Chemical formula: C₂₂H₁₉ClN₄O₅ Molecular mass: 454.863 g/mol PubChem compound: 9911830
Tivozanib interacts in the following cases:
Tivozanib inhibits the transporter protein BCRP in vitro, but the clinical relevance of this finding is unknown. Caution should be exercised if tivozanib is co-administered with rosuvastatin. Alternatively, a statin not subject to restriction of intestinal absorption by BCRP should be considered.
All patients should have liver function tests evaluated, including aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, and alkaline phosphatase (AP), to determine hepatic function before starting and during treatment with tivozanib.
Tivozanib is not recommended in patients with severe hepatic impairment. Patients with moderate hepatic impairment should only be treated with one tivozanib 1340 microgram capsule every other day as they may be at an increased risk of adverse reactions due to increased exposure with the dose of 1340 microgram every day. No dose adjustment is required when administering tivozanib to patients with mild hepatic impairment. Tivozanib should be used with caution in patients with mild and moderate hepatic impairment with close monitoring of tolerability.
In a clinical study in healthy volunteers, co-administration of a single 1340 microgram dose of tivozanib with a strong CYP3A4 inducer at steady-state (rifampin 600 mg once daily) decreased the average half-life of tivozanib from 121 to 54 hours which was associated with a decrease in the single dose AUC0-∞ of 48% compared with AUC0-∞ in the absence of rifampin. Average Cmax and AUC0-24hr were not significantly affected (8% increase and 6% decrease respectively). The clinical effects of strong CYP3A4 inducers on repeated daily dosing of tivozanib has not been studied but potentially the average time to reach steady-state and the average steady-state serum concentration of tivozanib may be reduced, due to the reduction in half-life. It is recommended that concomitant administration of tivozanib with strong CYP3A4 inducers, if used, should be undertaken with caution. Moderate CYP3A4 inducers are not expected to have a clinically relevant effect on tivozanib exposure.
Caution is advised in patients with severe renal impairment due to limited experience and in patients undergoing dialysis as there is no experience of tivozanib in this patient population.
It is currently unknown whether tivozanib may reduce the effectiveness of hormonal contraceptives, and therefore women using hormonal contraceptives should add a barrier method.
Animal studies indicate that male and female fertility may be affected by treatment with tivozanib.
In clinical studies with tivozanib, hypothyroidism has been reported. Hypothyroidism has been observed to occur at any time during treatment with tivozanib, developing as early as within two months of treatment initiation. Risk factors for hypothyroidism include prior history of hypothyroidism and use of anti-thyroid medications.
Thyroid function should be monitored before initiation of, and periodically throughout treatment with tivozanib. Hypothyroidism should be treated according to standard medical practice.
In clinical studies with tivozanib, QT/QTc interval prolongation has been reported. QT/QTc interval prolongation may lead to an increased risk for ventricular arrhythmias. It is recommended that tivozanib be used with caution in patients with a history of QT interval prolongation or other relevant pre-existing cardiac disease and those receiving other medications known to increase the QT interval. Baseline and periodic monitoring of electrocardiograms and maintenance of electrolytes (e.g. calcium, magnesium, potassium) within the normal range is recommended.
In clinical studies with tivozanib, haemorrhagic events have been reported. Tivozanib must be used with caution in patients who are at risk for, or who have a history of bleeding. If any bleeding requires medical intervention, tivozanib should be temporarily interrupted.
In clinical studies with tivozanib, hypertension (including persistent severe hypertension) has occurred. In approximately one-third of the patients, hypertension developed within the first 2 months of treatment. Blood pressure should be well controlled prior to initiating tivozanib. During treatment, patients should be monitored for hypertension and treated as needed with anti-hypertensive therapy according to standard medical practice. In the case of persistent hypertension despite use of anti-hypertensive therapy, the tivozanib dose should be reduced, or the treatment interrupted and re-initiated at a lower dose once the blood pressure is controlled, according to clinical judgment.
Discontinuation of treatment should be considered in cases of persistent severe hypertension, posterior reversible encephalopathy syndrome (see below), or other complications of hypertension. Patients receiving anti-hypertensive medication should still be monitored for hypotension when tivozanib is either interrupted or discontinued.
For precautionary reasons, temporary interruption of tivozanib therapy is recommended in patients undergoing major surgical procedures. The decision to resume tivozanib therapy after surgery should be based on clinical judgment of adequate wound healing.
