Osimertinib

Osimertinib may increase the exposure of breast cancer resistant protein (BCRP). Based on in vitro studies, osimertinib is a competitive inhibitor of BCRP transporters.

In a clinical PK study, co-administration of osimertinib with rosuvastatin (sensitive BCRP substrate) increased the AUC and C_max of rosuvastatin by 35% and 72%, respectively. Patients taking concomitant medicinal products with disposition dependent upon BCRP and with narrow therapeutic index should be closely monitored for signs of changed tolerability of the concomitant medication as a result of increased exposure whilst receiving osimertinib.

When possible, the use of osimertinib in patients with congenital long QT syndrome should be avoided. Periodic monitoring with electrocardiograms (ECGs) and electrolytes should be considered in patients with congestive heart failure, electrolyte abnormalities, or those who are taking medicinal products that are known to prolong the QTc interval.

In a clinical PK study, co-administration of osimertinib with simvastatin (sensitive CYP3A4 substrate) decreased the AUC and C_max of simvastatin by 9% and 23% respectively. These changes are small and not likely to be of clinical significance. Clinical PK interactions with CYP3A4 substrates are unlikely. A risk for decreased exposure of hormonal contraceptives cannot be excluded.

Osimertinib may increase the exposure of P-glycoprotein (P-gp) substrates.

In a clinical Pregnane X Receptor (PXR) interaction study, co-administration of osimertinib with fexofenadine (P-gp substrate) increased the AUC and C_max of fexofenadine by 56% (90% CI 35, 79) and 76% (90% CI 49, 108) after a single dose and 27% (90% CI 11, 46) and 25% (90% CI 6, 48) at steady- state, respectively. Patients taking concomitant medications with disposition dependent upon P-gp and with narrow therapeutic index (e.g. digoxin, dabigatran, aliskiren) should be closely monitored for signs of changed tolerability as a result of increased exposure of the concomitant medication whilst receiving osimertinib.

In a clinical pharmacokinetic study in patients, the steady-state AUC of osimertinib was reduced by 78% when co-administered with rifampicin (600 mg daily for 21 days). Similarly, the exposure to metabolite AZ5104 decreased by 82% for the AUC and 78% for C_max. It is recommended that concomitant use of strong CYP3A inducers (e.g. Phenytoin, rifampicin and carbamazepine) with osimertinib should be avoided.

Moderate CYP3A4 inducers (e.g. bosentan, efavirenz, etravirine, modafinil) may also decrease osimertinib exposure and should be used with caution, or avoided when possible. There are no clinical data available to recommend a dose adjustment of osimertinib.

Concomitant use of St. John’s Wort is contraindicated.

Based on clinical studies and population PK analysis, no dose adjustments are necessary in patients with severe renal impairment. The safety and efficacy of this medicinal product has not been established in patients with end-stage renal disease [creatinine clearance (CLcr) less than 15 mL/min, calculated by the Cockcroft and Gault equation], or on dialysis. Caution should be exercised when treating patients with severe and end-stage renal impairment.

The safety and efficacy of osimertinib has not been established in patients with severe hepatic impairment. Until additional data become available, use in patients with severe hepatic impairment is not recommended.

There are no data on the effect of osimertinib on human fertility. Results from animal studies have shown that osimertinib has effects on male and female reproductive organs and could impair fertility.

There are no or limited amount of data from the use of osimertinib in pregnant women. Studies in animals have shown reproductive toxicity (embryolethality, reduced foetal growth, and neonatal death). Based on its mechanism of action and preclinical data, osimertinib may cause foetal harm when administered to a pregnant woman. Osimertinib should not be used during pregnancy unless the clinical condition of the woman requires treatment with osimertinib.

It is unknown whether osimertinib/metabolites are excreted in human milk. There is insufficient information on the excretion of osimertinib/metabolites in animal milk. However, osimertinib and its metabolites were detected in the suckling pups and there was poor pup growth and a reduction in pup survival. A risk to the suckling child cannot be excluded. Breast-feeding should be discontinued during treatment with osimertinib.

Women of childbearing potential/Contraception in males and females

Women of childbearing potential should be advised to avoid becoming pregnant while receiving osimertinib. Patients should be advised to use effective contraception for the following periods after completion of treatment with this medicinal product: at least 2 months for females and 4 months for males. A risk for decreased exposure of hormonal contraceptives cannot be excluded.

Fertility

There are no data on the effect of osimertinib on human fertility. Results from animal studies have shown that osimertinib has effects on male and female reproductive organs and could impair fertility.

Osimertinib has no or negligible influence on the ability to drive and use machines.

