Note: Refer to aromatase inhibitor or fulvestrant monographs for respective dosing in combination with palbociclib.
Breast cancer, advanced, initial endocrine-based therapy: HER-2 negative: Oral: Tablets or capsules: 125 mg once daily for 21 days, followed by 7 days off, repeat every 28 days (in combination with continuous aromatase inhibitor therapy); continue until disease progression or unacceptable toxicity (Ref). Pre/perimenopausal patients should also receive a luteinizing hormone-releasing hormone (LHRH) agonist. For males receiving palbociclib in combination with an aromatase inhibitor, also consider treatment with an LHRH agonist.
Breast cancer, advanced, with disease progression following endocrine therapy: HER-2 negative: Oral: Tablets or capsules: 125 mg once daily for 21 days, followed by 7 days off, repeat every 28 days (in combination with fulvestrant [and an LHRH agonist or a gonadotropin-releasing hormone agonist if pre/perimenopausal]); continue until disease progression or unacceptable toxicity (Ref).
Missed/vomited doses: If a dose is vomited or missed, an additional dose should not be administered that day. Resume dosing with the next scheduled daily dose.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult Drug Interactions database for more information.
The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Kenar D. Jhaveri, MD; Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.
Altered kidney function: No dosage adjustment necessary for any degree of kidney dysfunction (Ref).
Hemodialysis, intermittent (thrice weekly): Unlikely to be significantly dialyzed (large Vd): No supplemental dose or dosage adjustment necessary (Ref).
Peritoneal dialysis: Unlikely to be significantly dialyzed (large Vd): No dosage adjustment necessary (Ref).
CRRT: No dosage adjustment necessary (Ref).
PIRRT (eg, sustained, low-efficiency diafiltration): No dosage adjustment necessary (Ref).
Mild or moderate impairment (Child-Pugh classes A and B): No dosage adjustment necessary.
Severe impairment (Child-Pugh class C): Reduce dose to 75 mg once daily for 21 days, followed by 7 days off; repeat every 28 days.
Note: Endocrine therapy (eg, aromatase inhibitor or fulvestrant) may also require dosage modification.
Dose level |
Palbociclib dose |
---|---|
a Discontinue palbociclib if unable to tolerate 75 mg/day. | |
Usual (initial) dose |
125 mg/day |
First dose reduction |
100 mg/day |
Second dose reduction |
75 mg/daya |
Adverse reaction |
Severity |
Palbociclib dosage modification |
---|---|---|
a Except lymphopenia (unless associated with clinical events [eg, opportunistic infection]). | ||
Hematologic toxicitya |
Grade 1 or 2 |
No palbociclib dosage modification is required. |
Grade 3 on day 1 of cycle |
Withhold palbociclib and repeat CBC with differential within 1 week. When improved to ≤ grade 2, initiate the next cycle at the same dose. | |
Grade 3 on day 15 of first 2 cycles |
If grade 3 on day 15, continue palbociclib at current dose to complete the cycle. Repeat CBC with differential on day 22. If grade 4 on day 22, withhold palbociclib until improved to ≤ grade 2, then resume at next lower dose. Consider dose reduction in future cycles if recovery from grade 3 neutropenia is prolonged (>1 week) or for recurrent grade 3 neutropenia on day 1 of subsequent cycles. | |
Grade 3 neutropenia with fever ≥38.5°C (≥101.3°F) and/or infection |
Withhold palbociclib until improved to ≤ grade 2, then resume at next lower dose. | |
Grade 4 |
Withhold palbociclib until improved to ≤ grade 2, then resume at next lower dose. | |
Pulmonary toxicity |
New or worsening respiratory symptoms, which may be indicative of pneumonitis |
Interrupt palbociclib treatment immediately and evaluate patient. |
Severe interstitial lung disease/pneumonitis |
Permanently discontinue palbociclib. | |
Other nonhematologic toxicity |
Grade 1 or 2 |
No dosage adjustment required. |
Grade 3 or higher (if persistent despite optimal medical management): |
Withhold palbociclib until symptoms improve to ≤ grade 1 or ≤ grade 2 (if toxicity is not a safety risk); after resolution, resume palbociclib at the next lower dose. |
Refer to adult dosing.
