Crizotinib: Drug information

For additional information see "Crizotinib: Patient drug information"

For abbreviations, symbols, and age group definitions show table

Brand Names: US

Xalkori

Brand Names: Canada

Xalkori

Pharmacologic Category

Antineoplastic Agent, Anaplastic Lymphoma Kinase Inhibitor;
Antineoplastic Agent, MET Inhibitor;
Antineoplastic Agent, Tyrosine Kinase Inhibitor

Dosing: Adult

Dosage guidance:

Clinical considerations: Crizotinib is associated with a moderate or high emetic potential (Ref); antiemetics are recommended to prevent nausea and vomiting. Provide standard antidiarrheals; consider hydration (IV or oral; if at risk for dehydration), electrolyte replacement, and nutritional support as clinically indicated.

Anaplastic large cell lymphoma, systemic ALK positive, relapsed or refractory

Anaplastic large cell lymphoma, systemic ALK positive, relapsed or refractory: Patients ≤21 years of age: Oral: 280 mg/m² twice daily until disease progression or unacceptable toxicity. Note: Consider IV or oral hydration for patients at risk of dehydration and replace electrolytes as needed. Antidiarrheal agents may also be necessary.

**Recommended Crizotinib Dose for Anaplastic Large Cell Lymphoma**
BSA	Recommended crizotinib dose
≥1.7 m²	500 mg twice daily
1.52 to 1.69 m²	450 mg twice daily
1.17 to 1.51 m²	400 mg twice daily
0.81 to 1.16 m²	250 mg twice daily
0.6 to 0.8 m²	200 mg twice daily

Inflammatory myofibroblastic tumor, ALK positive, unresectable, recurrent

Inflammatory myofibroblastic tumor, ALK positive, unresectable, recurrent, or refractory: Oral: 250 mg twice daily until disease progression or unacceptable toxicity.

Non–small cell lung cancer, metastatic, ALK or ROS1 positive

Non–small cell lung cancer, metastatic, ALK or ROS1 positive: Oral: 250 mg twice daily, continue until disease progression or unacceptable toxicity (Ref).

Missed doses: If a dose is missed, administer the missed dose unless the next dose is due within 6 hours (skip the dose if <6 hours before the next dose). If vomiting occurs after dose, administer the next dose at the regularly scheduled time.

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

Kidney function estimated using the modified Cockcroft-Gault equation.

Anaplastic large cell lymphoma, systemic ALK-positive, relapsed or refractory:

CrCl 30 to 89 mL/minute: No dosage adjustment necessary.

CrCl <30 mL/minute not requiring dialysis:

BSA ≥1.7 m²: 250 mg twice daily.

BSA ≥1.17 to 1.69 m²: 200 mg twice daily.

BSA ≥0.81 to 1.16 m²: 250 mg once daily.

BSA 0.6 to 0.8 m²: Permanently discontinue crizotinib.

Inflammatory myofibroblastic tumor (ALK-positive) or non–small cell lung cancer, metastatic (ALK- or ROS1-positive):

CrCl 30 to 89 mL/minute: No dosage adjustment necessary.

CrCl <30 mL/minute not requiring dialysis: Initial: 250 mg once daily.

Dosing: Liver Impairment: Adult

Anaplastic large cell lymphoma, systemic ALK-positive, relapsed or refractory:

Hepatotoxicity prior to treatment initiation:

Mild impairment (AST > ULN and total bilirubin ≤ ULN or total bilirubin >1 to ≤1.5 times ULN and any AST): No dose adjustment necessary.

Moderate impairment (total bilirubin >1.5 to ≤3 times ULN and any AST):

BSA ≥1.7 m²: 400 mg twice daily.

BSA ≥1.17 to 1.69 m²: 250 mg twice daily.

BSA ≥0.81 to 1.16 m²: 200 mg twice daily.

BSA 0.6 to 0.8 m²: 250 mg once daily.

Severe impairment (total bilirubin >3 times ULN and any AST):

BSA ≥1.7 m²: 250 mg twice daily.

BSA ≥1.17 to 1.69 m²: 200 mg twice daily.

BSA ≥0.81 to 1.16 m²: 250 mg once daily.

BSA 0.6 to 0.8 m²: Permanently discontinue crizotinib.

Hepatotoxicity during treatment:

ALT or AST >5 × ULN with total bilirubin ≤1.5 × ULN: Withhold crizotinib until recovery to baseline or ≤3 × ULN, then resume at the next lower dose. Refer to "Dosing: Adjustment for Toxicity: Adult" for dosage reduction levels.

ALT or AST >3 × ULN with concurrent total bilirubin >1.5 × ULN in the absence of cholestasis or hemolysis: Permanently discontinue crizotinib.

Inflammatory myofibroblastic tumor (ALK-positive) or non–small cell lung cancer, metastatic (ALK- or ROS1-positive):

Hepatotoxicity prior to treatment initiation:

Mild impairment (AST > ULN and total bilirubin ≤ ULN or total bilirubin >1 to ≤1.5 times ULN and any AST): No dose adjustment necessary.

Moderate impairment (total bilirubin >1.5 to ≤3 times ULN and any AST): 200 mg twice daily.

Severe impairment (total bilirubin >3 times ULN and any AST): 250 mg once daily.

Hepatotoxicity during treatment:

ALT or AST >5 x ULN with total bilirubin ≤1.5 × ULN: Withhold crizotinib until recovery to baseline or ≤3 × ULN, then resume at the next lower dose.

ALT or AST >3 × ULN with concurrent total bilirubin elevation >1.5 × ULN in the absence of cholestasis or hemolysis: Permanently discontinue crizotinib.

Dosing: Obesity: Adult

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. If dose reduction for toxicity is recommended in the prescribing information, the dose should be increased back to the initial or previously tolerated dose only if dose escalations are allowed in the prescribing information, if contributing underlying factors (eg, hepatic or kidney impairment) are sufficiently resolved, AND if performance status has markedly improved or is considered adequate (Ref).

Dosing: Adjustment for Toxicity: Adult

Anaplastic large cell lymphoma, systemic ALK-positive, relapsed or refractory:

**Crizotinib Dose Reduction Levels in Anaplastic Large Cell Lymphoma**
BSA	First dose reduction	Second dose reduction^a
^aPermanently discontinue crizotinib if unable to tolerate crizotinib after 2 dose reductions.
≥1.7 m²	400 mg twice daily	250 mg twice daily
1.17 to 1.69 m²	250 mg twice daily	200 mg twice daily
0.81 to 1.16 m²	200 mg twice daily	250 mg once daily
0.6 to 0.8 m²	250 mg once daily	Permanently discontinue crizotinib

**Crizotinib Dosage Modification for Adverse Reactions in Anaplastic Large Cell Lymphoma**
Adverse reaction severity	Crizotinib dose modification
Hematologic toxicities
ANC <500/mm³	1^st occurrence: Withhold crizotinib until recovery to ANC >1,000/mm³, then resume at the next lower dose.
ANC <500/mm³	2^nd occurrence: For uncomplicated grade 4 neutropenia, either withhold crizotinib until recovery to ANC >1,000/mm³then resume at the next lower dose or permanently discontinue. Permanently discontinue if unable to tolerate crizotinib after 2 dose reductions. Permanently discontinue crizotinib for recurrence complicated by febrile neutropenia or infection.
Platelets 25,000 to 50,000/mm³ with concurrent bleeding	Withhold crizotinib until platelets recover to >50,000/mm³ and bleeding resolves, then resume at the same dose.
Platelets <25,000/mm³	Withhold crizotinib until platelets recover to >50,000/mm³, then resume at the next lower dose. Permanently discontinue for recurrence.
Hemoglobin <8 g/dL	Withhold crizotinib until hemoglobin recovers to ≥8 g/dL, then resume at the same dose.
Life-threatening anemia; urgent intervention indicated	Withhold crizotinib until hemoglobin recovers to ≥8 g/dL, then resume at the next lower dose. Permanently discontinue for recurrence.
Cardiac effects
QTc >500 msec on at least 2 separate ECGs	Withhold crizotinib until recovery to QTc <481 msec or baseline, then resume at the next lower dose.
QTc >500 msec or ≥60 msec change from baseline with torsades de pointes or polymorphic ventricular tachycardia or signs/symptoms of serious arrhythmia	Permanently discontinue crizotinib.
Symptomatic bradycardia (heart rate <60 beats/minute), may be severe and medically significant with medical intervention indicated	Withhold until recovery to a resting heart rate of ≥60 beats/minute.
Life-threatening bradycardia with urgent intervention indicated	Withhold until recovery to asymptomatic bradycardia or to a heart rate of ≥60 beats/minute and evaluate concomitant medications. If contributing concomitant medication is identified and discontinued (or is dose adjusted), then (upon recovery) resume crizotinib at the 2^nd dose reduction (see previous table) with frequent monitoring. If no contributing concomitant medication is identified, permanently discontinue crizotinib. Permanently discontinue for recurrence.
GI toxicity
Nausea, grade 3 (inadequate oral intake for >3 days, medical intervention required)	Maximize medical management. If grade 3 nausea persists, withhold crizotinib until resolved, then resume at the next lower dose. Permanently discontinue if unable to tolerate crizotinib after 2 dose reductions.
Vomiting, grade 3 (>6 episodes in 24 hours for >3 days, medical intervention, such as tube feeding or hospitalization required), or grade 4 (life-threatening consequences, urgent intervention required)	Maximize medical management. If grade 3 or 4 vomiting persists, withhold crizotinib until resolved, then resume at the next lower dose. Permanently discontinue if unable to tolerate crizotinib after 2 dose reductions.
Diarrhea, grade 3 (increase of ≥7 stools per day over baseline; incontinence; hospitalization indicated, or grade 4 (life-threatening consequences, urgent intervention required)	Maximize medical management. If grade 3 or 4 diarrhea persists, withhold crizotinib until resolved, then resume at the next lower dose. Permanently discontinue if unable to tolerate crizotinib after 2 dose reductions.
Ocular toxicity, including visual loss
Visual symptoms, grade 1 (mild symptoms) or grade 2 (moderate symptoms affecting ability to perform activities of daily living)	Monitor; report any symptoms to an ophthalmic specialist. Consider dose reduction for grade 2 visual disorders.
Visual loss (grade 3 or 4 ocular disorder, marked decrease in vision)	Withhold crizotinib pending evaluation. Permanently discontinue crizotinib for grade 3 or 4 ocular disorders (if no other etiology is identified).
New onset of severe visual loss (best corrected vision <20/200 in one or both eyes)	Discontinue crizotinib during evaluation of severe vision loss (decision to resume crizotinib should consider potential benefits versus risks).
Pulmonary toxicity
Drug-related interstitial lung disease/pneumonitis (any grade)	Permanently discontinue crizotinib.

