Dosage guidance:
Safety: Advise patients to limit sun exposure during treatment with ensartinib and for at least 1 week after discontinuation to minimize the risk of dermatologic adverse reactions.
Clinical considerations: Select patients for the treatment of locally advanced or metastatic non–small cell lung cancer based on the presence of anaplastic lymphoma kinase (ALK) rearrangement(s) in tumor specimens.
Non–small cell lung cancer, locally advanced or metastatic, ALK positive: Oral: 225 mg once daily; continue until disease progression or unacceptable toxicity (Ref).
Missed doses: If a dose is missed, administer the missed dose as soon as possible, unless the next dose is due within 12 hours; do not administer 2 doses on the same day. If a dose is vomited, do not administer an additional dose; resume at the next scheduled treatment time.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
eGFR ≥30 mL/minute: There are no dosage adjustments provided in the manufacturer’s labeling; however, there was no clinically significant effect on ensartinib pharmacokinetics in patients with an eGFR of 30 to 89 mL/minute.
eGFR 15 to <30 mL/minute: There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied).
End-stage kidney disease (eGFR <15 mL/minute) with or without hemodialysis: There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied).
Hepatic impairment prior to treatment initiation:
Mild (total bilirubin ≤ ULN and AST > ULN or total bilirubin 1 to 1.5 × ULN and any AST) impairment: No dosage adjustment is necessary.
Moderate (total bilirubin >1.5 to ≤3 × ULN and any AST): Monitor for increased risk of adverse reactions and adjust ensartinib dosage as clinically indicated.
Severe (total bilirubin >3 × ULN and any AST) impairment: Avoid use.
Acute hepatotoxicity during treatment:
AST or ALT >5 × ULN (grade 3 or 4 elevation) with concurrent total bilirubin ≤2 × ULN: Withhold ensartinib until recovery to ≤ grade 1 (≤3 × ULN) or to baseline; resume ensartinib at a reduced dose.
AST or ALT >3 × ULN (grade 2 to 4 elevation) with concurrent total bilirubin >2 × ULN in the absence of cholestasis or hemolysis: Permanently discontinue ensartinib.
American Society of Clinical Oncology guidelines for appropriate systemic therapy dosing in adults with cancer with a BMI ≥30 kg/m2: The dosing in the FDA-approved prescribing information should be followed in all patients, regardless of obesity status. If a patient with a BMI ≥30 kg/m2 experiences high-grade toxicity from systemic anticancer therapy, the same dosage modification recommendations should be followed for all patients, regardless of obesity status (Ref).
Dosage reduction level |
Recommended ensartinib dosage and schedule |
---|---|
a Once the ensartinib dose has been reduced for adverse reactions, do not subsequently increase the dose. | |
Usual (initial) dose |
225 mg once daily |
First dose reduction levela |
200 mg once daily |
Second dose reduction levela |
150 mg once daily |
Permanently discontinue ensartinib if unable to tolerate 150 mg once daily. |
Adverse reaction |
Severity |
Ensartinib dosage modification |
---|---|---|
a bpm = beats per minute; CPK = creatine phosphokinase; ILD = interstitial lung disease. | ||
Cardiac toxicity: bradycardia (heart rate <60 bpm) |
Symptomatic |
Withhold ensartinib until recovery to asymptomatic bradycardia or until a resting heart rate ≥60 bpm. Evaluate concurrent medications; if a contributing concomitant medication is identified and discontinued (or dose adjusted), resume ensartinib at the previous dose upon recovery to asymptomatic bradycardia or resting heart rate ≥60 bpm. If no contributing concomitant medication is identified, or concomitant medication cannot be discontinued or dose adjusted, resume ensartinib at a reduced dose upon recovery to asymptomatic bradycardia or resting heart rate ≥60 bpm. |
Life-threatening, urgent intervention indicated |
Permanently discontinue ensartinib if no contributing concomitant medication is identified. If a contributing concomitant medication is identified and discontinued (or dose adjusted), resume ensartinib at a reduced dose (with frequent monitoring as clinically indicated) upon recovery to asymptomatic bradycardia or to a resting heart rate ≥60 bpm. Permanently discontinue for recurrent life-threatening bradycardia. | |
