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Cometriq

"The U.S. Food and Drug Administration today approved Cometriq (cabozantinib) to treat medullary thyroid cancer that has spread to other parts of the body (metastasized).

Medullary thyroid cancer develops in cells in the thyroid gland that m"...

Cometriq

SIDE EFFECTS

The following serious adverse reactions are discussed elsewhere in the label:

Clinical Trial Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

The safety of COMETRIQ was evaluated in 330 patients with progressive metastatic medullary thyroid cancer randomized to receive 140 mg COMETRIQ (n = 214) or placebo (n = 109) administered daily until disease progression or intolerable toxicity in a randomized, doubleblind, controlled trial. [See Clinical Studies] The data described below reflect a median exposure to COMETRIQ for 204 days. The population exposed to COMETRIQ was 70% male, 90% white, and had a median age of 55 years.

Adverse reactions which occurred in ≥ 25% of COMETRIQ-treated patients occurring more frequently in the COMETRIQ arm with a between-arm difference of ≥ 5% included, in order of decreasing frequency: diarrhea, stomatitis, palmar-plantar erythrodysesthesia syndrome (PPES), decreased weight, decreased appetite, nausea, fatigue, oral pain, hair color changes, dysgeusia, hypertension, abdominal pain, and constipation. The most common laboratory abnormalities ( > 25%) were increased AST, increased ALT, lymphopenia, increased ALP, hypocalcemia, neutropenia, thrombocytopenia, hypophosphatemia, and hyperbilirubinemia. Grade 3-4 adverse reactions and laboratory abnormalities which occurred in ≥ 5% of COMETRIQ-treated patients occurring more frequently in the COMETRIQ arm with a between-arm difference of ≥ 2% included, in order of decreasing frequency; diarrhea, PPES, lymphopenia, hypocalcemia, fatigue, hypertension, asthenia, increased ALT, decreased weight, stomatitis, and decreased appetite (see Table 1, Table 2).

Fatal adverse reactions occurred in 6% of patients receiving COMETRIQ and resulted from hemorrhage, pneumonia, septicemia, fistulas, cardiac arrest, respiratory failure, and unspecified death. Fatal adverse reactions occurred in 5% of patients receiving placebo and resulted from septicemia, pneumonia, and general deterioration.

The dose was reduced in 79% of patients receiving COMETRIQ compared to 9% of patients receiving placebo. The median number of dosing delays was one in patients receiving COMETRIQ compared to none in patients receiving placebo. Adverse reactions led to study treatment discontinuation in 16% of patients receiving COMETRIQ and in 8% of patients receiving placebo. The most frequent adverse reactions leading to permanent discontinuation in patients treated with COMETRIQ were: hypocalcemia, increased lipase, PPES, diarrhea, fatigue, hypertension, nausea, pancreatitis, tracheal fistula formation and vomiting.

Increased levels of thyroid stimulating hormone (TSH) were observed in 57% of patients receiving COMETRIQ after the first dose compared to 19% of patients receiving placebo (regardless of baseline value). Ninety-two percent (92%) of patients on the COMETRIQ arm had a prior thyroidectomy, and 89% were taking thyroid hormone replacement prior to the first dose.

Table 1 : Per-Patient Incidence of Selected Adverse Reactions in Protocol XL184-301 Occurring at a Higher Incidence in COMETRIQ-Treated Patients [Between Arm Difference of ≥ 5% (All Grades)1or ≥ 2% (Grades 3-4)]

MedDRA System Organ Class/ Preferred Terms Cabozantinib
(n=214)
Placebo
(n=109)
All Grades Grades 3-4 All Grades Grades 3-4
GASTROINTESTINAL DISORDERS
  Diarrhea 63 16 33 2
  Stomatitis2 51 5 6 0
  Nausea 43 1 21 0
  Oral pain3 36 2 6 0
  Constipation 27 0 6 0
  Abdominal pain4 27 3 13 1
  Vomiting 24 2 2 1
  Dysphagia 13 4 6 1
  Dyspepsia 11 0 0 0
  Hemorrhoids 9 0 3 0
GENERAL DISORDERS AND ADMINISTRATION SITE CONDITIONS
  Fatigue 41 9 28 3
  Asthenia 21 6 15 1
INVESTIGATIONS
  Decreased weight 48 5 10 0
METABOLISM AND NUTRITION DISORDERS
  Decreased appetite 46 5 16 1
  Dehydration 7 2 2 1
MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS
  Arthralgia 14 1 7 0
  Muscle spasms 12 0 5 0
  Musculoskeletal chest pain 9 1 4 0
NERVOUS SYSTEM DISORDERS
  Dysgeusia 34 0 6 0
  Headache 18 0 8 0
  Dizziness 14 0 7 0
  Paresthesia 7 0 2 0
  Peripheral sensory neuropathy 7 0 0 0
  Peripheral neuropathy 5 0 0 0
PSYCHIATRIC DISORDERS
  Anxiety 9 0 2 0
RESPIRATORY, THORACIC AND MEDIASTINAL DISORDERS
  Dysphonia 20 0 9 0
SKIN AND SUBCUTANEOUS TISSUE DISORDERS
  PPES5 50 13 2 0
  Hair color changes/ depigmentation, graying 34 0 1 0
  Rash 19 1 10 0
  Dry skin 19 0 3 0
  Alopecia 16 0 2 0
  Erythema 11 1 2 0
  Hyperkeratosis 7 0 0 0
VASCULAR DISORDERS
  Hypertension 33 8 4 0
  Hypotension 7 1 0 0
1 National Cancer Institute Common Terminology Criteria for Adverse Events Version 3.0
2 Includes the following terms: stomatitis, aphthous stomatitis, mouth ulceration, mucosal inflammation
3 Includes the following terms: oral pain, oropharyngeal pain, glossitis, burning mouth syndrome, glossodynia
4 Includes the following terms: abdominal pain, abdominal pain lower, abdominal pain upper, abdominal rigidity, abdominal tenderness, esophageal pain
5 Palmar-plantar erythrodysesthesia syndrome

