was evidence of disease progression, the patient experienced unacceptable toxicity, the patient became candidate for hematopoietic stem cell transplantation (HSCT), or the patient no longer continued to benefit from treatment.. 2.2 Dosage Modification. Discontinue nelarabine injection if the patient develops neurologic adverse reaction of NCI CTCAE Grade or greater. Dosage may be delayed for other toxicity, including hematologic toxicity [see Boxed Warning, Warnings and Precautions (5.1, 5.2)]. 2.3 Dosage in Special Populations. Nelarabine Injection has not been studied in patients with renal or hepatic dysfunction [see Use in Specific Populations (8.6, 8.7)]. No dose adjustment is recommended for patients with creatinine clearance (CLCr) greater than or equal to 50 mL/min [see Clinical Pharmacology (12.3)]. There are insufficient data to support dose recommendation for patients with CLCr less than 50 mL/min.. 2.4 Prevention of Hyperuricemia. Take precautions against hyperuricemia (e.g., hydration, urine alkalinization, and prophylaxis with allopurinol) [see Warnings and Precautions (5.4)].. 2.5 Instructions for Handling, Preparation, and Administration. Handling: Nelarabine is cytotoxic agent. Caution should be used during handling and preparation. Use of gloves and other protective clothing to prevent skin contact is recommended. Proper aseptic technique should be used. Guidelines for proper handling and disposal of anticancer drugs have been published.1Preparation and Administration: Administer nelarabine injection undiluted. Transfer the appropriate dose of nelarabine injection into polyvinylchloride (PVC) infusion bags or glass containers and administer as 2-hour infusion in adult patients and as 1-hour infusion in pediatric patients. Prior to administration, inspect the drug product visually for particulate matter and discoloration.Stability: Nelarabine Injection is stable in polyvinylchloride (PVC) infusion bags and glass containers for up to hours at up to 30.

INFORMATION FOR PATIENTS SECTION.

17 PATIENT COUNSELING INFORMATION. Advise the patient to read the FDA-approved patient labeling (Patient Information).Hematologic Adverse ReactionsAdvise patients that leukopenia, thrombocytopenia, anemia, and neutropenia, including febrile neutropenia, have been associated with nelarabine.Advise patients that complete blood counts, including platelets, will be monitored regularly during treatment [see Warnings and Precautions (5.2), Adverse Reactions (6.1)] .Embryo-Fetal ToxicityAdvise pregnant females of reproductive potential and males with female partners of reproductive potential of the potential risk to the fetus. Advise females of reproductive potential to use effective contraception during treatment with nelarabine. Instruct females to inform their physician of known or suspected pregnancy.Advise male patients with partners of reproductive potential to use condoms during treatment with nelarabine and for months after the last dose [see Warnings and Precautions (5.3), Use in Specific Populations (8.1, 8.3)]. Tumor Lysis SyndromeAdvise patients of the risk of tumor lysis syndrome [see Warnings and Precautions (5.4), Adverse Reactions (6.1)] .VaccinationsInstruct patients not to receive live vaccines during treatment with nelarabine [see Warnings and Precautions (5.5), Adverse Reactions (6.1)] .Effects on Ability to Drive and Use MachinesPatients receiving nelarabine may experience somnolence during and for several days after treatment. Instruct patients to not drive or engage in hazardous occupations or activities until somnolence has resolved [see Warnings and Precautions (5.6), Adverse Reactions (6.1)] .. Advise patients that leukopenia, thrombocytopenia, anemia, and neutropenia, including febrile neutropenia, have been associated with nelarabine.. Advise patients that complete blood counts, including platelets, will be monitored regularly during treatment [see Warnings and Precautions (5.2), Adverse Reactions (6.1)] .. Advise pregnant females of reproductive potential and males with female partners of reproductive potential of the potential risk to the fetus. Advise females of reproductive potential to use effective contraception during treatment with nelarabine. Instruct females to inform their physician of known or suspected pregnancy.. Advise male patients with partners of reproductive potential to use condoms during treatment with nelarabine and for months after the last dose [see Warnings and Precautions (5.3), Use in Specific Populations (8.1, 8.3)]. Advise patients of the risk of tumor lysis syndrome [see Warnings and Precautions (5.4), Adverse Reactions (6.1)] .. Instruct patients not to receive live vaccines during treatment with nelarabine [see Warnings and Precautions (5.5), Adverse Reactions (6.1)] .. Patients receiving nelarabine may experience somnolence during and for several days after treatment. Instruct patients to not drive or engage in hazardous occupations or activities until somnolence has resolved [see Warnings and Precautions (5.6), Adverse Reactions (6.1)].

