Cabometyx

INSTRUCTIONS FOR MEDICAL USE OF THE MEDICINAL PRODUCT KABOMETIX (CABOMETYX®)

Composition:

Active substance: cabozantinib (S)-malate

One film-coated tablet contains cabozantinib (S)-malate equivalent to 20 mg, 40 mg, or 60 mg of cabozantinib;

Excipients: microcrystalline cellulose, anhydrous lactose, hydroxypropylcellulose, sodium croscarmellose, colloidal silicon dioxide (anhydrous), magnesium stearate;

Film coating: Opadry Yellow (03K92254): hypromellose (HPMC) 2910 (E 464), titanium dioxide (E 171), triacetin, iron oxide yellow (E 172).

Pharmaceutical form.

Film-coated tablets.

Main physicochemical properties.

KABOMETIX, film-coated tablets, 20 mg

Yellow, round, film-coated tablets, with "XL" imprinted on one side and "20" on the other side of the tablet.

KABOMETIX, film-coated tablets, 40 mg

Yellow, triangular, film-coated tablets, with "XL" imprinted on one side and "40" on the other side of the tablet.

KABOMETIX, film-coated tablets, 60 mg

Yellow, oval, film-coated tablets, with "XL" imprinted on one side and "60" on the other side of the tablet.

Pharmacotherapeutic group.

Antineoplastic agents. Protein kinase inhibitors. Cabozantinib.

ATC code: L01E X07.

Pharmacological Properties.

Pharmacodynamics.

Mechanism of action

Cabozantinib is a low-molecular-weight tyrosine kinase inhibitor that inhibits multiple receptor tyrosine kinases (RTKs) involved in tumor growth and angiogenesis, pathological bone changes, drug resistance, and metastatic tumor progression. In evaluations of inhibitory activity against various kinases, cabozantinib was identified as an inhibitor of the MET receptor (hepatocyte growth factor receptor) and vascular endothelial growth factor (VEGFR) receptors. In addition, cabozantinib inhibits other tyrosine kinases, including the GAS6 receptor (AXL), RET, ROS1, TYRO3, MER, stem cell factor receptor (KIT), TRKB, Fms-like tyrosine kinase-3 (FLT3), and TIE-2.

Pharmacodynamic effects

Cabozantinib demonstrated dose-dependent tumor growth inhibition, tumor regression, and/or reduced metastasis in a broad range of preclinical tumor models.

Cardiac electrophysiology

An increase from baseline in the Fridericia-corrected QT interval (QTcF) of 10–15 msec was observed on day 29 (but not on day 1) after initiation of cabozantinib treatment (at a dose of 140 mg daily) in a controlled clinical trial involving patients with medullary thyroid cancer. This effect was not associated with morphological changes in the atrial wave or the emergence of new cardiac rhythms. In this study, no patient receiving cabozantinib had a confirmed QTcF > 500 msec, which was also not confirmed with treatment using sunitinib or everolimus (at a dose of 60 mg).

Clinical efficacy and safety

Clinical data in renal cell carcinoma (RCC) following prior therapy with vascular endothelial growth factor (VEGF)-targeted agents

The safety and efficacy of CABOMETYX in the treatment of renal cell carcinoma following prior therapy with VEGF-targeted agents were evaluated in a randomized, open-label, multicenter Phase III trial (METEOR). Patients with advanced clear-cell renal cell carcinoma (RCC) who had previously received at least one course of therapy with VEGF receptor tyrosine kinase inhibitors (VEGFR TKI) were randomized (1:1) to receive either CABOMETYX (N = 330) or everolimus (N = 328). Patients could have received other prior therapies, including cytokines, antibodies targeting VEGF, or antibodies targeting programmed cell death-1 (PD-1) or its ligands. Patients with previously treated brain metastases were allowed. Progression-free survival was assessed by a blinded independent radiology review committee, and the primary analysis was performed in the first 375 randomized patients. Secondary endpoints included the proportion of patients achieving objective response and overall survival (OS). Tumor assessments were performed every 8 weeks for the first 12 months and then every 12 weeks thereafter.

Baseline demographic characteristics and disease features were similar between the CABOMETYX and everolimus treatment groups. The majority of patients were male (75%), with a median age of 62 years. Seventy-one percent of patients had received only one prior VEGFR TKI regimen; 41% of patients received sunitinib as their only prior VEGFR TKI. According to the Memorial Sloan Kettering Cancer Center (MSKCC) prognostic risk category criteria, 46% had favorable risk (0 risk factors), 42% intermediate risk (1 risk factor), and 13% poor risk (2 or 3 risk factors). Fifty-four percent of patients had metastases in three or more organs, including lungs (63%), lymph nodes (62%), liver (29%), and bones (22%). The median duration of treatment was 7.6 months (range: 0.3–20.5) in patients receiving CABOMETYX and 4.4 months (range: 0.21–18.9) in those receiving everolimus.

A statistically significant improvement in progression-free survival was observed with CABOMETYX compared to everolimus (Figure 1 and Table 1). A planned interim analysis of overall survival conducted at the time of progression-free survival analysis did not reach the threshold for statistical significance (202 events, HR = 0.68 [0.51, 0.90], p = 0.006). However, a subsequent unplanned interim analysis of overall survival showed a statistically significant improvement in patients receiving CABOMETYX compared to the everolimus group (320 events, median 21.4 months vs. 16.5 months, HR = 0.66 [0.53, 0.83], p = 0.0003, Figure 2). Comparable results for OS were observed in a subsequent descriptive analysis of 430 events.

An exploratory analysis of progression-free survival and overall survival in the "all randomized patients who received at least one dose of study drug" population also demonstrated consistent favorable results for CABOMETYX compared to everolimus across various subgroups based on age (<65 vs. ≥65 years), sex, Memorial Sloan Kettering Cancer Center risk group (favorable, intermediate, poor), ECOG performance status (0 or 1), time from diagnosis to randomization (<1 year vs. ≥1 year), tumor MET status (high vs. low or unknown), bone metastases (absent vs. present), visceral metastases (absent vs. present), bone and visceral metastases (absent vs. present), number of prior VEGFR-TKI regimens (1 vs. >2), and duration of first VEGF-targeted therapy (<6 months vs. ≥6 months). Results regarding the proportion of patients achieving objective response are presented in Table 2.

