4.1. Therapeutic indications

Fotivda is indicated for the first line treatment of adult patients with advanced renal cell carcinoma (RCC) and for adult patients who are VEGFR and mTOR pathway inhibitor-naïve following disease progression after one prior treatment with cytokine therapy for advanced RCC.

4.2. Posology and method of administration

Fotivda should be supervised by a physician experienced in the use of anticancer therapies.

Posology

The recommended dose of tivozanib is 1340 microgram once daily for 21 days, followed by a 7-day rest period to comprise one complete treatment cycle of 4 weeks.

This treatment schedule should be continued until disease progression or unacceptable toxicity.

No more than one dose of Fotivda must be taken per day.

Dose modification

The occurrence of undesirable effects may require temporary interruption and/or dose reduction of tivozanib therapy (see section 4.4). In the pivotal study, the dose was reduced for grade 3 events and interrupted for grade 4 events.

When dose reduction is necessary, the tivozanib dose can be reduced to 890 microgram once daily with the normal treatment schedule of 21 days of dosing, followed by a 7-day rest period.

Missed dose

In the case of a missed dose a replacement dose must not be taken to make up for a forgotten dose. The next dose should be taken at the next scheduled time.

In the case of vomiting a replacement dose should not be taken; the next dose should be taken at the next scheduled time.

Special populations

Paediatric population

The safety and efficacy of tivozanib in children and adolescents aged below 18 years have not been established. No data are available. There is no relevant use of tivozanib in the paediatric population in the indication advanced renal cell carcinoma.

Elderly patients

No dose adjustment is required in patients 65 years of age or older (see sections 4.4 and 5.1).

Patients with renal impairment

No dose adjustment is required in patients with mild or moderate renal impairment (see section 5.2). Caution is advised in patients with severe renal impairment due to limited experience and in patients undergoing dialysis as there is no experience of tivozanib in this patient population.

Patients with hepatic impairment

All patients should have liver function tests evaluated, including alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, and alkaline phosphatase (AP), to determine hepatic function before starting and during treatment with tivozanib.

Tivozanib is not recommended in patients with severe hepatic impairment. Patients with moderate hepatic impairment should only be treated with one tivozanib 1340 microgram capsule every other day as they may be at an increased risk of adverse reactions due to increased exposure with the dose of 1340 microgram every day (see section 4.4 and section 5.2). No dose adjustment is required when administering tivozanib to patients with mild hepatic impairment. Tivozanib should be used with caution in patients with mild and moderate hepatic impairment with close monitoring of tolerability.

Method of administration

Fotivda is for oral use.

Fotivda may be taken with or without food (see section 5.2). The capsules must be swallowed whole with a glass of water and must not be opened.

4.3. Contraindications

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

Co-administration with herbal preparations containing St. John's wort (Hypericum perforatum) (see section 4.5).

4.4. Special warnings and precautions for use

Hypertension

In clinical studies with tivozanib, hypertension (including persistent severe hypertension) has occurred (see section 4.8). In approximately one-third of the patients, hypertension developed within the first 2 months of treatment. Blood pressure should be well controlled prior to initiating tivozanib. During treatment, patients should be monitored for hypertension and treated as needed with anti-hypertensive therapy according to standard medical practice. In the case of persistent hypertension despite use of anti-hypertensive therapy, the tivozanib dose should be reduced, or the treatment interrupted and re-initiated at a lower dose once the blood pressure is controlled, according to clinical judgment (see section 4.2). Discontinuation of treatment should be considered in cases of persistent severe hypertension, posterior reversible encephalopathy syndrome (see below), or other complications of hypertension. Patients receiving anti-hypertensive medicinal product should still be monitored for hypotension when tivozanib is either interrupted or discontinued.

