Zelboraf

Zelboraf

vemurafenib

Manufacturer:

Roche

Distributor:

Firma Chun Cheong
/
DKSH
Full Prescribing Info
Contents
Vemurafenib.
Description
Zelboraf also contains the following excipients: Core: Croscarmellose sodium, colloidal anhydrous silica, magnesium stearate, hydroxypropycellulose. Film-Coating: Polyvinyl alcohol, titanium dioxide (E171), macrogol 3350, talc, red iron oxide (E172).
Action
Pharmacotherapeutic Group: Antineoplastic agents, protein kinase inhibitor. ATC Code: L01XE15.
Pharmacology: Pharmacodynamics: Mechanism of Action and Pharmacodynamic Effects: Vemurafenib is a low molecular weight, orally available, inhibitor of BRAF serine-threonine kinase. Mutations in the BRAF gene which substitute the valine at amino acid position 600 result in constitutively activated BRAF proteins, which can cause cell proliferation in the absence of growth factors that would normally be required for proliferation.
Preclinical data generated in biochemical assays demonstrated that vemurafenib can potently inhibit BRAF kinases with activating codon 600 mutations (see Table 1).

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This inhibitory effect was confirmed in the extracellular-signal-regulated kinases (ERK) phosphorylation and cellular anti-proliferation assays in available melanoma cell lines expressing V600-mutant BRAF. In cellular anti-proliferation assays, the half maximal inhibitory concentration (IC50) against V600 mutated cell lines (V600E, V600R, V600D and V600K mutated cell lines) ranged from 0.016-1.131 micromolar whereas the IC50 against BRAF wild type cell lines were 12.06 and 14.32 micromolar, respectively.
Determination of BRAF Mutation Status: Before taking vemurafenib, patients must have BRAF V600 mutation-positive tumour status confirmed by a validated test. In the phase II and III clinical trials, eligible patients were identified using a real-time polymerase chain reaction assay (the cobas 4800 BRAF V600 Mutation Test). This test has CE marking and is used to assess the BRAF mutation status of deoxyribonucleic acid (DNA) isolated from formalin-fixed, paraffin-embedded (FFPE) tumour tissue. It was designed to detect the predominant BRAF V600E mutation with high sensitivity (down to 5% V600E sequence in a background of wild-type sequence from FFPE-derived DNA). Nonclinical and clinical studies with retrospective sequencing analyses have shown that the test also detects the less common BRAF V600D mutations and V600K mutations with lower sensitivity. Of the specimens available from the nonclinical and clinical studies (n=920), that were mutation-positive by the cobas test and additionally analyzed by sequencing, no specimen was identified as being wild type by both Sanger and 454 sequencing.
Clinical Efficacy and Safety: The efficacy of vemurafenib has been evaluated in 336 patients from a phase III clinical trial (NO25026) and 132 patients from a phase II clinical trial (NP 22657). All patients were required to have advanced melanoma with BRAF V600 mutations according to the cobas 4800 BRAF V600 Mutation Test.
Results from the Phase III Study (NO25026) in Previously Untreated Patients: An open-label, multicenter, international, randomised phase III study supports the use of vemurafenib in previously untreated patients with BRAF V600E mutation-positive unresectable or metastatic melanoma. Patients were randomised to treatment with vemurafenib (960 mg twice daily) or dacarbazine (1,000 mg/m2 on day 1 every 3 weeks).
A total of 675 patients were randomised to vemurafenib (n=337) or dacarbazine (n=338). Most patients were male (56%) and Caucasian (99%), the median age was 54 years (24% were ≥65 years), all patients had eastern cooperative oncology group (ECOG) performance status of 0 or 1, and the majority of patients had stage M1c disease (65%). The co-primary efficacy endpoints of the study were overall survival (OS) and progression-free survival (PFS).
At the prespecified interim analysis with a December 30, 2010 data cut-off, significant improvements in the co-primary endpoints of OS (p<0.0001) and PFS (p<0.0001) (unstratified log-rank test) were observed. Upon Data Safety Monitoring Board (DSMB) recommendation, those results were released in January 2011 and the study was modified to permit dacarbazine patients to cross over to receive vemurafenib. Post-hoc survival analyses were undertaken thereafter as described in Table 2. (See Figure and Table 2.)

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Table 3 shows the treatment effect for all prespecified stratification variables which are established as prognostic factors. (See Table 3.)

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Table 4 shows the overall response rate and PFS in previously untreated patients with BRAF V600 mutation positive melanoma. (See Table 4.)