Figure 1. Progression-free survival curve as assessed by independent radiology review committee in patients with mRCC following prior VEGF-targeted therapy (first 375 randomized patients) (Kaplan-Meier method, METEOR study)

Table 1

Summary of progression-free survival (PFS) results as assessed by independent radiology review committee in patients with mRCC following prior VEGF-targeted therapy (METEOR study)

1 Stratified log-rank test.

Fig. 2. Overall survival curve of patients with RCC after prior treatment with vascular endothelial growth factor (VEGF)-targeted agents (Kaplan-Meier method, METEOR study)

Table 2

Summary of data on the number of patients with objective response according to independent radiological review committee (IRC) and investigator assessment in patients with RCC after prior treatment with vascular endothelial growth factor (VEGF)-targeted agents

1 Chi-square test.

Clinical data on treatment of patients with previously untreated renal cell carcinoma

The safety and efficacy of CABOMETYX in patients with previously untreated renal cell carcinoma were evaluated in a randomized, open-label, multicenter study (CABOSUN). Patients (N = 157) with previously untreated, locally advanced or metastatic clear-cell RCC were randomized (1:1) to receive CABOMETYX (N = 79) or sunitinib (N = 78). Patients were required to have intermediate- or poor-risk disease as defined by the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) risk categories. Patients were stratified by IMDC risk group and presence of bone metastases (yes/no). Approximately 75% of patients had undergone nephrectomy prior to initiation of therapy.

Patients were required to have one or two of the following risk factors for intermediate risk and three or more risk factors for poor risk: time from diagnosis of RCC to systemic treatment < 1 year, hemoglobin < LLN (lower limit of normal), corrected calcium > ULN (upper limit of normal), KPS score < 80%, neutrophils > ULN, platelets > ULN.

The primary endpoint was progression-free survival. Secondary efficacy endpoints included objective response rate and overall survival. Tumor assessments were performed every 12 weeks.

Baseline demographic and disease characteristics were similar between the CABOMETYX and sunitinib treatment groups. The majority of patients were male (78%); median age was 62 years. Distribution of patients by IMDC risk group was as follows: 81% of patients in the intermediate-risk group (1–2 risk factors), and 19% in the poor-risk group (≥ 3 risk factors). Most patients (87%) had an ECOG performance status of 0 or 1; 13% had a score of 2. Bone metastases were present in 36% of patients.

A statistically significant improvement in progression-free survival, assessed retrospectively by an independent review committee using blinded radiological review (IRC), demonstrated the benefit of CABOMETYX over sunitinib (Figure 3, Table 3). Results from investigator-assessed and IRC-assessed progression-free survival were consistent with each other.

Patients with both positive and negative MET status showed favorable response to CABOMETYX compared to sunitinib; however, greater activity was observed in patients with positive MET status compared to those with negative MET status (HR = 0.32 (0.16, 0.63) vs. 0.67 (0.37, 1.23), respectively).

Treatment with CABOMETYX was associated with a trend toward longer survival compared to sunitinib (Table 3). This study was underpowered for analysis of overall survival, and the data were immature.

Data on objective response rate are presented in Table 3.

Figure 3. Progression-free survival curve in patients with advanced RCC who have not received prior treatment (IRC data, Kaplan-Meier method)

Table 3

Efficacy results in patients with advanced RCC who have not received prior treatment (ITT population, CABOSUN study)

a According to the data censoring standards adopted in the EU.

b Stratification factors according to IxRS included IMDC risk categories (intermediate risk, high risk, and presence of bone metastases (yes/no)).

c Calculated based on the Cox proportional hazards model adjusted for stratification factors according to IxRS. Hazard ratios < 1 indicate progression-free survival in favor of cabozantinib.

Clinical data in hepatocellular carcinoma (HCC)

The safety and efficacy of the medicinal product CABOMETYX were evaluated in a randomized, double-blind, placebo-controlled Phase III trial (CELESTIAL). Patients (N = 707) with HCC who were refractory to curative treatment and who had previously received sorafenib for advanced disease were randomized (2:1) to receive CABOMETYX (N = 470) or placebo (N = 237). Patients could have received one additional prior systemic therapy for advanced disease in addition to sorafenib. Randomization was stratified by disease etiology (hepatitis B virus [with or without hepatitis C virus], hepatitis C virus [without hepatitis B virus], or other patient category), geographic region (Asia, other regions), and presence of extrahepatic disease spread and/or macrovascular invasion (yes/no).

The primary efficacy endpoint was overall survival. Secondary efficacy endpoints were progression-free survival and objective response rate, assessed by the investigator using the Response Evaluation Criteria in Solid Tumors (RECIST) 1.1. Tumors were evaluated every 8 weeks. Subjects continued blinded treatment after radiological confirmation of disease progression until they experienced clinical benefit or until further systemic or locoregional liver-directed anti-tumor therapy was required. Crossover from placebo to cabozantinib was not permitted during the blinded treatment phase.

Baseline demographic characteristics and disease features were similar between the CABOMETYX and placebo groups and are presented below for all 707 randomized patients:

male – 82 %;

mean patient age – 64 years;

Caucasian – 56 %, Asian – 34 %;

ECOG performance status score of 0 – 53 % or 1 – 47 %;

Child-Pugh class A liver impairment – 99 %, class B – 1 %;

HCC etiology included 38 % of patients with hepatitis B virus (HBV), 21 % with hepatitis C virus (HCV), and 40 % other (neither HBV nor HCV);

presence of macroscopic vascular invasion and/or extrahepatic disease – 78 %;

alpha-fetoprotein (AFP) levels ≥ 400 μg/L – 41 %;

prior transarterial chemoembolization or chemoinfusion procedures – 44 %;

prior radiotherapy before cabozantinib treatment – 37 %;

median duration of sorafenib treatment – 5.32 months;

72 % of patients received one, and 28 % received two prior systemic therapy regimens for advanced disease.

A statistically significant improvement in overall survival was demonstrated for CABOMETYX compared to placebo (Table 4, Figure 4).

