Cotellic

Cobimetinib fumarate.

Each film-coated tablet contains 20 mg cobimetinib (22 mg as cobimetinib hemifumarate salt).
Sterile/Radioactive Statement: Not applicable.
Excipients/Inactive Ingredients: Core: microcrystalline cellulose, lactose monohydrate, croscarmellose sodium, magnesium stearate.
Film coat: polyvinyl alcohol, titanium dioxide, macrogol/PEG 3350, talc.

Therapeutic/Pharmacologic Class of Drug: Cobimetinib is a small molecule that is a potent and highly selective targeted inhibitor of MEK1 and MEK2 tyrosine-threonine kinases. ATC code: L01XE38.
Pharmacology: Pharmacodynamics:Mechanism of Action: The mitogen-activated protein kinase (MAPK)/extracellular signal regulated kinase (MEK) pathway is a key signaling pathway that regulates cell proliferation, cell cycle regulation, cell survival, angiogenesis, and cell migration.
Cobimetinib is an orally available inhibitor of MEK1 and MEK2 tyrosine-threonine kinases. It has shown high inhibitory potency in biochemical and cell based assays, as well as anti-tumour activity in vivo in xenograft tumour models mutated for BRAF. Cobimetinib also showed efficacy in some KRAS mutant models.
In biochemical and structural studies, cobimetinib has been shown to interact with MEK in a manner that is less susceptible to the dynamic conformational changes seen with the phosphorylation state of MEK. As a result cobimetinib maintains binding affinity and inhibitory activity when MEK becomes phosphorylated. Due to this distinct allosteric mechanism of inhibition, cobimetinib has shown strong activity in cancer cell lines and tumours with high phosphorylated MEK levels, as is frequently observed in BRAF mutant tumours.
In pre-clinical studies, treatment of MAPK-dysregulated cancer cells and tumours with cobimetinib results in inhibition of phosphorylation of ERK1/2, the only known substrates of MEK1/2. Functional mediation of the MAPK pathway is dependent upon ERK1/2 activity that phosphorylates protein targets in the cytoplasm and nucleus that induce cell-cycle progression, cell proliferation, survival and migration. Cobimetinib therefore opposes the pro-mitogenic and oncogenic activity induced by the MAPK pathway through inhibition of the MEK1/2 signaling node.
By simultaneously targeting BRAF and MEK the combination of vemurafenib and cobimetinib inhibits MAPK pathway reactivation through MEK1/2 resulting in stronger inhibition of signaling, greater tumour cell apoptosis and enhanced tumour responses in pre-clinical models than vemurafenib alone.
Clinical Trials: Study GO28141 (coBRIM): Study GO28141 is a multicentre, randomised, double-blind, placebo-controlled, Phase III study to evaluate the safety and efficacy of COTELLIC in combination with ZELBORAF compared to ZELBORAF plus placebo, in patients with previously untreated BRAF V600 mutation-positive unresectable locally advanced (stage IIIC) or metastatic melanoma (stage IV). Patients with abnormal liver function tests, history of acute coronary syndrome within 6 months, evidence of Class II or greater congestive heart failure (New York Heart Association), active central nervous system lesions, or evidence of retinal pathology were excluded from the study.
Key baseline characteristics included: 58% of patients were male, median age was 55 years (range 23 to 88 years), 60% had metastatic melanoma stage M1c and the proportion of patients with elevated lactate dehydrogenase (LDH) was 46.3% in the COTELLIC-plus-ZELBORAF arm and 43.0% in the placebo-plus-ZELBORAF arm.
Following confirmation of a BRAF V600 mutation using the cobas 4800 BRAF V600 mutation test, 495 patients with unresectable locally advanced or metastatic melanoma were randomised to receive either: COTELLIC 60 mg once daily on Days 1 - 21 of each 28-day treatment cycle and 960 mg ZELBORAF twice daily on Days 1-28.
Placebo once daily on Days 1 - 21 of each 28-day treatment cycle and 960 mg ZELBORAF twice daily on Days 1 - 28.
Progression-free survival (PFS) as assessed by the investigator (Inv) was the primary endpoint. Secondary efficacy endpoints included overall survival (OS), objective response rate, duration of response and PFS as assessed by an independent review facility (IRF).
Efficacy results are summarised in Table 1. (See Table 1 and Figures 1, 2, 3 and 4.)

