4.1. Therapeutic indications

COMETRIQ is indicated for the treatment of adult patients with progressive, unresectable locally advanced or metastatic medullary thyroid carcinoma.

For patients in whom rearranged during transfection (RET) mutation status is not known or is negative, a possible lower benefit should be taken into account before individual treatment decision (see important information in section 5.1).

4.2. Posology and method of administration

Therapy with COMETRIQ should be initiated by a physician experienced in the administration of anticancer medicinal products.

Posology

COMETRIQ (cabozantinib) capsules and CABOMETYX (cabozantinib) tablets are not bioequivalent and should not be used interchangeably (see section 5.2).

The recommended dose of COMETRIQ is 140 mg once daily, taken as one 80 mg orange capsule and three 20 mg grey capsules. Treatment should continue until the patient is no longer clinically benefiting from therapy or until unacceptable toxicity occurs.

It should be expected that a majority of patients treated with COMETRIQ will require one or more dose adjustments (reduction and/or interruption) due to toxicity. Patients should therefore be closely monitored during the first eight weeks of therapy (see section 4.4).

Management of suspected adverse drug reactions may require temporary interruption and/or dose reduction of COMETRIQ therapy. When dose reduction is necessary, it is recommended to reduce to 100 mg daily, taken as one 80 mg orange capsule and one 20 mg grey capsule, and then to 60 mg daily, taken as three 20 mg grey capsules.

Dose interruptions are recommended for management of CTCAE grade 3 or greater toxicities or intolerable grade 2 toxicities.

Dose reductions are recommended for events that, if persistent, could become serious or intolerable.

As most events can occur early in the course of treatment, the physician should evaluate the patient closely during the first eight weeks of treatment to determine if dose modifications are warranted. Events that generally have early onset include hypocalcaemia, hypokalaemia, thrombocytopenia, hypertension, palmar-plantar erythrodysaesthesia syndrome (PPES), and gastrointestinal (GI) events (abdominal or mouth pain, mucosal inflammation, constipation, diarrhoea, vomiting).

The occurrence of some serious adverse reactions (like GI fistula) might be dependent on the cumulative dose and might present in a later stage of treatment.

If a patient misses a dose, the missed dose should not be taken if it is less than 12 hours before the next dose.

Concomitant medicinal products

Concomitant medicinal products that are strong inhibitors of CYP3A4 should be used with caution, and chronic use of concomitant medicinal products that are strong inducers of CYP3A4 should be avoided (see sections 4.4 and 4.5).

Selection of an alternative concomitant medicinal product with no or minimal potential to induce or inhibit CYP3A4 should be considered.

Elderly patients

No specific dose adjustment for the use of cabozantinib in older people (≥ 65 years) is recommended. However, a trend in increased rate of SAEs has been observed in subjects aged 75 years and older.

Race

There is little experience with cabozantinib in non-White patients.

Renal impairment

Cabozantinib should be used with caution in patients with mild or moderate renal impairment.

Cabozantinib is not recommended for use in patients with severe renal impairment as safety and efficacy have not been established in this population.

Hepatic impairment

In patients with mild or moderate hepatic impairment the recommended dose of cabozantinib is 60 mg once daily. Close monitoring of overall safety is recommended in these patients (see section 5.2) as dose adjustment or interruption may be required. Cabozantinib is not recommended for use in patients with severe hepatic impairment as safety and efficacy have not been established in this population.

Patients with cardiac impairment

There is limited data in patients with cardiac impairment. No specific dosing recommendations can be made.

Paediatric population

The safety and efficacy of cabozantinib in children aged <18 years have not yet been established. No data are available.

Method of administration

COMETRIQ is for oral use. The capsules should be swallowed whole and not opened. Patients should be instructed to not eat anything for at least 2 hours before through 1 hour after taking COMETRIQ.

4.3. Contraindications

Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.

4.4. Special warnings and precautions for use

Dose reductions and dose interruptions occurred in 79% and 72%, respectively, of cabozantinib-treated patients in the pivotal clinical study. Two dose reductions were required in 41% of patients. The median time to first dose reduction was 43 days, and to first dose interruption was 33 days. Close monitoring of patients is therefore recommended during the first eight weeks of therapy (see section 4.2).