Proteinuria has been reported in clinical studies with tivozanib. Monitoring for proteinuria before initiation of, and periodically throughout treatment is recommended. For patients who develop Grade 2 (>1.0-3.4 g/24 hours) or Grade 3 (≥3.5 g/24 hours) proteinuria (National Cancer Institute Common Terminology Criteria for Adverse Events [NCI CTCAE]), the dose of tivozanib has to be reduced or the treatment temporarily interrupted. If the patient develops Grade 4 proteinuria (nephrotic syndrome) tivozanib has to be discontinued. Risk factors for proteinuria include high blood pressure.
In clinical studies with tivozanib, hand foot skin reaction (palmar-plantar erythrodysaesthesia) has been reported. Most events in the five renal cell carcinoma monotherapy studies were CTC Grade 1 or 2 (≥ CTC Grade 3 was observed in <2% of patients treated with tivozanib) and there were no serious events. Management of patients experiencing HFSR may include topical therapies for symptomatic relief with consideration of temporary interruption and/or reduction in treatment dose or, in severe or persistent cases, permanent discontinuation of treatment.
In clinical studies with tivozanib, elevations of ALT, AST, and bilirubin have been reported. The majority of AST and ALT elevations were not accompanied with concomitant elevations of bilirubin. AST, ALT, bilirubin, and AP should be monitored before initiation of and periodically throughout treatment with tivozanib because of the potential risk of hepatotoxicity.
Tivozanib is not recommended in patients with severe hepatic impairment. Patients with moderate hepatic impairment should only be treated with one tivozanib 1340 microgram capsule every other day as they may be at an increased risk of adverse reactions due to increased exposure with the dose of 1340 microgram every day. No dose adjustment is required when administering tivozanib to patients with mild hepatic impairment. Tivozanib should be used with caution in patients with mild and moderate hepatic impairment with close monitoring of tolerability.
In clinical studies with tivozanib, venous thromboembolic events (VTEs) have been reported including pulmonary embolism and deep vein thrombosis. Risk factors for VTEs include major surgery, multiple trauma, prior VTEs, advanced age, obesity, cardiac or respiratory failure, and prolonged immobility. Tivozanib has not been studied in patients who had a VTE within the preceding 6 months of clinical study initiation. Treatment decision, especially in patients who are at risk for VTEs, should be based on individual patient benefit/risk assessment.
The use of VEGF pathway inhibitors in patients with or without hypertension may promote the formation of aneurysms and/or artery dissections. Before initiating tivozanib, this risk should be carefully considered in patients with risk factors such as hypertension or history of aneurysm.
In clinical studies, one case of posterior reversible encephalopathy syndrome (PRES) was confirmed after treatment with tivozanib. PRES is a neurological disorder which can present with headache, seizure, lethargy, confusion, blindness and other visual and neurologic disturbances. Mild to severe hypertension may be present. Magnetic Resonance Imaging is necessary to confirm the diagnosis of PRES. Tivozanib must be discontinued in patients developing signs or symptoms of PRES. The safety of re-initiating tivozanib therapy in patients previously experiencing PRES is not known and tivozanib should only be used with caution in these patients.
It is recommended that symptoms of gastrointestinal perforation or fistula should be periodically monitored throughout treatment with tivozanib and that tivozanib should be used with caution in patients at risk for GI perforation or fistula.
In clinical studies with tivozanib, arterial thromboembolic events (ATEs) have occurred. Risk factors for ATE include malignant disease, age >65 years, hypertension, diabetes mellitus, smoking, hypercholesterolaemia, and prior thromboembolic disease. Tivozanib has not been studied in patients who had an ATE within the preceding 6 months of clinical study initiation. Tivozanib must be used with caution in patients who are at risk for, or who have a history of these events (such as myocardial infarction, stroke).
In clinical studies with tivozanib as monotherapy for the treatment of patients with RCC, cardiac failure has been reported. Signs or symptoms of cardiac failure should be periodically monitored throughout treatment with tivozanib. Management of cardiac failure events may require temporary interruption or permanent discontinuation and/or dose reduction of tivozanib therapy, plus treatment of potential underlying causes of cardiac failure e.g. hypertension.
There are no data from the use of tivozanib in pregnant women. Studies in animals have shown reproductive toxicity.
Tivozanib should not be used during pregnancy. If tivozanib is used during pregnancy, or if the patient becomes pregnant while receiving tivozanib, the potential hazard to the foetus must be explained to the patient.
It is unknown whether tivozanib is excreted in human milk, but the potential exists. Because of the potential for tivozanib-mediated adverse reactions in breastfed infants, women should not breast-feed while taking tivozanib.
Women of childbearing potential should avoid becoming pregnant while on tivozanib. Female partners of male patients taking tivozanib should also avoid pregnancy. Effective methods of contraception should be used by male and female patients and their partners during therapy, and for at least one month after completing therapy. It is currently unknown whether tivozanib may reduce the effectiveness of hormonal contraceptives and therefore women using hormonal contraceptives should add a barrier method.
