Enasidenib – Uses, Dosage, Side Effects, Interaction

Enasidenib is an orally available inhibitor of specific mutant forms of the mitochondrial enzyme isocitrate dehydrogenase type 2 (IDH2), with potential antineoplastic activity. Upon administration, enasidenib specifically inhibits various mutant forms of IDH2, including the IDH2 variants R140Q, R172S, and R172K, which inhibits the formation of 2-hydroxyglutarate (2HG). This may lead to both an induction of cellular differentiation and an inhibition of cellular proliferation in IDH2-expressing tumor cells. IDH2, an enzyme in the citric acid cycle, is mutated in a variety of cancers; it initiates and drives cancer growth by blocking differentiation and the production of the oncometabolite 2HG.

Indications

  • Indicated for the treatment of adult patients with relapsed or refractory acute myeloid leukemia (AML) with an isocitrate dehydrogenase-2 (IDH2) mutation.
  • Treatment of acute myeloid leukaemia
  • Enasidenib is an orally available small molecule inhibitor of isocitrate dehydrogenase and antineoplastic agent that is used in the therapy of selected cases of acute myeloid leukemia (AML).
  • Enasidenib is used to treat relapsed or refractory acute myeloid leukemia in people with specific mutations of the IDH2 gene, determined by an FDA-approved IDH2 companion diagnostic test.[rx]
  • Refractory Acute Myeloid Leukemia (AML)
  • Relapsed Acute Myelogenous Leukemia (AML)

Contraindications

  • high levels of white blood cells
  • the high amount of bilirubin in the blood
  • pregnancy
  • a patient who is producing milk and breastfeeding
  • a complication of treatment in certain types of leukemia called differentiation syndrome

Dosage

Strengths: 50 mg; 100 mg

Acute Myeloid Leukemia

  • 100 mg orally once a day with or without food
  • Duration of Therapy: Treat until disease progression or unacceptable toxicity.
  • For patients without disease progression or unacceptable toxicity, treatment for a minimum of 6 months to allow time for clinical response.

Select patients based on the presence of isocitrate dehydrogenase-2 (IDH2) mutations in the blood or bone marrow as detected by an FDA-approved test, http://www.fda.gov/CompanionDiagnostics. Treatment of relapsed or refractory acute myeloid leukemia (AML) with an IDH2 mutation.

Dose Adjustments

MANAGING TOXICITIES:
Differentiation Syndrome:

  • If differentiation syndrome is suspected, administer systemic corticosteroids and initiate hemodynamic monitoring.
  • Interrupt treatment if severe pulmonary symptoms requiring intubation or ventilator support, and/or renal dysfunction persist for more than 48 hours after initiation of corticosteroids.
  • Resume treatment when signs/symptoms improve to Grade 2 or lower.

Noninfectious Leukocytosis [white blood cell (WBC) count greater than 30 x 10(9)/L]:

  • Initiate hydroxyurea, as per standard institutional practices.
  • Interrupt enasidenib if leukocytosis is not improved with hydroxyurea, and then resume enasidenib at 100 mg daily when WBC is less than 30 x 10(9)/L.

Other Treatment-Related Grade 3 or Higher Toxicity (e.g., tumor lysis syndrome):

  • Interrupt treatment until toxicity resolves to Grade 2 or lower.
  • Resume treatment at 50 mg/day; may increase to 100 mg/day if toxicities resolve to Grade 1 or lower.
  • Discontinue treatment if Grade 3 or higher toxicity recurs.

Side Effects

The Most Common

  • nausea
  • vomiting
  • diarrhea
  • decreased appetite
  • change in the way things taste
  • yellowing of your eyes or skin
  • muscle spasms or twitching; burning, prickling, or tingling feeling on the skin; irregular heartbeat; or seizures
  • fever, cough, trouble breathing;
  • bone pain;
  • rapid weight gain; or
  • swelling in your arms, legs, underarms, groin, or neck.
  • severe or ongoing vomiting or diarrhea; or
  • signs of tumor cell breakdown–tiredness, weakness, muscle cramps, nausea, vomiting, diarrhea, fast or slow heart rate, tingling in your hands and feet or around your mouth.
  • dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes);
  • loss of appetite; or
  • jaundice.
  • nausea, vomiting, diarrhea;

More common

  • Agitation
  • blue lips, fingernails, or skin
  • bone pain
  • chest pain
  • chills
  • confusion
  • cough
  • coughing that sometimes produces a pink frothy sputum
  • decreased awareness or responsiveness
  • decreased urine output
  • depression
  • difficult or troubled breathing
  • difficult, fast, noisy breathing
  • dizziness
  • eye pain
  • fainting
  • fast heartbeat
  • fever
  • a general feeling of illness
  • headache
  • hostility
  • increased sweating
  • irregular, fast or slow, or shallow breathing
  • irritability
  • lightheadedness
  • loss of consciousness
  • muscle or joint pain
  • muscle twitching
  • nausea
  • pale skin
  • rapid weight gain
  • rapid, shallow breathing
  • seizures
  • severe sleepiness
  • sore throat
  • swelling around the neck, groin, or underarm area
  • swelling of the arms, feet, or lower legs
  • swelling of the face, ankles, or hands
  • unusual drowsiness, dullness, tiredness, weakness, or feeling of sluggishness
  • yellow skin or eyes