Hepatotoxicity

Abnormalities of liver function tests (increases in alanine aminotransferase (ALT), aspartate aminotransferase (AST) and bilirubin) have been frequently observed in patients treated with cabozantinib. It is recommended to perform liver function tests (ALT, AST and bilirubin) before initiation of cabozantinib treatment and to monitor closely during treatment. For patients with worsening of liver function tests considered related to cabozantinb treatment (i.e where no alternative cause is evident), the dose should be reduced or treatment interrupted following recommendations provided in section 4.2.

Perforations, fistulas, and intra-abdominal abscesses

Serious gastrointestinal (GI) perforations and fistulas, sometimes fatal, and intra-abdominal abscesses have been observed with cabozantinib. Patients who have had recent radiotherapy, have inflammatory bowel disease (e.g., Crohn's disease, ulcerative colitis, peritonitis, or diverticulitis), have tumour infiltration of trachea, bronchi, or oesophagus, have complications from prior GI surgery (particularly when associated with delayed or incomplete healing), or have complications from prior radiation therapy to the thoracic cavity (including mediastinum) should be carefully evaluated before initiating cabozantinib therapy and subsequently they should be monitored closely for symptoms of perforations and fistulas. Non‑GI fistula should be ruled out as appropriate in cases of onset of mucositis after start of therapy. Cabozantinib should be discontinued in patients who experience a GI perforation or a GI or non-GI fistula.

Thromboembolic events

Events of venous thromboembolism, including pulmonary embolism and events of arterial thromboembolism, sometimes fatal, have been observed with cabozantinib. Cabozantinib should be used with caution in patients who are at risk for, or who have a history of, these events. Cabozantinib should be discontinued in patients who develop an acute myocardial infarction or any other clinically significant arterial thromboembolic complication.

Haemorrhage

Severe haemorrhage, sometimes fatal, has been observed with cabozantinib. Patients who have evidence of involvement of the trachea or bronchi by tumour or a history of haemoptysis prior to treatment initiation should be carefully evaluated before initiating cabozantinib therapy. Cabozantinib should not be administered to patients with serious haemorrhage or recent haemoptysis.

Aneurysms and artery dissections

The use of VEGF pathway inhibitors in patients with or without hypertension may promote the formation of aneurysms and/or artery dissections. Before initiating cabozantinib, this risk should be carefully considered in patients with risk factors such as hypertension or history of aneurysm.

Gastrointestinal (GI) disorders

Diarrhoea, nausea/vomiting, decreased appetite, and stomatitis/oral pain were some of the most commonly reported GI adverse reactions (see section 4.8). Prompt medical management, including supportive care with antiemetics, antidiarrhoeals, or antacids, should be instituted to prevent dehydration, electrolyte imbalances and weight loss. Dose interruption or reduction, or permanent discontinuation of cabozantinib should be considered in case of persistent or recurrent significant GI adverse reactions (see section 4.2).

Wound complications

Wound complications have been observed with cabozantinib. Cabozantinib treatment should be stopped at least 28 days prior to scheduled surgery, including dental surgery or invasive dental procedures, if possible. The decision to resume cabozantinib therapy after surgery should be based on clinical judgment of adequate wound healing. Cabozantinib should be discontinued in patients with wound healing complications requiring medical intervention.

Hypertension

Hypertension, including hypertensive crisis, has been observed with cabozantinib. Blood pressure should be well-controlled prior to initiating cabozantinib. After cabozantinib initiation blood pressure should be monitored early and regularly and treated as needed with appropriate anti-hypertensive therapy. In the case of persistent hypertension despite use of anti‑hypertensives, the cabozantinib treatment should be interrupted until blood pressure is controlled, after which cabozantinib can be resumed at a reduced dose. Cabozantinib should be discontinued if hypertension is severe and persistent despite anti-hypertensive therapy and dose reduction of cabozantinib. In case of hypertensive crisis, cabozantinib should be discontinued.