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Additionally, in a post hoc analysis with a cut-off date of 16 January 2015, a median PFS benefit of 12.3 months (95% CI 9.5, 13.4) was seen in the COTELLIC-plus-ZELBORAF arm compared to 7.2 months (95% CI 5.6, 7.5) in the placebo-plus-ZELBORAF arm [HR 0.58 (0.46, 0.72)]. The median follow up of patients was 14.2 months.
Global health status/health-related quality of life, symptom severity, and functional interference of symptoms by patient-report were measured for each treatment arm using the EORTC QLQ-C30 questionnaire. Scores for all functioning domains (cognitive, emotional, social, role, and physical), and most symptoms (appetite loss, constipation, nausea and vomiting, dyspnea, pain, fatigue) did not demonstrate a clinically meaningful change (< 10 point change from baseline) and were similar between the two treatment arms. Patients in the COTELLIC-plus-ZELBORAF arm reported significant worsening of diarrhoea from baseline at only Cycle 1-Day 15 and Cycle 2-Day 15 as measured by the EORTC QLQ-C30; but not at subsequent timepoints.
Study NO25395 (BRIM7): The efficacy of COTELLIC was evaluated in a Phase Ib study, NO25395, which was designed to assess the safety, tolerability, pharmacokinetics and efficacy of COTELLIC when added to ZELBORAF for the treatment of patients with unresectable or metastatic melanoma with a BRAF V600 mutation (as detected by the cobas 4800 BRAF V600 Mutation Test).
This study treated 129 patients with COTELLIC and ZELBORAF: 63 were naïve to BRAF inhibitor (BRAFi) therapy and 66 patients had previously progressed on prior ZELBORAF therapy. Within the BRAFi naïve patient population (n = 63), there were 20 patients (32%) who had received prior systemic therapy.
Results of the BRAFi naïve population from study NO25395 were generally consistent with those from study GO28141. The BRAFi-naïve patients (n = 63) attained an 87% objective response rate, including a complete response in 10% of patients. The median duration of response was 12.5 months. The median PFS for BRAFi-naïve patients was 13.7 months, with median follow-up time of 12.7 months.
Among patients who had progressed on ZELBORAF (n = 66), the objective response rate was 15%, the median duration of response was 6.7 months and the median PFS was 2.8 months.
Pharmacokinetics: Absorption: Following oral dosing of 60 mg in cancer patients, cobimetinib showed a moderate rate of absorption with a median T_max of 2.4 hours. The mean steady-state C_max and AUC_0-24 were 273 ng/mL and 4340 ng.h/mL respectively. The mean accumulation ratio at steady state was approximately 2.4-fold.
Cobimetinib has linear pharmacokinetics in the dose range of ~3.5 mg to 100 mg.
The absolute bioavailability of cobimetinib was 45.9% (90% CI: 39.7%, 53.1%) in healthy subjects. A human mass balance study was conducted in healthy subjects, and showed that cobimetinib was extensively metabolised and eliminated in faeces. The fraction absorbed was ~88% indicating high absorption and first pass metabolism.
The pharmacokinetics of cobimetinib are not altered when administered in the fed state (high-fat meal) compared with the fasted state in healthy subjects. Since food does not alter the pharmacokinetics of cobimetinib, it can be administered with or without food.
Distribution: Cobimetinib is 94.8% bound to human plasma proteins in vitro. No preferential binding to human red blood cells was observed (blood to plasma ratio 0.93).
The volume of distribution (Vss) was 1050 L in healthy subjects given an intravenous (IV) dose of 2 mg. The apparent volume of distribution (Vss) was 806 L in cancer patients based on population PK analysis.
Metabolism: Oxidation by CYP3A and glucuronidation by UGT2B7 appear to be the major pathways of cobimetinib metabolism. Cobimetinib is the predominant moiety in plasma. No oxidative metabolites greater than 10% of total circulating radioactivity or human specific metabolites were observed in plasma. Unchanged drug in faeces and urine accounted for 6.6% and 1.6% of the administered dose, respectively, indicating that cobimetinib is primarily metabolised with very little renal elimination.
Excretion: Cobimetinib and its metabolites were characterised in a mass balance study in healthy subjects. On average, 94% of the dose was recovered within 17 days. Cobimetinib was extensively metabolised and eliminated in faeces; no single metabolite was predominant.
Following IV administration of a 2 mg dose of cobimetinib, the mean plasma clearance (CL) was 10.7 L/hr. The mean CL/F following oral dosing of 60 mg in cancer patients based on a population pharmacokinetic analysis was 13.4 L/hr.
The mean elimination half-life following oral dosing of cobimetinib was 43.6 hours (range: 23.1 to 69.6 hours).
Pharmacokinetics in Special Populations: Based on a population pharmacokinetic analysis, gender, race, ethnicity, baseline ECOG, mild and moderate renal impairment did not affect the PK of cobimetinib. Baseline age and baseline body weight were identified as statistically significant co-variates on cobimetinib clearance and volume of distribution respectively. However, sensitivity analysis suggests neither of these co-variates had a clinically significant impact on steady state exposure.
Gender: Gender does not have an effect on the exposure of cobimetinib, based on a population pharmacokinetic analysis including 210 women and 277 men.
Elderly: Age does not have a clinically significant effect on the exposure of cobimetinib, based on a population pharmacokinetic analysis which included 133 patients ≥ 65 years of age.
Renal Impairment: Based on pre-clinical data and the human mass balance study, cobimetinib is mainly metabolised, with minimal renal elimination. No formal PK study has been conducted in patients with renal impairment.
A population PK analysis using data from 151 patients with mild renal impairment [creatinine clearance (CrCl) 60 to less than 90 mL/min], 48 patients with moderate renal impairment (CrCl 30 to less than 60 mL/min), and 286 patients with normal renal function (CrCl greater than or equal to 90 mL/min), showed that CrCl had no meaningful influence on exposure of cobimetinib.
Mild to moderate renal impairment does not influence cobimetinib exposure based on the population PK analysis. The potential need for dose adjustment in patients with severe renal impairment cannot be determined due to limited data.
Hepatic Impairment: The pharmacokinetics of cobimetinib were evaluated in 6 subjects with mild hepatic impairment (Child Pugh A), 6 subjects with moderate hepatic impairment (Child Pugh B), 6 subjects with severe hepatic impairment (Child Pugh C) and 10 healthy subjects. Exposures of total cobimetinib after a single dose were similar in subjects with mild or moderate hepatic impairment compared to healthy subjects; while subjects with severe hepatic impairment had lower exposures (AUC_0-∞ geometric mean ratio of 0.69 compared to healthy subjects) which is not considered to be clinically significant. Exploratory analysis of unbound cobimetinib concentrations show that exposure of unbound cobimetinib in subjects with mild and moderate hepatic impairment were similar to subjects with normal hepatic function while subjects with severe hepatic impairment had 2-fold higher exposures.
Therefore, no dose adjustment is recommended when administering COTELLIC to patients with hepatic impairment (see Special Dosage Instructions under DOSAGE & ADMINISTRATION and Liver Laboratory Abnormalities under PRECAUTIONS).
QT Prolongation: No additive clinical effect on QT interval prolongation is observed when patients are treated with COTELLIC in combination with ZELBORAF. In vitro, cobimetinib produced moderate hERG ion channel inhibition (IC₅₀ = 0.5 μM [266 ng/mL]), which is approximately 18-fold higher than peak plasma concentrations (C_max) at the 60 mg dose (unbound C_max = 14 ng/mL [0.03 μM]).