Inflammatory myofibroblastic tumor (ALK-positive) or non–small cell lung cancer, metastatic (ALK- or ROS1-positive):

Note: If dose reduction is necessary, reduce dose to 200 mg orally twice daily; if necessary, further reduce to 250 mg once daily. If unable to tolerate 250 mg once daily, permanently discontinue crizotinib.

**Crizotinib Dosage Modification for Adverse Reactions in Inflammatory Myofibroblastic Tumor or Non–Small Cell Lung Cancer**
Adverse reaction severity	Crizotinib dose modification
^aExcept lymphopenia (unless associated with clinical events [eg, opportunistic infections]).
Hematologic toxicity^a
Grade 3 hematologic toxicity^a	Withhold crizotinib until recovery to grade ≤2, then resume at the same dose.
Grade 4 hematologic toxicity^a	Withhold crizotinib until recovery to grade ≤2, then resume at the next lower dose.
Cardiac effects
QTc >500 msec on at least 2 separate ECGs	Withhold crizotinib until recovery to QTc <481 msec or baseline, then resume at the next lower dose.
QTc >500 msec or ≥60 msec change from baseline with torsades de pointes or polymorphic ventricular tachycardia or signs/symptoms of serious arrhythmia	Permanently discontinue crizotinib.
Symptomatic bradycardia (heart rate <60 beats/minute), may be severe and medically significant with medical intervention indicated	Withhold crizotinib until recovery to asymptomatic bradycardia or to a heart rate of ≥60 beats/minute and evaluate concomitant medications associated with bradycardia and antihypertensives. If contributing concomitant medication is identified and discontinued (or is dose adjusted), then (upon recovery) resume crizotinib at the previous dose. If no contributing concomitant medication is identified (or cannot be discontinued or dose adjusted), then (upon recovery) resume crizotinib at a reduced dose.
Life-threatening bradycardia with urgent intervention indicated	Withhold crizotinib until recovery to asymptomatic bradycardia or to a heart rate of ≥60 beats/minute and evaluate concomitant medications. If contributing concomitant medication is identified and discontinued (or dose adjusted), then (upon recovery) resume crizotinib at 250 mg once daily with frequent monitoring. If no contributing concomitant medication is identified, permanently discontinue crizotinib. Permanently discontinue for recurrence.
Ocular toxicity
Visual loss (grade 4 ocular disorder) or new onset of severe visual loss (best corrected vision <20/200 in one or both eyes)	Discontinue crizotinib during evaluation of severe vision loss (decision to resume crizotinib should consider potential benefits versus risks).
Pulmonary toxicity
Any grade drug-related interstitial lung disease/pneumonitis	Permanently discontinue crizotinib.

Dosing: Older Adult

Refer to adult dosing.

Dosing: Pediatric

(For additional information see "Crizotinib: Pediatric drug information")

Dosage guidance:

Anaplastic large cell lymphoma, systemic ALK positive, relapsed or refractory

Anaplastic large cell lymphoma (ALCL), systemic ALK positive, relapsed or refractory:

Note: May require combining capsule strengths to achieve dose. Consider IV or oral hydration for patients at risk of dehydration and replace electrolytes as needed; antidiarrheal agents may be necessary for GI toxicities.

BSA-directed dosing: Children and Adolescents: Oral: 280 mg/m² twice daily; maximum dose: 500 mg/dose; continue until disease progression or unacceptable toxicity.

Fixed dosing (BSA-banded):

Children and Adolescents: Oral: Administer dose based on BSA-band in the following table; continue until disease progression or unacceptable toxicity. Some dosage forms may not be appropriate for use in all patients. Oral pellets available in multiple strengths and may be combined to achieve individual doses; however, no more than 4 oral pellet shells may be used for a single dose.

**Dose for** **ALCL in Children and Adolescents**
BSA band	Recommended crizotinib dose (mg) to achieve 280 mg/m² twice daily
0.38 to 0.46 m²	120 mg twice daily
0.47 to 0.51 m²	140 mg twice daily
0.52 to 0.61 m²	150 mg twice daily
0.62 to 0.8 m²	200 mg twice daily
0.81 to 0.97 m²	250 mg twice daily
0.98 to 1.16 m²	300 mg twice daily
1.17 to 1.33 m²	350 mg twice daily
1.34 to 1.51 m²	400 mg twice daily
1.52 to 1.69 m²	450 mg twice daily
≥1.7 m²	500 mg twice daily

Inflammatory myofibroblastic tumor, ALK positive, unresectable, recurrent, or refractory

Inflammatory myofibroblastic tumor (IMT), ALK positive, unresectable, recurrent, or refractory:

BSA-directed dosing: Children and Adolescents: Oral: 280 mg/m² twice daily; maximum dose: 500 mg/dose; continue until disease progression or unacceptable toxicity.

Fixed dosing (BSA-banded):

**Dose for IMT** **in Children and Adolescents**
BSA band	Recommended crizotinib dose (mg) to achieve 280 mg/m² twice daily
0.38 to 0.46 m²	120 mg twice daily
0.47 to 0.51 m²	140 mg twice daily
0.52 to 0.61 m²	150 mg twice daily
0.62 to 0.8 m²	200 mg twice daily
0.81 to 0.97 m²	250 mg twice daily
0.98 to 1.16 m²	300 mg twice daily
1.17 to 1.33 m²	350 mg twice daily
1.34 to 1.51 m²	400 mg twice daily
1.52 to 1.69 m²	450 mg twice daily
≥1.7 m²	500 mg twice daily

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing adjustment for toxicity:

Anaplastic large cell lymphoma (ALCL) or Inflammatory myofibroblastic tumor (IMT):

Children and Adolescents: Oral:

**Dosage Adjustment for Crizotinib Toxicity ALCL or IMT in Children and Adolescents**
BSA	First dose reduction	Second dose reduction^a
^a Permanently discontinue crizotinib if unable to tolerate crizotinib after 2 dose reductions.
0.38 to 0.46 m²	90 mg twice daily	70 mg twice daily
0.47 to 0.51 m²	100 mg twice daily	80 mg twice daily
0.52 to 0.61 m²	120 mg twice daily	90 mg twice daily
0.62 to 0.8 m²	150 mg twice daily	120 mg twice daily
0.81 to 0.97 m²	200 mg twice daily	150 mg twice daily
0.98 to 1.16 m²	220 mg twice daily	170 mg twice daily
1.17 to 1.33 m²	250 mg twice daily	200 mg twice daily
1.34 to 1.69 m²	250 mg twice daily	200 mg twice daily
≥1.7 m²	400 mg twice daily	250 mg twice daily

**Hematologic Toxicities**
Adverse reaction	Crizotinib dose adjustment
ANC <500/mm³	1^st occurrence: Withhold crizotinib until recovery to ANC >1,000/mm³, then resume at the next lower dose.
ANC <500/mm³	2^nd occurrence: For uncomplicated grade 4 neutropenia, either withhold crizotinib until recovery to ANC >1,000/mm³then resume at the next lower dose or permanently discontinue. Permanently discontinue crizotinib for recurrence complicated by febrile neutropenia or infection.
Platelets 25,000 to 50,000/mm³ with concurrent bleeding	Withhold crizotinib until recovery to >50,000/mm³ and bleeding resolves, then resume at the same dose.
Platelets <25,000/mm³	Withhold crizotinib until recovery to >50,000/mm³, then resume at the next lower dose. Permanently discontinue for recurrence.
Hemoglobin <8 g/dL	Withhold crizotinib until recovery to ≥8 g/dL, then resume at the same dose.
Anemia, life-threatening; urgent intervention indicated	Withhold crizotinib until recovery to ≥8 g/dL, then resume at the next lower dose. Permanently discontinue for recurrence.

**Nonhematologic Toxicities**
Adverse reaction	Crizotinib dose adjustment
Cardiac effects
QTc >500 msec on at least 2 separate ECGs	Withhold crizotinib until recovery to QTc <481 msec or baseline, then resume at the next lower dose.
QTc >500 msec or ≥60 msec change from baseline with torsades de pointes or polymorphic ventricular tachycardia or signs/symptoms of serious arrhythmia	Permanently discontinue crizotinib.
Bradycardia; symptomatic, may be severe and medically significant with medical intervention indicated	Withhold until recovery to the following age-dependent resting heart rate (based on 2.5^th percentile per age-specific norms): 1 to <2 years: ≥91 bpm 2 to <4 years: ≥82 bpm 4 to <6 years: ≥72 bpm 6 to ≤8 years: ≥64 bpm >8 years: ≥60 bpm
Bradycardia; life-threatening with urgent intervention indicated	Withhold until recovery to asymptomatic bradycardia or to a heart rate of ≥60 beats/minute and evaluate for contributing concomitant medications. • If contributing concomitant medication is identified and discontinued (or dose adjusted), then resume crizotinib at the 2^nd dose reduction (see previous table) with frequent monitoring. • If no contributing concomitant medication is identified, permanently discontinue crizotinib.
	If life-threatening bradycardia recurs, permanently discontinue.
GI toxicity
Nausea, grade 3	Maximize medical management. If grade 3 nausea persists, withhold crizotinib until resolved, then resume at the next lower dose.
Nausea, grade 3	Permanently discontinue if unable to tolerate crizotinib after 2 dose reductions.
Vomiting, grade 3 or grade 4	Maximize medical management. If grade 3 or 4 vomiting persists, withhold crizotinib until resolved, then resume at the next lower dose.
Vomiting, grade 3 or grade 4	Permanently discontinue if unable to tolerate crizotinib after 2 dose reductions.
Diarrhea, grade 3 or grade 4	Maximize medical management. If grade 3 or 4 diarrhea persists, withhold crizotinib until resolved, then resume at the next lower dose.
Diarrhea, grade 3 or grade 4	Permanently discontinue if unable to tolerate crizotinib after 2 dose reductions.
Ocular toxicity, including visual loss
Visual symptoms, grade 1 or grade 2	Monitor, and report symptoms to an ophthalmic specialist. Consider dose reduction for grade 2 visual disorders.
Visual loss, grade 3 or 4	Withhold crizotinib pending evaluation. Permanently discontinue crizotinib for grade 3 or 4 ocular disorders (if no other etiology is identified).
Pulmonary toxicity
Any grade drug-related interstitial lung disease (ILD)/pneumonitis	Permanently discontinue crizotinib.

Dosing: Kidney Impairment: Pediatric

Anaplastic large cell lymphoma (ALCL) or Inflammatory myofibroblastic tumor (IMT):

Altered Kidney Function:

Note: Kidney function is estimated using the Schwartz equation in pediatric patients.