Summary of the safety profile

Studies in EGFR mutation-positive NSCLC patients

The safety of osimertinib as a monotherapy is based on pooled data from 1813 patients with EGFR mutation-positive non-small cell lung cancer. These patients received osimertinib at a dose of 80 mg daily in four randomised Phase 3 studies (ADAURA, adjuvant; FLAURA and FLAURA2 (monotherapy arm), first line and AURA3, second line only), two Phase 2 single-arm studies (AURAex and AURA2, second line or later) and one Phase 1 study (AURA1, first-line or later). Most adverse reactions were Grade 1 or 2 in severity. The most commonly reported adverse drug reactions (ADRs) were diarrhoea (47%), rash (46%), paronychia (34%), dry skin (32%), and stomatitis (24%). Grade 3 and Grade 4 adverse reactions across the studies were 11% and 0.2%, respectively. In patients treated with osimertinib 80 mg once daily, dose reductions due to adverse reactions occurred in 3.9% of the patients. Discontinuation due to adverse reactions was 5.2%.

The safety of osimertinib given in combination with pemetrexed and platinum-based chemotherapy is based on data in 276 patients with EGFR mutation-positive NSCLC and was consistent with osimertinib monotherapy and known safety profiles of pemetrexed and platinum-based chemotherapy. The most commonly reported ADRs when osimertinib was given in combination with pemetrexed and platinum-based chemotherapy were rash (49%), diarrhoea (43%), decreased appetite (31%), stomatitis (31%), paronychia (27%) and dry skin (24%). When osimertinib is administered as combination therapy, refer to the Summary of Product Characteristics for the respective combination therapy components prior to initiation of treatment.

Patients with a medical history of ILD, drug-induced ILD, radiation pneumonitis that required steroid treatment, or any evidence of clinically active ILD were excluded from clinical studies. Patients with clinically important abnormalities in rhythm and conduction as measured by resting electrocardiogram (ECG) (e.g. QTc interval greater than 470 msec) were excluded from these studies. Patients were evaluated for LVEF at screening and every 12 weeks thereafter.

Tabulated list of adverse reactions

Adverse reactions have been assigned to the frequency categories in the table below where possible based on the incidence of comparable adverse event reports in a pooled dataset from the 1813 EGFR mutation-positive NSCLC patients who received osimertinib monotherapy at a dose of 80 mg daily in the ADAURA, FLAURA, FLAURA2, AURA3, AURAex, AURA2 and AURA1 studies and in 276 patients treated with osimertinib in combination with pemetrexed and platinum-based chemotherapy in the FLAURA2 study.

Adverse reactions are listed according to system organ class (SOC) in MedDRA. Within each system organ class, the adverse drug reactions are ranked by frequency, with the most frequent reactions first. Within each frequency grouping, adverse drug reactions are presented in order of decreasing seriousness. In addition, the corresponding frequency category for each adverse reaction is based on the CIOMS III convention and is defined as: 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); very rare (<1/10,000); not known (cannot be estimated from available data).

Adverse reactions reported in ADAURA, FLAURA, FLAURA2 and AURA studies:

^a Data is pooled from ADAURA, FLAURA, FLAURA2 (monotherapy arm) and AURA (AURA3, AURAex, AURA 2 and AURA1) studies; only events for patients receiving at least one dose of osimertinib as their randomised treatment are summarised.
^b Data is from the combination arm of the FLAURA2 study; only events for the patients receiving at least one dose of study treatment (osimertinib, pemetrexed, cisplatin or carboplatin) as their randomised treatment are summarised. The median duration of study treatment was 22.3 months for patients in the osimertinib with pemetrexed and platinum-based chemotherapy arm.
^c National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE), version 5.0.
^d Includes: corneal epithelium defect, corneal erosion, keratitis, punctate keratitis.
^e Two CTCAE Grade 5 events (fatal) were reported.
^f Includes: interstitial lung disease (1.9%), pneumonitis (2.0%), organising pneumonia (0.1%).
^g Seven CTCAE Grade 5 events (fatal) were reported.
^h Includes: interstitial lung disease (1.8%), pneumonitis (1.1%), organising pneumonia (0.4%).
ⁱ One CTCAE Grade 5 event (fatal) was reported.
^j Includes: mouth ulceration, stomatitis.
^k Includes: acne, dermatitis, dermatitis acneiform, drug eruption, erythema, folliculitis, pustule, rash, rash erythematous, rash follicular, rash macular, rash maculo-papular, rash papular, rash pustular, rash pruritic, rash vesicular, skin erosion.
^l Includes: nail bed disorder, nail bed infection, nail bed inflammation, nail discolouration, nail disorder, nail dystrophy, nail infection, nail pigmentation, nail ridging, nail toxicity, onychalgia, onychoclasis, onycholysis, onychomadesis, onychomalacia, paronychia.
^m Includes: dry skin, eczema, skin fissures, xeroderma, xerosis.
ⁿ Includes: eyelid pruritus, pruritus.
° Cases of erythema dyschromicum perstans have been reported in the post-marketing setting.
^p Six of the 1813 patients in the ADAURA, FLAURA, FLAURA2 (monotherapy arm) and AURA studies reported erythema multiforme. Post-marketing reports of erythema multiforme have also been received, including 7 reports from a post-marketing surveillance study (N=3578).
^q Estimated frequency. The upper limit of the 95% CI for the point estimate is 3/1813 (0.2%).
^r One event was reported in a post-marketing study, and the frequency has been derived from the ADAURA, FLAURA, FLAURA2 (monotherapy arm) and AURA studies and the post-marketing study (N=5391).
^s Reported during post-marketing use.
^t Represents the incidence of laboratory findings, not of reported adverse events.
^u Represents decreases greater than or equal to 10 percentage points and a drop to less than 50%.
^v Represents the incidence of patients who had a QTcF prolongation >500 msec.

