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Gilteritinib – Uses, Dosage, Side Effects, Interaction

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Mechanism of Action

Gilteritinib is a potent selective inhibitor of both of the mutations, internal tandem duplication (ITD) and tyrosine kinase domain (TKD), of the FLT3 receptor. On the same note, gilteritinib also inhibits AXL and ALK tyrosine kinases. FLT3 and AXL are molecules involved in the growth of cancer cells. The activity of gilteritinib permits inhibition of the phosphorylation of FLT3 and its downstream targets such as STAT5, ERK, and AKT. The interest in FLT3 transmembrane tyrosine kinases was raised when studies reported that approximately 30% of the patients with acute myeloid leukemia presented a mutationally activated isoform. As well, the mutation ITD is associated with poor patient outcomes while the mutation TKD produces a resistance mechanism to FLT3 tyrosine kinase inhibitors and the AXL tyrosine kinase tends to produce a resistance mechanism to chemotherapies.

In preclinical trials, gilteritinib demonstrate an IC50 for the wild-type receptor of 5 nM, 0.7-1.8 nM for ITD-mutated, and comparable inhibition to other therapies in the TKD-mutated. As well, data showed a gilteritinib-driven inhibition of the receptor tyrosine kinase AXL which is known to modulate the activity of FLT3 in acute myeloid leukemia. Another important result _in vivo_ was the localization in high levels in xenografted tumors which indicated high selectivity. In phase 1/2 clinical trials, gilteritinib was shown to present a composite complete response of 41%, an overall response rate of 52%, a median duration of response of 20 weeks with a median overall survival of 31 weeks. In phase III clinical trials, gilteritinib reported a complete remission or complete remission with partial hematologic recovery in 21% of the patients.

Indications

  • Gilteritinib is indicated for the treatment of adult patients who have relapsed or refractory acute myeloid leukemia with an FLT3 mutation detected by an FDA-approved test. This indication was expanded for a companion diagnostic to include use with gilteritinib such as the LeukoStrat CDx FLT3 Mutation Assay. Acute myeloid leukemia is a cancer that impacts the blood and bone marrow with a rapid progression. This condition produces low numbers of normal blood cells and the requirement of a continuous need for transfusions.
  • Gilteritinib is an AXL receptor tyrosine kinase inhibitor used to treat relapsed or refractory acute myeloid leukemia.
  • Xospata is indicated as monotherapy for the treatment of adult patients who have relapsed or refractory acute myeloid leukemia (AML) with an FLT3 mutation.
  • Gilteritinib is an orally available small molecule inhibitor of FMS-like tyrosine kinase 3 (FLT3) which is used as an antineoplastic agent in the treatment of acute myeloid leukemia with FLT3 mutations.
  • Xospata is indicated as monotherapy for the treatment of adult patients who have relapsed or refractory acute myeloid leukemia (AML) with an FLT3 mutation.
  • For the treatment of adult patients who have relapsed or refractory acute myeloid leukemia (AML) with an FMS-like tyrosine kinase 3 (FLT3) mutation.

Acute myeloid leukemia is cancer that impacts the blood and bone marrow with a rapid progression. This condition produces low numbers of normal blood cells and the requirement of continuous need for transfusions

Use in Cancer

Gilteritinib fumarate is approved to treat:

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

Contraindications

  • Hypersensitivity to the active component or any of the ingredients
  • Safety and efficacy have not been established in patients younger than 18 years.
  • low amount of magnesium in the blood
  • low amount of potassium in the blood
  • prolonged QT interval on EKG
  • abnormal EKG with QT changes from birth
  • pregnancy
  • a patient who is producing milk and breastfeeding
  • pancreatitis
  • a type of brain disorder called posterior reversible encephalopathy syndrome

Dosage

Strengths: 40 mg

Acute Myeloid Leukemia

  • 120 mg orally once a day until disease progression or unacceptable toxicity
  • The response may be delayed. In the absence of disease progression or unacceptable toxicity, patients should be treated for a minimum of 6 months to allow time for a clinical response.
  • Select patients for the treatment of AML with this drug based on the presence of FLT3 mutations in the blood or bone marrow.

Dose Adjustments

DOSAGE MODIFICATIONS FOR TOXICITY:
DIFFERENTIATION SYNDROME:

  • If differentiation syndrome is suspected, administer systemic corticosteroids and initiate hemodynamic monitoring until symptom resolution and for a minimum of 3 days.
  • Interrupt therapy if severe symptoms persist for more than 48 hours after initiation of corticosteroids.
  • Resume therapy when symptoms improve to Grade 2 or lower.

POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME:

  • Discontinue therapy.

QTc INTERVAL GREATER THAN 500 MSEC:

  • Interrupt therapy; resume therapy at 80 mg orally once a day when QTc interval returns to within 30 msec of baseline or less than or equal to 480 msec.

QTc INTERVAL INCREASED BY MORE THAN 30 MSEC ON ECG ON DAY 8 OF CYCLE 1:

  • Confirm with ECG on Day 9; if confirmed, consider dose reduction to 80 mg orally once a day.
  • Interrupt therapy until pancreatitis is resolved; resume therapy at 80 mg orally once a day.

OTHER GRADE 3 OR HIGHER TOXICITY CONSIDERED RELATED TO TREATMENT:

  • Interrupt therapy until toxicity resolves to Grade 1; resume therapy at 80 mg orally once a day.

Administration advice:

  • Do not break or crush tablets.
  • This drug may be taken with or without food.
  • Administer this drug at approximately the same time each day.
  • If a dose is missed or not taken at the usual time, administer it as soon as possible on the same day, and at least 12 hours prior to the next scheduled dose; return to normal schedule the following day.
  • Do not administer 2 doses within 12 hours.

Side Effects

The Most Common

  • joint or muscle pain
  • extreme tiredness
  • nausea
  • vomiting
  • diarrhea
  • mouth sores
  • change in the ability to taste food
  • headache
  • loss of appetite
  • difficulty falling asleep or staying asleep
  • seizures; headache; decreased alertness; confusion; or vision changes
  • fast, pounding, or irregular heartbeat; fainting; loss of consciousness; or seizures
  • ongoing pain that begins in the stomach area but may spread to the back that may occur with or without nausea and vomiting

More common

  • Bloody urine
  • blurred vision
  • chest pain or tightness
  • chills
  • confusion
  • cough
  • decreased frequency or amount of urine
  • dizziness
  • dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position
  • fainting
  • fast or irregular heartbeat
  • fever
  • headache
  • increased thirst
  • lightheadedness
  • loss of appetite
  • lower back or side pain
  • nausea
  • nervousness
  • pounding in the ears
  • rapid, shallow breathing
  • recurrent fainting
  • slow heartbeat
  • sneezing
  • sore throat
  • stomach pain
  • sweating
  • swelling of the face, fingers, or lower legs
  • trouble breathing
  • unusual tiredness or weakness
  • vomiting
  • weight gain

Rare

  • Anxiety
  • blue or pale skin
  • chest discomfort
  • chest pain, possibly moving to the left arm, neck, or shoulder
  • difficulty swallowing
  • the action of the mouth
  • trouble sleeping
  • stomach pain
  • painting
  • fever
  • fluid build-up around the lungs (e.g., chest pain, cough, hiccups, rapid breathing)
  • increased frequency or severity of infections (symptoms may include fever or chills, severe diarrhea, shortness of breath, prolonged dizziness, headache, stiff neck, weight loss, or listlessness)
  • inflammation of the mouth and lips
  • low magnesium levels in the blood (e.g., weakness, tremors, muscle cramps, seizures)
  • low potassium levels in the blood (e.g., weakness, fatigue, muscle cramps, irregular heartbeat)
  • pain, numbness, or weakness in the hands and feet
  • 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 heart problems (e.g., fast, irregular heartbeat or pulse; chest pain; sudden weight gain; difficulty breathing; leg swelling)
  • signs of kidney failure (e.g., decreased urine production, swelling, fatigue, abdominal pain)
  • signs of kidney problems (e.g., change in the amount or color of urine, increased urination at night, blood in the urine, swelling in the feet or legs)
  • symptoms of high blood sugar (e.g., frequent urination, increased thirst, excessive eating, unexplained weight loss, poor wound healing, infections, fruity breath odor)
  • swelling in the feet, ankles, hands
  •  vomiting, weakness
  • shortness of breath
  • fluid build-up around the heart (e.g., fever, fatigue, muscle aches, shortness of breath, nausea, vomiting, diarrhea, fast or pounding heartbeat, light-headedness)
  • signs of an allergic reaction (e.g., wheezing, tightness in chest, troubled breathing, shortness of breath, or cough)
  • signs of posterior reversible encephalopathy syndrome (e.g., headache, seizures, weakness, confusion, high blood pressure, vision changes, difficulty thinking clearly

Drug Interactions

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Drug-Food Interactions

  • Avoid grapefruit products. Grapefruit inhibits CYP3A metabolism, which may increase the serum concentration of gilteritinib.
  • Avoid St. John’s Wort. This herb induces CYP3A4 and p-glycoprotein, which may reduce the serum concentration of gilteritinib.
  • Take it at the same time every day.
  • Take it with or without food.

