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Entrectinib – Uses, Dosage, Side Effects, Interaction

Mechanism of Action

Entrectinib is a tyrosine kinase inhibitor that acts on several receptors. It functions as an ATP competitor to inhibit tropomyosin receptor tyrosine kinases (TRK) TRKA, TRKB, and TRKC, as well as proto-oncogene tyrosine-protein kinase ROS1 and anaplastic lymphoma kinase (ALK). TRK receptors produce cell proliferation via downstream signaling through the mitogen-activated protein kinase, phosphoinositide 3-kinase, and phospholipase C-γ. ALK produces similar signaling with the addition of downstream JAK/STAT activation. Inhibition of these pathways suppresses cancer cell proliferation and shifts the balance in favor of apoptosis resulting in the shrinking of tumor volume.

Indications

  • Entrectinib is indicated for the treatment of metastatic ROS1-positive non-small cell lung cancer in adults. Entrectinib is also indicated in adults and children over 12 years old for the treatment of NTRK gene fusion-positive solid tumors which have metastasized or for which surgical resection is likely to result in severe morbidity and for which has progressed on previous therapies or for which no comparable alternative therapies are available.
  • Rozlytrek as monotherapy is indicated for the treatment of adult and pediatric patients 12 years of age and older with solid tumors expressing a neurotrophic tyrosine receptor kinase (NTRK) gene fusion, who have a disease that is locally advanced, metastatic or where surgical resection is likely to result in severe morbidity, and who have not received a prior NTRK inhibitor who have no satisfactory treatment options.
  • Rozlytrek as monotherapy is indicated for the treatment of adult patients with ROS1-positive, advanced nonsmall cell lung cancer (NSCLC) not previously treated with ROS1 inhibitors.
  • Entrectinib is an oral selective inhibitor of the neurotrophic T receptor kinase (NTRK) and ROS1 that is used to treat solid tumors with NTRK gene fusion and non-small cell lung cancer with ROS1 mutations.
  • Metastatic Non-Small Cell Lung Cancer
  • Solid Metastatic Tumor
  • Solid Tumors

In the US, entrectinib is indicated to treat patients whose cancers are ROS1-positive (have a specific genetic feature (biomarker)).[rx] It is to be used in those with solid tumors that:[rx]

  • are caused by certain abnormal neurotrophic tyrosine receptor kinase (NTRK) genes, and
  • have spread or if surgery to remove their cancer is likely to cause severe complications, and
  • there is no acceptable treatment, or the cancer grew or spreads on other treatment

Entrectinib is not approved for use in those less than twelve years of age.

In the European Union, entrectinib as monotherapy is indicated for the treatment of adults and adolescents twelve years of age and older with solid tumors expressing a neurotrophic tyrosine receptor kinase (NTRK) gene fusion,[rx]

  • who have a disease that is locally advanced, metastatic, or where surgical resection is likely to result in severe morbidity, and[rx]
  • who have not received a prior NTRK inhibitor[rx]
  • who have no satisfactory treatment options?[rx]

It is also indicated for the treatment of adults with ROS1-positive, advanced non-small cell lung cancer (NSCLC) not previously treated with ROS1 inhibitors.[rx]

Use in Cancer

Entrectinib is approved to treat:

  • Non-small cell lung cancer that is ROS1 positive. It is used in adults whose cancer has metastasized (spread to other parts of the body).
  • Solid tumors that have an NTRK gene fusion without a drug-resistance mutation in certain TRK proteins. It is used in adults and in children aged 12 years or older whose cancer has metastasized or cannot be removed by surgery and has gotten worse after other treatments or cannot be treated with other therapies.¹

¹This use is approved under FDA’s Accelerated Approval Program. As a condition of approval, confirmatory trial(s) must show that entrectinib provides a clinical benefit in these patients.

Entrectinib is also being studied in the treatment of other types of cancer.

Contraindications

  • low amount of magnesium in the blood
  • low amount of calcium in the blood
  • low amount of potassium in the blood
  • chronic heart failure
  • abnormal EKG with QT changes from birth
  • liver problems
  • high amount of uric acid in the blood
  • pregnancy
  • a patient who is producing milk and breastfeeding

Dosage

Strengths: 100 mg; 200 mg

Non-Small Cell Lung Cancer

  • 600 mg orally once a day until disease progression or unacceptable toxicity
  • For adult patients with metastatic non-small cell lung cancer (NSCLC) whose tumors are ROS1-positive

Solid Tumors

  • 600 mg orally once a day until disease progression or unacceptable toxicity
  • For adult patients with solid tumors that have a neurotrophic tyrosine receptor kinase (NTRK) gene fusion without a known acquired resistance mutation; are metastatic or where surgical resection is likely to result in severe morbidity, and have progressed following treatment or have no satisfactory alternative therapy.

