Version May 2024
Non–small cell lung cancer (NSCLC), metastatic, with nonresistant EGFR mutations: Oral: 40 mg once daily until disease progression or unacceptable toxicity
Non–small cell lung cancer, metastatic squamous (previously treated): Oral: 40 mg once daily until disease progression or unacceptable toxicity
Missed doses: Do not take a missed dose within 12 hours of next dose.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Note: The manufacturer recommends using the Modification of Diet in Renal Disease (MDRD) formula to estimate the GFR.
Preexisting impairment:
eGFR >30 mL/minute/1.73 m2: No dosage adjustment is necessary.
eGFR 15 to 29 mL/minute/1.73 m2: Reduce starting dose to 30 mg once daily.
eGFR <15 mL/minute/1.73 m2 and hemodialysis: There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
Preexisting mild to moderate impairment (Child-Pugh class A or B): No dosage adjustment is necessary.
Preexisting severe impairment (Child-Pugh class C): There are no dosage adjustments provided in the manufacturer's labeling (has not been studied); closely monitor and adjust dose if necessary.
Hepatotoxicity during treatment: Withhold therapy for ≥ grade 3 hepatic dysfunction. Upon improvement to baseline or ≤ grade 1, resume therapy at 10 mg per day less than previous dose. Permanently discontinue for severe afatinib-induced hepatic impairment.
Note: Permanently discontinue for intolerability or severe reaction occurring at a dose of 20 mg daily.
Cardiovascular: Permanently discontinue for symptomatic left ventricular dysfunction.
Dermatologic: Withhold therapy for prolonged (>7 days) or intolerable grade 2 or higher cutaneous reactions. Upon improvement to baseline or ≤ grade 1, resume therapy at 10 mg per day less than previous dose. Discontinue permanently for life-threatening bullous, blistering, or exfoliating skin lesions, as well as for suspected toxic epidermal necrolysis (TEN) or Stevens-Johnson syndrome (SJS).
Gastrointestinal:
Diarrhea:
Grade 2 that persists for ≥2 consecutive days despite antidiarrheal therapy: Interrupt therapy until fully resolves, returns to baseline, or improves to ≤ grade 1, then resume with the dose reduced by 10 mg per day less than previous dose.
Grade 3 or higher: Interrupt therapy until resolution to ≤ grade 1, then resume at 10 mg per day less than previous dose.
GI perforation: Discontinue permanently.
Ocular: Interrupt therapy for suspected keratitis; consider discontinuation if diagnosis of ulcerative keratitis is confirmed. Permanently discontinue for persistent ulcerative keratitis.
Pulmonary: Interrupt therapy for suspected interstitial lung disease (ILD); permanently discontinue if diagnosis is confirmed.
Other toxicity: Grade 3 or higher adverse reactions: Withhold therapy for ≥ grade 3 adverse reactions. Upon improvement to baseline or ≤ grade 1, resume therapy at 10 mg per day less than previous dose.