Arterial thromboembolic events

In clinical studies with tivozanib, arterial thromboembolic events (ATEs) have occurred (see section 4.8). Risk factors for ATE include malignant disease, age > 65 years, hypertension, diabetes mellitus, smoking, hypercholesterolaemia, and prior thromboembolic disease. Tivozanib has not been studied in patients who had an ATE within the preceding 6 months of clinical study initiation. Tivozanib must be used with caution in patients who are at risk for, or who have a history of these events (such as myocardial infarction, stroke).

Venous thromboembolic events

In clinical studies with tivozanib, venous thromboembolic events (VTEs) have been reported including pulmonary embolism and deep vein thrombosis (see section 4.8). Risk factors for VTEs include major surgery, multiple trauma, prior VTEs, advanced age, obesity, cardiac or respiratory failure, and prolonged immobility. Tivozanib has not been studied in patients who had a VTE within the preceding 6 months of clinical study initiation. Treatment decision, especially in patients who are at risk for VTEs, should be based on individual patient benefit/risk assessment.

Cardiac failure

In clinical studies with tivozanib as monotherapy for the treatment of patients with RCC, cardiac failure has been reported (see section 4.8). Signs or symptoms of cardiac failure should be periodically monitored throughout treatment with tivozanib. Management of cardiac failure events may require temporary interruption or permanent discontinuation and/or dose reduction of tivozanib therapy, plus treatment of potential underlying causes of cardiac failure, e.g. hypertension.

Haemorrhage

In clinical studies with tivozanib, haemorrhagic events have been reported (see section 4.8). Tivozanib must be used with caution in patients who are at risk for, or who have a history of bleeding. If any bleeding requires medical intervention, tivozanib should be temporarily interrupted.

Proteinuria

Proteinuria has been reported in clinical studies with tivozanib (see section 4.8). Monitoring for proteinuria before initiation of, and periodically throughout treatment is recommended. For patients who develop Grade 2 (> 1.0-3.4 g/24 hours) or Grade 3 (≥ 3.5 g/24 hours) proteinuria (National Cancer Institute Common Terminology Criteria for Adverse Events [NCI CTCAE]), the dose of tivozanib has to be reduced or the treatment temporarily interrupted. If the patient develops Grade 4 proteinuria (nephrotic syndrome) tivozanib has to be discontinued. Risk factors for proteinuria include high blood pressure.

Hepatotoxicity

In clinical studies with tivozanib, elevations of ALT, AST, and bilirubin have been reported (see section 4.8). The majority of AST and ALT elevations were not accompanied with concomitant elevations of bilirubin. AST, ALT, bilirubin, and AP should be monitored before initiation of and periodically throughout treatment with tivozanib because of the potential risk of hepatotoxicity (see section 4.2).

Tivozanib is not recommended in patients with severe hepatic impairment.

Posterior reversible encephalopathy syndrome (PRES)

In clinical studies, one case of PRES was confirmed after treatment with tivozanib (see section 4.8). PRES is a neurological disorder which can present with headache, seizure, lethargy, confusion, blindness and other visual and neurologic disturbances. Mild to severe hypertension may be present. Magnetic Resonance Imaging is necessary to confirm the diagnosis of PRES. Tivozanib must be discontinued in patients developing signs or symptoms of PRES. The safety of re-initiating tivozanib therapy in patients previously experiencing PRES is not known and tivozanib should only be used with caution in these patients.

Hand foot skin reaction (HFSR)

In clinical studies with tivozanib, hand foot skin reaction (palmar-plantar erythrodysaesthesia) has been reported. Most events in the five renal cell carcinoma monotherapy studies were CTC Grade 1 or 2 (≥ CTC Grade 3 was observed in < 2% of patients treated with tivozanib) and there were no serious events (see section 4.8). Management of patients experiencing HFSR may include topical therapies for symptomatic relief with consideration of temporary interruption and/or reduction in treatment dose or, in severe or persistent cases, permanent discontinuation of treatment.