Animal studies indicate that male and female fertility may be affected by treatment with tivozanib.
Tivozanib may have a minor influence on the ability to drive and use machines. Patients should be advised to be cautious when driving or using machines if they experience asthenia, fatigue, and/or dizziness during treatment with tivozanib.
Pooled data of 674 patients with advanced RCC who continued to receive tivozanib as their initial on trial therapy in the five core RCC monotherapy studies have been evaluated in the overall assessment of safety and tolerability of tivozanib.
The most important serious adverse reaction is hypertension.
The most common adverse reactions of any grade include hypertension (47.6%), dysphonia (26.9%), fatigue (25.8%) and diarrhoea (25.5%).
In the five core RCC monotherapy studies tivozanib was discontinued in a total of 20 patients (3%) owing to adverse reactions, most commonly due to hypertension (0.4%), persistent severe hypertension (0.3%), or acute myocardial infarction (0.3%). The most frequent adverse reactions leading to tivozanib dose reduction/interruption were hypertension (4.7%), diarrhoea (3.1%), fatigue (1.8%).
In patients receiving tivozanib as initial therapy, there were three adverse reactions with outcome death; one was uncontrolled hypertension in the setting of a suspected overdose and two were reported simply as death.
Adverse reactions occurring in patients who continued to receive tivozanib as their initial on trial therapy in the five RCC monotherapy studies were pooled and are listed below by MedDRA body system organ class (SOC) and frequency. Frequencies are defined as follows: 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) and not known (cannot be estimated from available data). Within each SOC, adverse reactions are presented in order of decreasing seriousness.
Uncommon: Fungal infection, Pustular rash
Common: Anaemia
Uncommon: Thrombocytopenia, Haemoglobin increased
Common: Hypothyroidism
Uncommon: Hyperthyroidism, Goitre1
Very common: Decreased appetite
Common: Anorexia
Common: Insomnia
Very common: Headache
Common: Peripheral neuropathy2, Dizziness, Dysgeusia3
Uncommon: Transient ischaemic attack, Memory impairment4
Rare: Posterior reversible encephalopathy syndrome (PRES)5
Common: Vision impairment6
Uncommon: Increased lacrimation
Common: Vertigo, Tinnitus
Uncommon: Ear congestion
Common: Myocardial infarction (acute)/ischaemia7, Angina pectoris, Tachycardia8
Uncommon: Pulmonary oedema, Coronary artery insufficiency, Electrocardiogram QT prolonged
Very common: Hypertension
Common: Haemorrhage9, Arterial thromboembolism10, Venous thromboembolism11, Persistent severe hypertension12, Flushing13
Not known: Aneurysms and artery dissections
Very common: Dyspnoea14, Dysphonia, Cough
Common: Epistaxis, Rhinorrhoea, Nasal congestion
Very common: Abdominal pain15, Nausea, Diarrhoea, Stomatitis16
Common: Pancreatitis17, Dysphagia18, Vomiting, Gastrooesophageal reflux disease, Abdominal distension, Glossitis19, Gingivitis20, Dyspepsia, Constipation, Dry mouth, Flatulence
Uncommon: Duodenal ulcer
Common: ALT increased/AST increased21, Gamma-glutamyltransferase increased, Blood alkaline phosphatase increased
Very common: Palmar-plantar erythrodysaesthesia syndrome/Hand foot skin reaction (PPE/HFS)
Common: Skin exfoliation, Erythema22, Pruritus23, Alopecia, Rash24, Acne25, Dry skin
Uncommon: Urticaria, Dermatitis26, Hyperhidrosis, Xeroderma
Very common: Back pain
Common: Arthralgia, Myalgia, Musculoskeletal chest pain
Uncommon: Muscular weakness
Common: Proteinuria, Blood creatinine increased
Very common: Pain27, Asthenia, Fatigue
Common: Chest pain28, Chills29, Pyrexia, Peripheral oedema
Uncommon: Mucosal inflammation
Very common: Weight decreased
Common: Amylase increased, Lipase increased, Blood thyroid, stimulating hormone increased
Adverse reactions from clinical studies are presented using frequencies for all-causality adverse events.
The following terms have been combined:
1 Goitre including goitre and toxic nodular goitre
2 Peripheral neuropathy including hyperaesthesia, hypoaesthesia, mononeuropathy, neuropathy peripheral, peripheral sensory neuropathy and paraesthesia
3 Dysgeusia including ageusia, dysgeusia and hypogeusia
4 Memory impairment including amnesia and memory impairment
5 PRES was not observed in patients treated with tivozanib in the five RCC monotherapy studies. One patient experienced Grade 4 PRES and hypertension in Study AV-951-09-901.