Refer to adult dosing.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
>10%:
Dermatologic: Acneiform eruption (≤90%), erythema of skin (≤90%), skin rash (≤90%), paronychia (11% to 58%), xeroderma (31%), pruritus (10% to 21%), cheilitis (12%)
Endocrine & metabolic: Decreased serum potassium (11% to 30%), weight loss (17%)
Gastrointestinal: Diarrhea (75% to 96%), stomatitis (30% to 71%; grade 3: 9%; grades 3/4: 4%), decreased appetite (25% to 29%), nausea (21% to 25%), vomiting (13% to 23%)
Genitourinary: Cystitis (13%)
Hematologic & oncologic: Lymphocytopenia (38%; grades 3/4: 9%), decreased white blood cell count (12%; grades 3/4: 1%)
Hepatic: Increased serum alanine aminotransferase (10% to 54%), increased serum alkaline phosphatase (34% to 51%), increased serum aspartate aminotransferase (7% to 46%), abnormal hepatic function tests (6% to 18%), increased serum bilirubin (3% to 16%)
Ophthalmic: Conjunctivitis (11%)
Renal: Decreased creatinine clearance (49%)
Respiratory: Epistaxis (17%), rhinorrhea (11%)
Miscellaneous: Fever (12%)
1% to 10%:
Cardiovascular: Ventricular dysfunction (2%)
Central nervous system: Fatigue (2%)
Dermatologic: Nail disease (3% to 9%), palmar-plantar erythrodysesthesia (2% to 7%)
Gastrointestinal: Severe diarrhea (5% to 6%), severe vomiting (5%)
Endocrine & metabolic: Hypokalemia (2%)
Ophthalmic: Keratitis (≤2%)
Respiratory: Pneumonia (7%), dyspnea (2% to 3%), interstitial pulmonary disease (≤2%), pulmonary toxicity (≤1%)
<1%, postmarketing, and/or case reports: Acute renal function, bullous rash, gastrointestinal perforation, local skin exfoliation, pancreatitis, physical health deterioration, respiratory failure, sepsis, skin blister, Stevens-Johnson syndrome, toxic epidermal necrolysis
There are no contraindications listed in the manufacturer's US labeling.
Canadian labeling: Hypersensitivity to afatinib or any component of the formulation.
Concerns related to adverse effects:
• Cardiovascular toxicity: Decreases from baseline in left ventricular ejection fraction (LVEF) were noted in some patients receiving afatinib. Patients with abnormal LVEF or a significant cardiac history were excluded from clinical trials; use with caution in patients with cardiac risk factors and/or decreased LVEF. Permanently discontinue in patients who develop symptomatic left ventricular dysfunction.
• Dermatologic toxicity: Cutaneous reactions (eg, acneiform rash, erythema, rash) are common; grade 3 reactions (characterized by bullous, blistering, and exfoliating lesions) and palmar-plantar erythrodysesthesia syndrome were also seen in clinical trials. Cases of skin reactions consistent with Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) have been reported; SJS and TEN result from a mechanism that is distinct and separate from the bullous skin toxicity typically observed with EGFR inhibitor therapy. Dermatologic toxicity may require therapy interruption and dosage reduction; discontinue if life-threatening bullous, blistering, or exfoliating lesions occur or for suspected SJS or TEN. Patients should be cautioned to avoid sun exposure and/or utilize adequate sun protection.
• GI toxicity: In clinical trials, diarrhea (including grade 3 and 4 events) and stomatitis frequently occurred in patients treated with afatinib; diarrhea was observed in the majority of patients and typically appeared within the first 6 weeks of therapy. Dehydration and renal impairment may occur as a consequence of diarrhea; monitor closely. Patients may require antidiarrheal therapy (eg, loperamide); initiate at the onset of diarrhea and continue until free of loose bowel movements for 12 hours. May necessitate therapy interruption and dosage reduction. GI perforations (some fatal) have been reported; risk may be increased in older patients, patients with a history of GI ulceration, underlying diverticular disease or bowel metastases, or with concomitant use of corticosteroids, NSAIDs, or anti-angiogenic agents. Permanently discontinue afatinib in patients who develop GI perforation.
• Hepatitis B virus screening: 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 (HBsAg), hepatitis B core antibody (anti-HBc), total Ig or IgG, and antibody to hepatitis B surface antigen (anti-HBs) 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.
• Hepatotoxicity: Hepatic function test abnormalities (some fatal) were observed in clinical trials. Monitor liver function tests periodically; may require therapy interruption and dosage reduction. Discontinue if severe hepatic impairment occurs during therapy.
• Ocular toxicity: Keratitis (including rare grade 3 events) was reported rarely in clinical trials; monitor for signs/symptoms of keratitis (eg, acute or worsening eye inflammation, blurred vision, eye pain, lacrimation, light sensitivity, red eye). Interrupt therapy in patients with suspected keratitis; if diagnosis of ulcerative keratitis is confirmed, interrupt or discontinue afatinib (permanently discontinue for persistent ulcerative keratitis). Use with caution in patients with a history of keratitis, severe dry eye, ulcerative keratitis, or who wear contact lenses (risk factor for keratitis and ulceration).