Children and Adolescents: Oral:

**Crizotinib Dosing for Altered Kidney Function for ALCL or IMT in Children and Adolescents**
BSA	Mild to moderate renal impairment (CrCl ≥30 mL/minute/1.73 m²)	Severe renal impairment (CrCl <30 mL/minute/1.73 m²) not requiring dialysis
0.38 to 0.46 m²	No adjustment necessary	70 mg twice daily
0.47 to 0.51 m²		80 mg twice daily
0.52 to 0.61 m²		90 mg twice daily
0.62 to 0.8 m²		120 mg twice daily
0.81 to 0.97 m²		150 mg twice daily
0.98 to 1.16 m²		170 mg twice daily
1.17 to 1.33 m²		200 mg twice daily
1.34 to 1.69 m²		200 mg twice daily
≥1.7 m²		250 mg twice daily

Dosing: Liver Impairment: Pediatric

Anaplastic large cell lymphoma (ALCL) or Inflammatory myofibroblastic tumor (IMT):

Children and Adolescents: Oral:

Baseline hepatic impairment:

**Crizotinib Dosing for Patients With Baseline Hepatic Impairment for ALCL or IMT in Children and Adolescents**
Body surface area	Mild hepatic impairment	Moderate impairment (any AST and a total bilirubin >1.5 times ULN and ≤3 times ULN)	Severe impairment (any AST and a total bilirubin >3 times ULN)
0.38 to 0.46 m²	No adjustment necessary	90 mg twice daily	70 mg twice daily
0.47 to 0.51 m²		100 mg twice daily	80 mg twice daily
0.52 to 0.61 m²		120 mg twice daily	90 mg twice daily
0.62 to 0.8 m²		150 mg twice daily	120 mg twice daily
0.81 to 0.97 m²		200 mg twice daily	150 mg twice daily
0.98 to 1.16 m²		220 mg twice daily	170 mg twice daily
1.17 to 1.33 m²		250 mg twice daily	200 mg twice daily
1.34 to 1.69 m²		250 mg twice daily	200 mg twice daily
≥1.7 m²		400 mg twice daily	250 mg twice daily

Hepatotoxicity during treatment:

ALT or AST >5 times ULN with total bilirubin ≤1.5 times ULN: Withhold treatment until recovery to baseline or ≤3 times ULN, then resume at the next lower dose based on dosage reduction level tables.

ALT or AST >3 times ULN with concurrent total bilirubin elevation >1.5 times ULN in the absence of cholestasis or hemolysis: Permanently discontinue crizotinib.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Adverse reactions reported in adults.

>10%:

Cardiovascular: Bradycardia (5% to 14%), edema (31% to 49%)

Dermatologic: Skin rash (9% to 11%)

Endocrine & metabolic: Hypokalemia (18%), hypophosphatemia (28% to 32%)

Gastrointestinal: Abdominal pain (26%), constipation (42% to 43%), decreased appetite (27% to 30%), diarrhea (60% to 61%; grades 3/4: 2%), dysgeusia (26%), dyspepsia (8% to 14%), nausea (55% to 56%; grades 3/4: 1%), vomiting (46% to 47%; grades 3/4: 1% to 2%)

Hematologic & oncologic: Lymphocytopenia (48% to 51%; grades 3/4: 7% to 9%), neutropenia (49% to 52%; grades 3/4: 11% to 12%)

Hepatic: Increased serum alanine aminotransferase (76% to 79%), increased serum aspartate aminotransferase (61% to 66%)

Nervous system: Dizziness (18% to 22%), fatigue (27% to 29%), headache (22%), neuropathy (19% to 25%; including abnormal gait, abnormal sensory symptoms, burning sensation of skin, dysesthesia, hypoesthesia, myasthenia, neuralgia, paresthesia, peripheral neuropathy, peripheral sensory neuropathy, polyneuropathy)

Neuromuscular & skeletal: Limb pain (16%)

Ophthalmic: Visual disturbance (60% to 71%; onset: <1 week; including blurred vision, decreased visual acuity, diplopia, photophobia, photopsia, vision loss, visual field defect, vitreous opacity)

Renal: Decreased estimated GFR (eGFR) (<90 mL/min/1.73 m²: 76%; <60 mL/min/1.73 m²: 38%; <30 mL/min/1.73 m²: 4%), increased serum creatinine (96% to 99%)

Respiratory: Upper respiratory tract infection (26% to 32%)

Miscellaneous: Fever (19%)

1% to 10%:

Cardiovascular: Prolonged QT interval on ECG (5% to 6%), pulmonary embolism (6%), syncope (1% to 3%)

Endocrine & metabolic: Decreased plasma testosterone (1%; hypogonadism), weight gain (8%), weight loss (10%)

Gastrointestinal: Dysphagia (10%), esophagitis (2% to 6%)

Hepatic: Hepatic failure (1%)

Neuromuscular & skeletal: Muscle spasm (8%)

Renal: Renal cyst (3% to 5%)

Respiratory: Interstitial pulmonary disease (1% to 4%; including acute respiratory distress syndrome, pneumonitis)

<1%:

Dermatologic: Skin photosensitivity

Hepatic: Hepatotoxicity

Frequency not defined:

Cardiovascular: Cardiac arrhythmia, septic shock

Endocrine & metabolic: Diabetic ketoacidosis

Infection: Sepsis

Respiratory: Dyspnea (including severe dyspnea), pneumonia, respiratory failure (including acute respiratory failure)

Postmarketing: Neuromuscular & skeletal: Increased creatine phosphokinase in blood specimen

Contraindications

There are no contraindications listed in the manufacturer’s US labeling.

Canadian labeling: Known hypersensitivity to crizotinib or any component of the formulation; congenital long QT syndrome or with persistent Fridericia-corrected QT interval (QTcF) ≥500 msec

Warnings/Precautions

Concerns related to adverse effects:

• Cardiovascular toxicity: Symptomatic bradycardia may occur; grade 3 bradycardia has been observed (rare). Grade 3 syncope has been reported. When possible, avoid concurrent use with other agents known to cause bradycardia (eg, beta blockers, nondihydropyridine calcium channel blockers, clonidine, digoxin). QT prolongation may occur; QTcF ≥500 msec has been reported. Avoid crizotinib in patients with congenital long QT syndrome.

• GI toxicity: GI toxicity occurs in the majority of patients; grade 3 diarrhea, nausea, vomiting, and stomatitis have been reported. Provide standard antiemetics and antidiarrheals. Consider supportive care, such as hydration, electrolyte supplementation, and nutritional support as necessary.

• Hepatotoxicity: Fatalities due to crizotinib-induced hepatotoxicity have occurred with crizotinib. Elevations in ALT or AST >5 × ULN were observed; concurrent ALT or AST elevations ≥3 × ULN and total bilirubin elevations ≥2 × ULN (without alkaline phosphatase elevations) occurred rarely. Transaminase elevation onset generally was within 2 months of treatment initiation.

• Ocular toxicities: Visual disorders commonly occur with crizotinib. The most common visual symptoms were blurred vision and visual impairment. Grade 3 myopic optic nerve disorder has been observed and grade 4 visual field defect with vision loss had been reported (rare). Optic atrophy and optic nerve disorder have been reported as potential causes of vision loss. The risks of restarting crizotinib after severe vision loss have not been evaluated; the decision to resume therapy should consider the potential benefits of treatment.

• Pulmonary toxicity: Severe, life-threatening, and potentially fatal interstitial lung disease (ILD)/pneumonitis has been associated with crizotinib. In patients with non–small cell lung cancer (NSCLC), the onset was generally within 3 months of treatment initiation.

Other warnings/precautions:

• ALK or ROS1 positivity: Approved for use in patients with metastatic NSCLC who test positive for the abnormal ALK gene or ROS1 rearrangements, in pediatric and adult patients with ALK-positive unresectable/recurrent/refractory inflammatory myofibroblastic tumor, as well as in pediatric patients and young adults with ALK-positive anaplastic large cell lymphoma. Information on approved tests for ALK and ROS1 rearrangements in NSCLC may be found at http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/InVitroDiagnostics/ucm301431.htm.

• Photosensitivity: Patients should avoid prolonged sun exposure, wear protective clothing, and use a broad-spectrum sunscreen and lip balm during treatment.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Capsule, Oral:

Xalkori: 200 mg, 250 mg

Capsule Sprinkle, Oral:

Xalkori: 20 mg, 50 mg, 150 mg

Generic Equivalent Available: US

Pricing: US

Capsule, sprinkles (Xalkori Oral)

20 mg (per each): $47.55

50 mg (per each): $112.14

150 mg (per each): $336.41

Capsules (Xalkori Oral)

200 mg (per each): $475.46

250 mg (per each): $475.46

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Capsule, Oral:

Xalkori: 200 mg, 250 mg

Prescribing and Access Restrictions

Available through specialty pharmacies. Further information may be obtained from the manufacturer, Pfizer, at 1-877-744-5675, or at http://www.pfizerpro.com

Administration: Adult

Crizotinib is associated with a moderate or high emetic potential (Ref); antiemetics are recommended to prevent nausea and vomiting.

Oral: Administer with or without food. If vomiting occurs after dose, administer the next dose at the regularly scheduled time.

Capsules: Swallow whole; do not chew, crush, or split. For patients unable to swallow capsules whole, capsules may be dissolved using the following method (Ref) (not formally evaluated in pharmacokinetic studies):

Prepare ~240 mL of boiling water (tap or bottled). Pour 15 mL of boiling water into a drinking glass, add unopened crizotinib capsule(s) containing dose to the water, stir continuously with a spoon for ≥2 minutes, add another 15 mL of the boiling water to drinking glass, stir continuously with the spoon for 2 minutes, add 15 mL of room temperature or cold water to the solution (while pouring into glass, use this water to also rinse the stirring spoon), swirl vigorously for 10 seconds, and administer to patient immediately (preparation is stable for 2 hours). To ensure entire dose consumed, add 15 mL room temperature water to drinking glass, rinsing sides in process; swirl vigorously for 10 seconds and administer immediately. Repeat rinse of drinking glass with water and administration 2 more times. Note: To mask unpleasant taste, mint-flavored candy may be dissolved in the patient's mouth while preparing dose; remove any undissolved mint from the patient's mouth prior to dose administration.

Pellets: Pellets are supplied encapsulated in shells; do not swallow pellets encapsulated in the shell. Instead, open shell(s) and empty pellets directly into the patient's mouth or into an oral dosing aid (eg, medicine cup, spoon), and then directly into the patient's mouth via dosing aid; do not chew or crush pellets. Administer with a sufficient amount of water to ensure all pellets are swallowed.

Administration: Pediatric

Note: Crizotinib is associated with a moderate emetic potential (Ref); antiemetics should be offered.

Oral: Administer with or without food. If vomiting occurs after dose, administer the next dose at the regularly scheduled time.

Capsules: Swallow capsules whole; do not chew, crush, or split.