6 Vision impairment including reduced visual acuity, vision blurred and visual impairment
7 Myocardial infarction (acute)/ischaemia including acute myocardial infarction, ischaemia and myocardial infarction
8 Tachycardia including sinus tachycardia, supraventricular tachycardia, tachycardia and tachycardia paroxysmal
9 Haemorrhage including adrenal haemorrhage, anal haemorrhage, cervix haemorrhage uterine, duodenal ulcer haemorrhage, gingival bleeding, haematemesis, haemoptysis, haemorrhagic anaemia, haemorrhagic erosive gastritis, haemorrhagic stroke, mouth haemorrhage, pulmonary haemorrhage and respiratory tract haemorrhage
10 Arterial thromboembolism including acute myocardial infarction, arterial thrombosis, iliac artery thrombosis,
ischaemic stroke, myocardial infarction and transient ischaemic attack
11 Venous thromboembolism including deep vein thrombosis, embolism venous and pulmonary embolism
12 Persistent severe hypertension including hypertensive crisis
13 Flushing including flushing and hot flush
14 Dyspnoea including dyspnoea and exertional dyspnoea
15 Abdominal pain including abdominal discomfort, abdominal pain, abdominal pain lower, abdominal pain upper and abdominal rigidity
16 Stomatitis including oral discomfort, oral disorder and stomatitis
17 Pancreatitis including pancreatitis and pancreatitis acute
18 Dysphagia including dysphagia, odynophagia and oropharyngeal pain
19 Glossitis including glossitis and glossodynia
20 Gingivitis including gingival bleeding, gingival disorder, gingival pain and gingivitis
21 Alanine aminotransferase (ALT) increased/Aspartate aminotransferase (AST) increased including ALT increased and AST increased
22 Erythema including erythema, generalised erythema and palmar erythema
23 Pruritus including generalised pruritus and pruritus
24 Rash including rash, rash erythematous, rash generalised, rash maculo-papular, rash papular and rash pruritic
25 Acne including acne and dermatitis acneiform
26 Dermatitis including dermatitis and dermatitis bullous
27 Pain including bone pain, cancer pain, flank pain, groin pain, oral pain, pain, pain in extremity and tumour pain
28 Chest pain including chest pain and non-cardiac chest pain
29 Chills including chills and hypothermia
Hypertension was reported as an adverse reaction in 47.6% of patients receiving tivozanib as initial therapy; in 23.0% the hypertension was CTC ≥Grade 3. Persistent severe hypertension (‘hypertensive crisis’) was an adverse reaction in 1.0%, CTC Grade 3 or higher in 0.9%. One patient died as a result of uncontrolled hypertension in the setting of a suspected overdose.
PRES (also known as reversible posterior leukoencephalopathy syndrome (RPLS)) was confirmed in one non-RCC patient after approximately 8 weeks on tivozanib. PRES is a neurological disorder that may present with headache, seizure, lethargy, confusion, blindness and other visual and neurologic disturbances. Mild to severe hypertension may be present.
Pulmonary embolism was reported in patients (0.7%) receiving tivozanib as initial therapy in the five core RCC monotherapy studies, with the majority CTC Grade ≥3. Deep vein thrombosis was also reported in two patients (0.3%) and was CTC Grade ≥3 in one patient (0.1%) receiving initial tivozanib therapy.
Arterial thromboembolic adverse reactions in the patients receiving tivozanib as initial therapy were ischaemic stroke (1.0%), myocardial infarction (0.7%), transient ischaemic attack (0.7%) and acute myocardial infarction (0.4%), the majority of which were at least CTC Grade 3, plus iliac artery thrombosis (0.1%). There were no deaths due to arterial thromboembolic adverse reactions in those receiving tivozanib as initial therapy but a myocardial infarction in a patient receiving second-line tivozanib had a fatal outcome.
Pulmonary oedema was reported in two patients (0.3%) receiving tivozanib as initial therapy in the five core RCC monotherapy studies. Both events were CTC Grade 3.
QT prolongation was reported in two patients (CTC Grade 2 and Grade 3) in the tivozanib cardiac safety study, neither reaction was considered serious.
Hypothyroidism was reported as an adverse reaction for 5.6% of patients during initial therapy and was CTC Grade 2 or lower in all cases. It was reported as serious in one patient.
Haemorrhage adverse reactions were reported in the core monotherapy studies during initial treatment.
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