Carmustine
Alkylating agents
Alkylating agentsHigh alert
An error with this medicine can cause serious harm: double checks and protocols are used.
A nitrosourea that crosses into the brain. Its myelosuppression is delayed and cumulative, and it can scar the lungs even years after treatment.
Also called: BCNU
Quick facts
- Group
- Alkylating agents
- Target
- DNA (guanine), alkylated and cross-linked; proteins carbamoylated
- Used for
- Brain tumours · Multiple myeloma
- Key effects
- Nausea and vomiting · Flushing · Liver enzyme rises
- Monitor
- Pulmonary function tests before · Infusion site
- ATC
- L01AD01
No doses: the clinician sets them by the current guideline.
Mechanism of action
Carmustine breaks down without enzymes into two reactive pieces. A chloroethyl group alkylates guanines and then forms cross-links between DNA strands; an isocyanate group carbamoylates proteins, which may inhibit DNA repair enzymes. Because it is very lipid-soluble it reaches the brain and cerebrospinal fluid, and it is not fully cross-resistant with other alkylators.
- Carmustine breaks down spontaneously into reactive pieces
- The chloroethyl part alkylates and cross-links DNA
- The isocyanate part carbamoylates proteins
- Lipid-soluble: it reaches brain tumours
Indications
- Brain tumours: glioblastoma, other gliomas, medulloblastoma and brain metastases. Glioblastoma →
- Multiple myeloma, with prednisone. Multiple myeloma →
- Relapsed or refractory Hodgkin lymphoma. Hodgkin lymphoma →
- Relapsed or refractory non-Hodgkin lymphomas. Non-Hodgkin lymphoma →
Adverse effects
Common
- Nausea and vomiting
- Pain and burning at the infusion site
- Flushing
- Liver enzyme rises
Contraindications
- Previous hypersensitivity to carmustine or its components
Key interactions
- Cimetidine
- More myelosuppression (leukopenia, neutropenia).
- Phenobarbital
- Speeds up carmustine breakdown and may weaken it.
- Phenytoin
- Carmustine can lower phenytoin levels (seizure risk in brain tumour patients).
What is monitored
- Blood counts weekly for several weeks after each dose (delayed nadir)
- Pulmonary function tests before and during treatment
- Liver and kidney function
- Infusion site
Administration and safety
- Hazardous drug; the solution irritates veins and skin. The site is watched closely for extravasation.
- A new course is not given until blood counts have recovered.
- Not given into the carotid artery: that route has caused eye toxicity.
Pregnancy and breastfeeding
Can cause fetal harm; pregnancy is avoided during treatment.
Nursing care
- Check counts before each course and teach that the low point comes weeks later, not days.
- Ask about cough and breathlessness at every visit, and long after treatment.
- Bleeding precautions while platelets are low.
- Teaching: avoid pregnancy; report fever, bruising or breathing problems.
Pharmacokinetics
- Absorption
- Intravenous infusion (an implantable wafer is also used after brain surgery).
- Distribution
- Crosses the blood–brain barrier; cerebrospinal fluid levels are high compared with plasma.
- Metabolism
- Rapid chemical and liver breakdown; phenobarbital speeds it up.
- Elimination
- Metabolites mainly in the urine.
Test yourself
Think of the answer, then tap the question to see it.
Why can carmustine treat brain tumours?
It is highly lipid-soluble and crosses the blood–brain barrier.
When does carmustine's myelosuppression usually appear?
Late, weeks after the dose, and it builds up with repeated courses.
Which late organ toxicity is typical of carmustine?
Pulmonary fibrosis, which can appear years after treatment.
Connections
← Back to the class: Alkylating agents
Educational content on how drugs work; not a prescribing guide and no substitute for a health professional's advice. No doses are given.
Sources: DailyMed - CARMUSTINE- carmustine kit (DailyMed (U.S. National Library of Medicine), 2026); Carmustine: MedlinePlus Drug Information (MedlinePlus (U.S. National Library of Medicine), 2026); ATCDDD - ATC/DDD Index (WHO Collaborating Centre for Drug Statistics Methodology, 2026).
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Representative model, for educational purposes only.