Patients unable to swallow capsules whole: Capsules may be dissolved using the following method (Ref) (not formally evaluated in pharmacokinetic studies):

1. Prepare 236 mL (1 cup) of boiling water (tap or bottled). Pour 15 mL of the boiling water into a drinking glass, add unopened crizotinib capsule(s) containing dose to the water, stir continuously with spoon for ≥2 minutes, add another 15 mL of the boiling water to drinking glass, stir solution continuously for 2 minutes, add 15 mL of room temperature or cold water to the solution (while pouring into glass, use this water to also rinse the stirring spoon), swirl vigorously for 10 seconds, and administer to patient immediately (stable for 2 hours).

To mask unpleasant taste, mint-flavored candy may be dissolved in the patient's mouth while dose being prepared (if developmentally appropriate); any undissolved mint should be removed from the patient's mouth prior to dose administration.

2. To ensure entire dose consumed, add 15 mL room temperature water to drinking glass, rinsing sides in process; stir vigorously for 10 seconds and administer immediately, and repeat rinse of drinking glass with water and administration 2 more times.

Oral pellets: Pellets are encapsulated within shells; no more than 4 oral pellet shells should be used for a single dose. Oral pellets are available in multiple strengths which may be combined for a dose. Administer by either opening the shells and emptying contents directly into the patient's mouth or opening shells and emptying contents into an oral dosing aid (eg, spoon, medicine cup) and then administering pellets via the dosing aid directly into the patient's mouth. Immediately after administration, patient should drink a sufficient amount of water to ensure all medication is swallowed.

Missed doses: If a dose is missed, take as soon as remembered unless the next dose is due within 6 hours, then missed dose should be skipped; do not take 2 doses at the same time to make up for a missed dose.

Hazardous Drugs Handling Considerations

Hazardous agent (NIOSH 2024 [table 2]).

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 (NIOSH 2023; NIOSH 2024; USP-NF 2020).

Note: Facilities may perform risk assessment of some hazardous drugs to determine if appropriate for alternative handling and containment strategies (USP-NF 2020). Refer to institution-specific handling policies/procedures.

Medication Guide and/or Vaccine Information Statement (VIS)

An FDA-approved patient medication guide, which is available with the product information and at https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/202570s036lbl.pdf#page=41, must be dispensed with this medication.

Use: Labeled Indications

Anaplastic large cell lymphoma, systemic ALK positive, relapsed or refractory: Treatment of relapsed or refractory systemic anaplastic large cell lymphoma (ALK-positive) in pediatric patients ≥1 year of age and young adults.

Limitations of use: Safety and efficacy of crizotinib have not been established in older adults with relapsed or refractory systemic ALK-positive anaplastic large cell lymphoma.

Inflammatory myofibroblastic tumor, ALK positive, unresectable, recurrent, or refractory: Treatment of ALK-positive unresectable, recurrent, or refractory inflammatory myofibroblastic tumor in adult and pediatric patients ≥1 year of age.

Non–small cell lung cancer, metastatic, ALK or ROS1 positive: Treatment of metastatic non–small cell lung cancer in adult patients whose tumors are ALK-positive or are ROS1-positive (as detected by an approved test).

Medication Safety Issues

Sound-alike/look-alike issues:

Crizotinib may be confused with afatinib, alectinib, brigatinib, cabozantinib, capmatinib, ceritinib, cobimetinib, copanlisib, crizanlizumab, erlotinib, gefitinib, lorlatinib, PONATinib, tepotinib.

High alert medication:

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).

Metabolism/Transport Effects

Substrate of CYP3A4 (Major), P-glycoprotein (Minor); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential; Inhibits CYP3A4 (Moderate);

Drug Interactions

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.

Abemaciclib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Abemaciclib. Management: Monitor for increased abemaciclib toxicities if combined with moderate CYP3A4 inhibitors. Consider reducing the abemaciclib dose in 50 mg decrements if necessary. Risk C: Monitor

Acalabrutinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Acalabrutinib. Management: Reduce acalabrutinib dose to 100 mg once daily with concurrent use of a moderate CYP3A4 inhibitor. Monitor patient closely for both acalabrutinib response and evidence of adverse effects with any concurrent use. Risk D: Consider Therapy Modification

Acrivastine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Acrivastine. Risk C: Monitor

ALfentanil: CYP3A4 Inhibitors (Moderate) may increase serum concentration of ALfentanil. Management: If use of alfentanil and moderate CYP3A4 inhibitors is necessary, consider dosage reduction of alfentanil until stable drug effects are achieved. Frequently monitor patients for respiratory depression and sedation when these agents are combined. Risk D: Consider Therapy Modification

Alfuzosin: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Alfuzosin. Risk C: Monitor

Alitretinoin (Systemic): CYP3A4 Inhibitors (Moderate) may increase serum concentration of Alitretinoin (Systemic). Risk C: Monitor

ALPRAZolam: CYP3A4 Inhibitors (Moderate) may increase serum concentration of ALPRAZolam. Management: Consider alternatives to this combination when possible. If combined, consider an alprazolam dose reduction and monitor for increased alprazolam effects and toxicities (eg, sedation, lethargy). Risk D: Consider Therapy Modification

Amiodarone: QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase QTc-prolonging effects of Amiodarone. QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of Amiodarone. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider Therapy Modification

Amisulpride (Oral): May increase QTc-prolonging effects of QT-prolonging Agents (Moderate Risk). Risk C: Monitor

AmLODIPine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of AmLODIPine. Risk C: Monitor

Apixaban: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Apixaban. Risk C: Monitor

Aprepitant: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Aprepitant. Risk X: Avoid

ARIPiprazole Lauroxil: CYP3A4 Inhibitors (Moderate) may increase serum concentration of ARIPiprazole Lauroxil. Risk C: Monitor

ARIPiprazole: CYP3A4 Inhibitors (Moderate) may increase serum concentration of ARIPiprazole. Management: Monitor for increased aripiprazole pharmacologic effects. Aripiprazole dose adjustments may or may not be required based on concomitant therapy, indication, or dosage form. Consult full interaction monograph for specific recommendations. Risk C: Monitor

Atogepant: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Atogepant. Risk C: Monitor

Atorvastatin: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Atorvastatin. Risk C: Monitor

Avacopan: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Avacopan. Risk C: Monitor

Avanafil: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Avanafil. Management: The maximum avanafil dose is 50 mg per 24-hour period when used together with a moderate CYP3A4 inhibitor. Patients receiving such a combination should also be monitored more closely for evidence of adverse effects (eg, hypotension, syncope, priapism). Risk D: Consider Therapy Modification

Avapritinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Avapritinib. Management: Avoid use of moderate CYP3A4 inhibitors with avapritinib. If this combination cannot be avoided, reduce the avapritinib dose to 100 mg daily for the treatment of GIST or to 50 mg daily for the treatment of advanced systemic mastocytosis. Risk D: Consider Therapy Modification

Axitinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Axitinib. Risk C: Monitor

Barnidipine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Barnidipine. Risk C: Monitor

Benidipine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Benidipine. Risk C: Monitor

Benzhydrocodone: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Benzhydrocodone. Specifically, the concentration of hydrocodone may be increased. Risk C: Monitor

Blonanserin: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Blonanserin. Risk C: Monitor

Bortezomib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Bortezomib. Risk C: Monitor

Bosutinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Bosutinib. Risk X: Avoid

Bradycardia-Causing Agents: May increase bradycardic effects of Bradycardia-Causing Agents. Risk C: Monitor

Brexpiprazole: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Brexpiprazole. Management: The brexpiprazole dose should be reduced to 25% of usual if used together with both a moderate CYP3A4 inhibitor and a strong or moderate CYP2D6 inhibitor, or if a moderate CYP3A4 inhibitor is used in a CYP2D6 poor metabolizer. Risk C: Monitor

Brigatinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Brigatinib. Management: Avoid concurrent use of brigatinib with moderate CYP3A4 inhibitors when possible. If such a combination cannot be avoided, reduce the dose of brigatinib by approximately 40% (ie, from 180 mg to 120 mg, from 120 mg to 90 mg, or from 90 mg to 60 mg). Risk D: Consider Therapy Modification

Bromocriptine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Bromocriptine. Management: The bromocriptine dose should not exceed 1.6 mg daily with use of a moderate CYP3A4 inhibitor. The Cycloset brand specifically recommends this dose limitation, but other bromocriptine products do not make such specific recommendations. Risk D: Consider Therapy Modification

Budesonide (Oral Inhalation): CYP3A4 Inhibitors (Moderate) may increase serum concentration of Budesonide (Oral Inhalation). Risk C: Monitor

Budesonide (Systemic): CYP3A4 Inhibitors (Moderate) may increase serum concentration of Budesonide (Systemic). Management: Avoid the concomitant use of CYP3A4 inhibitors and oral budesonide. If patients receive both budesonide and CYP3A4 inhibitors, they should be closely monitored for signs and symptoms of corticosteroid excess. Risk D: Consider Therapy Modification

Budesonide (Topical): CYP3A4 Inhibitors (Moderate) may increase serum concentration of Budesonide (Topical). Risk X: Avoid

Buprenorphine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Buprenorphine. Risk C: Monitor

BusPIRone: CYP3A4 Inhibitors (Moderate) may increase serum concentration of BusPIRone. Risk C: Monitor

Cabozantinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Cabozantinib. Risk C: Monitor

Cannabis: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Cannabis. More specifically, tetrahydrocannabinol and cannabidiol serum concentrations may be increased. Risk C: Monitor

Capivasertib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Capivasertib. Management: If capivasertib is combined with moderate CYP3A4 inhibitors, reduce the capivasertib dose to 320 mg twice daily for 4 days, followed by 3 days off. Monitor patients closely for adverse reactions. Risk D: Consider Therapy Modification

Cariprazine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Cariprazine. CYP3A4 Inhibitors (Moderate) may increase active metabolite exposure of Cariprazine. Management: Cariprazine dose adjustments are recommended and depend upon whether a patient is initiating a moderate CYP3A4 inhibitor or cariprazine, as well as cariprazine indication. See full mono for details. Some non-US labels contraindicate this combination. Risk D: Consider Therapy Modification

Cilostazol: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Cilostazol. Management: Decrease the dose of cilostazol to 50 mg twice daily when combined with moderate CYP3A4 inhibitors. Risk D: Consider Therapy Modification

Citalopram: May increase QTc-prolonging effects of QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk). QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of Citalopram. Risk C: Monitor

Clindamycin (Systemic): CYP3A4 Inhibitors (Moderate) may increase serum concentration of Clindamycin (Systemic). Risk C: Monitor

Clofazimine: May increase serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor

Cobimetinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Cobimetinib. Management: Avoid this combination when possible. If concurrent short term (14 days or less) use cannot be avoided, reduce the cobimetinib dose from 60 mg to 20 mg daily. Avoid concomitant use in patients already receiving reduced cobimetinib doses. Risk D: Consider Therapy Modification

Codeine: CYP3A4 Inhibitors (Moderate) may increase active metabolite exposure of Codeine. Risk C: Monitor

