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COSMIC-311 safety data

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Treatment-emergent ARs in the primary analysis1*

Any cause, occurring in ≥5% of patients in either treatment arm

 

Patients (%)

 

Cabozantinib (n=125)

Placebo (n=62)

Adverse Reaction

Any Grade†

Grade 3-4

Any Grade†

Grade 3-4

Gastrointestinal

    

Diarrhea

51

7

3

0

Nausea

24

3

2

0

Vomiting

14

1

8

0

Stomatitis‡

26

5

3

0

Dry mouth

10

1

2

0

General

    

Fatigue§

42

10

23

0

Metabolism and nutrition

    

Decreased appetite

23

3

16

0

Skin and subcutaneous tissue

    

Palmar-plantar erythrodysesthesia

46

10

0

0

Vascular

    

Hypertension||

30

10

5

3

Investigations

    

Weight decreased

18

1

5

0

Nervous system

    

Dysgeusia

10

0

0

0

Headache

10

2

2

0

Respiratory, thoracic, and mediastinal

    

Dysphonia

10

0

2

0

Pulmonary embolism

5

2

0

0

Renal and urinary

    

Proteinuria

15

1

3

0

*

Includes terms that are more frequent in the CABOMETYX® (cabozantinib) arm and have a between-arm difference of ≥5% (all grades) or ≥2% (Grade 3-4).

†

NCI CTCAE Version 5.0.

‡

Includes the following terms: mucosal inflammation, stomatitis.

§

Includes the following terms: fatigue, asthenia.

||

Includes the following terms: hypertension, blood pressure increased, hypertensive crisis.

Lab abnormalities occurring in ≥10% of CABOMETYX-treated patients in the primary analysis1¶

 

Patients (%)

 

Cabozantinib (n=125)

Placebo (n=62)

Laboratory Abnormality

Any Grade

Grade 3-4

Any Grade

Grade 3-4

Chemistry

    

LDH increased**

90

10

32

3

AST increased

77

1

18

0

ALT increased

66

2

11

0

Hypocalcemia

36

9

10

2

ALP increased

34

0

15

0

GGT increased

26

2

21

2

Hypomagnesemia

25

2

5

0

Hypoalbuminemia

19

1

7

0

Hypokalemia

18

1

3

0

Hyponatremia

15

0

10

2

Hyperbilirubinemia

12

0

5

0

Hematology

    

Leukocytes decreased

38

2

7

2

Neutrophils decreased

31

2

5

2

Platelets decreased

26

0

5

0

Includes laboratory abnormalities with a between-arm difference of ≥5% (all grades) or ≥2% (Grade 3-4).

**

Sponsor-defined grades for LDH were as follows: Grade 1 (>ULN to ≤2 × ULN), Grade 2 (>2 × ULN to ≤3 × ULN), Grade 3 (>3 × ULN).

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ALP=alkaline phosphatase; ALT=alanine aminotransferase; AR=adverse reaction; AST=aspartate aminotransferase; CTCAE=common terminology criteria for adverse events; GGT=gamma-glutamyl transferase; LDH=lactate dehydrogenase; NCI=National Cancer Institute; ULN=upper limit of normal.

Reference:

  1. CABOMETYX® (cabozantinib) Prescribing Information. Exelixis, Inc.

IMPORTANT SAFETY INFORMATION 

WARNINGS AND PRECAUTIONS 

Hemorrhage: Severe and fatal hemorrhages occurred with CABOMETYX. The incidence of Grade 3 to 5 hemorrhagic events was 5% in CABOMETYX patients in RCC, HCC, and DTC studies. Discontinue CABOMETYX for Grade 3 or 4 hemorrhage and prior to surgery as recommended. Do not administer CABOMETYX to patients who have a recent history of hemorrhage, including hemoptysis, hematemesis, or melena. 

Perforations and Fistulas: Fistulas, including fatal cases, occurred in 1% of CABOMETYX patients. Gastrointestinal (GI) perforations, including fatal cases, occurred in 1% of CABOMETYX patients. Monitor patients for signs and symptoms of fistulas and perforations, including abscess and sepsis. Discontinue CABOMETYX in patients who experience a Grade 4 fistula or a GI perforation. 

Thrombotic Events: CABOMETYX increased the risk of thrombotic events. Venous thromboembolism occurred in 7% (including 4% pulmonary embolism) and arterial thromboembolism in 2% of CABOMETYX patients. Fatal thrombotic events occurred in CABOMETYX patients. Discontinue CABOMETYX in patients who develop an acute myocardial infarction or serious arterial or venous thromboembolic events that require medical intervention. 

Hypertension and Hypertensive Crisis: CABOMETYX can cause hypertension, including hypertensive crisis. Hypertension was reported in 37% (16% Grade 3 and <1% Grade 4) of CABOMETYX patients. Do not initiate CABOMETYX in patients with uncontrolled hypertension. Monitor blood pressure regularly during CABOMETYX treatment. Withhold CABOMETYX for hypertension that is not adequately controlled with medical management; when controlled, resume at a reduced dose. Permanently discontinue CABOMETYX for severe hypertension that cannot be controlled with anti-hypertensive therapy or for hypertensive crisis. 

Diarrhea: Diarrhea occurred in 62% of CABOMETYX patients. Grade 3 diarrhea occurred in 10% of CABOMETYX patients. Monitor and manage patients using antidiarrheals as indicated. Withhold CABOMETYX until improvement to ≤ Grade 1, resume at a reduced dose.