Data on progression-free survival and objective response rate are presented in Table 4.

Table 4

Efficacy results in patients with HCC (ITT population, CELESTIAL trial)

1 Two-sided, stratified, log-rank test, with stratification factors being etiology of the disease (hepatitis B virus [with or without hepatitis C virus], hepatitis C virus [without hepatitis B virus], or other category of patients), geographic region (Asia, other regions), and presence of extrahepatic disease spread and/or macrovascular invasion (yes/no) (based on IVRS data).

2 Calculated based on Cox proportional hazards model.

3 Investigator-assessed according to RECIST 1.1 criteria.

4 Stratified Cochran–Mantel–Haenszel (CMH) test.

Figure 4. Overall survival curve (Kaplan-Meier method, CELESTIAL study)

Figure 5. Progression-free survival curve (Kaplan-Meier method, CELESTIAL trial)

The proportion of non-protocol systemic non-radiation and local liver-directed systemic anticancer therapy (NPACT) was 26% in the cabozantinib group and 33% in the placebo group. Patients receiving such therapies had to discontinue treatment with the investigational regimen. A sensitivity analysis of overall survival with censoring for NPACT use supported the results of the primary analysis: the hazard ratio (HR), adjusted for stratification factors (by IxRS), was 0.66 (95% CI: 0.52, 0.84; stratified log-rank p-value = 0.0005). The median overall survival estimated by the Kaplan-Meier method was 11.1 months in the cabozantinib group compared to 6.9 months in the placebo group, resulting in an estimated median difference of 4.2 months.

Quality of life (QoL) was assessed using the disease-agnostic EuroQoL EQ-5D-5L questionnaire. A negative impact of CABOMETYX compared to placebo on the EQ-5D utility index score was observed during the first weeks of treatment. After this period, only limited QoL data were available.

Pediatric population

The European Medicines Agency has waived the obligation to submit results of studies with CABOMETYX in all subgroups of the pediatric population for the treatment of hepatocellular carcinoma, as well as renal and renal pelvis carcinomas (except nephroblastoma, nephroblastomatosis, clear cell sarcoma, mesoblastic nephroma, renal medullary carcinoma, and renal rhabdoid tumor) (see section "Dosage and method of administration" for information on use of the medicinal product in children).

Pharmacokinetics

Absorption

Following oral administration, peak plasma concentration of cabozantinib is reached within 3–4 hours. Plasma concentration-time profiles show a secondary absorption peak approximately 24 hours after administration, suggesting that cabozantinib may undergo enterohepatic recirculation.

Repeated daily administration of cabozantinib at a dose of 140 mg for 19 days resulted in an approximately 4- to 5-fold increase in mean cabozantinib accumulation (based on the area under the pharmacokinetic concentration-time curve) compared to single-dose administration; steady state was reached by approximately day 15.

A high-fat meal moderately increased the maximum plasma concentration and the area under the pharmacokinetic concentration-time curve (by 41% and 57%, respectively) compared to fasting conditions in healthy volunteers who received a single 140 mg oral dose of cabozantinib. Data on the effect of food administered 1 hour after cabozantinib intake are not available.

Bioequivalence between cabozantinib capsules and tablets could not be demonstrated after a single 140 mg dose was administered to healthy volunteers. A 19% increase in maximum plasma concentration of the active substance was observed after administration of the tablet formulation (CABOMETYX) compared to the capsule (COMETRIQ). Less than a 10% difference in the area under the pharmacokinetic concentration-time curve was observed between the cabozantinib tablet (CABOMETYX) and capsule (COMETRIQ) formulations.

Distribution

Cabozantinib is highly bound to human plasma proteins (≥ 99.7%). Based on pharmacokinetic measurements, the volume of distribution (Vz) is approximately 212 L. Plasma protein binding was not altered in patients with mild or moderate renal or hepatic impairment.

Biotransformation

Cabozantinib is metabolized in vivo. Four metabolites were present in plasma at exposure levels (area under the pharmacokinetic concentration-time curve) greater than 10% of the parent compound: XL184-N-oxide, amide cleavage product of XL184, monohydroxy-sulfate XL184, and sulfate of the 6-desmethyl amide cleavage product. Two unconjugated metabolites (XL184-N-oxide and amide cleavage product of XL184) have less than 1% of the original cabozantinib's kinase inhibition activity, and each contributes less than 10% to the total drug-related exposure in plasma.

Cabozantinib is a substrate for CYP3A4 metabolism in vitro, as a neutralizing antibody to CYP3A4 inhibited the formation of the XL184-N-oxide metabolite by > 80% in NADPH-catalyzed human liver microsomal incubations. In comparison, neutralizing antibodies to CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C19, CYP2D6, and CYP2E1 had no effect on cabozantinib metabolite formation. A neutralizing antibody to CYP2C9 showed minimal effect on cabozantinib metabolite formation (i.e., reduction of < 20%).

Elimination

Following oral administration of cabozantinib at doses ranging from 20 mg to 140 mg, the mean elimination half-life in plasma, based on data from studies involving 1883 patients and 140 healthy volunteers, is approximately 110 hours. The mean plasma clearance (apparent clearance) is nearly 2.48 L/h after steady-state exposure. Approximately 81% of the radiolabeled dose was recovered within 48 days after administration of a single 14C-cabozantinib dose in healthy volunteers, with about 54% of the dose excreted in feces and approximately 27% excreted in urine.

Pharmacokinetics in special patient populations

Renal impairment

Results from a study in patients with renal impairment who received a single 60 mg dose of cabozantinib indicate that the least-squares geometric mean ratios of cabozantinib plasma maximum concentration and area under the concentration-time curve from 0 to infinity were 19% and 30% higher, respectively, in patients with mild renal impairment (90% CI for maximum plasma concentration: 91.60% to 155.51%; area under the concentration-time curve from 0 to infinity: 98.79% to 171.26%) and 2% and 6–7% higher (90% CI for maximum plasma concentration: 78.64% to 133.52%; area under the concentration-time curve from 0 to infinity: 79.61% to 140.11%) in patients with moderate renal impairment, compared to patients with normal renal function. Patients with severe renal impairment were not studied.