Pregnancy and Lactation

US FDA pregnancy category Not Assigned

Pregnancy

This medication should not be used during pregnancy due to the risk that it may cause harm to the unborn baby. If you become pregnant while taking this medication, contact your doctor immediately.

Lactation

It is not known if gilteritinib passes into breast milk. If you are breast-feeding and are taking this medication, it may affect your baby. Women are advised to avoid breastfeeding while taking this medication and for 2 months after taking the last dose.

How should this medicine be used?

Gilteritinib comes as a tablet to take by mouth. It is usually taken once daily with or without food for at least 6 months. Take gilteritinib 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 gilteritinib 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 water; do not split, chew, or crush them.

Your doctor may adjust your dose or temporarily or permanently stop your treatment depending on how well the medication works for you and if you experience any side effects. Talk to your doctor about how you are feeling during your treatment. Continue to take gilteritinib even if you feel well. Do not stop taking gilteritinib without talking to your doctor.

What special precautions should I follow?

Before taking gilteritinib,

  • tell your doctor and pharmacist if you are allergic to gilteritinib, any other medications, or any of the ingredients in gilteritinib tablets. 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 any of the following: certain antifungals such as fluconazole (Diflucan), itraconazole (Onmel, Sporanox), and ketoconazole; clarithromycin (Biaxin, in PrevPac); escitalopram (Lexapro); fluoxetine (Prozac); certain medications for human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) such as efavirenz (Sustiva, in Atripla), indinavir (Crixivan), nelfinavir (Viracept), nevirapine (Viramune), ritonavir (Norvir, in Kaletra), and saquinavir (Invirase); certain medications for seizures such as carbamazepine (Carbatrol, Epitol, Tegretol, others), phenobarbital, and phenytoin (Dilantin, Phenytek); nefazodone; pioglitazone (Actos); rifabutin (Mycobutin); rifampin (Rifadin, Rimactane, in Rifamate, in Rifater); and sertraline (Zoloft). 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 gilteritinib, 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 QT interval prolongation (an irregular heart rhythm that can lead to fainting, loss of consciousness, seizures, or sudden death); a slow, fast, or irregular heartbeat; or low levels of potassium or magnesium in your blood.
  • tell your doctor if you are pregnant, plan to become pregnant, or if you plan to father a child. You or your partner should not become pregnant while you are taking gilteritinib. If you are female, you will need to have a pregnancy test at least 7 days before you start treatment, and you should use birth control during your treatment and for 6 months after your final dose. If you are male, you and your partner should use birth control to prevent pregnancy during your treatment and for 4 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 gilteritinib, call your doctor. Gilteritinib may harm the fetus.
  • tell your doctor if you are breastfeeding. You should not breastfeed during your treatment with gilteritinib and for 2 months after your final dose.

References

  1. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/211349s001lbl.pdf
  2. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/211349s000lbl.pdf
  3. https://www.fda.gov/drugs/fda-approves-gilteritinib-relapsed-or-refractory-acute-myeloid-leukemia-aml-flt3-mutatation
  4. https://medlineplus.gov/druginfo/meds/a619003.html
  5. https://pubchem.ncbi.nlm.nih.gov/compound/Gilteritinib
  6. https://pubchem.ncbi.nlm.nih.gov/compound/Gilteritinib-fumarate
  7. https://www.drugs.com/mtm/gilteritinib.html
  8. https://go.drugbank.com/drugs/DB12141
  9. https://en.wikipedia.org/wiki/Gilteritinib
  10. https://www.webmd.com/drugs/2/drug-176569/gilteritinib-oral/details/list-contraindications
  11. https://www.mayoclinic.org/drugs-supplements/gilteritinib-oral-route/side-effects/drg-20452316?p=1
  12. CompTox Chemicals Dashboard Chemical Lists
  13. NCI Thesaurus Tree
  14. PubChem
  15. Anatomical Therapeutic Chemical (ATC) classification
    Target-based classification of drugs

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