Colchicine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Colchicine. Management: Avoidance, dose reduction, or increased monitoring for colchicine toxicity may be needed and will depend on brand, indication for colchicine use, renal/hepatic function, and use of a P-gp inhibitor. See full monograph for details. Risk D: Consider Therapy Modification

Conivaptan: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Conivaptan. Risk C: Monitor

Copanlisib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Copanlisib. Risk C: Monitor

CycloSPORINE (Systemic): CYP3A4 Inhibitors (Moderate) may increase serum concentration of CycloSPORINE (Systemic). Risk C: Monitor

CYP3A4 Inducers (Moderate): May decrease serum concentration of Crizotinib. Risk C: Monitor

CYP3A4 Inducers (Strong): May decrease serum concentration of Crizotinib. Risk X: Avoid

CYP3A4 Inhibitors (Moderate): May increase serum concentration of Crizotinib. Risk C: Monitor

CYP3A4 Inhibitors (Strong): May increase serum concentration of Crizotinib. Management: Avoid concomitant use of crizotinib and strong CYP3A4 inhibitors whenever possible. If combined use cannot be avoided, crizotinib dose reductions are required, which vary according to indication. See full interaction monograph for details. Risk D: Consider Therapy Modification

Dabrafenib: May increase QTc-prolonging effects of Crizotinib. Dabrafenib may decrease serum concentration of Crizotinib. Crizotinib may increase serum concentration of Dabrafenib. Management: Monitor for QTc interval prolongation and ventricular arrhythmias, including torsades de pointes when these agents are combined. Additionally, monitor for decreased crizotinib efficacy and increased dabrafenib adverse effects. Risk C: Monitor

Dapoxetine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Dapoxetine. Management: The dose of dapoxetine should be limited to 30 mg per day when used together with a moderate inhibitor of CYP3A4. Risk D: Consider Therapy Modification

Daridorexant: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Daridorexant. Management: Limit the daridorexant dose to 25 mg, no more than once per night, when combined with moderate CYP3A4 inhibitors. Risk D: Consider Therapy Modification

Darifenacin: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Darifenacin. Risk C: Monitor

Deflazacort: CYP3A4 Inhibitors (Moderate) may increase active metabolite exposure of Deflazacort. Management: Administer one third of the recommended deflazacort dose when used together with a strong or moderate CYP3A4 inhibitor. Risk D: Consider Therapy Modification

DexAMETHasone (Systemic): CYP3A4 Inhibitors (Moderate) may increase serum concentration of DexAMETHasone (Systemic). Risk C: Monitor

DiazePAM: CYP3A4 Inhibitors (Moderate) may increase serum concentration of DiazePAM. Risk C: Monitor

Diazoxide Choline: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Diazoxide Choline. Risk C: Monitor

Dienogest: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Dienogest. Risk C: Monitor

DilTIAZem: CYP3A4 Inhibitors (Moderate) may increase serum concentration of DilTIAZem. Risk C: Monitor

DOCEtaxel: CYP3A4 Inhibitors (Moderate) may increase serum concentration of DOCEtaxel. Risk C: Monitor

Domperidone: May increase QTc-prolonging effects of QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk). QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of Domperidone. Risk X: Avoid

DOXOrubicin (Conventional): CYP3A4 Inhibitors (Moderate) may increase serum concentration of DOXOrubicin (Conventional). Risk X: Avoid

DroNABinol: CYP3A4 Inhibitors (Moderate) may increase serum concentration of DroNABinol. Risk C: Monitor

Dronedarone: QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase QTc-prolonging effects of Dronedarone. QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of Dronedarone. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider Therapy Modification

Ebastine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Ebastine. Risk C: Monitor

Elacestrant: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Elacestrant. Risk X: Avoid

Elbasvir and Grazoprevir: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Elbasvir and Grazoprevir. Risk C: Monitor

Eletriptan: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Eletriptan. Risk X: Avoid

Elexacaftor, Tezacaftor, and Ivacaftor: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Elexacaftor, Tezacaftor, and Ivacaftor. Management: When combined with moderate CYP3A4 inhibitors, elexacaftor/tezacaftor/ivacaftor should be given in the morning, every other day. Ivacaftor alone should be given in the morning, every other day on alternate days. Risk D: Consider Therapy Modification

Eliglustat: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Eliglustat. Management: Reduce eliglustat dose to 84 mg daily in CYP2D6 EMs when used with moderate CYP3A4 inhibitors. Avoid use of moderate CYP3A4 inhibitors in CYP2D6 IMs or PMs. Use in CYP2D6 EMs or IMs also taking strong or moderate CYP2D6 inhibitors is contraindicated. Risk D: Consider Therapy Modification

Encorafenib: Crizotinib may increase QTc-prolonging effects of Encorafenib. Crizotinib may increase serum concentration of Encorafenib. Encorafenib may decrease serum concentration of Crizotinib. Risk X: Avoid

Ensartinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Ensartinib. Risk X: Avoid

Entrectinib: May increase QTc-prolonging effects of QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk). QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of Entrectinib. Risk X: Avoid

Eplerenone: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Eplerenone. Management: If coadministered with moderate CYP3A4 inhibitors, the max dose of eplerenone is 25 mg daily if used for heart failure; if used for hypertension initiate eplerenone 25 mg daily, titrate to max 25 mg twice daily. Risk D: Consider Therapy Modification

Ergot Derivatives (Vasoconstrictive CYP3A4 Substrates): CYP3A4 Inhibitors (Moderate) may increase serum concentration of Ergot Derivatives (Vasoconstrictive CYP3A4 Substrates). Risk C: Monitor

Erlotinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Erlotinib. Risk C: Monitor

Escitalopram: May increase QTc-prolonging effects of QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk). Risk C: Monitor

Eszopiclone: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Eszopiclone. Risk C: Monitor

Etrasimod: May increase bradycardic effects of Bradycardia-Causing Agents. Risk C: Monitor

Etravirine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Etravirine. Risk C: Monitor

Everolimus: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Everolimus. Risk C: Monitor

Fedratinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Fedratinib. Risk C: Monitor

Felodipine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Felodipine. Risk C: Monitor

FentaNYL: CYP3A4 Inhibitors (Moderate) may increase serum concentration of FentaNYL. Management: Consider fentanyl dose reductions when combined with a moderate CYP3A4 inhibitor. Monitor for respiratory depression and sedation. Upon discontinuation of a CYP3A4 inhibitor, consider a fentanyl dose increase; monitor for signs and symptoms of withdrawal. Risk D: Consider Therapy Modification

Fexinidazole: QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase QTc-prolonging effects of Fexinidazole. Fexinidazole may decrease serum concentration of QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk). Specifically, concentrations of crizotinib, nilotinib, and ribociclib may be decreased. QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may decrease active metabolite exposure of Fexinidazole. Management: Consider alternatives to this combination. If combined, monitor for QT interval prolongation and ventricular arrhythmias. Also monitor for reduced efficacy of fexinidazole, crizotinib, nilotinib, and ribociclib. Risk D: Consider Therapy Modification

Finerenone: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Finerenone. 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

Flibanserin: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Flibanserin. Management: Use of flibanserin with moderate CYP3A4 inhibitors is contraindicated. If starting flibanserin, start 2 weeks after the last dose of the CYP3A4 inhibitor. If starting a CYP3A4 inhibitor, start 2 days after the last dose of flibanserin. Risk X: Avoid

Fluorouracil Products: QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase QTc-prolonging effects of Fluorouracil Products. Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor

Fluticasone (Nasal): CYP3A4 Inhibitors (Moderate) may increase serum concentration of Fluticasone (Nasal). Risk C: Monitor

Fluticasone (Oral Inhalation): CYP3A4 Inhibitors (Moderate) may increase serum concentration of Fluticasone (Oral Inhalation). Risk C: Monitor

Fosamprenavir: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Fosamprenavir. Risk C: Monitor

Fosaprepitant: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Fosaprepitant. Risk X: Avoid

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

Gepirone: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Gepirone. Management: Reduce the gepirone dose by 50% if combined with moderate CYP3A4 inhibitors. Monitor for QTc interval prolongation with combined use. Risk D: Consider Therapy Modification

Gepotidacin: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Gepotidacin. Risk C: Monitor

Glasdegib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Glasdegib. Risk C: Monitor

Grapefruit Juice: May increase serum concentration of Crizotinib. Risk X: Avoid

GuanFACINE: CYP3A4 Inhibitors (Moderate) may increase serum concentration of GuanFACINE. Management: Reduce the extended-release guanfacine dose 50% when combined with a moderate CYP3A4 inhibitor. Monitor for increased guanfacine toxicities when these agents are combined. Risk D: Consider Therapy Modification

Haloperidol: QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase QTc-prolonging effects of Haloperidol. Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor

HYDROcodone: CYP3A4 Inhibitors (Moderate) may increase serum concentration of HYDROcodone. Risk C: Monitor

Ibrutinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Ibrutinib. Management: When treating B-cell malignancies, decrease ibrutinib to 280 mg daily when combined with moderate CYP3A4 inhibitors. When treating graft versus host disease, monitor patients closely and reduce the ibrutinib dose as needed based on adverse reactions. Risk D: Consider Therapy Modification

Ifosfamide: CYP3A4 Inhibitors (Moderate) may increase adverse/toxic effects of Ifosfamide. CYP3A4 Inhibitors (Moderate) may decrease active metabolite exposure of Ifosfamide. Risk C: Monitor

Iloperidone: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Iloperidone. Risk C: Monitor

Irinotecan Products: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Irinotecan Products. CYP3A4 Inhibitors (Moderate) may increase active metabolite exposure of Irinotecan Products. Specifically, the serum concentration of SN-38 may be increased. Risk C: Monitor

Isavuconazonium Sulfate: CYP3A4 Inhibitors (Moderate) may increase active metabolite exposure of Isavuconazonium Sulfate. Specifically, CYP3A4 Inhibitors (Moderate) may increase isavuconazole serum concentrations. Risk C: Monitor

Isradipine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Isradipine. Risk C: Monitor

Ivabradine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Ivabradine. Risk X: Avoid

Ivacaftor: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Ivacaftor. Management: Ivacaftor dose reductions may be required; consult full drug interaction monograph content for age- and weight-specific dosage recommendations. Risk D: Consider Therapy Modification

Ivosidenib: May increase QTc-prolonging effects of QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk). QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of Ivosidenib. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider Therapy Modification

Ixabepilone: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Ixabepilone. 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

Lapatinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Lapatinib. Risk C: Monitor

Larotrectinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Larotrectinib. Risk C: Monitor

Lefamulin: May increase QTc-prolonging effects of QT-prolonging CYP3A4 Substrates. Management: Do not use lefamulin tablets with QT-prolonging CYP3A4 substrates. Lefamulin prescribing information lists this combination as contraindicated. Risk X: Avoid