Pediatric Dose for Solid Tumors

12 years and older:

  • Body surface area (BSA) greater than 1.5 m2: 600 mg orally once a day
  • BSA 1.11 to 1.5 m2: 500 mg orally once a day
  • BSA 0.91 to 1.1 m2: 400 mg orally once a day

Renal Dose Adjustments

  • Mild or moderate renal impairment (CrCl 30 to less than 90 mL/min: No adjustment recommended.
  • Severe renal impairment (CrCl greater than 30 mL/min): Data not available

Liver Dose Adjustments

  • Grade 3 hepatic impairment: Withhold therapy until recovery to less than or equal to Grade 1 or baseline; resume at the same dose if resolution occurs within 4 weeks; permanently discontinue if an adverse reaction does not resolve within 4 weeks; resume at a reduced dose for recurrent Grade 3 events that resolve within 4 weeks.
  • Grade 4 hepatic impairment: Withhold therapy until recovery to less than or equal to Grade 1 or baseline; resume at a reduced dose if resolution occurs within 4 weeks; permanently discontinue if an adverse reaction does not resolve within 4 weeks; permanently discontinue for recurrent Grade 4 events.
  • ALT or AST greater than 3 times the upper limit of normal (ULN) with concurrent total bilirubin greater than 1.5 x ULN (in the absence of cholestasis or hemolysis): Permanently discontinue therapy.

Dose Adjustments

DOSE REDUCTIONS FOR ADVERSE REACTIONS:
FIRST DOSE REDUCTION:

  • Adults and pediatric patients 12 years and older with BSA greater than 1.50 m2: 400 mg orally once daily
  • Pediatric patients 12 years and older with BSA of 1.11 to 1.50 m2: 400 mg orally once daily
  • Pediatric patients 12 years and older with BSA of 0.91 to 1.1 m2: 300 mg orally once daily

SECOND DOSE REDUCTION (if the patient cannot tolerate the second dose reduction permanently discontinue therapy):

  • Adults and pediatric patients 12 years and older with BSA greater than 1.50 m2: 200 mg orally once daily
  • Pediatric patients 12 years and older with BSA of 1.11 to 1.50 m2: 200 mg orally once daily
  • Pediatric patients 12 years and older with BSA of 0.91 to 1.1 m2: 200 mg orally once daily

DOSE MODIFICATIONS FOR ADVERSE REACTIONS:
CONGESTIVE HEART FAILURE:

  • Grade 2 or 3: Withhold therapy until recovered to less than or equal to Grade 1; resume at a reduced dose.
  • Grade 4: Permanently discontinue therapy.

CENTRAL NERVOUS SYSTEM EFFECTS:

  • Intolerable Grade 2: Withhold therapy until recovered to less than or equal to Grade 1 or baseline; resume at the same dose or reduced dose.
  • Grade 3: Withhold therapy until recovered to less than or equal to Grade 1 or baseline; resume at the same dose if resolution occurs within 4 weeks; permanently discontinue if the adverse reaction does not resolve within 4 weeks; resume at a reduced dose for recurrent Grade 3 events that resolve within 4 weeks.
  • Grade 4: Withhold therapy until recovered to less than or equal to Grade 1 or baseline; resume at the same dose or reduced dose if resolution occurs within 4 weeks; permanently discontinue if an adverse reaction does not resolve within 4 weeks; permanently discontinue therapy for recurrent Grade 4 events.

HYPERURICEMIA:

  • QTc greater than 500 ms: Withhold therapy until QTc interval recovers to baseline; resume at the same dose if factors that cause QT prolongation are identified and corrected; resume at a reduced dose if other factors that cause QT prolongation are not identified.
  • Torsade de Pointes; polymorphic ventricular tachycardia; signs/symptoms of serious arrhythmia: Permanently discontinue therapy.

VISION DISORDERS:

  • Grade 2 or higher: Withhold therapy until improvement or stabilization; resume at the same dose or reduced dose as appropriate.