PEDIATRIC USE SECTION.

8.4 Pediatric Use. The safety and effectiveness of nelarabine for relapsed or refractory T-ALL and T-LBL has been established in pediatric patients age year and older. The effectiveness of nelarabine in pediatric patients is supported by one single-arm clinical trial, and safety has been assessed in 165 pediatric patients age year and older across multiple Phase and Phase II trials. The trial establishing efficacy included 84 patients age 21 years and younger, who had relapsed or refractory T-ALL or T-LBL. The most frequent adverse reactions of any grade occurring on treatment in this study were hematologic laboratory abnormalities. Hematologic toxicity observed in the pediatric population was higher than that seen in the adult population. [see Dosage and Administration (2.1), Adverse Reactions (6.1), Clinical Studies (14.2)]. Nervous system adverse reactions have been reported for 42% of pediatric patients across the Phase and Phase II trials. The incidence of nervous system adverse reactions was less in the pediatric population than that seen in adult patients with relapsed/refractory T-ALL/T-LBL [see Adverse Reactions (6.1)].In phase III study of nelarabine in combination with multi-agent chemotherapy as first-line therapy, there were 411 patients with T-ALL or T-LBL treated with nelarabine. The safety profile in the 357 patients age to 16 years was consistent with that seen in older patients in the study. [see Adverse Reactions (6.1)].Due to lack of long-term follow up data, determination of the impact of nelarabine on the growth and pubertal development of pediatric patients cannot be made.

PHARMACOKINETICS SECTION.