• Paronychia: Paronychia requiring dose reduction and discontinuation of therapy has been observed.
• Pulmonary toxicity: Interstitial lung disease (ILD) or ILD-like reactions occurred in a small percentage of patients treated with afatinib (some fatal). ILD incidence appeared to be higher in Asian compared with non-Asian patients. Monitor closely for signs/symptoms of ILD (eg, acute respiratory distress syndrome, allergic alveolitis, lung infiltration, pneumonitis). Interrupt therapy for suspected ILD; discontinue therapy with confirmed diagnosis.
Disease-related concerns:
• Hepatic impairment: Use in severe hepatic impairment (Child-Pugh class C) has not been studied; closely monitor patients with severe impairment, may require dosage adjustments if not tolerated.
• Renal impairment: Dosage reduction is recommended in patients with severe renal impairment (eGFR 15 to 29 mL/minute/1.73 m2).
Dosage forms specific issues:
• Lactose: Formulation may contain lactose.
Other warnings/precautions:
• Appropriate use: For first-line therapy, safety and efficacy have not been established in patients with non-small cell lung cancer whose tumors express resistant EGFR mutations. Information on EGFR mutation testing is available at www.fda.gov/CompanionDiagnostics. Increased mortality has been observed in a clinical trial evaluating afatinib in combination with vinorelbine for HER2-positive metastatic breast cancer (not an approved use). This combination was also associated with a higher incidence of adverse events (eg, diarrhea, rash), as well as fatalities due to infection and cancer progression. Afatinib should not be used in combination with vinorelbine for the treatment of HER2-positive metastatic breast cancer.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Tablet, Oral:
Gilotrif: 20 mg
Gilotrif: 30 mg, 40 mg [contains fd&c blue #2 (indigotine,indigo carmine)]
No
Tablets (Gilotrif Oral)
20 mg (per each): $457.93
30 mg (per each): $457.93
40 mg (per each): $457.93
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Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Tablet, Oral:
Giotrif: 20 mg
Giotrif: 30 mg, 40 mg [contains fd&c blue #2 (indigotine,indigo carmine)]
Oral: Administer ≥1 hour before or 2 hours after a meal. Do not take a missed dose within 12 hours of the next dose.
Hazardous agent (NIOSH 2016 [group 1]).
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 2016; USP-NF 2020).
Non-small cell lung cancer, metastatic, EGFR mutation-positive: First-line treatment of metastatic non-small cell lung cancer (NSCLC) in patients whose tumors have nonresistant epidermal growth factor receptor (EGFR) mutations as detected by an approved test.
Limitations of use: Safety and efficacy have not been established in patients whose tumors express resistant EGFR mutations.
Non-small cell lung cancer, metastatic squamous: Treatment of previously treated metastatic squamous cell NSCLC that has progressed following platinum-based chemotherapy.
Afatinib may be confused with abemaciclib, acalabrutinib, Afinitor, alectinib, alpelisib, axitinib, ceritinib, crizotinib, dacomitinib, enasidenib, erlotinib, fedratinib, fostamatinib, gefitinib, neratinib
This medication is in a class the Institute for Safe Medication Practices (ISMP) includes among its list of drug classes which have a heightened risk of causing significant patient harm when used in error.
Substrate of BCRP/ABCG2, P-glycoprotein/ABCB1 (major); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.