Severe, life-threatening, and/or fatal interstitial lung disease (ILD) and/or pneumonitis may occur with palbociclib (and other cyclin-dependent kinase inhibitors) (Ref). Symptoms of ILD/pneumonitis may include hypoxia, cough, dyspnea, or interstitial infiltrates on radiologic exam. Pulmonary toxicity may be reversible with dose interruption, appropriate treatment, and/or discontinuation (Ref).
Onset: Delayed; cases describe onset of ILD and/or pneumonitis ranging from a few months to a couple years after initiation (Ref).
Neutropenia was commonly observed in clinical studies, including grades 3 and 4 neutropenia. The median duration of ≥ grade 3 neutropenia was 7 days. Febrile neutropenia and neutropenic sepsis have also been reported. Neutropenia is quickly reversible with cessation of palbociclib (Ref).
Mechanism: Dose-related; inhibits CDK6, a key regulator of hematopoietic precursor proliferation (Ref). Inhibiting CDK6 causes cytostatic effects on the cell cycle of neutrophils (Ref).
Onset: Intermediate; median onset for any grade neutropenia is 15 days. Median onset of grade ≥3 neutropenia is 28 days (Ref).
Risk factors:
• Baseline myelosuppression (Ref)
• Recent antibiotic use (Ref)
• Nonwhite race (Ref)
• Asian ethnicity (Ref)
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Percentages reported as part of combination therapy in adults.
>10%:
Dermatologic: Alopecia (18% to 33%), skin rash (17% to 18%), xeroderma (6% to 12%)
Gastrointestinal: Decreased appetite (15% to 16%), diarrhea (24% to 26%; grade 3: 1%), nausea (34% to 35%; grade 3: <1%), stomatitis (28% to 30%; grade 3: 1%), vomiting (16% to 19%; grade 3: 1%)
Hematologic & oncologic: Anemia (24% to 78%; grade 3: 3% to 6%; grade 4: <1%), leukopenia (39% to 53%; grade 3: 24% to 30%; grade 4: 1%), neutropenia (80% to 83%; grade 3: 55% to 56%; grade 4: 10% to 11%) (table 1) , thrombocytopenia (16% to 23%; grade 3: 1% to 2%; grade 4: ≤1%)
Drug (Palbociclib) |
Placebo |
Dose |
Indication |
Number of Patients (Palbociclib) |
Number of Patients (Placebo) |
Comments |
---|---|---|---|---|---|---|
All grades: 80% |
All grades: 6% |
125 mg/day plus letrozole (2.5 mg/day) |
Estrogen receptor (ER)-positive, HER2-negative advanced or metastatic breast cancer for initial endocrine based therapy |
444 |
222 |
Palbociclib plus letrozole; placebo plus letrozole |
Grade 3: 56% |
Grade 3: 1% |
125 mg/day plus letrozole (2.5 mg/day) |
Estrogen receptor (ER)-positive, HER2-negative advanced or metastatic breast cancer for initial endocrine based therapy |
444 |
222 |
Palbociclib plus letrozole; placebo plus letrozole |
Grade 4: 10% |
Grade 4: 1% |
125 mg/day plus letrozole (2.5 mg/day) |
Estrogen receptor (ER)-positive, HER2-negative advanced or metastatic breast cancer for initial endocrine based therapy |
444 |
222 |
Palbociclib plus letrozole; placebo plus letrozole |
All grades: 83% |
All grades: 4% |
125 mg/day plus fulvestrant (500 mg) |
HR-positive, HER2-negative advanced or metastatic breast cancer who have had disease progression on or after prior adjuvant or metastatic endocrine therapy |
345 |
172 |
Palbociclib plus fulvestrant; placebo plus fulvestrant |
Grade 3: 55% |
Grade 3: 1% |
125 mg/day plus fulvestrant (500 mg) |
HR-positive, HER2-negative advanced or metastatic breast cancer who have had disease progression on or after prior adjuvant or metastatic endocrine therapy |
345 |
172 |
Palbociclib plus fulvestrant; placebo plus fulvestrant |
Grade 4: 11% |
Grade 4: 0% |
125 mg/day plus fulvestrant (500 mg) |
HR-positive, HER2-negative advanced or metastatic breast cancer who have had disease progression on or after prior adjuvant or metastatic endocrine therapy |
345 |
172 |