Hepatic impairment

Based on an integrated population pharmacokinetic analysis of cabozantinib in healthy volunteers and cancer patients (including HCC), no clinically relevant differences in mean plasma exposure of cabozantinib were observed between patients with normal hepatic function (n = 1425) and those with mild hepatic impairment (n = 558). Data in patients with moderate hepatic impairment (n = 15) according to NCI-ODWG (National Cancer Institute-Organ Dysfunction Working Group) criteria are limited. Pharmacokinetics of cabozantinib have not been evaluated in patients with severe hepatic impairment.

Race

Population pharmacokinetic analysis did not reveal clinically significant differences in cabozantinib pharmacokinetics based on patient race.

Clinical characteristics.

Indications.

Renal cell carcinoma (RCC)

CABOMETYX is indicated for the treatment of advanced renal cell carcinoma (RCC):

• in adult patients who have not received prior therapy and who are at intermediate or poor risk (see section "Pharmacodynamic properties");
• in adult patients following prior therapy with vascular endothelial growth factor (VEGF)-targeted agents.

Hepatocellular carcinoma (HCC)

CABOMETYX is indicated as monotherapy for hepatocellular carcinoma (HCC) in adult patients previously treated with sorafenib.

Contraindications.

Hypersensitivity to the active substance or to any of the excipients of the medicinal product.

Interaction with other medicinal products and other forms of interaction.

Effect of other medicinal products on cabozantinib

Inhibitors and inducers of CYP3A4

Prior administration of ketoconazole, a strong CYP3A4 inhibitor, at a dose of 400 mg once daily for 27 days before a single dose of cabozantinib increased plasma exposure to cabozantinib by 38% (AUC) and decreased cabozantinib clearance by 29% in healthy volunteers. Strong CYP3A4 inhibitors should be used with caution (including ritonavir, itraconazole, erythromycin, clarithromycin, grapefruit juice).

Prior administration of rifampicin, a strong CYP3A4 inducer, at a dose of 600 mg once daily for 31 days before a single dose of cabozantinib decreased plasma exposure to cabozantinib by 77% (AUC) and increased cabozantinib clearance by 4.3-fold in healthy volunteers. Concomitant long-term use of strong CYP3A4 inducers should be avoided (including rifampicin, carbamazepine, phenytoin, phenobarbital, or medicinal products containing St John’s wort (Hypericum perforatum)).

Gastrointestinal pH modifiers

Prior administration of esomeprazole, a proton pump inhibitor (PPI), at a dose of 40 mg once daily for 6 days before a single 100 mg dose of cabozantinib indicated that this does not have a clinically significant effect on plasma exposure (AUC) of cabozantinib in healthy volunteers. Dose adjustment is not recommended when cabozantinib is administered concomitantly with agents that alter gastric pH (including PPIs, H2-receptor antagonists, and antacids).

MRP2 inhibitors

In vitro study data indicate that cabozantinib is a substrate of MRP2. Therefore, administration of MRP2 inhibitors may lead to increased plasma concentrations of cabozantinib.

Bile acid sequestrants

Bile acid sequestrants such as cholestyramine and cholestagel may interact with cabozantinib and affect absorption (or reabsorption), thereby reducing the dose, which is an undesirable effect (see section "Pharmacodynamics"). The clinical significance of these potential interactions is unknown.

Effect of cabozantinib on other medicinal products

The effect of cabozantinib on the pharmacokinetics of hormonal contraceptives has not been studied. Since contraceptive efficacy cannot be guaranteed, an additional method of contraception, such as a barrier method, is recommended.

Due to the high degree of plasma protein binding of cabozantinib (see section "Pharmacokinetics"), interaction with warfarin is possible—displacement from plasma proteins. In such cases, international normalized ratio (INR) should be monitored.

P-glycoprotein (P-gp) inhibitors

Cabozantinib is an inhibitor (IC50 = 7.0 μM), but not a substrate, of P-glycoprotein (P-gp) transport activity in a bidirectional system using cells engineered to express P-glycoprotein (MDCK-MDR1). Concomitant use of P-gp inhibitors may increase cabozantinib plasma concentrations. Patients should be advised about taking medicinal products that affect P-gp (such as fexofenadine, aliskiren, ambrisentan, dabigatran etexilate, digoxin, colchicine, maraviroc, posaconazole, ranolazine, saxagliptin, sitagliptin, talinolol, tolvaptan) during treatment with cabozantinib.

Special precautions for use.

Since most adverse reactions may occur at the beginning of treatment, careful monitoring is required during the first eight weeks of therapy to detect adverse reactions and increased individual sensitivity to the medicinal product, with a view to possible dose modification. Events that typically have an early onset include hypocalcemia, hypokalemia, thrombocytopenia, arterial hypertension, palmar-plantar erythrodysesthesia syndrome (PPES), proteinuria, and gastrointestinal disorders (abdominal pain, mucositis, constipation, diarrhea, vomiting).

Temporary interruption of the drug or dose reduction of cabozantinib may be required to manage suspected adverse reactions (see section "Dosage and administration").

In the pivotal clinical study (METEOR trial), 59.8% and 70% of patients with previously treated renal cell carcinoma required dose reduction and treatment interruption, respectively, due to adverse reactions. Two dose reductions were required in 19.3% of patients. The median time to first dose reduction was 55 days, and to first treatment interruption was 38 days.

In patients with renal cell carcinoma who had not received prior therapy, dose reduction and treatment interruption occurred in 46% and 73% of patients, respectively, receiving cabozantinib in the clinical trial (CABOSUN study).

In the treatment of hepatocellular carcinoma after prior systemic therapy, dose reduction and treatment discontinuation occurred in 62% and 84% of patients, respectively, receiving cabozantinib in the clinical trial (CELESTIAL study). Two dose reductions were required in 33% of patients. The median time to first dose reduction was 38 days, and to first treatment interruption was 28 days. More intensive monitoring is recommended for patients with mild or moderate hepatic impairment.