COTELLIC is indicated for use in combination with ZELBORAF (vemurafenib) for the treatment of patients with unresectable or metastatic melanoma with BRAF V600 mutation.

General: COTELLIC therapy should only be initiated and supervised by a healthcare professional experienced in the treatment of patients with cancer.
Patients treated with COTELLIC in combination with ZELBORAF must have BRAF V600 mutation-positive melanoma tumour status confirmed by a validated test.
Please also refer to the full Pack Insert for ZELBORAF, which is used in combination with COTELLIC.
Standard Dosage: The recommended dose of COTELLIC is 60 mg (three 20 mg tablets) once daily for 21 days in a 28 day cycle.
Each COTELLIC dose consists of three 20 mg tablets (60 mg) and should be taken once daily for 21 consecutive days (days 1 to 21 - treatment period); followed by a 7 day break in COTELLIC treatment (days 22 to 28 - treatment break).
Each dose of three 20 mg tablets (60 mg) can be taken with or without food (see PHARMACOLOGY: Pharmacokinetics: Absorption under Actions). COTELLIC tablets should be swallowed whole with water.
Duration of Treatment: Treatment with COTELLIC should continue until the patient no longer derives benefit or until the development of unacceptable toxicity.
Delayed or Missed Doses: If a dose is missed, it can be taken up to 12 hours prior to the next dose to maintain the once-daily regimen.
Vomiting: In case of vomiting after COTELLIC administration, the patient should not take an additional dose of COTELLIC on that day, and treatment should be continued as prescribed the following day.
Dose Modification Recommendations: General: COTELLIC dose modification should be based on the prescriber's assessment of individual patient safety or tolerability.
If doses are omitted for toxicity; missed doses should not be replaced.
Once the dose has been reduced, it should not be increased at a later time.
Dose modification of COTELLIC is independent of ZELBORAF dose modification. The decision on whether to dose reduce either or both drugs should be based on clinical assessment.
Table 2 as follows gives general COTELLIC dose modification advice. (See Table 2.)

