Ninlaro (Ixazomib Citrate)

• Ninlaro (ixazomib citrate) is used in the treatment pathway for plasma‑cell cancers, specifically multiple myeloma that has returned after prior therapy or does not respond to earlier regimens. It is administered orally as part of a three‑drug combination.
• Relapsed or refractory multiple myeloma: improves progression‑free survival when used with lenalidomide and dexamethasone in adults who have received prior therapy.
• Multiple myeloma (relapsed/refractory): contributes to deeper and more durable responses when added to the lenalidomide‑dexamethasone backbone.

• Ixazomib citrate reversibly binds to the catalytic site of the 20S proteasome, inhibiting its chymotrypsin‑like activity. This blockade prevents degradation of polyubiquitinated proteins, leading to accumulation of misfolded proteins within malignant plasma cells and triggering apoptotic pathways that reduce tumor burden.

Common Side Effects

• Nausea: mild to moderate gastrointestinal upset.
• Diarrhea: watery stools that may require hydration.
• Fatigue: reduced energy levels and general tiredness.
• Thrombocytopenia: lowered platelet counts increasing bleed risk.
• Peripheral neuropathy: tingling or numbness in extremities.
• Constipation: difficulty passing stool.

Serious or Rare Side Effects

• Neutropenia: severe drop in neutrophils leading to infection risk.
• Severe infections: opportunistic bacterial or fungal infections.
• Pulmonary embolism: blood clot formation in lungs.
• Cardiac failure: reduced heart function presenting with dyspnea.
• Tumor lysis syndrome: rapid tumor cell breakdown causing metabolic disturbances.
• Severe rash or hypersensitivity reactions.

Before initiating therapy, clinicians should assess baseline blood counts and organ function.

• Monitor blood counts: regular CBC to detect cytopenias.
• Assess hepatic function: liver enzymes should be checked prior to and during treatment.
• Evaluate infection risk: watch for signs of febrile neutropenia.
• Use contraception: avoid pregnancy due to unknown fetal risk.
• Adjust for renal impairment: dose may need modification in severe renal dysfunction.
• Store at below 25°C: keep in the original pack, protect from moisture.

Ixazomib may interact with drugs affecting its metabolism or pharmacodynamic profile.

Major Interactions (Avoid)

• Strong CYP3A inducers (e.g., rifampin): may reduce ixazomib exposure.
• Strong CYP3A inhibitors (e.g., ketoconazole): may increase ixazomib levels and toxicity.
• P‑glycoprotein inhibitors (e.g., verapamil): can raise systemic exposure.

Moderate Interactions (Monitor Closely)

• Lenalidomide: additive myelosuppression requires blood count monitoring.
• Dexamethasone: may enhance immunosuppression.
• Antacids containing aluminum or magnesium: can affect oral absorption; separate dosing recommended.