Hepatobiliary system effects

Abnormal liver function test results (elevated alanine aminotransferase [ALT], aspartate aminotransferase [AST], and bilirubin levels) are frequently observed in patients receiving cabozantinib. Liver function tests (ALT, AST, bilirubin) are recommended before initiating cabozantinib therapy, and these parameters should be closely monitored during treatment. In case of worsening liver function test results related to cabozantinib treatment (i.e., in the absence of alternative causes), dose modification recommendations as presented in Table 5 should be followed (see section "Dosage and administration").

Cabozantinib is primarily eliminated by the liver. More intensive monitoring of overall safety is recommended for patients with mild or moderate hepatic impairment (see also sections "Special precautions for use" and "Pharmacokinetics"). Hepatic encephalopathy occurred in a relatively higher proportion of patients with moderate hepatic impairment (Child-Pugh class B). CABOMETYX is not recommended for patients with severe hepatic impairment (Child-Pugh class C), as cabozantinib has not been studied in this population and its exposure may increase in these patients.

Hepatic encephalopathy

In the HCC study (CELESTIAL trial), hepatic encephalopathy was reported more frequently in the cabozantinib group than in the placebo group. Diarrhea, vomiting, decreased appetite, and electrolyte imbalances may occur during cabozantinib treatment. In patients with HCC and impaired liver function, these reactions may be precursors to the development of hepatic encephalopathy. Patients should be monitored for signs and symptoms of hepatic encephalopathy.

Perforations and fistulas

Serious gastrointestinal (GI) tract perforations and fistulas, including fatal cases, have been observed with cabozantinib treatment. Patients with inflammatory bowel disease (e.g., Crohn’s disease, ulcerative colitis, peritonitis, diverticulitis, or appendicitis), tumor infiltration into the GI tract, or complications from prior GI surgery (especially when associated with delayed or incomplete wound healing) should be carefully evaluated before initiating cabozantinib and monitored during treatment for signs of perforation or fistula, including abscesses and sepsis. Persistent or intermittent diarrhea during treatment may be a risk factor for development of rectal fistula. Cabozantinib treatment should be permanently discontinued in patients who develop GI perforation or fistula that cannot be adequately managed.

Gastrointestinal (GI) disorders

Diarrhea, nausea/vomiting, decreased appetite, and stomatitis/oral pain are the most commonly reported adverse reactions affecting the GI tract (see section "Adverse reactions"). Prompt pharmacological management, including supportive therapy with antiemetics, antidiarrheals, and antacids, should be initiated to prevent dehydration, electrolyte imbalances, and weight loss. In cases of persistent or recurrent GI adverse reactions, consideration should be given to interrupting therapy, reducing the dose, or permanently discontinuing cabozantinib (see Table 5).

Thromboembolic events

Episodes of venous thromboembolism, including pulmonary embolism, and arterial thromboembolism, sometimes fatal, have been observed during cabozantinib treatment. Cabozantinib should be administered with caution in patients at high risk for thromboembolic events or with a history of such events. In the HCC study (CELESTIAL), portal vein thrombosis was observed during cabozantinib treatment, including one fatal case. Patients with prior portal vein invasion are likely at increased risk of developing portal vein thrombosis. Cabozantinib should be discontinued in patients who experience acute myocardial infarction or any other clinically significant thromboembolic complication.

Bleeding

Serious bleeding events, sometimes fatal, have been reported with cabozantinib. Patients with a history of severe bleeding should be carefully evaluated before initiating cabozantinib therapy.

Cabozantinib should not be administered to patients with active severe bleeding or those at risk of bleeding.

In the HCC study (CELESTIAL), fatal bleeding events occurred more frequently with cabozantinib than with placebo. Risk factors for severe bleeding in patients with advanced HCC may include tumor invasion into large blood vessels and presence of liver cirrhosis, leading to esophageal varices, portal hypertension, and thrombocytopenia. Patients receiving concomitant anticoagulant or antiplatelet therapy were not enrolled in the CELESTIAL study.

Patients with untreated or incompletely treated varices associated with bleeding or at high risk of bleeding were also excluded from this study.

Aneurysms and arterial dissections

VEGF pathway inhibitors may promote the formation of aneurysms and/or arterial dissections in patients with or without hypertension. This risk should be carefully considered before initiating treatment in patients with risk factors such as hypertension or history of aneurysm.

Thrombocytopenia

In the HCC study (CELESTIAL), cases of thrombocytopenia and decreased platelet levels were reported. Platelet levels should be monitored during cabozantinib treatment, and dosing should be adjusted according to the severity of thrombocytopenia (see Table 5).

Impaired wound healing

Impaired wound healing has been reported during cabozantinib treatment. It is recommended to discontinue cabozantinib therapy 28 days prior to elective surgery, including dental surgery or invasive dental procedures, if possible. The decision to resume cabozantinib treatment after surgical procedures should be based on clinical assessment of wound healing. Cabozantinib treatment should be discontinued in patients who develop wound healing complications requiring medical intervention.

Arterial hypertension

Cabozantinib use has been associated with increased blood pressure and hypertensive crisis. Arterial blood pressure should be carefully stabilized before initiating cabozantinib therapy. After starting cabozantinib, all patients should undergo regular blood pressure monitoring, and antihypertensive therapy should be initiated as needed. In cases of severe or persistent hypertension uncontrolled by antihypertensive medications, the physician should consider discontinuing cabozantinib until blood pressure is controlled, after which cabozantinib may be restarted at a reduced dose.

Cabozantinib treatment should be discontinued in case of hypertensive crisis.

Osteonecrosis

Cases of osteonecrosis of the jaw (ONJ) have been observed with cabozantinib use. Oral examinations should be performed before initiating and periodically during cabozantinib therapy. Patients should be informed about oral hygiene. Cabozantinib should be discontinued at least 28 days before planned dental surgery or invasive dental procedures, if possible. Caution is advised in patients receiving agents associated with ONJ, such as bisphosphonates. Cabozantinib should be discontinued in patients who develop ONJ.

Palmar-plantar erythrodysesthesia syndrome (PPES)

Cases of palmar-plantar erythrodysesthesia syndrome (PPES) have been reported in patients receiving cabozantinib. In cases of severe PPES, discontinuation of cabozantinib should be considered. Treatment with cabozantinib should be interrupted until symptoms resolve or improve to grade 1.