12.3 Pharmacokinetics. Absorption: Following intravenous administration of nelarabine to adult patients with refractory leukemia or lymphoma, plasma ara-G Cmax values generally occurred at the end of the nelarabine infusion and were generally higher than nelarabine Cmax values, suggesting rapid and extensive conversion of nelarabine to ara-G. Mean plasma nelarabine and ara-G Cmax values were 5.0 +- 3.0 mcg/mL and 31.4 +- 5.6 mcg/mL, respectively, after 1,500 mg/m2 nelarabine dose infused over hours in adult patients. The area under the concentration- time curve (AUC) of ara-G is 37 times higher than that for nelarabine on day after nelarabine IV infusion of 1,500 mg/m2 dose (162 +- 49 mcg.h/mL versus 4.4 +- 2.2 mcg.h/mL, respectively). Comparable Cmax and AUC values were obtained for nelarabine between days and at the nelarabine adult dosage of 1,500 mg/m2, indicating that nelarabine does not accumulate after multiple-dosing. There are not enough ara-G data to make comparison between day and day 5. After nelarabine adult dose of 1,500 mg/m2, intracellular Cmax for ara-GTP appeared within to 25 hours on day 1. Exposure (AUC) to intracellular ara-GTP was 532 times higher than that for nelarabine and 14 times higher than that for ara-G (2,339 +- 2,628 mcg.h/mL versus 4.4 +- 2.2 mcg.h/mL and 162 +- 49 mcg.h/mL, respectively). Because the intracellular levels of ara-GTP were so prolonged, its elimination half-life could not be accurately estimated.Distribution: Nelarabine and ara-G are extensively distributed throughout the body. For nelarabine, VSS values were 197 +- 216 L/m2 in adult patients. For ara-G, VSS/F values were 50 +- 24 L/m2 in adult patients.Nelarabine and ara-G are not substantially bound to human plasma proteins (< 25%) in vitro, and binding is independent of nelarabine or ara-G concentrations up to 600 uM.Metabolism: The principal route of metabolism for nelarabine is O-demethylation by adenosine deaminase to form ara-G, which undergoes hydrolysis to form guanine. In addition, some nelarabine is hydrolyzed to form methylguanine, which is O-demethylated to form guanine. Guanine is N-deaminated to form xanthine, which is further oxidized to yield uric acid.Excretion: Nelarabine and ara-G are partially eliminated by the kidneys. Mean urinary excretion of nelarabine and ara-G was 6.6 +- 4.7% and 27 +- 15% of the administered dose, respectively, in 28 adult patients over the 24 hours after nelarabine infusion on day 1. Renal clearance averaged 24 +- 23 L/h for nelarabine and 6.2 +- 5.0 L/h for ara-G in 21 adult patients. Combined Phase pharmacokinetic data at nelarabine doses of 199 to 2,900 mg/m2 (n 66 adult patients) indicate that the mean clearance (CL) of nelarabine is 197 +- 189 L/h/m2 on day 1. The apparent clearance of ara-G (CL/F) is 10.5 +- 4.5 L/h/m2 on day 1. Nelarabine and ara-G are rapidly eliminated from plasma with mean half-life of 18 minutes and 3.2 hours, respectively, in adult patients.Pediatrics: No pharmacokinetic data are available in pediatric patients at the once-daily 650 mg/m2 nelarabine dosage. Combined Phase pharmacokinetic data at nelarabine doses of 104 to 2,900 mg/m2 indicate that the mean clearance (CL) of nelarabine is about 30% higher in pediatric patients than in adult patients (259 +- 409 L/h/m2 versus 197 +- 189 L/h/m2, respectively) (n 66 adults, = 22 pediatric patients) on day 1. The apparent clearance of ara-G (CL/F) is comparable between the two groups (10.5 +- 4.5 L/h/m2 in adult patients and 11.3 +- 4.2 L/h/m2 in pediatric patients) on day 1. Nelarabine and ara-G are extensively distributed throughout the body. For nelarabine, VSS values were 213 +- 358 L/m2 in pediatric patients. For ara-G, VSS/F values were 33 +- 9.3 L/m2 in pediatric patients. Nelarabine and ara-G are rapidly eliminated from plasma in pediatric patients, with half-life of 13 minutes and hours, respectively.Effect of Age: Age has no effect on the pharmacokinetics of nelarabine or ara-G in adults. Decreased renal function, which is more common in the elderly, may reduce ara-G clearance [see Use in Specific Populations (8.5)].Effect of Gender: Gender has no effect on nelarabine or ara-G pharmacokinetics.Effect of Race: In general, nelarabine mean clearance and volume of distribution values tend to be higher in whites (n 63) than in blacks (by about 10%) (n 15). The opposite is true for ara-G; mean apparent clearance and volume of distribution values tend to be lower in whites than in blacks (by about 15% to 20%). No differences in safety or effectiveness were observed between these groups.Effect of Renal Impairment: The pharmacokinetics of nelarabine and ara-G have not been specifically studied in renally impaired or hemodialyzed patients. Nelarabine is excreted by the kidney to small extent (5% to 10% of the administered dose). Ara-G is excreted by the kidney to greater extent (20% to 30% of the administered nelarabine dose). In the combined Phase trials, patients were categorized into groups: normal with CLCr greater than 80 mL/min (n 67), mild with CLCr 50 to 80 mL/min (n 15), and moderate with CLCr less than 50 mL/min (n 3). The mean apparent clearance (CL/F) of ara-G was about 15% and 40% lower in patients with mild and moderate renal impairment, respectively, than in patients with normal renal function [see Use in Specific Populations (8.6), Dosage and Administration (2.3)]. No differences in safety or effectiveness were observed.Effect of Hepatic Impairment: The influence of hepatic impairment on the pharmacokinetics of nelarabine has not been evaluated [see Use in Specific Populations (8.7)].Drug Interactions: Cytochrome P450: Nelarabine and ara-G did not significantly inhibit the activities of the human hepatic cytochrome P450 isoenzymes 1A2, 2A6, 2B6, 2C8, 2C9, 2C19, 2D6, or 3A4 in vitro at concentrations of nelarabine and ara-G up to 100 uM.Fludarabine: Administration of fludarabine 30 mg/m2 as 30-minute infusion hours before 1,200-mg/m2 infusion of nelarabine did not affect the pharmacokinetics of nelarabine, ara-G, or ara-GTP in 12 patients with refractory leukemia.Pentostatin: There is in vitro evidence that pentostatin is strong inhibitor of adenosine deaminase. Inhibition of adenosine deaminase may result in reduction in the conversion of the prodrug nelarabine to its active moiety and consequently in reduction in efficacy of nelarabine and/or change in adverse reaction profile of either drug [see Drug Interactions (7)].