Rare

  • changed sense of taste
  • decreased appetite
  • diarrhea
  • fatigue
  • nausea
  • vomiting
  • difficulty breathing at rest or worsens when lying down
  • fever
  • signs of anemia (low red blood cells; e.g., dizziness, pale skin, unusual tiredness or weakness, shortness of breath)
  • signs of clotting problems (e.g., unusual nosebleeds, bruising, blood in urine, coughing blood, bleeding gums, cuts that don’t stop bleeding)
  • signs of infection (e.g., fever or chills, severe diarrhea, shortness of breath, prolonged dizziness, headache, stiff neck, weight loss, or listlessness)
  • signs of liver problems (e.g., nausea, vomiting, diarrhea, loss of appetite, weight loss, yellowing of the skin or whites of the eyes, dark urine, pale stools)
  • low levels of oxygen (hypoxia; changes in skin color, confusion, fast heart rate, rapid breathing, shortness of breath, sweating, wheezing)
  • symptoms of differentiation syndrome (e.g., fever, cough, shortness of breath, arm, leg, or neck swelling, fast weight gain, dizziness, lightheadedness, bone pain)
  • symptoms of tumor lysis syndrome (e.g., producing less urine, cloudy urine, kidney problems, muscle spasms, nausea, shortness of breath)

Drug Interactions

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Drug-Food Interactions

  • Exercise caution with grapefruit products. Grapefruit inhibits CYP3A4 metabolism, which may increase the serum concentration of enasidenib; however, CYP3A4 is one of many enzymes involved in enasidenib metabolism.
  • Exercise caution with St. John’s Wort. This herb induces CYP3A4 metabolism, which may reduce the serum concentration of enasidenib; however, CYP3A4 is one of many enzymes involved in enasidenib metabolism.
  • Take it at the same time every day.
  • Take it with a full glass of water.
  • Take it with or without food.

Pregnancy And Lactation

US FDA pregnancy category Not Assigned:

Pregnancy

Based on animal embryo-fetal toxicity studies, IDHIFA can cause fetal harm when administered to a pregnant woman. There are no available data on IDHIFA use in pregnant women to inform a drug-associated risk of major birth defects and miscarriage. In animal embryo-fetal toxicity studies, oral administration of enasidenib to pregnant rats and rabbits during organogenesis was associated with embryo-fetal mortality and alterations to growth starting at 0.1 times the steady-state clinical exposure based on the AUC at the recommended human dose (see Data). If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, advise the patient of the potential risk to a fetus. Adverse outcomes in pregnancy occur regardless of the health of the mother or the use of medications. The background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2%-4% and 15%-20%, respectively.

Lactation

No information is available on the clinical use of enasidenib during breastfeeding. Because enasidenib is 98.5% bound to plasma proteins and its active metabolite is 96.6% bound to plasma proteins, the amount in milk is likely to be low. However, the half-life of enasidenib is 137 hours and it might accumulate in the infant. The manufacturer recommends that breastfeeding be discontinued during enasidenib therapy and for at least 2 months after the end of therapy.

How should this medicine be used?

Enasidenib comes as a tablet to take by mouth. It is usually taken once a day with or without food. Take enasidenib at around the same time every day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take enasidenib exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor.

Swallow the tablets whole with a cup (8 ounces [240 mL]) of water; do not split, chew, or crush them.

If you vomit after taking a dose of enasidenib, take another dose as soon as possible on the same day.

Your doctor may temporarily or permanently stop your treatment, decrease your dose of enasidenib, or treat you with other medications depending on the side effects that you experience. Be sure to talk to your doctor about how you are feeling during your treatment. Do not stop taking enasidenib without talking to your doctor.

What special precautions should I follow?

Before taking enasidenib,

  • tell your doctor and pharmacist if you are allergic to enasidenib, any other medications, or any of the ingredients in enasidenib tablets. Ask your pharmacist or check the Medication Guide for a list of the ingredients.
  • tell your doctor and pharmacist what prescription and nonprescription medications, vitamins, nutritional supplements, and herbal products you are taking or plan to take. Your doctor may need to change the doses of your medications or monitor you carefully for side effects.
  • tell your doctor if you are pregnant, plan to become pregnant, or plan to father a child. You should not become pregnant while you are taking enasidenib. You will need to have a negative pregnancy test before you begin taking this medication. Use effective birth control during your treatment with enasidenib and for one month after your final dose. If you are a male and your partner can become pregnant, you should use effective birth control during your treatment and for one month after your final dose. Enasidenib may decrease the effectiveness of certain oral contraceptives so talk to your doctor about birth control methods that will work for you. If you or your partner become pregnant while taking enasidenib, call your doctor.
  • tell your doctor if you are breastfeeding. You should not breastfeed while you are enasidenib and for one month after your final dose.
  • you should know that this medication may decrease fertility in men and women. Talk to your doctor about the risks of taking enasidenib.
References

  1. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/209606s000lbl.pdf
  2. https://www.fda.gov/drugs/resources-information-approved-drugs/fda-granted-regular-approval-enasidenib-treatment-relapsed-or-refractory-aml
  3. https://pubchem.ncbi.nlm.nih.gov/compound/Enasidenib
  4. https://pubchem.ncbi.nlm.nih.gov/compound/Enasidenib-mesylate
  5. https://www.webmd.com/drugs/2/drug-173965/enasidenib-oral/details/list-contraindications
  6. https://www.mayoclinic.org/drugs-supplements/enasidenib-oral-route/precautions/drg-20406484?p=1
  7. https://medlineplus.gov/druginfo/meds/a617040.html
  8. https://www.drugs.com/mtm/enasidenib.html
  9. https://en.wikipedia.org/wiki/Enasidenib
  10. https://go.drugbank.com/drugs/DB13874
  11. ChemIDplus Chemical Information Classification
  12. CompTox Chemicals Dashboard Chemical Lists
  13. NCI Thesaurus Tree
  14. Guide to Pharmacology Target Classification
  15. PubChem
  16. Anatomical Therapeutic Chemical (ATC) classification
    Target-based classification of drugs
  17. NORMAN Suspect List Exchange Classification