Cardiac Failure

Cabozantinib has been associated with an increased risk of cardiac failure. This risk may be exacerbated by common adverse drug reactions of cabozantinib (e.g. hypertension, hypothyroidism and arterial thrombotic events), which can lead to cardiac failure. Patients should be monitored for signs and symptoms of cardiac failure throughout treatment. These adverse events should be managed promptly, dose interruptions and/or adjustments should be considered if necessary (see section 4.2) and TKI therapy should be discontinued in patients who develop severe cardiac failure.

Osteonecrosis

Events of osteonecrosis of the jaw (ONJ) have been observed with cabozantinib. An oral examination should be performed prior to initiation of cabozantinib and periodically during cabozantinib therapy. Patients should be advised regarding oral hygiene practice. Cabozantinib treatment should be held at least 28 days prior to scheduled dental surgery or invasive dental procedures, if possible. Caution should be used in patients receiving agents associated with ONJ, such as bisphosphonates. Cabozantinib should be discontinued in patients who experience ONJ.

Palmar-plantar erythrodysaesthesia syndrome

Palmar-plantar erythrodysaesthesia syndrome (PPES) has been observed with cabozantinib. When PPES is severe, interruption of treatment with cabozantinib should be considered. Cabozantinib should be restarted with a lower dose when PPES has been resolved to grade 1.

Proteinuria

Proteinuria has been observed with cabozantinib. Urine protein should be monitored regularly during cabozantinib treatment. Cabozantinib should be discontinued in patients who develop nephrotic syndrome.

Posterior reversible encephalopathy syndrome

Posterior reversible encephalopathy syndrome (PRES) has been observed with cabozantinib. PRES should be considered in any patient presenting with symptoms suggestive of the diagnosis, including seizures, headache, visual disturbances, confusion or altered mental function. Cabozantinib treatment should be discontinued in patients with PRES.

Prolongation of QT interval

Cabozantinib should be used with caution in patients with a history of QT interval prolongation, patients who are taking antiarrhythmics, or patients with relevant pre-existing cardiac disease, bradycardia, or electrolyte disturbances. When using cabozantinib, periodic monitoring with on-treatment ECGs and electrolytes (serum calcium, potassium, and magnesium) should be considered. Concomitant treatment with strong CYP3A4 inhibitors, which may increase cabozantinib plasma concentrations, should be used with caution.

CYP3A4 inducers and inhibitors

Cabozantinib is a CYP3A4 substrate. Concurrent administration of cabozantinib with the strong CYP3A4 inhibitor ketoconazole resulted in an increase in cabozantinib plasma exposure. Caution is required when administering cabozantinib with agents that are strong CYP3A4 inhibitors. Concurrent administration of cabozantinib with the strong CYP3A4 inducer rifampicin resulted in a decrease in cabozantinib plasma exposure. Therefore chronic administration of agents that are strong CYP3A4 inducers with cabozantinib should be avoided (see sections 4.2 and 4.5).

P-glycoprotein substrates

Cabozantinib was an inhibitor (IC50 = 7.0 μM), but not a substrate, of P-glycoprotein (P‑gp) transport activities in a bi‑directional assay system using MDCK-MDR1 cells. Therefore, cabozantinib may have the potential to increase plasma concentrations of co-administered substrates of P‑gp. Subjects should be cautioned regarding taking a P‑gp substrate (e.g., fexofenadine, aliskiren, ambrisentan, dabigatran etexilate, digoxin, colchicine, maraviroc, posaconazole, ranolazine, saxagliptin, sitagliptin, talinolol, tolvaptan) while receiving cabozantinib.

MRP2 inhibitors

Administration of MRP2 inhibitors may result in increases in cabozantinib plasma concentrations. Therefore, concomitant use of MRP2 inhibitors (e.g. cyclosporine, efavirenz, emtricitabine) should be approached with caution.

Excipient

Sodium

This medicinal product contains less than 1 mmol sodium (23 mg) per capsule, that is to say essentially “sodium-free”.