QT interval prolongation

In clinical studies with tivozanib, QT/QTc interval prolongation has been reported (see section 4.8 and section 5.1). QT/QTc interval prolongation may lead to an increased risk for ventricular arrhythmias. It is recommended that tivozanib be used with caution in patients with a history of QT interval prolongation or other relevant pre-existing cardiac disease and those receiving other medications known to increase the QT interval. Baseline and periodic monitoring of electrocardiograms and maintenance of electrolytes (e.g. calcium, magnesium, potassium) within the normal range is recommended.

Gastrointestinal (GI) perforation/fistula

It is recommended that symptoms of GI perforation or fistula should be periodically monitored throughout treatment with tivozanib and that tivozanib should be used with caution in patients at risk for GI perforation or fistula.

Wound healing complications

For precautionary reasons, temporary interruption of tivozanib therapy is recommended in patients undergoing major surgical procedures. The decision to resume tivozanib therapy after surgery should be based on clinical judgment of adequate wound healing.

Hypothyroidism

In clinical studies with tivozanib, hypothyroidism has been reported (see section 4.8). Hypothyroidism has been observed to occur at any time during treatment with tivozanib, developing as early as within two months of treatment initiation. Risk factors for hypothyroidism include prior history of hypothyroidism and use of anti-thyroid medications. Thyroid function should be monitored before initiation of, and periodically throughout treatment with tivozanib. Hypothyroidism should be treated according to standard medical practice.

Elderly patients

Dysphonia, diarrhoea, fatigue, weight decreased, appetite decreased and hypothyroidism occurred more commonly in patients ≥ 65 years of age. Healthcare professions should be aware that elderly patients may be at increased risk of adverse reactions.

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 Fotivda, this risk should be carefully considered in patients with risk factors such as hypertension or history of aneurysm

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

Contraindication of concomitant use

Herbal preparations containing St. John's wort (Hypericum perforatum) are contraindicated. If a patient is already taking St John's wort, this should be stopped before starting tivozanib treatment. The inducing effect of St John's wort may persist for at least 2 weeks after cessation of treatment with St John's wort (see section 4.3).

Strong CYP3A4 inducers

In a clinical study in healthy volunteers, co-administration of a single 1340 microgram dose of tivozanib with a strong CYP3A4 inducer at steady-state (rifampin 600 mg once daily) decreased the average half-life of tivozanib from 121 to 54 hours which was associated with a decrease in the single dose AUC0-∞ of 48% compared with AUC0-∞ in the absence of rifampin. Average Cmax and AUC0-24hr were not significantly affected (8% increase and 6% decrease respectively). The clinical effects of strong CYP3A4 inducers on repeated daily dosing of tivozanib has not been studied but potentially the average time to reach steady-state and the average steady-state serum concentration of tivozanib may be reduced, due to the reduction in half-life. It is recommended that concomitant administration of tivozanib with strong CYP3A4 inducers, if used, should be undertaken with caution.

Moderate CYP3A4 inducers are not expected to have a clinically relevant effect on tivozanib exposure.

CYP3A4 inhibitors

In a clinical study in healthy volunteers, co-administration of tivozanib with a potent CYP3A4 inhibitor, ketoconazole (400 mg once daily), had no influence on tivozanib serum concentrations (Cmax or AUC); therefore, tivozanib exposure is unlikely to be altered by CYP3A4 inhibitors.

Medicinal products for which intestinal absorption is restricted by BCRP

Tivozanib inhibits the transporter protein BCRP in vitro, but the clinical relevance of this finding is unknown (see section 5.2). Caution should be exercised if tivozanib is co-administered with rosuvastatin. Alternatively, a statin not subject to restriction of intestinal absorption by BCRP should be considered. Patients taking an oral BCRP substrate with a clinically-relevant efflux interaction in the gut should ensure that a suitable time window (e.g. 2 hours) is applied between administration of tivozanib and the BCRP substrate.