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Dose Modification Advice for Specified Adverse Drug Reactions: Haemorrhage: Grade 3 events: Interrupt COTELLIC treatment. There are no data on the effectiveness of COTELLIC dose modification for haemorrhage events. Clinical judgment should be applied when considering restarting COTELLIC treatment. ZELBORAF dosing can be continued when COTELLIC treatment is interrupted, if clinically indicated.
Grade 4 events or cerebral haemorrhage (all grades): Interrupt COTELLIC treatment. Permanently discontinue COTELLIC for haemorrhage events attributed to COTELLIC.
Left ventricular dysfunction: Permanent discontinuation of COTELLIC treatment should be considered if cardiac symptoms are attributed to COTELLIC and do not improve after temporary interruption of COTELLIC. (See Table 3.)

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ZELBORAF treatment can be continued when COTELLIC treatment is modified (if clinically indicated).
Rhabdomyolysis and Creatine Phosphokinase (CPK) Elevations: Rhabdomyolysis or symptomatic CPK elevations: Interrupt COTELLIC treatment. If severity is improved by at least one grade within 4 weeks, restart COTELLIC at a dose reduced by 20 mg, if clinically indicated. ZELBORAF dosing can be continued when COTELLIC treatment is modified, if clinically indicated.
If rhabdomyolysis or symptomatic CPK elevations do not improve within 4 weeks, permanently discontinue COTELLIC treatment.
Asymptomatic CPK elevations: Grade ≤ 3: COTELLIC dosing does not need to be modified or interrupted to manage asymptomatic Grade ≤ 3 creatine phosphokinase elevations (see Laboratory Abnormalities under ADVERSE REACTIONS).
Grade 4: Interrupt COTELLIC treatment. If improved to Grade ≤ 3 within 4 weeks, restart COTELLIC at a dose reduced by 20 mg, if clinically indicated. ZELBORAF dosing can be continued when COTELLIC treatment is modified, if clinically indicated. If CPK elevations do not improve to Grade ≤3 within 4 weeks following dose interruption, permanently discontinue COTELLIC treatment.
Liver Laboratory Abnormalities: Grade ≤ 2: COTELLIC and ZELBORAF should be continued at the prescribed dose.
Grade 3: Continue COTELLIC at the prescribed dose. The dose of ZELBORAF may be reduced as clinically appropriate. Please refer to the full Pack Insert for ZELBORAF.
Grade 4: Interrupt COTELLIC treatment and ZELBORAF treatment. If liver laboratory abnormalities improve to Grade ≤ 1 within 4 weeks, restart COTELLIC at a dose reduced by 20 mg and ZELBORAF at a clinically appropriate dose; please refer to the full Pack Insert for ZELBORAF. If liver laboratory abnormalities do not resolve to Grade ≤ 1 within 4 weeks or if Grade 4 liver laboratory abnormalities recur, discontinue COTELLIC treatment and ZELBORAF treatment.
Photosensitivity: Grade ≤ 2 (tolerable): manage with supportive care.
Grade 2 (intolerable) or Grade ≥ 3: COTELLIC and ZELBORAF should be interrupted until resolution to Grade ≤ 1. Treatment can be restarted with no change in COTELLIC dose. ZELBORAF dosing should be reduced, please refer to the full Pack Insert for ZELBORAF.
Rash: Rash events may occur with either COTELLIC or ZELBORAF treatment. The dose of COTELLIC and/or ZELBORAF may be either interrupted and/or reduced as clinically indicated.
Grade ≤ 2 (tolerable): manage with supportive care.
Grade 2 (intolerable) or Grade ≥ 3: Acneiform rash: Follow general dose modification recommendations in Table 2 for COTELLIC. ZELBORAF dosing can be continued when COTELLIC treatment is modified (if clinically indicated).
Non-acneiform or maculopapular rash: COTELLIC dosing can be continued without modification (if clinically indicated). ZELBORAF dosing may be either temporarily interrupted and/or reduced, please refer to the full Pack Insert for ZELBORAF.
Special Dosage Instructions: Elderly: No dose adjustment of COTELLIC is required in patients ≥ 65 years of age.
Children: The safety and efficacy of COTELLIC in children and adolescents (< 18 years) has not been established.
Renal impairment: No dose adjustment is recommended in patients with mild or moderate renal impairment, based on population pharmacokinetic analysis. The safety and efficacy of COTELLIC have not been established in patients with severe renal impairment (see PHARMACOLOGY: Pharmacokinetics: Pharmacokinetics in Special Populations under Actions). COTELLIC should be used with caution in patients with severe renal impairment.
Hepatic impairment: No dose adjustment is recommended in patients with hepatic impairment (see PHARMACOLOGY: Pharmacokinetics: Pharmacokinetics in Special Populations under Actions). Liver laboratory abnormalities can occur when COTELLIC is used in combination with ZELBORAF (see Liver Laboratory Abnormalities under PRECAUTIONS).
Route of administration: Oral.