CPK elevation |
CPK >5 × ULN |
Withhold ensartinib until recovery to baseline or to ≤2.5 × ULN; resume ensartinib at the same dose. |
CPK >10 × ULN or second occurrence of CPK >5 × ULN |
Withhold ensartinib until recovery to baseline or to ≤2.5 × ULN; resume ensartinib at a reduced dose. | |
Dermatologic toxicity |
Any |
Treat with antihistamine, topical or systemic steroids based on the severity. |
Grade 1 |
Consider topical corticosteroids. | |
Grade 2 |
Administer topical corticosteroids. If no improvement in ≤7 days after initiation of topical corticosteroids: Administer oral corticosteroids. If no improvement in ≤7 days after initiation of oral corticosteroids: Withhold ensartinib until recovery to ≤ grade 1; resume ensartinib at a reduced dose. | |
Grade 3 |
Withhold ensartinib and administer topical corticosteroids. If no improvement in ≤7 days after initiation of topical corticosteroids: Administer oral corticosteroids. Upon improvement to ≤ grade 1, resume ensartinib at a reduced dose. | |
Grade 4 |
Permanently discontinue ensartinib. Administer systemic corticosteroids and consider antibiotic use. | |
Hyperglycemia |
Grade 3 (blood glucose >250 mg/dL) despite optimal antihyperglycemic therapy or grade 4 |
Withhold ensartinib until hyperglycemia is adequately controlled; resume at a reduced dose. Permanently discontinue ensartinib if adequate hyperglycemic control cannot be achieved with medical management. |
Hyperuricemia |
Symptomatic or grade 4 |
Initiate urate-lowering medication as clinically indicated. Withhold ensartinib until improvement of signs or symptoms; resume ensartinib at the same or a reduced dose. |
Ocular toxicity: visual disturbance |
Grade 2 or 3 |
Withhold ensartinib until recovery to grade 1 or baseline; consider resuming ensartinib at a reduced dose. |
Grade 4 |
Permanently discontinue ensartinib. | |
Pulmonary toxicity: ILD/pneumonitis |
Any grade (suspected) |
Immediately withhold ensartinib. |
Any grade (confirmed) |
Permanently discontinue ensartinib. | |
Other adverse reactions |
Grade 3 or 4 |
Withhold ensartinib until recovery to grade 1 or baseline; resume ensartinib at a reduced dose. |
Recurrent grade 4 |
Permanently discontinue ensartinib. |
Refer to adult dosing.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Reported adverse reactions are for adults.
>10%:
Cardiovascular: Edema (27%)
Dermatologic: Alopecia (11%), dermatological reaction (80%; including drug reaction with eosinophilia and systemic symptoms [<1%], pruritus [30% to 32%], skin photosensitivity [<1%], skin rash [66% to 72%])
Endocrine & metabolic: Decreased serum albumin (46%), decreased serum calcium (36%), decreased serum phosphate (39%), decreased serum sodium (27%), increased serum glucose (44% to 49%)
Gastrointestinal: Constipation (31%), decreased appetite (15%), nausea (28%; grades 3/4: 1%), vomiting (16%; grades 3/4: <1%)
Hematologic & oncologic: Decreased hemoglobin (43%; grades 3/4: <1%), lymphocytopenia (57%; grades 3/4: 7%)
Hepatic: Increased serum alanine aminotransferase (59% to 73%), increased serum alkaline phosphatase (64%), increased serum aspartate aminotransferase (58% to 64%), increased serum bilirubin (12%)
Nervous system: Dizziness (12%), fatigue (21%)
Neuromuscular & skeletal: Increased creatine phosphokinase in blood specimen (43%), musculoskeletal pain (36%)
Renal: Increased serum creatinine (37%)
Respiratory: Cough (31%), respiratory tract infection (13%)
Miscellaneous: Fever (22%)
1% to 10%:
Cardiovascular: Bradycardia (6%)
Dermatologic: Xeroderma (10%)
Endocrine & metabolic: Decreased serum potassium (grades 3/4: ≥2%), hypermagnesemia (grades 3/4: ≥2%), hyperuricemia (6%)
Gastrointestinal: Dysgeusia (10%), increased serum amylase (grades 3/4: ≥2%)
Hematologic & oncologic: Hemorrhage (10%; grades 3/4: 1%)
Hepatic: Increased serum gamma-glutamyl transferase (grades 3/4: ≥2%)
Ophthalmic: Visual disturbance (8%)
Respiratory: Interstitial lung disease (5%; including pneumonitis)
<1%: Hepatic: Hepatic injury
Frequency not defined:
Dermatologic: Cellulitis
Respiratory: Pneumonia
Severe hypersensitivity to ensartinib, FD&C Yellow No. 5 dye (tartrazine), or any component of the formulation.