Contraceptives

It is currently unknown whether tivozanib may reduce the effectiveness of hormonal contraceptives, and therefore women using hormonal contraceptives should add a barrier method (see section 4.6).

4.6. Fertility, pregnancy and lactation

Women of childbearing potential/Contraception in males and females

Women of childbearing potential should avoid becoming pregnant while on tivozanib. Female partners of male patients taking tivozanib should also avoid pregnancy. Effective methods of contraception should be used by male and female patients and their partners during therapy, and for at least one month after completing therapy. It is currently unknown whether tivozanib may reduce the effectiveness of hormonal contraceptives and therefore women using hormonal contraceptives should add a barrier method.

Pregnancy

There are no data from the use of tivozanib in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3).

Tivozanib should not be used during pregnancy. If tivozanib is used during pregnancy, or if the patient becomes pregnant while receiving tivozanib, the potential hazard to the foetus must be explained to the patient.

Breast-feeding

It is unknown whether tivozanib is excreted in human milk, but the potential exists. Because of the potential for tivozanib-mediated adverse reactions in breastfed infants, women should not breast-feed while taking tivozanib.

Fertility

Animal studies indicate that male and female fertility may be affected by treatment with tivozanib (see section 5.3).

4.7. Effects on ability to drive and use machines

Tivozanib may have a minor influence on the ability to drive and use machines. Patients should be advised to be cautious when driving or using machines if they experience asthenia, fatigue, and/or dizziness during treatment with tivozanib (see section 4.8).

4.8. Undesirable effects

Summary of the safety profile

Pooled data of 674 patients with advanced RCC who continued to receive tivozanib as their initial on trial therapy in the five core RCC monotherapy studies have been evaluated in the overall assessment of safety and tolerability of tivozanib.

The most important serious adverse reaction is hypertension.

The most common adverse reactions of any grade include hypertension (47.6%), dysphonia (26.9%), fatigue (25.8%) and diarrhoea (25.5%).

In the five core RCC monotherapy studies tivozanib was discontinued in a total of 20 patients (3%) owing to adverse reactions, most commonly due to hypertension (0.4%), persistent severe hypertension (0.3%), or acute myocardial infarction (0.3%). The most frequent adverse reactions leading to tivozanib dose reduction/ interruption were hypertension (4.7%), diarrhoea (3.1%), fatigue (1.8%).

In patients receiving tivozanib as initial therapy, there were three adverse reactions with outcome death; one was uncontrolled hypertension in the setting of a suspected overdose (see section 4.9) and two were reported simply as death.

Tabulated summary of adverse reactions

Adverse reactions occurring in patients who continued to receive tivozanib as their initial on trial therapy in the five RCC monotherapy studies were pooled and are listed below by MedDRA body system organ class (SOC) and frequency. Frequencies are defined as follows: 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 not known (cannot be estimated from available data). Within each SOC, adverse reactions are presented in order of decreasing seriousness.

Table 1: Tabulated list of adverse reactions (presented using frequencies for all-causality adverse events)