There is no experience with overdosage in human clinical trials. In case of suspected overdose, COTELLIC should be withheld and supportive care instituted. There is no specific antidote for overdosage with COTELLIC.

COTELLIC is contraindicated in patients with known hypersensitivity to cobimetinib or any of the excipients.

Please also refer to the full Pack Insert for ZELBORAF, which is used in combination with COTELLIC.
Haemorrhage: Haemorrhage, including major haemorrhages defined as symptomatic bleeding in a critical area or organ, can occur with COTELLIC (see ADVERSE REACTIONS).
Caution should be used in patients with additional risk factors for bleeding, such as brain metastases, and/or in patients that use concomitant medications that increase the risk of bleeding (including antiplatelet or anticoagulant therapy).
Prescribers should follow the dose modification guidance for haemorrhage management (see Dose Modification Recommendations under DOSAGE & ADMINISTRATION).
Serous Retinopathy: Serous retinopathy (fluid accumulation within the layers of the retina) has been observed in patients treated with MEK inhibitors, including COTELLIC (see ADVERSE REACTIONS). The majority of events were reported as chorioretinopathy or retinal detachment.
Median time to initial onset of serous retinopathy events was 1 month (range 0 - 9 months). Most events observed in clinical trials were resolved, or improved to asymptomatic grade 1, following dose interruption or reduction.
For patients reporting any symptoms of new or worsening visual disturbances, prompt ophthalmologic examination is recommended. If serous retinopathy is diagnosed, COTELLIC treatment should be withheld until visual symptoms improve to Grade ≤ 1. Serous retinopathy can be managed with treatment interruption, dose reduction or with treatment discontinuation (see Dose Modification Recommendations under DOSAGE & ADMINISTRATION).
Left Ventricular Dysfunction: Decrease in left ventricular ejection fraction (LVEF) from baseline has been reported in patients receiving COTELLIC (see ADVERSE REACTIONS). Median time to initial onset of events was 4 months (1 - 13 months).
LVEF should be evaluated before initiation of treatment to establish baseline values, then after the first month of treatment and at least every 3 months or as clinically indicated until treatment discontinuation. Decrease in LVEF from baseline can be managed using treatment interruption, dose reduction or with treatment discontinuation (see Dose Modification Recommendations under DOSAGE & ADMINISTRATION).
All patients restarting treatment with a dose reduction of COTELLIC should have LVEF measurements taken after approximately 2 weeks, 4 weeks, 10 weeks and 16 weeks, and then as clinically indicated.
Patients with a baseline LVEF either below institutional lower limit of normal (LLN) or below 50% have not been studied.
Liver Laboratory Abnormalities: Liver laboratory abnormalities can occur when COTELLIC is used in combination with ZELBORAF, and when ZELBORAF is used as a single agent (please refer to the full Pack Insert for ZELBORAF).
Liver laboratory abnormalities, specifically increases in alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase (ALP), have been observed in patients treated with COTELLIC plus ZELBORAF (see Laboratory Abnormalities under ADVERSE REACTIONS).
Monitor for liver value abnormalities by liver laboratory tests before initiation of combination treatment and monthly during treatment, or more frequently as clinically indicated.
Manage Grade 3 liver laboratory abnormalities with treatment interruption or dose reduction of ZELBORAF. Manage Grade 4 liver laboratory abnormalities with dose interruption, reduction or discontinuation of treatment of both COTELLIC and ZELBORAF (see Dose Modification Recommendations under DOSAGE & ADMINISTRATION).
Rhabdomyolysis and CPK elevations: Rhabdomyolysis has been reported in patients receiving COTELLIC (see Post-Marketing Experience under ADVERSE REACTIONS).
Interrupt treatment with COTELLIC if rhabdomyolysis is diagnosed, and monitor CPK levels and other symptoms until resolution. Depending on the severity of rhabdomyolysis, dose reduction or treatment discontinuation may be required (see Dose Modification Recommendations under DOSAGE & ADMINISTRATION).
Grade 3 or 4 CPK elevations, including asymptomatic elevations over baseline, have been reported in patients receiving COTELLIC with ZELBORAF in clinical trials (see Laboratory Abnormalities under ADVERSE REACTIONS). The median time to first occurrence of Grade 3 or 4 CPK elevations was 16 days (range: 11 days to 10 months); the median time to complete resolution was 16 days (range: 2 days to 15 months).
Serum CPK and creatinine levels should be measured before initiation of treatment to establish baseline values and then monitored monthly during treatment, or as clinically indicated. If serum CPK is elevated, evaluate for signs and symptoms of rhabdomyolysis or other causes. Depending on the severity of symptoms or CPK elevation, treatment interruption, dose reduction or treatment discontinuation may be required (see Dose Modification Recommendations under DOSAGE & ADMINISTRATION).