Proteinuria

Cases of proteinuria have been reported during cabozantinib treatment. Urinary protein levels should be monitored regularly during therapy. Cabozantinib should be discontinued if nephrotic syndrome develops.

Reversible posterior encephalopathy syndrome (RPES)

Reversible posterior encephalopathy syndrome (RPES) has been reported in patients receiving cabozantinib. RPES may present with seizures, visual disturbances, headache, confusion, and neurological deficits. Patients with RPES should discontinue cabozantinib treatment.

QT interval prolongation

Cabozantinib should be used with caution in patients with a history of QT interval prolongation, those taking medications that prolong the QT interval, and patients with underlying cardiac conditions, bradycardia, or electrolyte imbalances. Periodic ECG monitoring and assessment of serum potassium, calcium, and magnesium concentrations are required during cabozantinib treatment.

Thyroid function disorders

All patients should undergo laboratory thyroid function testing before starting the medicinal product. Patients with pre-existing hypothyroidism or hyperthyroidism should be treated according to standard medical practice before initiating cabozantinib therapy. All patients should be closely monitored during treatment for signs and symptoms of thyroid dysfunction, and periodic thyroid function monitoring is recommended. Patients who develop thyroid dysfunction should be managed according to standard medical practice based on the type of dysfunction identified.

Abnormal blood biochemistry results

Cabozantinib use is associated with an increased frequency of electrolyte imbalances (including hypo- and hyperkalemia, hypomagnesemia, hypocalcemia, hyponatremia). Parameters of blood biochemistry should be monitored during cabozantinib treatment, and appropriate replacement therapy should be administered as needed according to clinical practice standards. Hepatic encephalopathy in patients with HCC may be explained by electrolyte imbalances occurring during treatment. If severe laboratory abnormalities persist or recur intermittently, consideration should be given to interrupting therapy, reducing the dose, or permanently discontinuing cabozantinib (see Table 5).

CYP3A4 inhibitors and inducers

Cabozantinib is a substrate of CYP3A4. Concomitant use of cabozantinib and the CYP3A4 inhibitor ketoconazole may lead to a marked increase in cabozantinib exposure. Particular caution is required when strong CYP3A4 inhibitors are used concomitantly with cabozantinib. Concomitant use of cabozantinib with strong CYP3A4 inducers, such as rifampicin, may reduce cabozantinib exposure and distribution. Therefore, concomitant use of agents that are strong CYP3A4 inducers and cabozantinib should be avoided (see sections "Dosage and administration" and "Interaction with other medicinal products and other forms of interaction").

P-glycoprotein substrate

Cabozantinib is an inhibitor (IC50 = 7.0 μM), but not a substrate, of P-glycoprotein (P-gp) transport activity in a bidirectional system using cells engineered to express P-glycoprotein (MDCK–MDR1). Concomitant use of P-gp inhibitors may increase cabozantinib plasma concentrations. Patients should be warned about taking medicinal products that affect P-gp (such as fexofenadine, aliskiren, ambrisentan, dabigatran etexilate, digoxin, colchicine, maraviroc, posaconazole, ranolazine, saxagliptin, sitagliptin, talinolol, tolvaptan) during cabozantinib treatment (see section "Interaction with medicinal products and other forms of interaction").

MRP2 inhibitors

Administration of MRP2 inhibitors may increase cabozantinib plasma concentrations. MRP2 inhibitors should be used with caution (including cyclosporine, efavirenz, emtricitabine) (see section "Interaction with medicinal products and other forms of interaction").

Precautions regarding excipients

Patients with rare hereditary intolerance to galactose, complete lactase deficiency, or glucose-galactose malabsorption should not take this medicinal product.

One 20 mg film-coated tablet contains 15.54 mg of lactose.

One 40 mg film-coated tablet contains 31.07 mg of lactose.

One 60 mg film-coated tablet contains 46.61 mg of lactose.

Sodium compounds

This medicinal product contains less than 1 mmol sodium (23 mg) per tablet, i.e., essentially sodium-free.

Any unused medicinal product or waste material should be disposed of in accordance with hospital practice standards.

Use during pregnancy or breastfeeding.

Females of reproductive potential/contraception in males and females

Females of reproductive potential should avoid pregnancy during cabozantinib treatment. Females whose partners are receiving cabozantinib should avoid pregnancy. Females of reproductive potential and males should use effective contraceptive methods during treatment and for 4 months after completion of therapy. Since oral contraceptives may not be considered effective contraceptive methods, additional preventive measures should be used if oral contraceptives are used (see section "Interaction with medicinal products and other forms of interaction").

Pregnancy

There are no data on the use of cabozantinib in pregnant women. Animal studies have shown embryofetal and teratogenic effects. The potential risk to humans is unknown. Cabozantinib should not be used during pregnancy except in cases of urgent clinical necessity.

Breastfeeding

It is unknown whether cabozantinib or its metabolites are excreted in human breast milk. Risk to the breastfed infant cannot be excluded; therefore, breastfeeding must be discontinued during cabozantinib treatment and for at least 4 months after completion of therapy.

Fertility

There are no data on the effect of cabozantinib on human fertility. Study results indicate that cabozantinib may negatively affect fertility in both males and females. Males and females should use effective contraceptive methods during treatment.

Ability to affect reaction speed when driving vehicles or operating machinery.

Cabozantinib has a minor influence on the ability to drive vehicles or operate machinery. During treatment, some patients have reported adverse reactions such as fatigue and weakness. Caution should be exercised when driving vehicles or operating machinery during treatment.

Dosage and Administration

Treatment with CABOMECTICS must be initiated and supervised by a physician experienced in the use of anticancer medicinal products.

Administration

CABOMECTICS is intended for oral administration. Tablets should be swallowed whole, without crushing. Patients should avoid eating for 2 hours before and at least 1 hour after taking CABOMECTICS.

Dosage

CABOMECTICS tablets and cabozantinib capsules are not bioequivalent and should not be used interchangeably (see section "Pharmacokinetics").

Monotherapy

The recommended dose of CABOMECTICS for the treatment of RCC and HCC is 60 mg once daily. Treatment should continue until the patient no longer derives clinical benefit or until unacceptable toxicity occurs.