Concerns related to adverse effects:
• Bradycardia: Symptomatic bradycardia has occurred with ensartinib; all events were grade 1 or 2 and rarely resulted in dose modification or interruption.
• CPK elevation: In the clinical trial, elevations in creatine phosphokinase (CPK) occurred in almost one-half of ensartinib-treated patients, including grade 3 and 4 events. The median time to onset of increased CPK was 123 days (range: 13 days to 22 months). Advise patients to report any unexplained muscle pain, tenderness, or weakness.
• Dermatologic toxicity: Ensartinib may cause dermatologic adverse reactions, including drug reaction with eosinophilia and systemic symptoms (DRESS), rash, pruritus, and photosensitivity, including grade 3 events. In the clinical trial, dermatologic adverse reactions occurred in a majority of ensartinib-treated patients. Rash occurred in approximately three-fourths of patients receiving ensartinib; the median time to onset of rash was 9 days (range: 1 day to 17.3 months). Approximately one-third of patients receiving ensartinib experienced pruritus. Dermatologic toxicities resulted in dosage modification, interruption, or discontinuation in some ensartinib-treated patients. Photosensitivity occurred rarely; all events were grade 1 in severity.
• Hepatotoxicity: Hepatotoxicity, including drug-induced liver injury, has occurred with ensartinib. Elevations in ALT or AST occurred in over one-half of ensartinib-treated patients, including grade 3 events; elevations in total bilirubin have also occurred (including grade 3 or 4 events). The median time to onset of elevated transaminases was 5.3 weeks (range: 0.4 to 152 weeks). Dosage modification, interruption, or discontinuation occurred secondary to hepatotoxicity in a small percentage of ensartinib-treated patients.
• Hyperglycemia: Ensartinib may cause hyperglycemia, including grade 3 events. The median time to onset of increased blood glucose was 5.9 weeks (0.4 weeks to 3.4 years).
• Hyperuricemia: Hyperuricemia has occurred with ensartinib, including grade 3 and 4 events. Hydration and urate-lowering medications were required in some patients to manage hyperuricemia.
• Ocular toxicity: Visual disturbances, including blurred vision, diplopia, photopsia, vitreous floaters, visual impairment, visual field defect, and reduced visual acuity, may occur with ensartinib.
• Pulmonary toxicity: Ensartinib may cause severe interstitial lung disease (ILD)/ pneumonitis. ILD/pneumonitis has occurred with ensartinib in a small percentage of patients; grade 3 and 4 ILD/pneumonitis has been observed, with some patients requiring ensartinib treatment interruption or discontinuation. Signs/symptoms suggestive if ILD/pneumonitis include cough, dyspnea, and fever.
Special populations:
• Older adults: A higher incidence of serious adverse events, adverse events leading to treatment discontinuations, and dose modifications was observed in patients ≥65 years of age when compared to patients <65 years of age.
Dosage form specific issues:
• Propylene glycol: Some dosage forms may contain propylene glycol; large amounts are potentially toxic and have been associated hyperosmolality, lactic acidosis, seizures and respiratory depression; use caution (Ref). See manufacturer’s labeling.
• Yellow dye: Ensartinib capsules contain FD&C Yellow No. 5 dye (tartrazine). Tartrazine may cause allergic-type reactions, including bronchial asthma; tartrazine sensitivity is frequently observed in patients who also have aspirin hypersensitivity.