Dermatological reactions: Severe rash and other skin reactions can occur with COTELLIC (see ADVERSE REACTIONS). Prescribers should follow the dosage modification recommendations for rash if events occur (see Dose Modification Recommendations under DOSAGE & ADMINISTRATION).
Photosensitivity: Photosensitivity, including severe cases, can occur with COTELLIC, when used with ZELBORAF (see ADVERSE REACTIONS).
Advise patients to avoid sun exposure, wear protective clothing and use a broad spectrum UVA/UVB sun screen and lip balm (SPF ≥ 30+) when outdoors. Manage photosensitivity with dose modification (see Dose Modification Recommendations under DOSAGE & ADMINISTRATION).
Use in patients who have progressed on a BRAF inhibitor: There are limited data in patients taking the combination of COTELLIC with ZELBORAF who have progressed on a prior BRAF inhibitor. These data show that the efficacy of the combination will be lower in these patients [see Pharmacology: Pharmacodynamics: CLINICAL TRIALS: Study NO25395 (BRIM7) under Actions]. Use of COTELLIC in this population should be guided by careful benefit-risk assessment of the treatment and disease.
Effect of Gender: Gender does not have an effect on COTELLIC exposure (see PHARMACOLOGY: Pharmacokinetics: Pharmacokinetics in Special Populations under Actions).
Ability to Drive and Use Machines: No studies on the effects on the ability to drive and to use machines have been performed.
Visual disturbances have been reported in some patients treated with COTELLIC during clinical trials (see Serous Retinopathy as previously mentioned and ADVERSE REACTIONS). Patients should be advised not to drive or use machines without first consulting with their prescriber if their vision is impaired.
Use in Renal Impairment: No dose adjustment is recommended in patients with mild or moderate renal impairment, based on population pharmacokinetic analysis. The safety and efficacy of COTELLIC have not been established in patients with severe renal impairment (see PHARMACOLOGY: Pharmacokinetics: Pharmacokinetics in Special Populations under Actions).
Use in Hepatic Impairment: No dose adjustment is recommended in patients with hepatic impairment (see PHARMACOLOGY: Pharmacokinetics: Pharmacokinetics in Special Populations under Actions). Liver laboratory abnormalities can occur when COTELLIC is used in combination with ZELBORAF (see Liver Laboratory Abnormalities as previously mentioned).
Genotoxicity: Standard genotoxicity studies with cobimetinib were all negative. Cobimetinib was assessed for genotoxicity in S. typhimurium and E. coli, in vitro in primary human lymphocytes, and in vivo in a rat bone marrow micronucleus assay.
Carcinogenicity: No carcinogenicity studies have been conducted with COTELLIC.
Other Toxicological Information: Toxicity studies in rats and dogs identified generally reversible degenerative changes in the bone marrow, gastrointestinal tract, skin, thymus, adrenal gland, liver, spleen, lymph node, kidney, heart, ovary, and vagina at plasma exposures below clinical efficacious levels.
Non-clinical studies revealed no other special hazard for humans based on conventional studies of safety pharmacology and genotoxicity.
Effects on Fertility: No dedicated fertility studies in animals have been performed with COTELLIC.
In toxicology studies, degenerative changes were observed in reproductive tissues including increased apoptosis/necrosis of corpora lutea and seminal vesicle, epididymal and vaginal epithelial cells and follicular cysts of ovaries in rats, and apoptosis/necrosis of epididymal epithelial cells in dogs at exposure ≥ 3 times the expected clinical exposure based on AUC. The effect of cobimetinib on human fertility is unknown.
Use in Pregnancy: Category D: COTELLIC is not recommended during pregnancy.
There are no data regarding the use of COTELLIC in pregnant women.
Use two effective forms of contraception during treatment with COTELLIC and for at least three months following treatment discontinuation.
When administered to pregnant rats, cobimetinib caused embryolethality and foetal malformations of the great vessels and skull, and decreased ossification sites at clinically relevant exposures (systemic exposures approximately 0.9 to 1.4 times the human clinical plasma AUC exposure).
The safe use of COTELLIC during labour and delivery has not been established.
Use in Lactation: It is not known whether COTELLIC is excreted in human breast milk. A risk to newborns/infants cannot be excluded. A decision should be made whether to recommend breast-feeding or to administer COTELLIC, taking into account the importance of the medicine to the mother.
Use in Children: The safety and efficacy of COTELLIC in children and adolescents (< 18 years) have not yet been established.
Use in Elderly: Age does not have a clinically significant effect on the exposure of cobimetinib, based on a population pharmacokinetic analysis (see PHARMACOLOGY: Pharmacokinetics: Pharmacokinetics in Special Populations under Actions).