Aminolevulinic Acid (Systemic): Photosensitizing Agents may enhance the photosensitizing effect of Aminolevulinic Acid (Systemic). Risk X: Avoid combination
Aminolevulinic Acid (Topical): Photosensitizing Agents may enhance the photosensitizing effect of Aminolevulinic Acid (Topical). Risk C: Monitor therapy
Asciminib: May increase the serum concentration of P-glycoprotein/ABCB1 Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk C: Monitor therapy
Elacestrant: May increase the serum concentration of P-glycoprotein/ABCB1 Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk C: Monitor therapy
Erdafitinib: May increase the serum concentration of P-glycoprotein/ABCB1 Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Management: If coadministration with these narrow therapeutic index/sensitive P-gp substrates is unavoidable, separate erdafitinib administration by at least 6 hours before or after administration of these P-gp substrates. Risk D: Consider therapy modification
Futibatinib: May increase the serum concentration of P-glycoprotein/ABCB1 Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk C: Monitor therapy
Gilteritinib: May increase the serum concentration of P-glycoprotein/ABCB1 Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk C: Monitor therapy
Lasmiditan: May increase the serum concentration of P-glycoprotein/ABCB1 Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk X: Avoid combination
Lumacaftor and Ivacaftor: May increase the serum concentration of P-glycoprotein/ABCB1 Substrates (High risk with Inhibitors or Inducers). Lumacaftor and Ivacaftor may decrease the serum concentration of P-glycoprotein/ABCB1 Substrates (High risk with Inhibitors or Inducers). Risk C: Monitor therapy
Methoxsalen (Systemic): Photosensitizing Agents may enhance the photosensitizing effect of Methoxsalen (Systemic). Risk C: Monitor therapy
Mitapivat: May increase the serum concentration of P-glycoprotein/ABCB1 Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk C: Monitor therapy
Nelfinavir: May increase the serum concentration of Afatinib. Management: Monitor for signs and symptoms of afatinib toxicity when these agents are combined. Consider administering nelfinavir simultaneously with, or after, the dose of afatinib. If the combination is not tolerated, consider reducing the afatinib dose by 10 mg. Risk C: Monitor therapy
Pacritinib: May increase the serum concentration of P-glycoprotein/ABCB1 Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk X: Avoid combination
P-glycoprotein/ABCB1 Inducers: May decrease the serum concentration of Afatinib. Management: Increase the afatinib dose by 10 mg as tolerated in patients requiring chronic coadministration of P-gp inducers with afatinib. Reduce afatinib dose back to the original afatinib dose 2 to 3 days after discontinuation of the P-gp inducer. Risk D: Consider therapy modification
P-glycoprotein/ABCB1 Inhibitors: May increase the serum concentration of Afatinib. Management: If combined, administer the P-gp inhibitor simultaneously with, or after, the dose of afatinib. Monitor closely for signs and symptoms of afatinib toxicity and if the combination is not tolerated, reduce the afatinib dose by 10 mg. Risk D: Consider therapy modification
PHENobarbital: May decrease the serum concentration of Afatinib. Management: Consider increasing the afatinib dose by 10 mg as tolerated in patients requiring chronic coadministration of phenobarbital with afatinib. Reduce afatinib dose back to the original afatinib dose 2 to 3 days after discontinuation of phenobarbital. Risk D: Consider therapy modification
Porfimer: Photosensitizing Agents may enhance the photosensitizing effect of Porfimer. Risk C: Monitor therapy
Pretomanid: May increase the serum concentration of P-glycoprotein/ABCB1 Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk C: Monitor therapy
Primidone: May decrease the serum concentration of Afatinib. Management: Consider increasing the afatinib dose by 10 mg as tolerated in patients requiring chronic coadministration of phenobarbital with afatinib. Reduce afatinib dose back to the original afatinib dose 2 to 3 days after discontinuation of phenobarbital. Risk D: Consider therapy modification
Saquinavir: May increase the serum concentration of Afatinib. Management: Monitor for signs and symptoms of afatinib toxicity when these agents are combined. Consider administering saquinavir simultaneously with, or after, the dose of afatinib. If the combination is not tolerated, consider reducing the afatinib dose by 10 mg. Risk C: Monitor therapy
Sotorasib: May increase the serum concentration of P-glycoprotein/ABCB1 Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Management: Consider avoiding use of sotorasib and narrow therapeutic index/sensitive P-gp substrates. If combined use is unavoidable, monitor for increased toxicities of the substrate and consider a decrease in the substrate dosage. Risk D: Consider therapy modification
Sparsentan: May increase the serum concentration of P-glycoprotein/ABCB1 Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk X: Avoid combination
Tacrolimus (Systemic): May increase the serum concentration of Afatinib. Management: Monitor for signs and symptoms of afatinib toxicity when these agents are combined. Consider administering tacrolimus simultaneously with, or after, the dose of afatinib. If the combination is not tolerated, consider reducing the afatinib dose by 10 mg. Risk C: Monitor therapy
Taurursodiol: May increase the serum concentration of P-glycoprotein/ABCB1 Substrates (Narrow Therapeutic Index/Sensitive with Inhibitors). Risk X: Avoid combination
Verteporfin: Photosensitizing Agents may enhance the photosensitizing effect of Verteporfin. Risk C: Monitor therapy
Administration with a high-fat meal decreases Cmax by 50% and AUC by 39% as compared to the fasted state. Management: Take at least 1 hour before or 2 hours after a meal.