4.5. Interaction with other medicinal products and other forms of interaction

Effect of other medicinal products on cabozantinib

CYP3A4 inhibitors and inducers

Administration of the strong CYP3A4 inhibitor ketoconazole (400 mg daily for 27 days) to healthy volunteers decreased cabozantinib clearance (by 29%) and increased single-dose plasma cabozantinib exposure (AUC) by 38%. Therefore co-administration of strong CYP3A4 inhibitors (e.g., ritonavir, itraconazole, erythromycin, clarithromycin, grapefruit juice) with cabozantinib should be approached with caution.

Administration of the strong CYP3A4 inducer rifampicin (600 mg daily for 31 days) to healthy volunteers increased cabozantinib clearance (4.3-fold) and decreased single-dose plasma cabozantinib exposure (AUC) by 77%. Chronic co-administration of strong CYP3A4 inducers (e.g., phenytoin, carbamazepine, rifampicin, phenobarbital or herbal preparations containing St. John's Wort [Hypericum perforatum]) with cabozantinib should therefore be avoided.

Gastric pH modifying agents

Co-administration of proton pump inhibitor (PPI) esomeprazole (40 mg daily for 6 days) with a single dose of 100 mg cabozantinib to healthy volunteers resulted in no clinically-significant effect on plasma cabozantinib exposure (AUC). No dose adjustment is indicated when gastric pH modifying agents (i.e., PPIs, H2 receptor antagonists, and antacids) are co-administered with cabozantinib.

MRP2 inhibitors

In vitro data demonstrate that cabozantinib is a substrate of MRP2. Therefore, administration of MRP2 inhibitors may result in increases in cabozantinib plasma concentrations.

Bile salt-sequestering agents

Bile salt-sequestering agents such as cholestyramine and cholestagel may interact with cabozantinib and may impact absorption (or reabsorption) resulting in potentially decreased exposure (see section 5.2). The clinical significance of these potential interactions is unknown.

Effect of cabozantinib on other medicinal products

The effect of cabozantinib on the pharmacokinetics of contraceptive steroids has not been investigated. As unchanged contraceptive effect may not be guaranteed, an additional contraceptive method, such as a barrier method, is recommended.

Because of high plasma protein binding levels of cabozantinib (section 5.2) a plasma protein displacement interaction with warfarin may be possible. In case of such combination, INR values should be monitored.

P-glycoprotein substrates

Cabozantinib was an inhibitor (IC50 = 7.0 μM), but not a substrate, of P‑gp transport activities in a bi‑directional assay system using MDCK-MDR1 cells. Therefore, cabozantinib may have the potential to increase plasma concentrations of co-administered substrates of P‑gp. Subjects should be cautioned regarding taking a P‑gp substrate (e.g., fexofenadine, aliskiren, ambrisentan, dabigatran etexilate, digoxin, colchicine, maraviroc, posaconazole, ranolazine, saxagliptin, sitagliptin, talinolol, tolvaptan) while receiving cabozantinib.

4.6. Fertility, pregnancy and lactation

Women of childbearing potential/Contraception in males and females

Women of childbearing potential must be advised to avoid pregnancy while on cabozantinib. Female partners of male patients taking cabozantinib must also avoid pregnancy. Effective methods of contraception should be used by male and female patients and their partners during therapy, and for at least 4 months after completing therapy. Because oral contraceptives might possibly not be considered as “effective methods of contraception,” they should be used together with another method, such as a barrier method (see section 4.5).

Pregnancy

There are no studies in pregnant women using cabozantinib. Studies in animals have shown embryo‑foetal and teratogenic effects (see section 5.3). The potential risk for humans is unknown. Cabozantinib should not be used during pregnancy unless the clinical condition of the woman requires treatment with cabozantinib.

Breast-feeding

It is not known whether cabozantinib and/or its metabolites are excreted in human milk. Because of the potential harm to the infant, mothers should discontinue breast-feeding during treatment with cabozantinib, and for at least 4 months after completing therapy.