Other warnings/precautions:
• Appropriate use: Select patients for the treatment of locally advanced or metastatic non–small cell lung cancer based on the presence of anaplastic lymphoma kinase (ALK) rearrangement(s) in tumor specimens.
Ensacove: FDA approved December 2024; anticipated availability unknown.
Oral: Administer with or without food at the same time each day. Swallow capsules whole; do not crush or chew, do not open or dissolve the contents of the capsule.
This medication is not on the NIOSH (2024) list; however, it may meet the criteria for a hazardous drug. Ensartinib may cause teratogenicity and/or has a structural/toxicity profile similar to existing hazardous agents.
Use appropriate precautions for receiving, handling, storage, preparation, dispensing, transporting, administration, and disposal. Follow NIOSH and USP 800 recommendations and institution-specific policies/procedures for appropriate containment strategy (Ref).
Note: Facilities may perform risk assessment of some hazardous drugs to determine if appropriate for alternative handling and containment strategies (Ref). Refer to institution-specific handling policies/procedures.
Non–small cell lung cancer, locally advanced or metastatic, ALK positive: Treatment of anaplastic lymphoma kinase (ALK)-positive (as detected by an approved test) locally advanced or metastatic non–small cell lung cancer in adults who have not previously received an ALK-inhibitor.
Ensartinib may be confused with alectinib, enasidenib, encorafenib, entecavir, entrectinib, enzalutamide, erdafitinib, erlotinib.
The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drug classes (chemotherapeutic agent, parenteral and oral) which have a heightened risk of causing significant patient harm when used in error (High-Alert Medications in Acute Care, Community/Ambulatory Care, and Long-Term Care Settings).
Substrate of CYP3A4 (Major), P-glycoprotein (Major with inhibitors), P-glycoprotein (Minor with inducers); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential;
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
Bradycardia-Causing Agents: May increase bradycardic effects of Bradycardia-Causing Agents. Risk C: Monitor
Clofazimine: May increase serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor
CYP3A4 Inducers (Moderate): May decrease serum concentration of Ensartinib. Risk X: Avoid
CYP3A4 Inducers (Strong): May decrease serum concentration of Ensartinib. Risk X: Avoid
CYP3A4 Inhibitors (Moderate): May increase serum concentration of Ensartinib. Risk X: Avoid
CYP3A4 Inhibitors (Strong): May increase serum concentration of Ensartinib. Risk X: Avoid
Etrasimod: May increase bradycardic effects of Bradycardia-Causing Agents. Risk C: Monitor
Fingolimod: Bradycardia-Causing Agents may increase bradycardic effects of Fingolimod. Management: Consult with the prescriber of any bradycardia-causing agent to see if the agent could be switched to an agent that does not cause bradycardia prior to initiating fingolimod. If combined, perform continuous ECG monitoring after the first fingolimod dose. Risk D: Consider Therapy Modification
Fusidic Acid (Systemic): May increase serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Consider avoiding this combination if possible. If required, monitor patients closely for increased adverse effects of the CYP3A4 substrate. Risk D: Consider Therapy Modification
Grapefruit Juice: May increase serum concentration of Ensartinib. Risk X: Avoid
Ivabradine: Bradycardia-Causing Agents may increase bradycardic effects of Ivabradine. Risk C: Monitor
Lacosamide: Bradycardia-Causing Agents may increase AV-blocking effects of Lacosamide. Risk C: Monitor
Landiolol: Bradycardia-Causing Agents may increase bradycardic effects of Landiolol. Risk X: Avoid
Midodrine: May increase bradycardic effects of Bradycardia-Causing Agents. Risk C: Monitor
Ozanimod: May increase bradycardic effects of Bradycardia-Causing Agents. Risk C: Monitor
P-glycoprotein/ABCB1 Inhibitors: May increase serum concentration of Ensartinib. Risk X: Avoid
Ponesimod: Bradycardia-Causing Agents may increase bradycardic effects of Ponesimod. Management: Avoid coadministration of ponesimod with drugs that may cause bradycardia when possible. If combined, monitor heart rate closely and consider obtaining a cardiology consult. Do not initiate ponesimod in patients on beta-blockers if HR is less than 55 bpm. Risk D: Consider Therapy Modification
Siponimod: Bradycardia-Causing Agents may increase bradycardic effects of Siponimod. Management: Avoid coadministration of siponimod with drugs that may cause bradycardia. If combined, consider obtaining a cardiology consult regarding patient monitoring. Risk D: Consider Therapy Modification
Vimseltinib: May increase serum concentration of P-glycoprotein/ABCB1 Substrates (High risk with Inhibitors). Management: Avoid concomitant use of vimseltinib and P-gp substrates when possible. If combined, administer vimseltinib at least 4 hours before the P-gp substrate. Risk D: Consider Therapy Modification
Grapefruit: Coadministration with grapefruit may increase ensartinib plasma concentrations. Management: Avoid concomitant administration with grapefruit and grapefruit products.