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A total of 57 patients out of 673 whose tumours were analysed retrospectively by sequencing were reported to have BRAF V600K mutation-positive melanoma in NO25026. Although limited by the low number of patients, efficacy analyses among these patients with V600K-positive tumours suggested similar treatment benefit of vemurafenib in terms of OS, PFS and confirmed best overall response. No data are available in patients with melanoma harboring rare BRAF V600 mutations other than V600E and V600K.
Results from the Phase II Study (NP22657) in Patients who Failed at Least One Prior Therapy: A phase II single-arm, multicenter, multinational study was conducted in 132 patients who had BRAF V600E mutation-positive metastatic melanoma according to the cobas 4800 BRAF V600 Mutation Test and had received at least 1 prior therapy. The median age was 52 years with 19% of patients being >65 years. The majority of patients was male (61%), Caucasian (99%) and had stage M1c disease (61%). Forty-nine percent (49%) of patients failed ≥2 prior therapies.
With a median follow-up of 12.9 months (range, 0.6-20.1), the primary endpoint of confirmed best overall response rate [complete response (CR) + partial response (PR)] as assessed by an independent review committee (IRC) was 53% (95% CI: 44%, 62%). Median overall survival was 15.9 months (95% CI: 11.6, 18.3). The OS rate at 6 months was 77% (95% CI: 70%, 85%) and at 12 months was 58% (95% CI: 49%, 67%).
Nine (9) of the 132 patients enrolled into NP22657 had V600K mutation positive tumors according to retrospective Sanger sequencing. Amongst these patients, 3 had a PR, 3 had stable disease (SD), 2 had PD and one was not evaluable.
Pharmacokinetics: Vemurafenib is a class IV substance (low solubility and permeability), using the criteria described in the Biopharmaceutics Classification System. The pharmacokinetic parameters for vemurafenib were determined using non-compartmental analysis in a phase I and phase III studies (20 patients after 15 days of dosing at 960 mg twice daily, and 204 patients in steady-state day 22) as well as by population pharmacokinetic analysis using pooled data from 458 patients. Among these patients, 457 were Caucasians.
Absorption: The absolute bioavailability of the vemurafenib 240 mg tablet is unknown.
Vemurafenib at 960 mg twice daily is absorbed with a median time to peak plasma concentration (Tmax) of approximately 4 hrs. Vemurafenib exhibits high interpatient variability. In the phase II study, area under the concentration-time curve (AUC0-8hrs) and peak plasma concentration (Cmax) at day 1 were 22.1±12.7 mcg⋅hr/mL and 4.1±2.3 mcg/mL. Accumulation occurs upon multiple twice daily dosing of vemurafenib. In the non-compartmental analysis, after dosing with vemurafenib 960 mg twice daily, the day 15/day 1 ratio ranged from 15- to 17-fold for AUC and 13- to 14-fold for Cmax, yielding AUC0-8hrs and Cmax of 380.2±143.6 mcg⋅hr/mL and 56.7±21.8 mcg/mL, respectively, under steady-state conditions.
Food (high-fat meal) increases the relative bioavailability of a single 960 mg dose of vemurafenib. The geometric mean ratios between the fed and fasted states for Cmax and AUC were 2.6- and 4.7-fold, respectively. The median Tmax was increased from 4-8 hrs when a single vemurafenib dose was taken with food.
The effect of food on steady-state vemurafenib exposure is currently unknown. Consistent intake of vemurafenib on an empty stomach may lead to significantly lower steady-state exposure than consistent intake of vemurafenib with or a short time after a meal. Occasional intake of vemurafenib on an empty stomach is expected to have limited influence on steady-state exposure due to the high accumulation of vemurafenib at steady-state. Safety and efficacy data from pivotal studies were collected from patients taking vemurafenib with or without food.
Variability in exposure may also occur due to differences in gastrointestinal fluid content, volumes, pH, motility and transition time and bile composition.
At steady-state, the mean vemurafenib exposure in plasma is stable during the 24-hr interval as indicated by the mean ratio of 1.13 between the plasma concentrations before and 2-4 hrs after the morning dose. Following oral dosing, the absorption rate constant for the population of metastatic melanoma patients is estimated to be 0.19 hr-1 (with 101% between patient variability).
Distribution: The population apparent volume of distribution for vemurafenib in metastatic melanoma patients is estimated to be 91 L (with 64.8% between patient variability). It is highly bound to human plasma proteins in vitro (>99%).
Biotransformation: The relative proportions of vemurafenib and its metabolites were characterized in a human mass balance study with a single dose of 14C-labeled vemurafenib administered orally. CYP3A4 is the primary enzyme responsible for the metabolism of vemurafenib in vitro. Conjugation metabolites (glucuronidation and glycosylation) were also identified in humans. However, the parent compound was the predominant component (95%) in plasma. Although metabolism does not appear to result in a relevant amount of metabolites in plasma, the importance of metabolism for excretion cannot be excluded.