Description of selected adverse reactions

Interstitial lung disease (ILD)

In the ADAURA, FLAURA, FLAURA2 (monotherapy arm) and AURA studies, the incidence of ILD was 11.2% in patients of Japanese ethnicity, 2.3% in patients of non-Japanese Asian ethnicity and 2.7% in non-Asian patients. The median time from first dose to onset of ILD or ILD-like adverse reactions was 85 days.

QTc interval prolongation

Of the 1813 patients in ADAURA, FLAURA, FLAURA2 and AURA studies treated with osimertinib monotherapy (80 mg), 1.1% of patients (n=20) were found to have a QTc greater than 500 msec, and 4.3% of patients (n=78) had an increase from baseline QTc greater than 60 msec. A pharmacokinetic/pharmacodynamic analysis with osimertinib predicted a concentration-dependent increase in QTc interval prolongation. No QTc-related arrhythmias were reported in the ADAURA, FLAURA, FLAURA2, or AURA studies. In patients who received osimertinib in combination with pemetrexed and platinum-based chemotherapy, the proportion of patients who experienced a QTc interval prolongation of greater than 500 msec with a greater than 60 msec increase from baseline was low and was similar with monotherapy (1.8% versus 1.5%).

Gastrointestinal effects

In the ADAURA, FLAURA, FLAURA2 and AURA studies (osimertinib monotherapy; N=1813), diarrhoea was reported in 47% of patients of which 37% were Grade 1 events, 8.6% Grade 2 and 1.4% were Grade 3; no Grade 4 or 5 events were reported. Dose reduction was required in 0.5% of patients and dose interruption in 1.9%. Four events (0.2%) led to discontinuation. In ADAURA, FLAURA, FLAURA2 (monotherapy arm) and AURA3 the median time to onset was 22 days, 19 days, 22 days and 22 days, respectively, and the median duration of the Grade 2 events was 11 days, 19 days, 17 days and 6 days, respectively. In patients who received osimertinib in combination with pemetrexed and platinum-based chemotherapy, diarrhoea was reported in 43% of patients versus 41% of patients in monotherapy, most of these diarrhoea events were Grade 1 and Grade 2 events.

Haematological events

Early reductions in the median laboratory counts of leukocytes, lymphocytes, neutrophils and platelets have been observed in patients treated with osimertinib, which stabilised over time and then remained above the lower limit of normal. Adverse events of leukopenia, lymphopenia, neutropenia and thrombocytopenia have been reported, most of which were mild or moderate in severity and did not lead to dose interruptions. Rare cases of aplastic anaemia, including fatal events, have been reported in association with osimertinib treatment. Osimertinib should be discontinued in patients with confirmed aplastic anaemia.

Elderly

In ADAURA, FLAURA, FLAURA2 and AURA3 (osimertinib monotherapy; N=1813), 42% of patients were 65 years of age and older, and 11% were 75 years of age and older. Compared with younger patients (<65), more patients ≥65 years old had reported adverse reactions that led to study dose modifications (interruptions or reductions) (17% versus 10%). The types of adverse events reported were similar regardless of age. Older patients reported more Grade 3 or higher adverse reactions compared to younger patients (14% versus 10%). No overall differences in efficacy were observed between older and younger patients. A consistent pattern in safety and efficacy results was observed in the analysis of AURA Phase 2 studies. Of the 276 patients treated with osimertinib in combination with pemetrexed and platinum-based chemotherapy, 104 patients were ≥65 years and 23 patients were ≥75 years of age. Older patients (≥65 years) reported similar Grade 3 or higher adverse reactions compared to <65 years old patients (36% versus 36%) respectively. Dose modification for adverse reactions were reported in a higher proportion of patients ≥65 years as compared to <65 years (34% vs 20%).

Low body weight

Patients receiving osimertinib monotherapy (80 mg) with low body weight (<50 kg) reported higher frequencies of Grade ≥3 adverse reactions (20% versus 10%) and QTc prolongation (13% versus 6%) than patients with higher body weight (≥50 kg). Patients who received osimertinib in combination with pemetrexed and platinum-based chemotherapy with low body weight (<50 kg) reported similar frequencies of Grade ≥3 adverse reactions (32% versus 37%) when compared to patients with higher body weight (≥50 kg). In contrast, dry skin (34% versus 22%) and stomatitis (40% versus 30%) were reported at higher frequencies in patients with low body weight (<50 kg) versus higher body weight (≥50 kg).