Lemborexant: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Lemborexant. Risk X: Avoid

Leniolisib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Leniolisib. Risk C: Monitor

Lercanidipine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Lercanidipine. Risk C: Monitor

Levamlodipine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Levamlodipine. Risk C: Monitor

Levoketoconazole: QT-prolonging CYP3A4 Substrates may increase QTc-prolonging effects of Levoketoconazole. Levoketoconazole may increase serum concentration of QT-prolonging CYP3A4 Substrates. Risk X: Avoid

Levomethadone: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Levomethadone. Risk C: Monitor

Levomilnacipran: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Levomilnacipran. Risk C: Monitor

Lidocaine (Systemic): CYP3A4 Inhibitors (Moderate) may increase serum concentration of Lidocaine (Systemic). CYP3A4 Inhibitors (Moderate) may increase active metabolite exposure of Lidocaine (Systemic). Specifically, concentrations of monoethylglycinexylidide (MEGX) may be increased. Risk C: Monitor

Lomitapide: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Lomitapide. Risk X: Avoid

Lovastatin: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Lovastatin. Risk C: Monitor

Lumateperone: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Lumateperone. Management: Limit the lumateperone dose to 21 mg once daily when used with a moderate CYP3A4 inhibitor. Risk D: Consider Therapy Modification

Lurasidone: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Lurasidone. Management: Reduce the lurasidone dose by half when initiating therapy with a moderate CYP3A4 inhibitor. If initiating lurasidone in a patient already receiving a moderate CYP3A4 inhibitor, start lurasidone at 20 mg/day with a max dose of 80 mg/day. Risk D: Consider Therapy Modification

Lurbinectedin: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Lurbinectedin. Management: Avoid concomitant use of lurbinectedin and moderate CYP3A4 inhibitors when possible. If combined, reduce the lurbinectedin dose by 50%. Risk D: Consider Therapy Modification

Macitentan: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Macitentan. Risk C: Monitor

Manidipine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Manidipine. Risk C: Monitor

Maraviroc: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Maraviroc. Risk C: Monitor

Mavacamten: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Mavacamten. Management: Start mavacamten at 5 mg/day if stable on a moderate CYP3A4 inhibitor, and reduce the mavacamten dose by one dose level if initiating a moderate CYP3A4 inhibitor. Avoid initiating moderate CYP3A4 inhibitors in patients on mavacamten 2.5 mg/day. Risk D: Consider Therapy Modification

Mavorixafor: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Mavorixafor. Risk C: Monitor

Meperidine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Meperidine. Risk C: Monitor

Methadone: May increase QTc-prolonging effects of QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk). QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of Methadone. Management: Consider alternatives to this drug combination. If combined, monitor for increased methadone toxicities (eg, respiratory depression, QTc interval prolongation). Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider Therapy Modification

MethylPREDNISolone: CYP3A4 Inhibitors (Moderate) may increase serum concentration of MethylPREDNISolone. Risk C: Monitor

Methysergide: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Methysergide. Risk X: Avoid

Midazolam: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Midazolam. Management: Avoid concomitant use of nasal midazolam and moderate CYP3A4 inhibitors. Consider alternatives to use with oral midazolam whenever possible and consider using lower midazolam doses. Monitor patients for sedation and respiratory depression if combined. Risk D: Consider Therapy Modification

Midodrine: May increase bradycardic effects of Bradycardia-Causing Agents. Risk C: Monitor

Mirodenafil: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Mirodenafil. Risk C: Monitor

Mitapivat: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Mitapivat. Management: When coadministered with moderate CYP3A4 inhibitors, doses of mitapivat should not exceed 20 mg twice daily. Additionally, patients should be monitored for changes in hemoglobin response and increased mitapivat adverse effects. Risk D: Consider Therapy Modification

Mobocertinib: QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase QTc-prolonging effects of Mobocertinib. QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of Mobocertinib. QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase active metabolite exposure of Mobocertinib. Management: Avoid use of QT prolonging moderate CYP3A4 inhibitors with mobocertinib when possible. If combined, the mobocertinib dose should be reduced by approximately 50% (ie, from 160 mg to 80 mg, 120 mg to 40 mg, or 80 mg to 40 mg). Monitor QTc interval closely. Risk D: Consider Therapy Modification

Naldemedine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Naldemedine. Risk C: Monitor

Nalfurafine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Nalfurafine. Risk C: Monitor

Naloxegol: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Naloxegol. Management: The use of naloxegol and moderate CYP3A4 inhibitors should be avoided. If concurrent use is unavoidable, reduce naloxegol dose to 12.5 mg once daily and monitor for signs of opiate withdrawal (eg, hyperhidrosis, chills, diarrhea, anxiety, irritability). Risk D: Consider Therapy Modification

Neratinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Neratinib. Risk C: Monitor

NIFEdipine (Topical): CYP3A4 Inhibitors (Moderate) may increase serum concentration of NIFEdipine (Topical). Risk C: Monitor

NIFEdipine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of NIFEdipine. Risk C: Monitor

NiMODipine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of NiMODipine. Risk C: Monitor

Nirogacestat: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Nirogacestat. Risk X: Avoid

Nisoldipine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Nisoldipine. Risk X: Avoid

Nitrendipine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Nitrendipine. Risk C: Monitor

Olaparib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Olaparib. Management: Avoid use of moderate CYP3A4 inhibitors with olaparib, if possible. If such concurrent use cannot be avoided, the dose of olaparib tablets should be reduced to 150 mg twice daily and the dose of olaparib capsules should be reduced to 200 mg twice daily. Risk D: Consider Therapy Modification

Oliceridine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Oliceridine. Risk C: Monitor

Olmutinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Olmutinib. Risk C: Monitor

Omaveloxolone: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Omaveloxolone. Management: Avoid this combination if possible. If coadministration is required, decrease the omaveloxolone dose to 100 mg daily and monitor closely for adverse reactions. If adverse reactions occur, decrease omaveloxolone to 50 mg daily. Risk D: Consider Therapy Modification

Ondansetron: May increase QTc-prolonging effects of QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor

OxyCODONE: CYP3A4 Inhibitors (Moderate) may increase serum concentration of OxyCODONE. Serum concentrations of the active metabolite Oxymorphone may also be increased. Risk C: Monitor

Ozanimod: May increase bradycardic effects of Bradycardia-Causing Agents. Risk C: Monitor

PACLitaxel (Conventional): CYP3A4 Inhibitors (Moderate) may increase serum concentration of PACLitaxel (Conventional). Risk C: Monitor

PACLitaxel (Protein Bound): CYP3A4 Inhibitors (Moderate) may increase serum concentration of PACLitaxel (Protein Bound). Risk C: Monitor

Pacritinib: Crizotinib may increase serum concentration of Pacritinib. Pacritinib may decrease serum concentration of Crizotinib. Risk C: Monitor

Palbociclib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Palbociclib. Risk C: Monitor

Palovarotene: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Palovarotene. Management: Avoid concomitant use of palovarotene and moderate CYP3A4 inhibitors when possible. If combined, decrease palovarotene dose by 50% as described in the full interaction monograph. Monitor for palovarotene toxicities when combined. Risk D: Consider Therapy Modification

Panobinostat: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Panobinostat. Risk C: Monitor

PAZOPanib: QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase QTc-prolonging effects of PAZOPanib. QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of PAZOPanib. Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor

Pemigatinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Pemigatinib. Management: If combined use cannot be avoided, reduce the pemigatinib dose from 13.5 mg daily to 9 mg daily, or from 9 mg daily to 4.5 mg daily. Resume prior pemigatinib dose after stopping the moderate inhibitor once 3 half-lives of the inhibitor has passed. Risk D: Consider Therapy Modification

Pentamidine (Systemic): May increase QTc-prolonging effects of QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor

Pexidartinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Pexidartinib. Management: If combined use cannot be avoided, pexidartinib dose should be reduced as follows: reduce pexidartinib doses of 500 mg or 375 mg daily to 125 mg twice daily; reduce pexidartinib 250 mg daily to 125 mg once daily. Risk D: Consider Therapy Modification

Pimavanserin: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Pimavanserin. Risk C: Monitor

Pimecrolimus: CYP3A4 Inhibitors (Moderate) may decrease metabolism of Pimecrolimus. Risk C: Monitor

Pimozide: May increase QTc-prolonging effects of QT-prolonging Agents (Moderate Risk). Risk X: Avoid

Piperaquine: QT-prolonging Agents (Moderate Risk) may increase QTc-prolonging effects of Piperaquine. Risk X: Avoid

Pirtobrutinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Pirtobrutinib. Risk C: Monitor

PONATinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of PONATinib. Risk C: Monitor

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

Posaconazole: May increase serum concentration of QT-prolonging CYP3A4 Substrates. Such increases may lead to a greater risk for proarrhythmic effects and other similar toxicities. Risk X: Avoid

Pralsetinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Pralsetinib. Management: If this combo cannot be avoided, decrease pralsetinib dose from 400 mg daily to 300 mg daily; from 300 mg daily to 200 mg daily; and from 200 mg daily to 100 mg daily. Risk D: Consider Therapy Modification

Prazepam: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Prazepam. Risk C: Monitor

Praziquantel: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Praziquantel. Risk C: Monitor

QT-prolonging Antidepressants (Moderate Risk): May increase QTc-prolonging effects of QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk). Risk C: Monitor

QT-prolonging Antipsychotics (Moderate Risk): QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase QTc-prolonging effects of QT-prolonging Antipsychotics (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor

QT-prolonging Class IA Antiarrhythmics (Highest Risk): May increase QTc-prolonging effects of Crizotinib. Crizotinib may increase QTc-prolonging effects of QT-prolonging Class IA Antiarrhythmics (Highest Risk). Crizotinib may increase serum concentration of QT-prolonging Class IA Antiarrhythmics (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider Therapy Modification

QT-prolonging Class IC Antiarrhythmics (Moderate Risk): May increase QTc-prolonging effects of QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor

QT-prolonging Class III Antiarrhythmics (Highest Risk): May increase QTc-prolonging effects of QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk). QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of QT-prolonging Class III Antiarrhythmics (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider Therapy Modification

QT-Prolonging Inhalational Anesthetics (Moderate Risk): May increase QTc-prolonging effects of QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor

QT-prolonging Kinase Inhibitors (Highest Risk): May increase QTc-prolonging effects of QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk). QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of QT-prolonging Kinase Inhibitors (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider Therapy Modification

QT-prolonging Kinase Inhibitors (Moderate Risk): QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase QTc-prolonging effects of QT-prolonging Kinase Inhibitors (Moderate Risk). QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of QT-prolonging Kinase Inhibitors (Moderate Risk). Risk C: Monitor