Elimination: The population apparent clearance of vemurafenib in patients with metastatic melanoma is estimated to be 29.3 L/day (with 31.9% between patient variability). The population elimination half-life (t½) estimated by the population pharmacokinetic analysis for vemurafenib is 51.6 hrs (the 5th and 95th percentile range of the individual t½ estimates is 29.8-119.5 hrs).
In the human mass balance study with vemurafenib administered orally, on average 95% of the dose was recovered within 18 days. The majority of vemurafenib-related material (94%) was recovered in faeces, and <1% in urine. Biliary excretion of unchanged compound may be an important route of elimination. However, due to the unknown absolute bioavailability, the importance of hepatic and renal excretion for the clearance of parent vemurafenib is uncertain. Vemurafenib is a substrate and inhibitor of P-gp in vitro.
Special Populations: Elderly: Based on the population pharmacokinetic analysis, age has no statistically significant effect on vemurafenib pharmacokinetics.
Gender: The population pharmacokinetic analysis indicated a 17% greater apparent clearance (CL/F) and a 48% greater apparent volume of distribution (V/F) in males than in females. It is unclear whether this is a gender or a body size effect. However, the differences in exposure are not large enough to warrant dose adjustment based on body size or gender.
Renal Impairment: In the population pharmacokinetic analysis using data from clinical trials in patients with metastatic melanoma, mild and moderate renal impairment did not influence the apparent clearance of vemurafenib [creatinine clearance (CrCl) >40 mL/min]. There are no data in patients with severe renal impairment (see Dosage & Administration and Precautions).
Hepatic Impairment: Based on preclinical data and the human mass balance study, major part of vemurafenib is eliminated via the liver. In the population pharmacokinetic analysis using data from clinical trials in patients with metastatic melanoma, increases in aspartate transaminase (AST) and alanine transaminse (ALT) up to 3 times the upper limit of normal (ULN) did not influence the apparent clearance of vemurafenib. Data are insufficient to determine the effect of metabolic or excretory hepatic impairment on vemurafenib pharmacokinetics (see Dosage & Administration and Precautions).
Children: No studies have been conducted to investigate the pharmacokinetics of vemurafenib in paediatric patients.
Toxicology: Preclinical Safety Data: The preclinical safety profile of vemurafenib was assessed in rats, dogs and rabbits.
Repeat-dose toxicology studies identified the liver and bone marrow as target organs in the dog. Reversible toxic effects (hepatocellular necrosis and degeneration) in the liver at exposures below the anticipated clinical exposure (based on AUC comparisons) were noted in the 13-week dog study. Focal bone marrow necrosis was noted in 1 dog in a prematurely terminated 39-week twice daily dog study at exposures similar to the anticipated clinical exposure (based on AUC comparisons). In an in vitro bone marrow cytotoxicity study, slight cytotoxicity was observed in some lympho-hematopoietic cell populations of rat, dog and human at clinically relevant concentrations.
Vemurafenib was shown to be phototoxic, in vitro, on cultured murine fibroblasts after UVA irradiation, but not in vivo in a rat study at doses up to 450 mg/kg/day (at exposures below the anticipated clinical exposure based on AUC comparison). No specific studies with vemurafenib have been conducted in animals to evaluate the effect on fertility. However, in repeat-dose toxicity studies, no histopathological findings were noted on reproductive organs in males and females in rats and dogs at doses up to 450 mg/kg/day (at exposures below the anticipated clinical exposure based on AUC comparison). No teratogenicity was observed in embryofoetal development studies in rats and rabbits at doses up to respectively 250 mg/kg/day and 450 mg/kg/day leading to exposures below the anticipated clinical exposure (based on AUC comparison). However, exposures in the embryofoetal development studies were below the clinical exposure based on AUC comparison, it is therefore difficult to define to what extent these results can be extrapolated to humans. Therefore, an effect of vemurafenib on the foetus cannot be excluded. No studies were performed regarding pre- and postnatal development.
No signs of genotoxicity were identified in in vitro assays [bacterial mutation (AMES Assay), human lymphocyte chromosome aberration] nor in the in vivo rat bone marrow micronucleus test conducted with vemurafenib.
Carcinogenicity studies have not been conducted with vemurafenib.
Indications/Uses
Monotherapy for the treatment of adult patients with BRAF V600 mutation-positive unresectable or metastatic melanoma (see Pharmacology: Pharmacodynamics under Actions).
Dosage/Direction for Use
Treatment with vemurafenib should be initiated and supervised by a qualified physician experienced in the use of anticancer medicinal products.