Verify pregnancy status prior to use in patients who could become pregnant.
Patients who could become pregnant should use effective contraception during therapy and for 1 week after the last dose of ensartinib. Patients with partners who may become pregnant should also use effective contraception during therapy and for 1 week after the last ensartinib dose.
Based on the mechanism of action and data from animal reproduction studies, in utero exposure to ensartinib may cause fetal harm. Embryo-fetal mortality, growth alternations, and structural abnormalities were observed following oral doses equivalent to the human dose based on AUC to pregnant rats.
It is not known if ensartinib is present in breast milk.
Due to the potential for serious adverse reactions in the breastfed infant, breastfeeding is not recommended by the manufacturer during therapy and for 1 week after the last dose of ensartinib.
Avoid grapefruit and grapefruit products.
Anaplastic lymphoma kinase (ALK) rearrangement(s) in tumor specimens. Verify pregnancy status prior to use in patients who could become pregnant.
LFTs (ALT, AST, and total bilirubin) at baseline, every 2 weeks during the first cycle of treatment, then monthly and as clinically indicated, creatine phosphokinase (CPK) levels during treatment, fasting blood glucose at baseline and serum glucose periodically during treatment, and uric acid levels at baseline and periodically during treatment. Monitor heart rate regularly during treatment.
Monitor for signs/symptoms of dermatologic toxicity, hepatotoxicity, hyperglycemia, interstitial lung disease (ILD)/pneumonitis (evaluate promptly for ILD/pneumonitis in patients who present with worsening of respiratory symptoms or who have signs/symptoms suggestive of ILD/pneumonitis such as cough, dyspnea, or fever), and ocular toxicity (obtain an ophthalmologic evaluation in patients with new or worsening visual symptoms). Monitor patients with moderate hepatic function impairment more closely for increased adverse reactions. Monitor adherence.
The American Society of Clinical Oncology hepatitis B virus (HBV) screening and management provisional clinical opinion (Ref) recommends HBV screening with hepatitis B surface antigen, hepatitis B core antibody, total Ig or IgG, and antibody to hepatitis B surface antigen prior to beginning (or at the beginning of) systemic anticancer therapy; do not delay treatment for screening/results. Detection of chronic or past HBV infection requires a risk assessment to determine antiviral prophylaxis requirements, monitoring, and follow-up.
Cardiovascular monitoring: Comprehensive assessment prior to treatment, including a history and physical examination, screening for cardiovascular disease risk factors such as hypertension, diabetes, dyslipidemia, obesity, and smoking (Ref).
Ensartinib is a second-generation, potent, and selective kinase inhibitor of anaplastic lymphoma kinase (ALK) (Ref). Ensartinib additionally inhibits other kinases, including MET and ROS1. In vitro, ensartinib inhibited phosphorylation of ALK and its downstream signaling proteins AKT, ERK, and S6, subsequently inhibiting ALK-mediated signaling pathways cell proliferation in ALK-positive cell lines. In vivo, ensartinib showed antitumor activity in mouse models of human ALK fusion-positive non–small cell lung cancer.
Duration: Vd: 1,720 L.
Protein binding: ~92% bound to plasma proteins.
Metabolism: Hepatic; primarily via CYP3A.
Half-life elimination: 30 hours.
Time to peak: 3 hours.
Excretion: Feces (91%; 38% as unchanged drug); urine (10%; 4.4% as unchanged drug).