PREGNANCY SECTION.

8.1 Pregnancy. Risk SummaryBased on its mechanism of action and findings in animal studies, nelarabine can cause fetal harm when administered to pregnant woman [see Clinical Pharmacology (12.1)]. Limited available data with nelarabine use in pregnant women are insufficient to determine drug-associated risk for major birth defects, miscarriage or adverse maternal or fetal outcomes. There are risks to the pregnant woman associated with untreated leukemia or lymphoma (see Clinical Considerations). In animal reproduction studies, intravenous administration of nelarabine to pregnant rabbits during the period of organogenesis resulted in teratogenicity at maternal doses below the recommended human adult dose of 1,500 mg/m2/day (see Data). Advise pregnant women of the potential risk to the fetus.The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies are 2% to 4% and 15% to 20%, respectively.Clinical ConsiderationsDisease-Associated Maternal and/or Embryo-fetal RiskThere are risks to the mother from untreated leukemia or lymphoma, including anemia, thrombocytopenia, and death.DataAnimal DataIn an embryo-fetal development study in which pregnant rabbits were administered daily doses of nelarabine during organogenesis, increased incidences of fetal malformations, anomalies, and variations were observed at doses greater than or equal to 360 mg/m2/day (8-hour IV infusion; approximately 25% of the recommended human adult dose compared on mg/m2 basis), which was the lowest dose tested. Cleft palate was seen in rabbits given 3,600 mg/m2/day (approximately 2-fold the adult dose), absent pollices (digits) in rabbits given greater than or equal to 1,200 mg/m2/day (approximately 75% of the recommended adult dose), while absent gall bladder, absent accessory lung lobes, fused or extra sternebrae, and delayed ossification was seen at all doses. Maternal body weight gain and fetal body weights were reduced in rabbits given 3,600 mg/m2/day (approximately 2-fold the adult dose), but could not account for the increased incidence of malformations seen at this or lower administered doses.

SPL PATIENT PACKAGE INSERT SECTION.