Fertility

There are no data on human fertility. Based on non-clinical safety findings, male and female fertility may be compromised by treatment with cabozantinib (see section 5.3). Both men and women should be advised to seek advice and consider fertility preservation before treatment.

4.7. Effects on ability to drive and use machines

Cabozantinib has minor influence on the ability to drive and use machines. Adverse reactions such as fatigue and weakness have been associated with cabozantinib. Therefore, caution should be recommended when driving or operating machines.

4.8. Undesirable effects

Summary of safety profile

The most common serious adverse reactions associated with cabozantinib are pneumonia, mucosal inflammation, hypocalcaemia, dysphagia, dehydration, pulmonary embolism, and hypertension. The most frequent adverse reactions of any grade (experienced by at least 20% of patients) included diarrhoea, PPES, weight decreased, decreased appetite, nausea, fatigue, dysgeusia, hair colour changes, hypertension, stomatitis, constipation, vomiting, mucosal inflammation, asthenia, and dysphonia.

The most common laboratory abnormalities were increased aspartate aminotransferase (AST), increased alanine aminotransferase (ALT), increased alkaline phosphatase (ALP), lymphopenia, hypocalcaemia, neutropenia, thrombocytopenia, hypophosphatemia, hyperbilirubinemia, hypomagnesaemia, and hypokalaemia.

Tabulated list of adverse reactions

Adverse reactions are listed in Table 1 according to MedDRA system organ class and frequency categories. Frequencies are based on all grades and defined as very common (≥1/10), common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100), not known (cannot be estimated from the available data). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.

Table 1: Adverse reactions reported with cabozantinib

Infections and infestations

Common

abscess* (including visceral, skin, tooth), pneumonia, folliculitis, fungal infection (including skin, oral, genital)

Uncommon

aspergilloma

Endocrine disorders

Common

hypothyroidism

Metabolism and nutrition disorders

Very Common

decreased appetite, hypocalcaemiac, hypokalaemiac, hypomagnesaemiac

Common

dehydration*, hypoalbuminaemiac, hyperbilirubinaemiad, hypophosphatemiac

Psychiatric disorders

Common

anxiety, depression, confusional state

Uncommon

abnormal dreams, delirium

Nervous system disorders

Very Common

dysgeusia, headache, dizziness

Common

cerebrovascular accident*, peripheral neuropathy, paraesthesia, ageusia, tremor

Uncommon

ataxia, disturbance in attention, hepatic encephalopathy, loss of consciousness, speech disorder, posterior reversible encephalopathy syndrome*

Eye disorders

Common

vision blurred

Uncommon

cataract, conjunctivitis

Ear and labyrinth disorders

Common

ear pain, tinnitus

Uncommon

hypoacusis

Cardiac disorders

Common

atrial fibrillation, cardiac failure

Uncommon

angina pectoris, supraventricular tachycardia

Not Known

myocardial infarction

Vascular disorders

Very Common

hypertension*f

Common

hypotensiong, deep vein thrombosis*, venous thrombosis*, arterial thrombosis*, pallor, peripheral coldness

Uncommon

hypertensive crisish, embolism arterial

Not Known

aneurysms and artery dissections

Respiratory, thoracic, and mediastinal disorders

Very Common

dysphonia, oropharyngeal pain

Common

non-gastrointestinal fistula* (including tracheal, pneumomediastinum, tracheo-oesophageal), pulmonary embolism*, respiratory tract haemorrhage* (including pulmonary, bronchial, tracheal), pneumonia aspiration

Uncommon

atelectasis, pharyngeal oedema, pneumonitis, pneumothorax

Gastrointestinal disorders

Very Common

diarrhoea*, nausea*, stomatitis, constipation, vomiting*, abdominal paine, dyspepsia, dysphagia, glossodynia

Common

gastrointestinal perforation*, gastrointestinal fistula*, gastrointestinal haemorrhage*, pancreatitis, haemorrhoids, anal fissure, anal inflammation, cheilitis

Uncommon

oesophagitis

Hepatobiliary disorders

Common

cholelithiasis

Skin and subcutaneous tissue disorders

Very Common

palmar-plantar erythrodysaesthesia syndrome*, hair colour changes, rash, dry skin, alopecia, erythema