Palmar-Plantar Erythrodysesthesia (PPE): PPE occurred in 45% of CABOMETYX patients. Grade 3 PPE occurred in 13% of CABOMETYX patients. Withhold CABOMETYX until improvement to Grade 1 and resume at a reduced dose for intolerable Grade 2 PPE or Grade 3 PPE. 

Proteinuria: Proteinuria was observed in 8% of CABOMETYX patients. Monitor urine protein regularly during CABOMETYX treatment. For Grade 2 or 3 proteinuria, withhold CABOMETYX until improvement to ≤ Grade 1 proteinuria; resume CABOMETYX at a reduced dose. Discontinue CABOMETYX in patients who develop nephrotic syndrome. 

Osteonecrosis of the Jaw (ONJ): ONJ occurred in <1% of CABOMETYX patients. ONJ can manifest as jaw pain, osteomyelitis, osteitis, bone erosion, tooth or periodontal infection, toothache, gingival ulceration or erosion, persistent jaw pain, or slow healing of the mouth or jaw after dental surgery. Perform an oral examination prior to CABOMETYX initiation and periodically during treatment. Advise patients regarding good oral hygiene practices. Withhold CABOMETYX for at least 3 weeks prior to scheduled dental surgery or invasive dental procedures, if possible. Withhold CABOMETYX for development of ONJ until complete resolution, resume at a reduced dose. 

Impaired Wound Healing: Wound complications occurred with CABOMETYX. Withhold CABOMETYX for at least 3 weeks prior to elective surgery. Do not administer CABOMETYX for at least 2 weeks after major surgery and until adequate wound healing. The safety of resumption of CABOMETYX after resolution of wound healing complications has not been established. 

Reversible Posterior Leukoencephalopathy Syndrome (RPLS): RPLS, a syndrome of subcortical vasogenic edema diagnosed by characteristic findings on MRI, can occur with CABOMETYX. Evaluate for RPLS in patients presenting with seizures, headache, visual disturbances, confusion, or altered mental function. Discontinue CABOMETYX in patients who develop RPLS. 

Thyroid Dysfunction: Thyroid dysfunction, primarily hypothyroidism, has been observed with CABOMETYX. Based on the safety population, thyroid dysfunction occurred in 19% of patients treated with CABOMETYX, including Grade 3 in 0.4% of patients. 

Patients should be assessed for signs of thyroid dysfunction prior to the initiation of CABOMETYX and monitored for signs and symptoms of thyroid dysfunction during CABOMETYX treatment. Thyroid function testing and management of dysfunction should be performed as clinically indicated. 

Hypocalcemia: CABOMETYX can cause hypocalcemia. Based on the safety population, hypocalcemia occurred in 13% of patients treated with CABOMETYX, including Grade 3 in 2% and Grade 4 in 1% of patients. Laboratory abnormality data were not collected in CABOSUN. 

In COSMIC-311, hypocalcemia occurred in 36% of patients treated with CABOMETYX, including Grade 3 in 6% and Grade 4 in 3% of patients. 

Monitor blood calcium levels and replace calcium as necessary during treatment. Withhold and resume at reduced dose upon recovery or permanently discontinue CABOMETYX depending on severity.

Embryo-Fetal Toxicity: CABOMETYX can cause fetal harm. Advise pregnant women and females of reproductive potential of the potential risk to a fetus. Verify the pregnancy status of females of reproductive potential prior to initiating CABOMETYX and advise them to use effective contraception during treatment and for 4 months after the last dose. 

ADVERSE REACTIONS 

The most common (≥20%) adverse reactions are: 

CABOMETYX as a single agent: diarrhea, fatigue, PPE, decreased appetite, hypertension, nausea, vomiting, weight decreased, and constipation. 

DRUG INTERACTIONS 

Strong CYP3A4 Inhibitors: If coadministration with strong CYP3A4 inhibitors cannot be avoided, reduce the CABOMETYX dosage. Avoid grapefruit or grapefruit juice. 

Strong CYP3A4 Inducers: If coadministration with strong CYP3A4 inducers cannot be avoided, increase the CABOMETYX dosage. Avoid St. John’s wort. 

USE IN SPECIFIC POPULATIONS 

Lactation: Advise women not to breastfeed during CABOMETYX treatment and for 4 months after the final dose. 

Hepatic Impairment: In patients with moderate hepatic impairment, reduce the CABOMETYX dosage. Avoid CABOMETYX in patients with severe hepatic impairment. 

Pediatric Use: Physeal widening has been observed in children with open growth plates when treated with CABOMETYX. Physeal and longitudinal growth monitoring is recommended in children (12 years and older with DTC) with open growth plates. Consider interrupting or discontinuing CABOMETYX if abnormalities occur. 

Please see full Prescribing Information. 
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.FDA.gov/medwatch or call 1-800-FDA-1088.

Indication

CABOMETYX is indicated for the treatment of adult and pediatric patients 12 years of age and older with locally advanced or metastatic differentiated thyroid cancer (DTC) that has progressed following prior VEGFR-targeted therapy and who are radioactive iodine-refractory or ineligible.

CABOMETYX is indicated for the treatment of adult and pediatric patients 12 years of age and older with locally advanced or metastatic differentiated thyroid cancer (DTC) that has progressed following prior VEGFR-targeted therapy and who are radioactive iodine-refractory or ineligible.

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