Before taking vemurafenib, patients must have BRAF V600 mutation-positive tumour status confirmed by a validated test (see Pharmacology: Pharmacodynamics under Actions and Precautions).
Recommended Dose: 960 mg (4 tablets of 240 mg) twice daily (equivalent to a total daily dose of 1,920 mg). Vmurafenib may be taken with or without food, but consistent intake of both daily doses on an empty stomach should be avoided (see Pharmacology: Pharmacodynamics under Actions).
Duration of Treatment: Treatment with vemurafenib should continue until disease progression or the development of unacceptable toxicity (see Tables 5 and 6 as follows).
Missed Doses: If a dose is missed, it can be taken up to 4 hrs prior to the next dose to maintain the twice daily regimen. Both doses should not be taken at the same time.
Vomiting: In case of vomiting after vemurafenib administration, the patient should not take an additional dose of the medicinal product but the treatment should be continued as usual.
Dosage Adjustments: Management of adverse drug reactions or QTc prolongation may require dose reduction, temporary interruption and/or treatment discontinuation (see Tables 5 and 6). Dosage adjustments resulting in a dose <480 mg twice daily are not recommended.
In the event the patient develops cutaneous squamous cell carcinoma (cuSCC), it is recommended to continue the treatment without modifying the dose of vemurafenib (see Precautions and Adverse Reactions). (See Table 5.)

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Exposure-dependent QT prolongation was observed in an uncontrolled, open-label phase II study in previously treated patients with metastatic melanoma. Management of QTc prolongation may require specific monitoring measures (see Precautions). (See Table 6.)

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Special Population: Elderly: No special dose adjustment is required in patients >65 years.
Renal Impairment: Limited data are available in patients with renal impairment. A risk for increased exposure in patients with severe renal impairment cannot be excluded. Patients with severe renal impairment should be closely monitored (see Pharmacology: Pharmacokinetics under Actions and Precautions).
Hepatic Impairment: Limited data are available in patients with hepatic impairment. As vemurafenib is cleared by the liver, patients with moderate to severe hepatic impairment may have increased exposure and should be closely monitored (see Pharmacology: Pharmacokinetics under Actions and Precautions).
Non-Caucasian Patients: The safety and efficacy of vemurafenib has not been established in non-Caucasian patients. No data are available.
Administration: Vemurafenib tablets are to be swallowed whole with water. Vemurafenib tablets should not be chewed or crushed.
Overdosage
There is no specific antidote for overdosage of vemurafenib. Patients who develop adverse reactions should receive appropriate symptomatic treatment. No cases of overdosage have been observed with vemurafenib in clinical trials. In case of suspected overdosage, vemurafenib should be withheld and supportive care initiated.
Contraindications
Hypersensitivity to vemurafenib or to any of the excipients of Zelboraf.
Special Precautions
Before taking vemurafenib, patients must have BRAF V600 mutation-positive tumour status confirmed by a validated test. The efficacy and safety of vemurafenib in patients with tumours expressing rare BRAF V600 mutations other than V600E and V600K have not been convincingly established (see Pharmacology: Pharmacodynamics under Actions). Vemurafenib should not be used in patients with wild type BRAF malignant melanoma.
Hypersensitivity Reaction: Serious hypersensitivity reactions, including anaphylaxis have been reported in association with vemurafenib (see Contraindications and Adverse Reactions). Severe hypersensitivity reactions may include Stevens-Johnson syndrome, generalised rash, erythema or hypotension. In patients who experience severe hypersensitivity reactions, vemurafenib treatment should be permanently discontinued.
Dermatologic Reactions: Severe dermatologic reactions have been reported in patients receiving vemurafenib, including rare cases of Stevens-Johnson syndrome and toxic epidermal necrolysis in the pivotal clinical trial. Drug reaction with eosinophilia and systemic symptoms (DRESS) has been reported in association with vemurafenib in the post-marketing setting (see Adverse Reactions). In patients who experience a severe dermatologic reaction, vemurafenib treatment should be permanently discontinued.
QT Prolongation: Exposure-dependent QT prolongation was observed in an uncontrolled, open-label phase II study in previously treated patients with metastatic melanoma (see Adverse Reactions). QT prolongation may lead to an increased risk of ventricular arrhythmias including Torsade de pointes. Treatment with vemurafenib is not recommended in patients with uncorrectable electrolyte abnormalities (including magnesium), long QT syndrome or who are taking medicinal products known to prolong the QT interval.