ANEMIA OR NEUTROPENIA:

  • Grade 3 or 4: Withhold therapy until adverse reaction resolves or improves to recovery or improvement to Grade 1 or baseline; resume at the same or reduced dose, if resolution occurs within 4 weeks; permanently discontinue if an adverse reaction does not resolve within 4 weeks; permanently discontinue for recurrent Grade 4 events.

DOSAGE MODIFICATIONS FOR DRUG INTERACTIONS: MODERATE AND STRONG CYP450 3A INHIBITORS:
Adults and pediatric patients 12 years and older with BSA Greater than 1.5 m2: Avoid coadministration of this drug with moderate or strong CYP450 3A inhibitors; if coadministration cannot be avoided, reduce the dose of this drug as follows:

  • Moderate CYP450 3A Inhibitors: 200 mg orally once daily
  • Strong CYP450 3A Inhibitors: 100 mg orally once daily

After discontinuation of a strong or moderate CYP450 3A inhibitor for 3 to 5 elimination half-lives, resume the dose that was taken prior to initiating the CYP450 3A inhibitor.

Administration advice:

  • This drug may be taken with or without food.
  • Swallow capsules whole do not open, crush, chew, or dissolve the contents of the capsule.
  • If a dose is missed, take it as soon as it is remembered unless the next dose is due within 12 hours.
  • If a patient vomits immediately after taking a dose, instruct them to repeat that dose.

Side Effects

The Most Common

  • tiredness
  • constipation
  • diarrhea
  • taste changes
  • headache
  • cough, fever, or other signs of infection
  • muscle or joint pain
  • back pain
  • weight changes
  • rash
  • difficulty falling or staying asleep
  • difficulty with learning, memory, attention, or problem solving
  • mood changes such as anxiety, depression, confusion, or agitation
  • bone pain or difficulty moving
  • vision problems or changes in vision
  • joint pain, stiffness, redness, or swelling
  • pain in upper right part of the stomach, yellowing of skin or eyes, loss of appetite, or bleeding or bruising easily
  • shortness of breath; difficulty breathing when lying down; or swelling of the arms, legs, hands, or feet

More common

  • Abdominal or stomach pain or tenderness
  • blurred vision
  • burning, crawling, itching, numbness, prickling, “pins and needles”, or tingling feelings
  • change in color vision
  • clay-colored stools
  • confusion
  • dark urine
  • decreased appetite
  • defects in intelligence, short-term memory, learning ability, and attention
  • difficulty seeing at night
  • dizziness
  • fever
  • headache
  • increased sensitivity of the eyes to sunlight
  • itching or skin rash
  • joint pain, stiffness, or swelling
  • loss of appetite
  • lower back, side, or stomach pain
  • nausea and vomiting
  • problems with balance
  • sleepiness or unusual drowsiness
  • swelling of the feet or lower legs
  • trouble sleeping
  • unusual tiredness or weakness
  • yellow eyes or skin

Rare

  • Chest pain
  • decreased urine output
  • dilated neck veins
  • double vision
  • extreme fatigue
  • fainting
  • irregular breathing
  • irregular heartbeat recurrent
  • loss of memory
  • problems with memory
  • problems with speech or speaking
  • seeing double
  • seeing, hearing, or feeling things that are not there
  • swelling of the face, fingers, feet, or lower legs
  • tightness in the chest
  • trouble remembering
  • troubled breathing
  • weight gain

Drug Interaction

Pregnancy and Lactation

US FDA pregnancy category: Not assigned.

Pregnancy

This drug can harm a developing fetus. Verify negative pregnancy status in females of reproductive potential prior to initiating therapy. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential harm to the fetus. Advise female patients of reproductive potential to use effective contraception during therapy and for at least 5 weeks after. Advise male patients with female partners of reproductive potential to use effective contraception during therapy and for 3 months after.

Lactation

Use is not recommended.

Excreted into human milk: Unknown
Excreted into animal milk: Data not available
The effects in the nursing infant are unknown. Because of the potential for adverse reactions in breastfed infants from this drug, advise lactating women to discontinue breastfeeding during therapy and for 7 days after.

How should this medicine be used?

Entrectinib comes as a capsule to take by mouth. It is usually taken with or without food once daily. Take entrectinib 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 entrectinib exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor.

Swallow the capsules whole; do not open, chew, or crush them.

If you vomit immediately after you take entrectinib, take another dose as soon as possible.

Ask your pharmacist or doctor for a copy of the manufacturer’s information for the patient.