Women of reproductive potential should use highly effective contraception during therapy and for at least 2 weeks after the last afatinib dose.
Based on animal reproduction studies and on the mechanism of action, afatinib may cause fetal harm if used during pregnancy.
It is not known if afatinib is present into breast milk. Due to the potential for serious adverse reactions in the breastfed infant, the manufacturer recommends against breastfeeding during therapy and for at least 2 weeks after the last afatinib dose.
EGFR mutation status (for first-line therapy); liver and renal function (periodically). Hepatitis B virus screening with hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc), total Ig or IgG, and antibody to hepatitis B surface antigen (anti-HBs) prior to beginning systemic anticancer therapy (ASCO [Hwang 2020]). Consider left ventricular ejection fraction assessment prior to and during therapy in patients with cardiac risk factors or conditions that may impair left ventricular function. Monitor for skin toxicity, diarrhea, signs/symptoms of dehydration; monitor for signs/symptoms of interstitial lung disease (eg, acute respiratory distress syndrome, allergic alveolitis, lung infiltration, pneumonitis) and keratitis (eg, acute or worsening eye inflammation, blurred vision, eye pain, lacrimation, light sensitivity, red eye). Monitor adherence.
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]).
Afatinib is a highly selective tyrosine kinase inhibitor that covalently binds to EGFR (ErbB1), HER2 (ErbB2), and HER4 (ErbB4) to irreversibly inhibit tyrosine kinase autophosphorylation and downregulate ErbB signaling. Certain EGFR mutations (including nonresistant mutations) result in increased receptor autophosphorylation, leading to receptor activation (sometimes without ligand binding), and may support NSCLC cell proliferation. Nonresistant mutations occur in exons constituting the EGFR kinase domain that lead to increased receptor activation; efficacy is predicted by tumor shrinkage and/or inhibition of cellular proliferation or EGFR tyrosine kinase phosphorylation. The most common mutations are exon 21 L858R substitutions and exon 19 deletions. Afatinib inhibits autophosphorylation and/or proliferation (in vitro) in cell lines expressing both wild-type EGFR and selected EGFR exon 19 deletion mutations, exon 21 L858R mutations, or other less common nonresistant mutations. Additionally, afatinib inhibited in vitro proliferation of cell lines overexpressing HER2.
Absorption: Decreased with high-fat meals
Protein binding: ~95%
Metabolism: Covalently adducted to proteins and nucleophilic small molecules (minimal enzymatic metabolism) (Wind 2013); ~2% of a dose is metabolized by FMO3
Bioavailability: Tablets: 92% (as compared to an oral solution)
Half-life elimination: 37 hours
Time to peak: 2 to 5 hours
Excretion: Feces (85%); urine (4%); primarily as unchanged drug
Altered kidney function: A small pharmacokinetic study demonstrated a 50% increase and a 22% increase in mean AUCinf in patients with severe renal impairment (eGFR 15 to 29 mL/minute/1.73 m2) and moderate renal impairment (eGFR 30 to 59 mL/minute/1.73 m2), respectively, as compared to patients with normal renal function (eGFR 90 mL/minute/1.73 m2 or higher). Cmax was 22% higher in patients with severe renal impairment and was comparable in patients with moderate renal impairment and patients with normal renal function.
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