Electrocardiogram (ECG) and electrolytes (including magnesium) must be monitored in all patients before treatment with vemurafenib, after 1 month of treatment and after dose modification. Further monitoring is recommended in particular in patients with moderate to severe hepatic impairment monthly during the first 3 months of treatment followed by every 3 months thereafter or more often as clinically indicated. Initiation of treatment with vemurafenib is not recommended in patients with QTc >500 msec. If during treatment the QTc exceeds 500 msec, vemurafenib treatment should be temporarily interrupted, electrolyte abnormalities (including magnesium) should be corrected, and cardiac risk factors for QT prolongation (eg, congestive heart failure, bradyarrhythmias) should be controlled. Re-initiation of treatment should occur once the QTc decreases <500 msec and at a lower dose as described in Table 6. Permanent discontinuation of vemurafenib treatment is recommended if the QTc increase meets values of both >500 msec and >60 ms change from pre-treatment values. (See Table 6.)
Ophthalmologic Reactions: Serious ophthalmologic reactions, including uveitis, iritis and retinal vein occlusion, have been reported. Monitor patients routinely for ophthalmologic reactions.
Cutaneous Squamous Cell Carcinoma (cuSCC): Cases of cuSCC (which include those classified as keratoacanthoma or mixed keratoacanthoma subtype) have been reported in patients treated with vemurafenib (see Adverse Reactions).
It is recommended that all patients receive a dermatologic evaluation prior to initiation of therapy and be monitored routinely while on therapy. Any suspicious skin lesions should be excised, sent for dermatopathologic evaluation and treated as per local standard of care. The prescriber should examine the patient monthly during and up to 6 months after treatment for cuSCC. In patients who develop cuSCC, it is recommended to continue the treatment without dose adjustment. Monitoring should continue for 6 months following discontinuation of vemurafenib or until initiation of another anti-neoplastic therapy. Patients should be instructed to inform their physicians upon the occurrence of any skin changes.
Non-Cutaneous Squamous Cell Carcinoma (non-cuSCC): Cases of non-cuSCC have been reported in clinical trials where patients received vemurafenib. Patients should undergo a head and neck examination, consisting of at least a visual inspection of oral mucosa and lymph node palpation prior to initiation of treatment and every 3 months during treatment.
In addition, patients should undergo a chest computerised tomography (CT) scan, prior to treatment and every 6 months during treatment.
Anal examinations and pelvic examinations (for women) are recommended before and at the end of treatment or when considered clinically indicated.
Following discontinuation of vemurafenib, monitoring for non-cuSCC should continue for up to 6 months or until initiation of another anti-neoplastic therapy. Abnormal findings should be managed according to clinical practices.
New Primary Melanoma: New primary melanomas have been reported in clinical trials. Cases were managed with excision and patients continued treatment without dose adjustment. Monitoring for skin lesions should occur as outlined above for cuSCC.
Other Malignancies: Based on mechanism of action, vemurafenib may cause progression of cancers associated with RAS mutations (see Adverse Reactions). Vemurafenib should be used with caution in patients with a prior or concurrent cancer associated with RAS mutation.
Liver Injury: Liver injury, including cases of severe liver injury, has been reported with vemurafenib (see Adverse Reactions). Liver enzymes (transaminases and alkaline phosphatase) and bilirubin should be monitored before initiation of treatment and monthly during treatment, or as clinically indicated. Laboratory abnormalities should be managed with dose reduction, treatment interruption or with treatment discontinuation (see Dosage & Administration and Precautions).
Hepatic Impairment: No adjustment to the starting dose is needed for patients with hepatic impairment. Patients with mild hepatic impairment due to liver metastases without hyperbilirubinaemia may be monitored according to the general recommendations. There are only very limited data available in patients with moderate to severe hepatic impairment. Patients with moderate to severe hepatic impairment may have increased exposure (see Pharmacology: Pharmacokinetics under Actions). Thus close monitoring is warranted especially after the 1st few weeks of treatment as accumulation may occur over an extended period of time (several weeks). In addition, ECG monitoring every month during the first 3 months is recommended.
Renal Impairment: No adjustment to the starting dose is needed for patients with mild or moderate renal impairment. There are only limited data available in patients with severe renal impairment (see Pharmacology: Pharmacokinetics under Actions). Vemurafenib should be used with caution in patients with severe renal impairment and patients should be closely monitored.
Photosensitivity: Mild to severe photosensitivity was reported in patients who received vemurafenib in clinical studies (see Adverse Reactions). All patients should be advised to avoid sun exposure while taking vemurafenib. While taking Zelboraf, patients should be advised to wear protective clothing and use a broad spectrum ultraviolet A (UVA)/ultraviolet B (UVB) sunscreen and lip balm (sun protection factor ≥30) when outdoors to help protect against sunburn.
For photosensitivity grade 2 (intolerable) or greater, dose modifications are recommended (see Dosage & Administration).