Use in Pregnancy: Category D: COTELLIC is not recommended during pregnancy.
There are no data regarding the use of COTELLIC in pregnant women.
Use two effective forms of contraception during treatment with COTELLIC and for at least three months following treatment discontinuation.
When administered to pregnant rats, cobimetinib caused embryolethality and foetal malformations of the great vessels and skull, and decreased ossification sites at clinically relevant exposures (systemic exposures approximately 0.9 to 1.4 times the human clinical plasma AUC exposure).
The safe use of COTELLIC during labour and delivery has not been established.
Use in Lactation: It is not known whether COTELLIC is excreted in human breast milk. A risk to newborns/infants cannot be excluded. A decision should be made whether to recommend breast-feeding or to administer COTELLIC, taking into account the importance of the medicine to the mother.

The safety of COTELLIC in combination with ZELBORAF has been evaluated in 247 patients with advanced BRAF V600 mutated melanoma in the Phase III study GO28141. The median time to onset of first Grade ≥ 3 adverse events was 0.6 months in the COTELLIC-plus-ZELBORAF arm vs. 0.8 months in the placebo-plus-ZELBORAF control arm.
The safety of COTELLIC in combination with ZELBORAF has also been evaluated in 129 patients with advanced BRAF V600 mutated melanoma in the Phase Ib study NO25395. The safety profile of COTELLIC in NO25395 was consistent with that observed in study GO28141.
The following table summarises the ADRs occurring at a ≥ 5% higher incidence (all grades) or at a ≥ 2% higher incidence (grades 3 - 4) of patients treated with COTELLIC in combination with ZELBORAF in the GO28141 study. The following categories of frequency have been used: very common (≥ 1/10), common (≥ 1/100 to < 1/10), uncommon (≥ 1/1,000 to < 1/100), rare (≥ 1/10,000 to < 1/1000), very rare (< 1/10,000). (See Table 4.)