System Organ Class

Very common

Common

Uncommon

Rare

Not known

Infections and infestations

Fungal infection

Pustular rash

Blood and lymphatic system disorders

Anaemia

Thrombocytopenia

Haemoglobin increased

Endocrine disorders

Hypothyroidism

Hyperthyroidism

Goitre1

Metabolism and nutrition disorders

Decreased appetite

Anorexia

Psychiatric disorders

Insomnia

Nervous system disorders

Headache

Peripheral neuropathy2

Dizziness

Dysgeusia3

Transient ischaemic attack

Memory impairment4

Posterior reversible encephalopathy syndrome (PRES)5

Eye disorders

Vision impairment6

Increased lacrimation

Ear and labyrinth disorders

Vertigo

Tinnitus

Ear congestion

Cardiac disorders

Myocardial infarction (acute) / ischaemia7

Angina pectoris

Tachycardia8

Pulmonary oedema

Coronary artery insufficiency

Electrocardiogram

QT prolonged

Vascular disorders

Hypertension

Haemorrhage9

Arterial thromboembolism10

Venous thromboembolism11

Persistent severe hypertension12

Flushing13

Aneurysms and artery dissections

Respiratory, thoracic and mediastinal disorders

Dyspnoea14

Dysphonia

Cough

Epistaxis

Rhinorrhoea

Nasal congestion

Gastrointestinal disorders

Abdominal pain15

Nausea

Diarrhoea

Stomatitis16

Pancreatitis17

Dysphagia18

Vomiting

Gastrooesophageal reflux disease

Abdominal distension

Glossitis19

Gingivitis20

Dyspepsia

Constipation

Dry mouth

Flatulence

Duodenal ulcer

Hepatobiliary disorders

ALT increased / AST increased21

Gamma-glutamyltransferase increased

Blood alkaline phosphatase increased

Skin and subcutaneous tissue disorders

Palmar-plantar erythrodysaesthesia syndrome / Hand foot skin reaction (PPE/HFS)

Skin exfoliation

Erythema22

Pruritus23

Alopecia

Rash24

Acne25

Dry skin

Urticaria

Dermatitis26

Hyperhidrosis

Xeroderma

Musculoskeletal and connective tissue disorders

Back pain

Arthralgia

Myalgia

Musculoskeletal chest pain

Muscular weakness

Renal and urinary disorders

Proteinuria

Blood creatinine increased

General disorders and administration site conditions

Pain27

Asthenia

Fatigue

Chest pain28

Chills29

Pyrexia

Peripheral oedema

Mucosal inflammation

Investigations

Weight decreased

Amylase increased

Lipase increased

Blood thyroid stimulating hormone increased

Adverse reactions from clinical studies are presented using frequencies for all-causality adverse events. The following terms have been combined:

1 Goitre including goitre and toxic nodular goitre

2 Peripheral neuropathy including hyperaesthesia, hypoaesthesia, mononeuropathy, neuropathy peripheral, peripheral sensory neuropathy and paraesthesia

3 Dysgeusia including ageusia, dysgeusia and hypogeusia

4 Memory impairment including amnesia and memory impairment

5 PRES was not observed in patients treated with tivozanib in the five RCC monotherapy studies. One patient experienced Grade 4 PRES and hypertension in Study AV-951-09-901.

6 Vision impairment including reduced visual acuity, vision blurred and visual impairment

7 Myocardial infarction (acute) / ischaemia including acute myocardial infarction, ischaemia and myocardial infarction

8 Tachycardia including sinus tachycardia, supraventricular tachycardia, tachycardia and tachycardia paroxysmal

9 Haemorrhage including adrenal haemorrhage, anal haemorrhage, cervix haemorrhage uterine, duodenal ulcer haemorrhage, gingival bleeding, haematemesis, haemoptysis, haemorrhagic anaemia, haemorrhagic erosive gastritis, haemorrhagic stroke, mouth haemorrhage, pulmonary haemorrhage and respiratory tract haemorrhage

10 Arterial thromboembolism including acute myocardial infarction, arterial thrombosis, iliac artery thrombosis, ischaemic stroke, myocardial infarction and transient ischaemic attack

11 Venous thromboembolism including deep vein thrombosis, embolism venous and pulmonary embolism

12 Persistent severe hypertension including hypertensive crisis

13 Flushing including flushing and hot flush

14 Dyspnoea including dyspnoea and exertional dyspnoea

15 Abdominal pain including abdominal discomfort, abdominal pain, abdominal pain lower, abdominal pain upper and abdominal rigidity

16 Stomatitis including oral discomfort, oral disorder and stomatitis

17 Pancreatitis including pancreatitis and pancreatitis acute

18 Dysphagia including dysphagia, odynophagia and oropharyngeal pain

19 Glossitis including glossitis and glossodynia

20 Gingivitis including gingival bleeding, gingival disorder, gingival pain and gingivitis

21 Alanine aminotransferase (ALT) increased / Aspartate aminotransferase (AST) increased including ALT increased and AST increased