Dose Modifications

Suspected adverse reactions may require temporary interruption and/or dose reduction of CABOMECTICS (see Table 5). If necessary, the dose should be reduced to 40 mg once daily, and subsequently to 20 mg once daily.

In the event of CTCAE (Common Terminology Criteria for Adverse Events) Grade 3 or higher toxicity, or intolerable Grade 2 toxicity, treatment should be temporarily withheld. Dose reduction is recommended in case of severe or intolerable toxicities.

A missed dose should not be taken if less than 12 hours remain before the next scheduled dose.

Table 5

Recommended dose modifications of CABOMECTICS and required actions in the event of adverse reactions

Note: Criteria for assessing the severity of adverse reactions according to NCI-CTCAE v4.

Concomitant Medications

Concomitant use of strong CYP3A4 inhibitors should be approached with caution, and continuous concomitant use of strong CYP3A4 inducers should be avoided (see sections "Special Warnings and Precautions for Use" and "Interaction with Other Medicinal Products and Other Forms of Interaction").

Consider selecting an alternative concomitant medicinal product that has no or minimal inhibitory activity on the CYP3A4 isoenzyme.

Special Patient Populations

Elderly Patients

Dose adjustment of cabozantinib is not required in elderly patients (≥ 65 years of age).

Ethnicity

Dose adjustment based on patient's ethnicity is not required (see section "Pharmacokinetics").

Patients with Renal Impairment

Cabozantinib should be administered with caution to patients with mild or moderate renal impairment.

Cabozantinib is contraindicated in patients with severe renal impairment, as the safety and efficacy of cabozantinib in this patient population have not been established.

Patients with Hepatic Impairment

Dose adjustment is not required in patients with mild hepatic impairment. Due to limited data available on the use of cabozantinib in patients with moderate hepatic impairment (Child-Pugh class B), dosing recommendations cannot be provided. For these patients, monitoring of overall safety is recommended (see sections "Special Warnings and Precautions for Use" and "Pharmacokinetics"). Due to the lack of clinical experience with cabozantinib in patients with severe hepatic impairment (Child-Pugh class C), cabozantinib is not recommended for use in this patient group (see section "Pharmacokinetics").

Patients with Cardiac Impairment

Data on use in patients with cardiac impairment are limited. There are no specific dosing recommendations for this patient population.

Children

The safety and efficacy of cabozantinib in children and adolescents (< 18 years of age) have not been established. Appropriate data are lacking. Do not use in children.

Overdose

There is no specific antidote for cabozantinib overdose, and potential overdose symptoms have not been established. In case of suspected overdose, administration of cabozantinib should be discontinued and supportive treatment initiated. Laboratory biochemical parameters and metabolic parameters should be monitored, at least weekly or more frequently if clinically indicated. Adverse reactions associated with overdose should be treated symptomatically.

Adverse Reactions

Summary of Safety Profile

The most common serious adverse reactions in patients with RCC (frequency ≥ 1%) are pneumonia, abdominal pain, diarrhea, nausea, arterial hypertension, embolism, hyponatremia, pulmonary embolism, vomiting, dehydration, fatigue, asthenia, decreased appetite, deep vein thrombosis, dizziness, hypomagnesemia, and palmar-plantar erythrodysesthesia (PPES).

The most common adverse reactions of any grade (observed in at least 25% of patients) in patients with RCC were diarrhea, fatigue, nausea, decreased appetite, PPES, arterial hypertension, weight decreased, vomiting, dysgeusia, constipation, and increased AST. Arterial hypertension was observed more frequently in RCC patients who had not received prior VEGF-targeted therapy (67%) compared to those who had received prior VEGF-targeted therapy (37%).

The most common serious adverse reactions in patients with HCC (frequency ≥ 1%) are hepatic encephalopathy, asthenia, fatigue, PPES, diarrhea, hyponatremia, vomiting, abdominal pain, and thrombocytopenia.

The most common adverse reactions of any grade (observed in at least 25% of patients) in patients with HCC were diarrhea, decreased appetite, fatigue, nausea, PPES, arterial hypertension, and vomiting. The list of adverse reactions is presented in Table 6.

In Table 6, adverse reactions observed during clinical trials or in the post-marketing period with cabozantinib are categorized by system organ class according to MedDRA terminology and classified by frequency based on data across all severity grades as follows: very common (≥ 1/10), common (≥ 1/100 and < 1/10), uncommon (≥ 1/1000 and < 1/100), not known (cannot be estimated from available data). Within each frequency grouping, adverse reactions are listed in order of decreasing severity.

Table 6

Adverse Drug Reactions (ADRs) reported during clinical studies or post-marketing use of cabozantinib

* Description of selected adverse reactions for further characterization.

The following terms have been grouped to correspond to the frequency classification:

1 Decreased hematological parameters: lymphopenia and decreased lymphocyte count; neutropenia and decreased neutrophil count; thrombocytopenia and decreased platelet count.

2 Decreased biochemical parameters: hypoproteinemia and decreased blood albumin; hypocalcemia and decreased blood calcium levels; hypoglycemia and decreased blood glucose level; hypokalemia and decreased blood potassium levels; hypomagnesemia and decreased blood magnesium levels; hyponatremia and decreased blood sodium levels; hypophosphatemia and decreased blood phosphorus levels.

3 Increased biochemical parameters: increased blood cholesterol and hypercholesterolemia; hyperbilirubinemia and increased blood bilirubin levels; hyperglycemia and increased blood glucose levels; increased hypothyroidism and increased thyroid-stimulating hormone in blood; hyperkalemia and increased blood potassium levels; increased triglyceride levels and hypertriglyceridemia.

4 Abdominal pain, abdominal discomfort, upper abdominal pain, and lower abdominal pain.

5 Hypertension and increased blood pressure.

6 Impaired wound healing and surgical site complications.

Description of selected adverse reactions

Data on the following reactions in patients treated with CABOMETYX at a dose of 60 mg once daily (orally) were obtained from pivotal studies involving patients with RCC after VEGF-targeted therapy and treatment-naïve RCC patients, as well as HCC patients after prior systemic therapy (see section "Pharmacodynamics").