Effects of Vemurafenib on Other Medicinal Products: Vemurafenib may increase the plasma exposure of medicinal products predominantly metabolized by CYP1A2 and decrease the plasma exposure of medicines predominantly metabolized by CYP3A4, including oral contraceptives. Dose adjustments for medicinal products predominantly metabolized via CYP1A2 or CYP3A4 should be considered based on their therapeutic windows before concomitantly treating with vemurafenib (see Interactions).
Exercise caution and consider additional international normalized ratio (INR) monitoring when vemurafenib is used concomitantly with warfarin.
Effect of Other Medicinal Products on Vemurafenib: Vemurafenib pharmacokinetics could be affected by medicines that inhibit or influence P-gp (eg, verapamil, clarithromycin, cyclosporine, ritonavir, quinidine, dronedarone, amiodarone, itraconazole, ranolazine) (see Interactions).
Concomitant administration of potent inducers of P-glycoprotein (P-gp), glucuronidation, CYP3A4 [eg, rifampicin, rifabutin, carbamazepine, phenytoin or St. John’s wort (hypericin)] should be avoided when possible (see Interactions). Alternative treatment with less inducing potential should be considered to maintain the efficacy of vemurafenib.
Concurrent Administration with Ipilimumab: In a phase I trial, asymptomatic grade 3 increases in transaminases (ALT/AST >5 x ULN) and bilirubin (total bilirubin >3 x ULN) were reported with concurrent administration of ipilimumab (3 mg/kg) and vemurafenib (960 mg twice daily or 720 mg twice daily). Based on these preliminary data, the concurrent administration of ipilimumab and vemurafenib is not recommended.
Effects on the Ability to Drive or Operate Machinery: The effects of vemurafenib on the ability to drive and use machines have not been studied. Patients should be made aware of the potential fatigue or eye problems that could be a reason for not driving.
Impairment of Fertility: No specific studies with vemurafenib have been conducted in animals to evaluate the effect on fertility. However, in repeat-dose toxicity studies in rats and dogs, no histopathological findings were noted on reproductive organs (see Pharmacology: Toxicology: Preclinical Safety Data under Actions).
Use in pregnancy: There are no data regarding the use of vemurafenib in pregnant women.
Vemurafenib revealed no evidence of teratogenicity in rat or rabbit embryo/foetuses (see Pharmacology: Toxicology: Preclinical Safety Data under Actions). In animal studies, vemurafenib was found to cross the placenta. Vemurafenib should not be administered to pregnant women unless the possible benefit to the mother outweighs the possible risk to the foetus.
Women of Childbearing Potential/Contraception in Females: Women of childbearing potential have to use effective contraception during treatment and for at least 6 months after treatment.
Vemurafenib might decrease the efficacy of hormonal contraceptives (see Interactions).
Use in lactation: It is not known whether vemurafenib is excreted in human milk. A risk to the newborns/infants cannot be excluded. A decision must be made whether to discontinue breastfeeding or to discontinue vemurafenib therapy taking into account the benefit of breastfeeding for the child and the benefit of therapy for the woman.
Use in children: The safety and efficacy of vemurafenib has not been yet established in children and adolescents (<18 years). No data are available.
Use In Pregnancy & Lactation
Use in pregnancy: There are no data regarding the use of vemurafenib in pregnant women.
Vemurafenib revealed no evidence of teratogenicity in rat or rabbit embryo/foetuses (see Pharmacology: Toxicology: Preclinical Safety Data under Actions). In animal studies, vemurafenib was found to cross the placenta. Vemurafenib should not be administered to pregnant women unless the possible benefit to the mother outweighs the possible risk to the foetus.
Women of Childbearing Potential/Contraception in Females: Women of childbearing potential have to use effective contraception during treatment and for at least 6 months after treatment.
Vemurafenib might decrease the efficacy of hormonal contraceptives (see Interactions).
Use in lactation: It is not known whether vemurafenib is excreted in human milk. A risk to the newborns/infants cannot be excluded. A decision must be made whether to discontinue breastfeeding or to discontinue vemurafenib therapy taking into account the benefit of breastfeeding for the child and the benefit of therapy for the woman.
Adverse Reactions
Summary of the Safety Profile: The most common adverse drug reactions (>30%) reported with vemurafenib include arthralgia, fatigue, rash, photosensitivity reaction, nausea, alopecia and pruritus. CuSCC was very commonly reported and was most commonly treated by local excision.
Tabulated Summary of Adverse Reactions: Adverse drug reactions which were reported in melanoma patients are listed as follows by MedDRA body system organ class, frequency and grade of severity. The following convention has been used for the classification of frequency: Very common ≥1/10, common ≥1/100 to <1/10, uncommon ≥1/1,000 to <1/100, rare ≥1/10,000 to <1/1,000 and very rare <1/10,000.