Common

hyperkeratosis, acne, blister, hair growth abnormal, skin exfoliation, skin hypopigmentation

Uncommon

skin ulcer, telangiectasia

Not known

cutaneous vasculitis

Musculoskeletal and connective tissue disorders

Very Common

arthralgia, muscle spasms, pain in extremity

Common

musculoskeletal chest pain, osteonecrosis of jaw*

Uncommon

rhabdomyolysis

Renal and urinary disorders

Common

proteinuria*, dysuria, haematuria

Uncommon

renal failure acute

Reproductive system and breast disorders

Uncommon

amenorrhoea, vaginal haemorrhage

General disorders and administration site conditions

Very Common

fatigue, mucosal inflammation, asthenia

Common

impaired wound healing*, chills, face oedema

Uncommon

cyst, facial pain, localised oedema

Investigations

Very Common

weight decreased, serum ALT, AST, and ALP increased, blood LDH increased, blood TSH increased*d, thrombocytopeniaa

Common

blood creatinine increased, lymphopeniaa, neutropeniaa, lipase increased

Uncommon

activated partial thromboplastin time shortened, eosinophil count increasedb, platelet count increasedb

*See section 4.8 Description of selected adverse reactions for further characterisation.

The following terms have been combined to derive appropriate frequency categorisation:

a Lowered haematology parameters: Lymphopenia and lymphocyte count decreased; Neutropenia and neutrophil count decreased; Thrombocytopenia and platelet count decreased.

bElevated haematology parameters: Eosinophil count increased and eosinophilia; Platelet count increased and thrombocytosis

c Lowered biochemistry parameters: Hypoalbuminaemia and blood albumin decreased; Hypocalcaemia and blood calcium decreased; Hypokalaemia and blood potassium decreased; Hypomagnesaemia and blood magnesium decreased; Hypohosphatemia and blood phosphorus decreased.

d Elevated biochemistry parameters: Hyperbilirubinaemia and blood bilirubin increased; Hypothyroidism and blood thyroid stimulating hormone increased.

e Abdominal pain, abdominal discomfort, abdominal pain upper and abdominal pain lower

f Hypertension and blood pressure increased.

g Hypotension and blood pressure decreased.

h No hypertensive crisis was reported in Cometriq clinical trials; the frequency is based on pooled cabozantinib data (including Cabometyx 60 mg tablet data).

Description of selected adverse reactions

A thyroid stimulating hormone (TSH) value above normal after first dose was observed in 57% of patients on cabozantinib versus 19% of patients on placebo (regardless of baseline values). Ninety-two percent of patients on the cabozantinib arm had a prior thyroidectomy, and 89% were taking thyroid hormones prior to first dose.

An increase from baseline in corrected QT interval by Fridericia (QTcF) of 10 ‑ 15 ms on Day 29 (but not on Day 1) following initiation of cabozantinib treatment (at a dose of 140 mg qd) was observed in a controlled clinical study in cancer patients (see section 4.4). This effect was not associated with a change in cardiac wave form morphology or new rhythms. No cabozantinib-treated subjects had a QTcF >500 ms.

Please refer to section 4.4 for recommendations about the monitoring and management of the following adverse events: perforations, fistulas, and intra-abdominal abscesses; thromboembolic events; haemorrhage; aneurysms and artery dissections; gastrointestinal disorders; wound complications; hypertension; osteonecrosis; palmar-plantar erythrodysaesthesia syndrome; proteinuria; and posterior reversible encephalopathy syndrome.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the national reporting system listed below.

United Kingdom

Yellow Card Scheme

Website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9. Overdose

There is no specific treatment for cabozantinib overdose and possible symptoms of overdose have not been established.

In the event of suspected overdose, cabozantinib should be withheld and supportive care instituted. Metabolic clinical laboratory parameters should be monitored at least weekly or as deemed clinically appropriate to assess any possible changing trends. Adverse reactions associated with overdose are to be treated symptomatically.