22 Erythema including erythema, generalised erythema and palmar erythema

23 Pruritus including generalised pruritus and pruritus

24 Rash including rash, rash erythematous, rash generalised, rash maculo-papular, rash papular and rash pruritic

25 Acne including acne and dermatitis acneiform

26 Dermatitis including dermatitis and dermatitis bullous

27 Pain including bone pain, cancer pain, flank pain, groin pain, oral pain, pain, pain in extremity and tumour pain

28 Chest pain including chest pain and non-cardiac chest pain

29 Chills including chills and hypothermia

Description of selected adverse reactions

Hypertension

Hypertension was reported as an adverse reaction in 47.6% of patients receiving tivozanib as initial therapy; in 23.0% the hypertension was CTC ≥Grade 3. Persistent severe hypertension ('hypertensive crisis') was an adverse reaction in 1.0%, CTC Grade 3 or higher in 0.9%. One patient died as a result of uncontrolled hypertension in the setting of a suspected overdose.

Posterior Reversible Encephalopathy Syndrome (PRES)

PRES (also known as reversible posterior leukoencephalopathy syndrome (RPLS)) was confirmed in one non-RCC patient after approximately 8 weeks on tivozanib. PRES is a neurological disorder that may present with headache, seizure, lethargy, confusion, blindness and other visual and neurologic disturbances. Mild to severe hypertension may be present (see section 4.4).

Venous thromboembolism

Pulmonary embolism was reported in patients (0.7%) receiving tivozanib as initial therapy in the five core RCC monotherapy studies, with the majority CTC Grade ≥ 3 (see section 4.4). Deep vein thrombosis was also reported in two patients (0.3%) and was CTC Grade ≥ 3 in one patient (0.1%) receiving initial tivozanib therapy.

Arterial thromboembolic events

Arterial thromboembolic adverse reactions in the patients receiving tivozanib as initial therapy were ischaemic stroke (1.0%), myocardial infarction (0.7%), transient ischaemic attack (0.7%) and acute myocardial infarction (0.4%), the majority of which were at least CTC Grade 3, plus iliac artery thrombosis (0.1%). There were no deaths due to arterial thromboembolic adverse reactions in those receiving tivozanib as initial therapy but a myocardial infarction in a patient receiving second-line tivozanib had a fatal outcome.

Cardiac failure

Pulmonary oedema was reported in two patients (0.3%) receiving tivozanib as initial therapy in the five core RCC monotherapy studies. Both events were CTC Grade 3 (see section 4.4).

QT/QTc prolongation

QT prolongation was reported in two patients (CTC Grade 2 and Grade 3) in the tivozanib cardiac safety study, neither reaction was considered serious (see section 4.4 and section 5.1).

Hypothyroidism

Hypothyroidism was reported as an adverse reaction for 5.6% of patients during initial therapy and was CTC Grade 2 or lower in all cases. It was reported as serious in one patient.

Haemorrhage

Haemorrhage adverse reactions were reported in the core monotherapy studies during initial treatment (see section 4.4).

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 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

Two patients received excessive doses of tivozanib during the monotherapy studies. A patient with a history of hypertension experienced aggravated uncontrolled hypertension that was fatal after taking 3 doses of 1340 microgram tivozanib in one day (total 4020 microgram). No adverse reaction was experienced by the second patient who took 2 doses of 1340 microgram tivozanib in one day (total 2680 microgram).

Blood pressure should be well controlled prior to initiating tivozanib and patients should be monitored for hypertension during treatment (see section 4.4).

In cases of suspected overdose, tivozanib should be discontinued and the patient monitored for hypertension and treated as needed with standard anti- hypertensive therapy.

There is no specific treatment or antidote for tivozanib overdose.