Other uses for this medicine

This medication may be prescribed for other uses; ask your doctor or pharmacist for more information.

What special precautions should I follow?

Before taking entrectinib,

  • tell your doctor and pharmacist if you are allergic to entrectinib, any other medications, or any of the ingredients in entrectinib capsules. Ask your pharmacist for a list of the ingredients.
  • tell your doctor and pharmacist what other prescription and nonprescription medications, vitamins, nutritional supplements, and herbal products you are taking or plan to take. Be sure to mention the following: aprepitant (Emend), certain antifungal medications such as fluconazole (Diflucan), itraconazole (Omel, Sporanox), or ketoconazole; certain medications for arrhythmias such as amiodarone (Nexterone, Pacerone), procainamide, quinidine (in Nuedexta), and sotalol (Betapace, Sorine, Sotylize); azithromycin (Zithromax); clarithromycin (Biaxin, in Prevpac); diltiazem (Cardizem, Tiazac, others); erythromycin (E.E.S., Erythrocin, others); enzalutamide (Xtandi); certain HIV medications such as efavirenz (Sustiva, in Atripla), indinavir (Crixivan), nelfinavir (Viracept), nevirapine (Viramune), ritonavir (Norvir, in Kaletra, others), or saquinavir (Invirase); lithium (Lithobid); modafinil (Provigil); nefazodone; oxcarbazepine (Trileptal); phenobarbital; phenytoin (Dilantin, Phenytek); pioglitazone (Actos, in Actoplus, Duetact, Oseni); rifabutin (Mycobutin); rifampin (Rifadin, Rimactane, in Rifater); oral steroids such as dexamethasone, methylprednisolone (Medrol), and prednisone (Rayos); and verapamil (Calan). Your doctor may need to change the doses of your medications or monitor you carefully for side effects. Many other medications may also interact with entrectinib, so be sure to tell your doctor about all the medications you are taking, even those that do not appear on this list.
  • tell your doctor what herbal products you are taking, especially St. John’s Wort.
  • tell your doctor if you have or have ever had a nervous system condition, a prolonged QT interval (a rare heart problem that may cause irregular heartbeat, fainting, or sudden death), a slow or irregular heartbeat, a heart attack, heart failure, or heart or liver disease.
  • tell your doctor if you are pregnant, plan to become pregnant, or if you plan on fathering a child. If you are female, you will need to take a pregnancy test before you start treatment and use birth control to prevent pregnancy during your treatment and for at least 5 weeks after your final dose. If you are a male, you and your partner should use birth control during your treatment with entrectinib and for 3 months after your final dose. Talk to your doctor about birth control methods that you can use during your treatment. If you or your partner become pregnant while taking entrectinib, call your doctor immediately. Entrectinib may harm the fetus.
  • tell your doctor if you are breastfeeding. You should not breastfeed while you are taking entrectinib and for 7 days after the final dose.
  • you should know that entrectinib may make cause dizziness or confusion. Do not drive a car or operate machinery until you know how this medication affects you.

References

  1. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/212725s000lbl.pdf
  2. https://www.fda.gov/drugs/resources-information-approved-drugs/fda-approves-entrectinib-ntrk-solid-tumors-and-ros-1-nsclc
  3. https://pubmed.ncbi.nlm.nih.gov/32967940/
  4. https://www.cancer.gov/about-cancer/treatment/drugs/entrectinib
  5. https://go.drugbank.com/drugs/DB11986
  6. https://en.wikipedia.org/wiki/Entrectinib
  7. https://medlineplus.gov/druginfo/meds/a619049.html
  8. https://www.mayoclinic.org/drugs-supplements/entrectinib-oral-route/side-effects/drg-20470004?p=1
  9. https://www.drugs.com/mtm/entrectinib.html
  10. https://pubchem.ncbi.nlm.nih.gov/compound/Entrectinib
  11. ChemIDplus Chemical Information Classification
  12. CompTox Chemicals Dashboard Chemical Lists
  13. NCI Thesaurus Tree
  14. PubChem
  15. Protein Kinase Inhibitors
  16. Therapeutic category of drugs in Japan
    Anatomical Therapeutic Chemical (ATC) classification
    Target-based classification of drugs
  17. LICENSE
    Data: CC-BY 4.0; Code (hosted by ECI, LCSB): Artistic-2.0
    NORMAN Suspect List Exchange Classification

 

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