Table 2: Percent-Patient Incidence of Laboratory Abnormalities Occurring at a Higher Incidence in COMETRIQ-Treated Patients in Protocol XL184-301 [Between Arm Difference of ≥ 5% (All Grades) or ≥ 2% (Grades 3-4)]

Adverse Event COMETRIQ
(n=214)
Placebo
(n=109)
All Grades Grade 3-4 All Grades Grade 3-4
Chemistries
  Increased AST 86 3 35 2
  Increased ALT 86 6 41 2
  Increased ALP 52 3 35 3
  Hypocalcemia 52 12 27 3
  Hypophosphatemia 28 3 10 1
  Hyperbilirubinemia 25 2 14 5
  Hypomagnesemia 19 1 4 0
  Hypokalemia 18 4 9 3
  Hyponatremia 10 2 5 0
Hematologic
  Lymphopenia 53 16 51 11
  Neutropenia 35 3 15 2
  Thrombocytopenia 35 0 4 3
ALT, alanine aminotransferase; ALP, alkaline phosphatase; AST, aspartate Aminotransferase

Nearly all COMETRIQ-treated patients (96% vs. 84% placebo) experienced elevated blood pressure and there was a doubling in the incidence of overt hypertension in COMETRIQ-treated patients over placebo-treated patients (61% vs. 30%) according to modified Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) staging criteria. No patients developed malignant hypertension.

Table 3: Per-Patient Incidence of Hypertensio n in Protocol XL184-301

Hypertension, JNC1 Stage COMETRIQ
N = 2113(%)
Placebo
N = 1073 (%)
Normal: Grade 0: Systolic < 120 mmHg and Diastolic < 80 mmHg 4 15
Pre-hypertension: Systolic ≥ 120 mmHg or Diastolic ≥ 80 mmHg 34 54
Stage 1: Systolic ≥ 140 mmHg or Diastolic ≥ 90 mmHg 46 25
Stage 2: Systolic ≥ 160 mmHg or Diastolic ≥ 100 mmHg 15 5
Malignant: Diastolic ≥ 120 mmHg 0 0
1Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, JAMA 2003: 289:2560. Criteria applied were modified, as multiple readings were not available per timepoint, and therefore not averaged.
2Subjects classified by highest category based on all recorded blood pressure readings beginning after the first dose through 30 days after last dose.
3Subjects with at least two blood pressure measurements after the first dose

Read the Cometriq (cabozantinib capsules) Side Effects Center for a complete guide to possible side effects

DRUG INTERACTIONS

Effect of CYP3A4 Inhibitors

Administration of a strong CYP3A4 inhibitor, ketoconazole (400 mg daily for 27 days) to healthy subjects increased single-dose plasma cabozantinib exposure (AUC0-inf) by 38%. Avoid taking a strong CYP3A4 inhibitor (e.g., ketoconazole, itraconazole, clarithromycin, atazanavir, indinavir, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, voriconazole) when taking COMETRIQ [see DOSAGE AND ADMINISTRATION and WARNINGS AND PRECAUTIONS].

Effect of CYP3A4 Inducers

Administration of a strong CYP3A4 inducer, rifampin (600 mg daily for 31 days) to healthy subjects decreased single-dose plasma cabozantinib exposure (AUC0-inf) by 77%. Avoid chronic co-administration of strong CYP3A4 inducers (e.g., dexamethasone, phenytoin, carbamazepine, rifampin, rifabutin, rifapentine, phenobarbital, St. John's Wort) with COMETRIQ [see DOSAGE AND ADMINISTRATION and WARNINGS AND PRECAUTIONS].

Last reviewed on RxList: 12/6/2012
This monograph has been modified to include the generic and brand name in many instances.

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