QT-prolonging Miscellaneous Agents (Highest Risk): QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase QTc-prolonging effects of QT-prolonging Miscellaneous Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider Therapy Modification

QT-prolonging Miscellaneous Agents (Moderate Risk): QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase QTc-prolonging effects of QT-prolonging Miscellaneous Agents (Moderate Risk). QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of QT-prolonging Miscellaneous Agents (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor

QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk): May increase QTc-prolonging effects of Crizotinib. QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of Crizotinib. Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor

QT-prolonging Quinolone Antibiotics (Moderate Risk): May increase QTc-prolonging effects of QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor

QT-prolonging Strong CYP3A4 Inhibitors (Highest Risk): May increase QTc-prolonging effects of Crizotinib. QT-prolonging Strong CYP3A4 Inhibitors (Highest Risk) may increase serum concentration of Crizotinib. Management: Avoid concomitant use of crizotinib and strong CYP3A4 inhibitors whenever possible. If combined use cannot be avoided, crizotinib dose reductions are required, which vary according to indication. See full interaction monograph for details. Risk D: Consider Therapy Modification

QT-prolonging Strong CYP3A4 Inhibitors (Moderate Risk): Crizotinib may increase QTc-prolonging effects of QT-prolonging Strong CYP3A4 Inhibitors (Moderate Risk). QT-prolonging Strong CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of Crizotinib. Management: Avoid concomitant use of crizotinib and strong CYP3A4 inhibitors that prolong the QTc interval whenever possible. If combined, crizotinib dose adjustments are required, which vary according to indication. See full interaction monograph for details. Risk D: Consider Therapy Modification

QUEtiapine: QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase QTc-prolonging effects of QUEtiapine. QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of QUEtiapine. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation, ventricular arrhythmias, and other quetiapine toxicities. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider Therapy Modification

Quinidine (Non-Therapeutic): CYP3A4 Inhibitors (Moderate) may increase serum concentration of Quinidine (Non-Therapeutic). Risk C: Monitor

Ranolazine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Ranolazine. Management: Limit the ranolazine dose to a maximum of 500 mg twice daily in patients concurrently receiving moderate CYP3A4 inhibitors. Monitor for increased ranolazine effects and toxicities during concomitant use. Risk D: Consider Therapy Modification

Red Yeast Rice: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Red Yeast Rice. Risk C: Monitor

Regorafenib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Regorafenib. CYP3A4 Inhibitors (Moderate) may decrease active metabolite exposure of Regorafenib. Risk C: Monitor

Repotrectinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Repotrectinib. Risk X: Avoid

Revumenib: QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase QTc-prolonging effects of Revumenib. QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of Revumenib. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider Therapy Modification

Rifabutin: Crizotinib may increase serum concentration of Rifabutin. Rifabutin may decrease serum concentration of Crizotinib. Risk C: Monitor

Rimegepant: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Rimegepant. Management: If taking rimegepant for the acute treatment of migraine, avoid a second dose of rimegepant within 48 hours when used concomitantly with moderate CYP3A4 inhibitors. No dose adjustment needed if using rimegepant for prevention of episodic migraine. Risk D: Consider Therapy Modification

RisperiDONE: QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase QTc-prolonging effects of RisperiDONE. Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor

Rivaroxaban: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Rivaroxaban. This warning is more specifically for drugs that are inhibitors of both CYP3A4 and P-glycoprotein. For erythromycin, refer to more specific erythromycin-rivaroxaban monograph recommendations. Risk C: Monitor

Roflumilast-Containing Products: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Roflumilast-Containing Products. Risk C: Monitor

Rupatadine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Rupatadine. Risk C: Monitor

Ruxolitinib (Systemic): CYP3A4 Inhibitors (Moderate) may increase serum concentration of Ruxolitinib (Systemic). Risk C: Monitor

Salmeterol: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Salmeterol. Risk C: Monitor

SAXagliptin: CYP3A4 Inhibitors (Moderate) may increase serum concentration of SAXagliptin. Risk C: Monitor

Selpercatinib: QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase QTc-prolonging effects of Selpercatinib. QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of Selpercatinib. Management: Avoid combination if possible. If use is necessary, reduce selpercatinib dose as follows: from 120mg twice/day to 80mg twice/day, or from 160mg twice/day to 120mg twice/day. Monitor QT interval more closely for QTc interval prolongation and arrhythmias. Risk D: Consider Therapy Modification

Selumetinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Selumetinib. Management: Avoid concomitant use when possible. If combined, selumetinib dose reductions are recommended and vary based on body surface area and selumetinib dose. For details, see the full drug interaction monograph or selumetinib prescribing information. Risk D: Consider Therapy Modification

Sertindole: QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase QTc-prolonging effects of Sertindole. QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of Sertindole. Risk X: Avoid

Sildenafil: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Sildenafil. Risk C: Monitor

Silodosin: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Silodosin. Risk C: Monitor

Simeprevir: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Simeprevir. Risk X: Avoid

Simvastatin: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Simvastatin. CYP3A4 Inhibitors (Moderate) may increase active metabolite exposure of Simvastatin. Risk C: Monitor

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

Sirolimus (Conventional): CYP3A4 Inhibitors (Moderate) may increase serum concentration of Sirolimus (Conventional). Management: Monitor for increased serum concentrations of sirolimus if combined with a moderate CYP3A4 inhibitor. Lower initial sirolimus doses or sirolimus dose reductions will likely be required. Risk D: Consider Therapy Modification

Sirolimus (Protein Bound): CYP3A4 Inhibitors (Moderate) may increase serum concentration of Sirolimus (Protein Bound). Management: Reduce the dose of protein bound sirolimus to 56 mg/m² when used concomitantly with a moderate CYP3A4 inhibitor. Risk D: Consider Therapy Modification

Solifenacin: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Solifenacin. Risk C: Monitor

Sonidegib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Sonidegib. Management: Avoid concomitant use of sonidegib and moderate CYP3A4 inhibitors when possible. When concomitant use cannot be avoided, limit CYP3A4 inhibitor use to less than 14 days and monitor for sonidegib toxicity (particularly musculoskeletal adverse reactions). Risk D: Consider Therapy Modification

Sparsentan: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Sparsentan. Risk C: Monitor

SUFentanil: CYP3A4 Inhibitors (Moderate) may increase serum concentration of SUFentanil. Risk C: Monitor

SUNItinib: QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase QTc-prolonging effects of SUNItinib. QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase serum concentration of SUNItinib. Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor

Suvorexant: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Suvorexant. Management: The recommended dose of suvorexant is 5 mg daily in patients receiving a moderate CYP3A4 inhibitor. The dose can be increased to 10 mg daily (maximum dose) if necessary for efficacy. Risk D: Consider Therapy Modification

Suzetrigine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Suzetrigine. Management: Reduce suzetrigine dose as follows: initiate with 100 mg for 1 dose; then 12 hours after first dose, give 50 mg every 12 hours for doses 2, 3, and 4; then 50 mg every 24 hours for dose 5 and thereafter. Risk D: Consider Therapy Modification

Tacrolimus (Systemic): CYP3A4 Inhibitors (Moderate) may increase serum concentration of Tacrolimus (Systemic). Risk C: Monitor

Tacrolimus (Topical): CYP3A4 Inhibitors (Moderate) may increase serum concentration of Tacrolimus (Topical). Risk C: Monitor

Tadalafil: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Tadalafil. Risk C: Monitor

Tamsulosin: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Tamsulosin. Risk C: Monitor

Tazemetostat: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Tazemetostat. Management: Avoid when possible. If combined, reduce tazemetostat dose from 800 mg twice daily to 400 mg twice daily, from 600 mg twice daily to 400 mg in AM and 200 mg in PM, or from 400 mg twice daily to 200 mg twice daily. Risk D: Consider Therapy Modification

Temsirolimus: CYP3A4 Inhibitors (Moderate) may increase active metabolite exposure of Temsirolimus. Specifically, concentrations of sirolimus may be increased. Risk C: Monitor

Tetrahydrocannabinol and Cannabidiol: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Tetrahydrocannabinol and Cannabidiol. Risk C: Monitor

Tetrahydrocannabinol: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Tetrahydrocannabinol. Risk C: Monitor

Tezacaftor and Ivacaftor: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Tezacaftor and Ivacaftor. Management: If combined with moderate CYP3A4 inhibitors, give tezacaftor/ivacaftor in the morning, every other day; give ivacaftor in the morning, every other day on alternate days. Tezacaftor/ivacaftor dose depends on age and weight; see full Lexi-Interact monograph Risk D: Consider Therapy Modification

Thioridazine: QT-prolonging Agents (Moderate Risk) may increase QTc-prolonging effects of Thioridazine. Risk X: Avoid

Thiotepa: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Thiotepa. CYP3A4 Inhibitors (Moderate) may decrease active metabolite exposure of Thiotepa. Risk C: Monitor

Ticagrelor: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Ticagrelor. CYP3A4 Inhibitors (Moderate) may decrease active metabolite exposure of Ticagrelor. Risk C: Monitor

Tilidine: CYP3A4 Inhibitors (Moderate) may increase active metabolite exposure of Tilidine. CYP3A4 Inhibitors (Moderate) may increase serum concentration of Tilidine. Risk C: Monitor

Tofacitinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Tofacitinib. Risk C: Monitor

Tolterodine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Tolterodine. Risk C: Monitor

Tolvaptan: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Tolvaptan. Management: Avoid this combination with Samsca brand of tolvaptan. Reduce dose for Jynarque brand: 90 mg AM and 30 mg PM, reduce to 45 mg AM and 15 mg PM; 60 mg AM and 30 mg PM, reduce to 30 mg AM and 15 mg PM; 45 mg AM and 15 mg PM, reduce to 15 mg AM and PM. Risk D: Consider Therapy Modification

Trabectedin: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Trabectedin. Risk C: Monitor

TraMADol: CYP3A4 Inhibitors (Moderate) may increase serum concentration of TraMADol. CYP3A4 Inhibitors (Moderate) may increase active metabolite exposure of TraMADol. Risk C: Monitor

TraZODone: CYP3A4 Inhibitors (Moderate) may increase serum concentration of TraZODone. Risk C: Monitor

Tretinoin (Systemic): CYP3A4 Inhibitors (Moderate) may increase serum concentration of Tretinoin (Systemic). Risk C: Monitor

Triamcinolone (Systemic): CYP3A4 Inhibitors (Moderate) may increase serum concentration of Triamcinolone (Systemic). Risk C: Monitor

Triazolam: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Triazolam. Management: Consider triazolam dose reduction in patients receiving concomitant moderate CYP3A4 inhibitors. Risk D: Consider Therapy Modification

Ubrogepant: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Ubrogepant. Management: Use an initial ubrogepant dose of 50 mg and avoid a second dose for 24 hours when used with moderate CYP3A4 inhibitors. Risk D: Consider Therapy Modification