Gastrointestinal perforation

In the RCC study following VEGF-targeted agents (METEOR), gastrointestinal (GI) perforation of grade 2 or 3 was reported in 0.9% of patients with renal cell carcinoma receiving cabozantinib (3 out of 331). The median time to onset of perforation was 10 weeks.

In the treatment-naïve RCC study (CABOSUN), GI perforation of grade 4 and 5 was observed in 2.6% (2 out of 78) of patients receiving cabozantinib.

In the HCC study (CELESTIAL), GI perforation of grade 3 or 4 was observed in 0.9% of patients treated with cabozantinib (4 out of 467). The median time to onset of perforation was 5.9 weeks.

Fatal cases of perforation have been reported in the clinical development program of cabozantinib.

Hepatic encephalopathy

In the HCC study (CELESTIAL), hepatic encephalopathy (hepatic encephalopathy, encephalopathy, hyperammonemic encephalopathy) was reported in 5.6% of patients receiving cabozantinib (26 out of 467). Grade 3–4 reactions occurred in 2.8%; one case of grade 5 (0.2%) was also reported. The median time to onset of encephalopathy was 5.9 weeks. Hepatic encephalopathy was not reported in the RCC studies (METEOR and CABOSUN).

Diarrhea

In the RCC study following prior VEGF-targeted therapy (METEOR), diarrhea was reported in 74% of patients receiving cabozantinib (245 out of 331). Grade 3–4 reactions occurred in 11%. The median time to onset of diarrhea was 4.9 weeks.

In the treatment-naïve RCC study (CABOSUN), diarrhea was observed in 73% of patients receiving cabozantinib (57 out of 78). Grade 3–4 reactions occurred in 10% of cases.

In the HCC study (CELESTIAL), diarrhea was observed in 54% of patients receiving cabozantinib (251 out of 467); grade 3–4 reactions occurred in 9.9%. The median time to onset of these events was 4.1 weeks. Dose modifications due to diarrhea occurred in 84 out of 467 (18%), discontinuation of treatment in 69 out of 467 (15%), and complete discontinuation of therapy in 5 out of 467 (1%) patients.

Fistula

In the RCC study following prior VEGF-targeted therapy (METEOR), fistulas were observed in 1.2% (4 out of 331) of patients receiving cabozantinib, including rectal fistulas in 0.6% (2 out of 331). One case was classified as a grade 3 adverse reaction, and the rest as grade 2 reactions. The median time to onset of fistula was 30.3 weeks.

Fistulas were not observed in the treatment-naïve RCC study (CABOSUN).

In the HCC study (CELESTIAL), fistulas were observed in 1.5% (7 out of 467) of HCC patients. The median time to onset of fistula was 14 weeks.

Fatal cases of fistula have been reported in the clinical development program of cabozantinib.

Bleeding

In the RCC study following prior VEGF-targeted therapy (METEOR), the incidence of severe hemorrhagic events (grade ≥3) was 2.1% in RCC patients receiving cabozantinib (7 out of 331). The median time to onset of bleeding was 20.9 weeks.

In the treatment-naïve RCC study (CABOSUN), the incidence of severe hemorrhagic events (grade ≥3) was 5.1% (4 out of 78) in RCC patients receiving cabozantinib.

In the HCC study (CELESTIAL), the incidence of severe hemorrhagic events (grade ≥3) was 7.3% in patients receiving cabozantinib (34 out of 467). The median time to onset of bleeding was 9.1 weeks.

Fatal bleeding events have been reported in the clinical development program of cabozantinib.

Reversible posterior leukoencephalopathy syndrome (RPLS)

There were no reports of RPLS in the METEOR, CABOSUN, or CELESTIAL studies, but rare cases of RPLS have been reported in other clinical trials (2 out of 4872 patients; 0.04%).

Hypothyroidism

In the RCC study following VEGF-targeted agents (METEOR), hypothyroidism was reported in 21% of patients (68 out of 331).

In the treatment-naïve RCC study (CABOSUN), hypothyroidism was reported in 23% of patients (18 out of 78) receiving cabozantinib.

In the HCC study (CELESTIAL), hypothyroidism was reported in 8.1% of patients (38 out of 467) receiving cabozantinib, with grade 3 reactions occurring in 0.4% (2 out of 467).

Reporting of adverse reactions

Reporting suspected adverse reactions after marketing authorization is important. It allows continued monitoring of the benefit-risk balance of the medicinal product. Healthcare professionals and patients, or their legal representatives, should report all suspected adverse reactions and lack of efficacy through the Automated Information System for Pharmacovigilance at the following link: https://aisf.dec.gov.ua

Shelf life.

4 years.

Storage conditions.

The medicinal product does not require special storage conditions. Keep out of reach and sight of children.

Packaging.

20 mg: 7 film-coated tablets in a blister; 4 blisters in a cardboard box, or 30 film-coated tablets in a high-density polyethylene (HDPE) bottle with a child-resistant closure, containing three 1 g silica gel desiccant canisters and polyester fiber; 1 bottle in a cardboard box;

40 mg: 7 film-coated tablets in a blister; 4 blisters in a cardboard box, or 30 film-coated tablets in a high-density polyethylene (HDPE) bottle with a child-resistant closure, containing three 1 g silica gel desiccant canisters and polyester fiber; 1 bottle in a cardboard box;

60 mg: 7 film-coated tablets in a blister; 4 blisters in a cardboard box, or 30 film-coated tablets in a high-density polyethylene (HDPE) bottle with a child-resistant closure, containing three 1 g silica gel desiccant canisters and polyester fiber; 1 bottle in a cardboard box.

Prescription status.

Prescription only.

Manufacturers.

Rottendorf Pharma GmbH, Germany.

Patheon France.

Tjoapak Netherlands B.V.

Manufacturer addresses.

Ostenfelder Strasse 51-61, Ennigerloh, North Rhine-Westphalia, 59320, Germany.

40 Boulevard de Champvert, Bourgoin-Jallieu, 38300, France.

Nieuwe Donk 9, Etten-Leur, 4879AC, Netherlands.

Marketing Authorization Holder.

IPSEN PHARMA.

Address of the Marketing Authorization Holder.

70, Boulevard Brune, 75015 Paris, France