Adverse drug reactions are based on results in 468 patients from a phase III randomised open-label study in adult patients with BRAF V600 mutation-positive unresectable or stage IV melanoma, as well as a phase II single-arm study in patients with BRAF V600 mutation-positive stage IV melanoma who had previously failed at least 1 prior systemic therapy (see Pharmacology: Pharmacodynamics under Actions). In addition, adverse drug reactions originating from safety reports across all clinical trials are reported. All terms included are based on the highest percentage observed among phase II and phase III clinical trials. Within each frequency grouping, adverse drug reactions are presented in order of decreasing severity and were reported using NCI-CTCAE v4 (common toxicity criteria) for assessment of toxicity.

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Description of Selected Adverse Reactions: Increased Hepatic Enzymeb: Liver enzyme abnormalities reported in the phase III clinical study are expressed as follows as the proportion of patients who experienced a shift from baseline to a grade 3 or 4 liver enzyme abnormalities: Very Common: γ-glutamyl transpeptidase (GGT); common: ALT, alkaline phosphatase, bilirubin; uncommon: AST.
There were no increases to grade 4 ALT, alkaline phosphatase or bilirubin.
Liver Injuryf: Based on the criteria for drug induced liver injury developed by an international expert working group of clinicians and scientists, liver injury was defined as any one of the following laboratory abnormalities: ≥5 x ULN ALT; ≥2 x ULN ALP [without other cause for alkaline phosphatase (ALP) elevation]; ≥3 x ULN ALT with simultaneous elevation of bilirubin concentration >2 x ULN.
Cutaneous Squamous Cell Carcinomac (cuSCC): Cases of cuSCC have been reported in patients treated with vemurafenib. The incidence of cuSCC in vemurafenib-treated patients across studies was approximately 20%. The majority of the excised lesions reviewed by an independent central dermatopathology laboratory were classified as SCC-keratoacanthoma subtype or with mixed-keratoacanthoma features (52%). Most lesions classified as "other" (43%) were benign skin lesions (eg, verruca vulgaris, actinic keratosis, benign keratosis, cyst/benign cyst). Cutaneous squamous cell carcinoma usually occurred early in the course of treatment with a median time to the 1st appearance of 7-8 weeks. Of the patients who experienced cuSCC, approximately 33% experienced >1 occurrence with median time between occurrences of 6 weeks. Cases of cuSCC were typically managed with simple excision, and patients generally continued on treatment without dose modification (see Dosage & Administration and Precautions).
Non-Cutaneous Squamous Cell Carcinoma (Non-cuSCC): Cases of non-cuSCC have been reported in patients receiving vemurafenib while enrolled in clinical trials. Surveillance for non-cuSCC should occur as outlined in Precautions.
New Primary Melanoma: New primary melanomas have been reported in clinical trials. These cases were managed with excision and patients continued treatment without dose adjustment. Monitoring for skin lesions should occur as outlined in Precautions.
Hypersensitivity Reactionsd: Serious hypersensitivity reactions, including anaphylaxis have been reported in association with vemurafenib. Severe hypersensitivity reactions may include Stevens-Johnson syndrome, generalised rash, erythema or hypotension. In patients who experience severe hypersensitivity reactions, vemurafenib treatment should be permanently discontinued (see Precautions).
Dermatologic Reactionse: Severe dermatologic reactions have been reported in patients receiving vemurafenib, including rare cases of Stevens-Johnson syndrome and toxic epidermal necrolysis in the pivotal clinical trial. In patients who experience a severe dermatologic reaction, vemurafenib treatment should be permanently discontinued.
QT Prolongation: Analysis of centralised ECG data from an open-label uncontrolled phase II QT substudy in 132 patients dosed with vemurafenib 960 mg twice daily (NP22657) showed an exposure-dependent QTc prolongation. The mean QTc effect remained stable between 12-15 msec beyond the 1st month of treatment, with the largest mean QTc prolongation (15.1 msec; upper 95% CI: 17.7 msec) observed within the first 6 months (n=90 patients). Two (2) patients (1.5%) developed treatment-emergent absolute QTc values >500 msec (CTC grade 3), and only 1 patient (0.8%) exhibited a QTc change from baseline of >60 msec (see Precautions).
Special Populations: Elderly: In the phase III study, 94 (28%) of 336 patients with unresectable or metastatic melanoma treated with vemurafenib were ≥65 years. Older patients (≥65 years) may be more likely to experience adverse reactions including cuSCC, decreased appetite and cardiac disorders.
Gender: During clinical trials with vemurafenib, grade 3 adverse reactions reported more frequently in females than males were rash, arthralgia and photosensitivity.