Udenafil: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Udenafil. Risk C: Monitor

Valbenazine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Valbenazine. CYP3A4 Inhibitors (Moderate) may increase active metabolite exposure of Valbenazine. Risk C: Monitor

Vamorolone: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Vamorolone. Risk C: Monitor

Vanzacaftor, Tezacaftor, and Deutivacaftor: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Vanzacaftor, Tezacaftor, and Deutivacaftor. Management: Age- and weight-specific dose reductions of vanzacaftor, tezacaftor, and deutivacaftor are recommended. Please see full Interact monograph or labeling for details. Risk D: Consider Therapy Modification

Vardenafil: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Vardenafil. Management: Limit Levitra (vardenafil) dose to a single 5 mg dose within a 24-hour period if combined with moderate CYP3A4 inhibitors. Avoid concomitant use of Staxyn (vardenafil) and moderate CYP3A4 inhibitors. Combined use is contraindicated outside of the US. Risk D: Consider Therapy Modification

Venetoclax: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Venetoclax. Management: Reduce the venetoclax dose by at least 50% in patients requiring concomitant treatment with moderate CYP3A4 inhibitors. Resume the previous venetoclax dose 2 to 3 days after discontinuation of moderate CYP3A4 inhibitors. Risk D: Consider Therapy Modification

Verapamil: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Verapamil. Risk C: Monitor

Vilazodone: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Vilazodone. Risk C: Monitor

VinBLAStine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of VinBLAStine. Risk C: Monitor

VinCRIStine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of VinCRIStine. Risk C: Monitor

Vindesine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Vindesine. Risk C: Monitor

Vinflunine: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Vinflunine. CYP3A4 Inhibitors (Moderate) may increase active metabolite exposure of Vinflunine. Risk C: Monitor

Voclosporin: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Voclosporin. Management: Decrease the voclosporin dose to 15.8 mg in the morning and 7.9 mg in the evening when combined with moderate CYP3A4 inhibitors. Risk D: Consider Therapy Modification

Vorapaxar: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Vorapaxar. Risk C: Monitor

Warfarin: Crizotinib may increase anticoagulant effects of Warfarin. Risk C: Monitor

Zanubrutinib: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Zanubrutinib. Management: Decrease the zanubrutinib dose to 80 mg twice daily during coadministration with a moderate CYP3A4 inhibitor. Further dose adjustments may be required for zanubrutinib toxicities, refer to prescribing information for details. Risk D: Consider Therapy Modification

Zopiclone: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Zopiclone. Risk C: Monitor

Zuranolone: CYP3A4 Inhibitors (Moderate) may increase serum concentration of Zuranolone. Risk C: Monitor

Food Interactions

Grapefruit juice may increase serum crizotinib levels. Management: Avoid grapefruit and grapefruit juice.

Reproductive Considerations

Evaluate pregnancy status prior to use in patients who could become pregnant. Patients who could become pregnant should use effective contraception during treatment and for at least 45 days after the last crizotinib dose; males with partners who could become pregnant should use condoms during treatment and for at least 90 days after the final crizotinib dose.

Pregnancy Considerations

Based on the mechanism of action and data from animal reproduction studies, crizotinib may cause fetal harm if administered during pregnancy.

Breastfeeding Considerations

It is not known if crizotinib is present in breast milk. Due to the potential for serious adverse reactions in the breastfed infant, the manufacturer recommends against breastfeeding during treatment and for 45 days after the final crizotinib dose.

Dietary Considerations

Avoid grapefruit and grapefruit juice.

Monitoring Parameters

ALK or ROS1 positivity (in tumor specimen) for non–small cell lung cancer (NSCLC); CBC with differential monthly (inflammatory myofibroblastic tumor [IMT] or NSCLC) or weekly for the first month (anaplastic large cell lymphoma [ALCL]), then monthly, and as clinically appropriate (monitor more frequently if grades 3 or 4 abnormalities observed or with fever or infection), LFTs (including ALT, AST, and total bilirubin) every 2 weeks for the first 2 months, then monthly and as clinically appropriate (monitor more frequently, including alkaline phosphatase, if increased transaminases observed); renal function (baseline and periodic); electrolytes (baseline and as clinically indicated). Evaluate pregnancy status prior to use (in patients who could become pregnant). Monitor pulmonary symptoms (for interstitial lung disease/pneumonitis). Monitor heart rate and BP regularly; monitor ECG and electrolytes in patients with heart failure, bradycardia, bradyarrhythmias, electrolyte abnormalities, or who are taking medications known to prolong the QT interval. Monthly assessment of visual symptoms for all patients is recommended; refer to eye specialist for evaluation with new visual symptoms. In ALCL or IMT, perform baseline ophthalmologic examinations prior to initiating therapy; a follow-up exam, including retinal evaluation, is recommended within 1 month of therapy initiation, every 3 months thereafter, and as clinically warranted. Obtain ophthalmic evaluation (including best corrected visual acuity, retinal photographs, visual fields, optical coherence tomography, and other evaluations as appropriate) if severe visual loss occurs. Monitor for GI toxicity and hydration status. Monitor adherence.

The American Society of Clinical Oncology hepatitis B virus (HBV) screening and management provisional clinical opinion (ASCO [Hwang 2020]) 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.

Additional 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 (ASCO [Armenian 2017]; ESC [Lyon 2022]). Consider home BP monitoring; assess cholesterol profile every 3 to 6 months (ESC [Lyon 2022]).

Mechanism of Action

Crizotinib is a tyrosine kinase receptor inhibitor which inhibits ALK, Hepatocyte Growth Factor Receptor (HGFR, c-MET), ROS1 (c-ros), and Recepteur d’Origine Nantais (RON). ALK gene abnormalities due to mutations or translocations may result in expression of oncogenic fusion proteins (eg, ALK fusion protein) which alter signaling and expression and result in increased cellular proliferation and survival in tumors which express these fusion proteins. Crizotinib shows antitumor activity in cell lines that express echinoderm microtubule-associated protein-like 4, or EML4-ALK gene. Inhibition of ALK, ROS1, and c-Met phosphorylation is concentration-dependent. Crizotinib induces apoptosis and inhibits proliferation and ALK-mediated signaling in ALCL-derived cell lines.

Pharmacokinetics (Adult Data Unless Noted)

Distribution: V_ss: 1772 L.

Protein binding: 91%.

Metabolism: Hepatic, predominantly via CYP3A4/5 (oxidation and dealkylation).

Bioavailability: 43% (range: 32% to 66%); bioavailability is reduced 14% with a high-fat meal.

Half-life elimination: Terminal: 42 hours.

Time to peak: 4 to 6 hours.

Excretion: Feces (63%; 53% as unchanged drug); urine (22%; 2% as unchanged drug).

Clearance: 100 L/hour (single 250 mg oral dose); 60 L/hour (steady state at 250 mg twice daily).

Pharmacokinetics: Additional Considerations (Adult Data Unless Noted)

Altered kidney function: In patients with severe renal impairment (CrCl <30 mL/minute) not requiring dialysis, following a single 250 mg oral dose, the mean AUC_∞ and mean C_max were increased 79% and 34%, respectively, compared to patients with normal renal function.

Hepatic function impairment: Compared to subjects with normal hepatic function, steady-state crizotinib AUC and C_max decreased by 9% in subjects with mild hepatic impairment following 250 mg twice daily dosing. AUC and C_max increased by 14% and 9%, respectively, in subjects with moderate hepatic impairment following 200 mg twice daily dosing compared to subjects with normal hepatic function receiving 250 mg twice daily. Mean crizotinib AUC decreased by 35% and C_max decreased by 27% in subjects with severe hepatic impairment following 250 mg once daily dosing compared to subjects with normal hepatic function receiving 250 mg twice daily.

Brand Names: International

International Brand Names by Country

For country code abbreviations (show table)

(AE) United Arab Emirates: Xalkori;
(AR) Argentina: Xalkori;
(AT) Austria: Xalkori;
(AU) Australia: Xalkori;
(BD) Bangladesh: Crizonix;
(BE) Belgium: Xalkori;
(BG) Bulgaria: Xalkori;
(BR) Brazil: Xalkori;
(CH) Switzerland: Xalkori;
(CL) Chile: Xalkori;
(CN) China: Sai ke rui;
(CO) Colombia: Xalkori;
(CZ) Czech Republic: Xalkori;
(DE) Germany: Xalkori;
(DO) Dominican Republic: Xalkori;
(EC) Ecuador: Xalkori;
(EE) Estonia: Xalkori;
(EG) Egypt: Xalkori;
(ES) Spain: Xalkori;
(FI) Finland: Xalkori;
(FR) France: Xalkori;
(GB) United Kingdom: Xalkori;
(GR) Greece: Xalkori;
(HK) Hong Kong: Xalkori;
(HR) Croatia: Xalkori;
(HU) Hungary: Xalkori;
(ID) Indonesia: Xalkori;
(IE) Ireland: Xalkori;
(IN) India: Crizalk;
(IT) Italy: Xalkori;
(JO) Jordan: Xalkori;
(JP) Japan: Xalkori;
(KE) Kenya: Algrofin;
(KR) Korea, Republic of: Xalkori;
(KW) Kuwait: Xalkori;
(LB) Lebanon: Xalkori;
(LT) Lithuania: Xalkori;
(LV) Latvia: Xalkori;
(MX) Mexico: Xalkori;
(MY) Malaysia: Xalkori;
(NL) Netherlands: Xalkori;
(NO) Norway: Xalkori;
(NZ) New Zealand: Xalkori;
(PE) Peru: Xalkori;
(PH) Philippines: Xalkori;
(PL) Poland: Xalkori;
(PR) Puerto Rico: Xalkori;
(PT) Portugal: Xalkori;
(QA) Qatar: Xalkori;
(RO) Romania: Xalkori;
(RU) Russian Federation: Xalkori;
(SA) Saudi Arabia: Xalkori;
(SE) Sweden: Xalkori;
(SG) Singapore: Xalkori;
(SI) Slovenia: Xalkori;
(SK) Slovakia: Xalkori;
(TH) Thailand: Xalkori;
(TN) Tunisia: Xalkori;
(TR) Turkey: Xalkori;
(TW) Taiwan: Xalkori;
(UA) Ukraine: Xalkori;
(UY) Uruguay: Xalkori;
(ZA) South Africa: Xalkori

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Xalkori (crizotinib) disintegration of capsules for patients unable to swallow capsules. Pfizer [data on file]; February 2021.
Xalkori (crizotinib) [prescribing information]. New York, NY: Pfizer Labs; July 2022.
Xalkori (crizotinib) [prescribing information]. New York, NY: Pfizer Labs; September 2023.
Xalkori (crizotinib) [product monograph]. Kirkland, Quebec, Canada: Pfizer Canada ULC; April 2023.

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خرید پکیج

Crizotinib: Drug information