PATIENT INFORMATION Nelarabine (nel ar been Injection Read the Patient Information that comes with nelarabine injection before you or your child starts treatment with nelarabine injection. Read the information you get each time before each treatment with nelarabine injection. There may be new information. This information does not take the place of talking with the doctor about your or your childs medical condition or treatment. Talk to your or your childs doctor, if you have any questions. What is the most important information should know about nelarabine injection Nelarabine Injection may cause blood related adverse reactions. Your doctor will do blood tests regularly during treatment to monitor blood counts, including platelets. Nelarabine Injection may cause serious nervous system problems including: extreme sleepinessseizurescomanumbness and tingling in the hands, fingers, feet, or toes (peripheral neuropathy)weakness and paralysis Call the doctor right away if you or your child has the following symptoms:seizuresnumbness and tingling in the hands, fingers, feet, or toesproblems with fine motor skills such as buttoning clothesunsteadiness while walkingincreased tripping while walkingweakness when getting out of chair or walking upstairs These symptoms may not go away even when treatment with nelarabine injection is stopped. What is nelarabine injection Nelarabine Injection is an anti-cancer medicine used to treat adults and children who have: T-cell acute lymphoblastic leukemiaT-cell lymphoblastic lymphoma What should you tell the doctor before you or your child starts nelarabine injection Tell the doctor about all health conditions you or your child have, including if you or your child: have any nervous system problems.have kidney problems.are breastfeeding or plan to breastfeed. It is not known whether nelarabine injection passes through breast milk. You should not breastfeed during treatment with nelarabine injection.are pregnant or plan to become pregnant. Nelarabine Injection can harm your unborn baby. You should not become pregnant while you are taking nelarabine injection. You should use effective birth control to avoid getting pregnant. Talk with your doctor about your choices.are male (including if you have had vasectomy) with sexual partner who is pregnant, think that they may be pregnant, or who could become pregnant. You should use condoms during sexual intercourse during treatment with nelarabine injection and for months after last dose. Tell the doctor about all the medicines you or your child take, including prescription and nonprescription medicines, vitamins, and herbal supplements. How is nelarabine injection given Nelarabine Injection is an intravenous medicine. This means it is given through tube in your vein. What should you or your child avoid during treatment with nelarabine injectionYou or your child should not drive or operate dangerous machines. Nelarabine Injection may cause sleepiness during and for several days after treatment.You or your child should not receive vaccines made with live germs during treatment with nelarabine injection. What are the possible side effects of nelarabine injection Nelarabine Injection may cause serious nervous system problems. See What is the most important information should know about nelarabine injection Nelarabine Injection may also cause: decreased blood counts such as low red blood cells, low white blood cells, and low platelets. Blood tests should be done regularly to check blood counts. Call the doctor right away if you or your child:is more tired than usual, pale, or has trouble breathinghas fever or other signs of an infectionbruises easy or has any unusual bleedingstomach area problems such as nausea, vomiting, diarrhea, and constipationheadachesleepinessblurry eyesight Call your doctor right away if you experience unexplained muscle pain, tenderness, or weakness while taking nelarabine injection. This is because on rare occasions, muscle problems can be serious. These are not all the side effects associated with nelarabine injection. Ask your doctor or pharmacist for more information. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. General Advice about nelarabine injection This leaflet summarizes important information about nelarabine injection. If you have questions or problems, talk with your or your childs doctor. You can ask your doctor or pharmacist for information about nelarabine injection that is written for healthcare providers. Manufactured by Cadila Healthcare Ltd. Ahmedabad, India Distributed by Zydus Pharmaceuticals (USA) Inc. Pennington, NJ 08534 Rev.: 01/22 Novaplus is registered trademark of Vizient, Inc.. extreme sleepiness. seizures. coma. numbness and tingling in the hands, fingers, feet, or toes (peripheral neuropathy). weakness and paralysis. seizures. numbness and tingling in the hands, fingers, feet, or toes. problems with fine motor skills such as buttoning clothes. unsteadiness while walking. increased tripping while walking. weakness when getting out of chair or walking upstairs. T-cell acute lymphoblastic leukemia. T-cell lymphoblastic lymphoma. have any nervous system problems.. have kidney problems.. are breastfeeding or plan to breastfeed. It is not known whether nelarabine injection passes through breast milk. You should not breastfeed during treatment with nelarabine injection.. are pregnant or plan to become pregnant. Nelarabine Injection can harm your unborn baby. You should not become pregnant while you are taking nelarabine injection. You should use effective birth control to avoid getting pregnant. Talk with your doctor about your choices.. are male (including if you have had vasectomy) with sexual partner who is pregnant, think that they may be pregnant, or who could become pregnant. You should use condoms during sexual intercourse during treatment with nelarabine injection and for months after last dose.. You or your child should not drive or operate dangerous machines. Nelarabine Injection may cause sleepiness during and for several days after treatment.. You or your child should not receive vaccines made with live germs during treatment with nelarabine injection.. decreased blood counts such as low red blood cells, low white blood cells, and low platelets. Blood tests should be done regularly to check blood counts. Call the doctor right away if you or your child:. is more tired than usual, pale, or has trouble breathing. has fever or other signs of an infection. bruises easy or has any unusual bleeding. stomach area problems such as nausea, vomiting, diarrhea, and constipation. headache. sleepiness. blurry eyesight.