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ADRs (all grades) Reported with < 5% Greater Incidence in the COTELLIC-Plus- ZELBORAF Arm than the Placebo-Plus-ZELBORAF Control Arm in Study GO28141: Eye disorders: visual impairment (3% in the COTELLIC arm vs. 0% in the control arm) (see PRECAUTIONS).
Metabolism and nutrition disorders: hyperglycemia (3% in the COTELLIC arm vs. 1% in the control arm), hypophosphatemia (4% in the COTELLIC arm vs 1% in the control arm).
Respiratory, thoracic and mediastinal disorders: pneumonitis (1% in the COTELLIC arm vs. < 1% in the control arm).
Skin and subcutaneous tissue disorders: rash (40% in the COTELLIC arm vs. 38% in the control arm).
Further Information on Selected Adverse Reactions: Haemorrhage: Bleeding events have been reported more frequently in the COTELLIC arm than in the control arm (all types and grades: 13% vs. 7%). Higher frequencies in the COTELLIC arm were observed for cerebral haemorrhage (1% vs. 0%), gastrointestinal (GI) tract haemorrhage (4% vs. 1%), reproductive system haemorrhage (2% vs. <1%), and haematuria (3% vs. 1%).
The majority of events were Grade 1 or 2 and non-serious (12% of patients in the COTELLIC arm vs. 7% patients in the control arm). Most events resolved or were resolving with no change in COTELLIC dose.
Grade 3 to 4 events were experienced by 1% of patients in each arm (see PRECAUTIONS).
Photosensitivity: Photosensitivity has been observed with a higher frequency in the COTELLIC arm vs. the control arm (47% vs. 35%). The majority of events were Grades 1 or 2, with Grade ≥ 3 events occurring in 4% of patients in the COTELLIC arm vs. 0% in the control arm.
There were no apparent trends in the time of onset of Grade ≥ 3 events. Grade ≥ 3 photosensitivity events in the COTELLIC arm were treated with primary topical medication in conjunction with dose interruptions of both COTELLIC and ZELBORAF (see Dose Modification Recommendations under DOSAGE & ADMINISTRATION).
No evidence of phototoxicity was observed with COTELLIC as a single agent.
Cutaneous Squamous Cell Carcinoma, Keratoacanthoma and Hyperkeratosis: Cutaneous squamous cell carcinoma has been reported with a lower frequency in the COTELLIC arm vs. the control arm (all grade: 3% vs. 13%). Keratoacanthoma has been reported with a lower frequency in the COTELLIC arm vs. control arm (all grade: 2% vs. 9%). Hyperkeratosis has been reported with a lower frequency in the COTELLIC arm vs. control arm (all grades: 11% vs. 30%).
Laboratory Abnormalities: (See Table 5).

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Post-Marketing Experience: (See Table 6).

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Effects of Concomitant Medications on Cobimetinib: CYP3A Inhibitors/Inducers: Cobimetinib is metabolised by CYP3A. Cobimetinib AUC increased approximately 7-fold in the presence of a potent CYP3A inhibitor (itraconazole) in healthy subjects. Since cobimetinib is a sensitive substrate of CYP3A, it is likely that cobimetinib exposures will be significantly lower in the presence of CYP3A inducers. Therefore concomitant administration of potent CYP3A inducers and inhibitors is not recommended. Use of cobimetinib in the presence of moderate CYP3A inhibitors or inducers should be avoided where possible. Caution should be exercised when cobimetinib must be co-administered with moderate CYP3A inducers and inhibitors (see Dose Modification Recommendations under DOSAGE & ADMINISTRATION for advice about reducing dose on the basis of adverse events).
Acid-Reducing Agents: Cobimetinib was administered in the presence of rabeprazole (a proton pump inhibitor) in healthy subjects to determine the effect of increased gastric pH. Cobimetinib pharmacokinetics were not altered and thus, gastric pH elevations do not affect cobimetinib absorption.
Effects of Cobimetinib on Concomitant Medications: CYP Substrates: In vitro data indicate that cobimetinib is an inhibitor of CYP3A and CYP2D6. A clinical drug-drug interaction study in cancer patients showed that plasma concentrations of midazolam (a sensitive CYP3A substrate) and dextromethorphan (a sensitive CYP2D6 substrate) were not altered in the presence of cobimetinib. Therefore cobimetinib can be co-administered with medications that are substrates of CYP3A and CYP2D6.
Other Anti-Cancer Agents: ZELBORAF: There is no evidence of any clinically significant drug-drug interaction between COTELLIC and ZELBORAF in unresectable or metastatic melanoma patients.
Interactions Mediated by Drug Transport Systems: In vitro studies show that cobimetinib is a substrate but not an inhibitor of P-glycoprotein (P-gp). In vitro studies also show that cobimetinib is not a substrate of breast cancer resistance protein (BCRP) but is a weak to moderate inhibitor of BCRP.
In vitro studies show that cobimetinib is not a substrate of the liver uptake transporters OATP1B1, OATP1B3, or OCT1, however, it weakly inhibits these transporters. The clinical relevance of these findings has not been investigated.
Cobimetinib is not an inhibitor of OAT1, OAT3 or OCT2. It is unlikely that cobimetinib would alter the renal uptake or renal excretion of drugs that are substrates of these transporters.

Disposal of Medicines: The release of medicines into the environment should be minimised. Medicines should not be disposed of via wastewater and disposal through household waste should be avoided. Unused or expired medicine should be returned to a pharmacy for disposal.

Store at or below 30 °C.

Targeted Cancer Therapy

L01EE02 - cobimetinib ; Belongs to the class of mitogen-activated protein kinase (MEK) inhibitors. Used in the treatment of cancer.

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