Drug Interactions
Effects of Vemurafenib on CYP Substrates: CYP1A2 inhibition was observed when a single dose of caffeine was co-administered after repeat dosing with vemurafenib for 15 days. This resulted in an average 2.5-fold increase (maximum up to 10-fold) in caffeine plasma exposure after vemurafenib treatment. Vemurafenib may increase the plasma exposure of substances predominantly metabolised by CYP1A2 and dose adjustments should be considered.
CYP3A4 induction was observed when a single dose of midazolam was co-administered after repeat dosing with vemurafenib for 15 days. This resulted in an average 32% decrease (maximum up to 80%) in midazolam plasma exposure after vemurafenib treatment. Vemurafenib may decrease the plasma exposure of substances predominantly metabolised by CYP3A4. On this basis, the efficacy of contraceptive pills metabolized by CYP3A4 used concomitantly with vemurafenib might be decreased. Dose adjustments for CYP3A4 substrates with narrow therapeutic window should be considered (see Precautions).
Mild induction of CYP2B6 by vemurafenib was noted in vitro at a vemurafenib concentration of 10 micromolar. It is currently unknown whether vemurafenib at a plasma level of 100 micromolar observed in patients at steady-state (approximately 50 mcg/mL) may decrease plasma concentrations of concomitantly administered CYP2B6 substrates eg, bupropion.
When a single dose of warfarin was co-administered after repeat dosing with vemurafenib for 15 days, some patients exhibited increased warfarin exposure (mean 20%) (see Precautions). Caution should be exercised when vemurafenib is co-administered with warfarin (CYP2C9) in patients with melanoma.
Vemurafenib inhibited CYP2C8 in vitro. The in vivo relevance of this finding is unknown, but a risk for a clinically relevant effect on concomitantly administered CYP2C8 substrates cannot be excluded.
Due to the long t½ of vemurafenib, the full inhibitory effect of vemurafenib on a concomitant medicinal product might not be observed before 8 days of vemurafenib treatment.
After cessation of vemurafenib treatment, a washout of 8 days might be necessary to avoid an interaction with a subsequent treatment.
Effects of Vemurafenib on Substance Transport Systems: In vitro studies have demonstrated that vemurafenib is an inhibitor of the efflux transporters P-gp and breast cancer resistance protein (BCRP). The clinical relevance of this finding is unknown. It cannot be excluded that vemurafenib may increase the exposure of other medicines transported by P-gp (eg, aliskiren, colchicine, digoxin, everolimus, fexofenadine) or BCRP (eg, methotrexate, mitoxantrone, rosuvastatin).
Many anticancer drugs are substrates of P-gp and/or BCRP and therefore there is a theoretical risk for an interaction with vemurafenib.
In vitro studies have also demonstrated that vemurafenib is a weak inhibitor of bile salt export pump. The in vivo relevance of this finding is unknown.
The possible effect of vemurafenib on other transporters is currently unknown.
Effects of Concomitant Medicines on Vemurafenib: In vitro studies suggest that CYP3A4 metabolism and glucuronidation are responsible for the metabolism of vemurafenib. Biliary excretion appears to be another important elimination pathway.
There are no clinical data available showing the effect of strong inducers or inhibitors of CYP3A4 and/or transport protein activity on vemurafenib exposure. Vemurafenib should be used with caution in combination with potent inhibitors of CYP3A4, glucuronidation and/or transport proteins (eg, ritonavir, saquinavir, telithromycin, ketoconazole, itraconazole, voriconazole, posaconazole, nefazodone, atazanavir).
Concomitant administration of potent inducers of P-gp, glucuronidation, and/or CYP3A4 [eg, rifampicin, rifabutin, carbamazepine, phenytoin or St. John’s wort (Hypericum perforatum)] may lead to suboptimal exposure to vemurafenib and should be avoided.
In vitro studies have demonstrated that vemurafenib is a substrate of the efflux transporters, P-gp and BCRP. The effects of P-gp and BCRP inducers and inhibitors on vemurafenib exposure are unknown. It cannot be excluded that vemurafenib pharmacokinetics could be affected by medicines that inhibit or influence P-gp (eg, verapamil, cyclosporine, ritonavir, quinidine, itraconazole) or BCRP (eg, cyclosporine, gefitinib).
It is currently unknown whether vemurafenib is a substrate also to other transport proteins.
Storage
Protect from moisture.
ATC Classification
L01XE15 - vemurafenib ; Belongs to the class of protein kinase inhibitors, other antineoplastic agents. Used in the treatment of cancer.
Presentation/Packing
FC tab 240 mg (pinkish white to orange white, oval, biconvex, approximately 19 mm with 'VEM' engraved on one side) x 56's.
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