Palbociclib plus fulvestrant; placebo plus fulvestrant |
Hepatic: Increased serum alanine aminotransferase (6% to 43%), increased serum aspartate aminotransferase (8% to 52%)
Infection: Infection (47% to 60%)
Nervous system: Asthenia (8% to 17%), fatigue (37% to 41%)
Miscellaneous: Fever (12% to 13%)
1% to 10%:
Gastrointestinal: Dysgeusia (7% to 10%)
Hematologic & oncologic: Febrile neutropenia (≤3%)
Ophthalmic: Blurred vision (4% to 6%), dry eye syndrome (4%), increased lacrimation (6%)
Respiratory: Epistaxis (7% to 9%)
Postmarketing:
Dermatologic: Bullous rash (Khan 2020), erythema multiforme (Vrana 2022), palmar-plantar erythrodysesthesia, Stevens-Johnson syndrome (Karagounis 2018), vitiligo (Gao 2023)
Hepatic: Hepatic injury (including hepatic encephalopathy, hepatitis, increased serum alkaline phosphatase, increased serum bilirubin, jaundice) (Atallah 2020, Hyppolite 2021)
Neuromuscular & skeletal: Discoid lupus erythematous (Calabrese 2020), subacute cutaneous lupus erythematous (Russell-Goldman 2020)
Respiratory: Interstitial lung disease (Di Cosimo 2023), pneumonitis (Di Cosimo 2023)
There are no contraindications listed in the manufacturer's US labeling.
Canadian labeling: Hypersensitivity to palbociclib or any component of the formulation
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Capsule, Oral:
Ibrance: 75 mg, 100 mg, 125 mg
Tablet, Oral:
Ibrance: 75 mg, 100 mg, 125 mg [contains fd&c blue #2 (indigo carm) aluminum lake]
No
Capsules (Ibrance Oral)
75 mg (per each): $913.28
100 mg (per each): $913.28
125 mg (per each): $913.28
Tablets (Ibrance Oral)
75 mg (per each): $913.28
100 mg (per each): $913.28
125 mg (per each): $913.28
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.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Capsule, Oral:
Ibrance: 75 mg, 100 mg, 125 mg
Tablet, Oral:
Ibrance: 75 mg, 100 mg, 125 mg [contains fd&c blue #2 (indigo carm) aluminum lake]
Palbociclib is available through specialty pharmacies. For more information, refer to https://www.pfizeroncologytogether.com
Oral: Administer at approximately the same time each day. Swallow whole, do not crush or chew; do not split tablets or open capsules prior to swallowing (do not ingest if tablets or capsules are broken, cracked, or not intact).
Tablets: Administer with or without food.
Capsules: Administer with food.
Breast cancer, advanced, initial endocrine-based therapy: Treatment of hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative advanced or metastatic breast cancer (in combination with an aromatase inhibitor) in adults as initial endocrine-based therapy.
Breast cancer, advanced, with disease progression following endocrine therapy: Treatment of HR-positive, HER2-negative advanced or metastatic breast cancer (in combination with fulvestrant) in adults with disease progression following endocrine therapy.
Palbociclib may be confused with abemaciclib, panobinostat, PAZOPanib, pexidartinib, ribociclib, trilaciclib.
Ibrance may be confused with ibrutinib.
This medication is in a class the Institute for Safe Medication Practices (ISMP) includes among its lists of drug classes which have a heightened risk of causing significant patient harm when used in error.
Substrate of CYP3A4 (major); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential; Inhibits CYP3A4 (weak)
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.
5-Aminosalicylic Acid Derivatives: May enhance the myelosuppressive effect of Myelosuppressive Agents. Risk C: Monitor therapy
Abrocitinib: May enhance the immunosuppressive effect of Immunosuppressants (Miscellaneous Oncologic Agents). Risk X: Avoid combination
ALPRAZolam: CYP3A4 Inhibitors (Weak) may increase the serum concentration of ALPRAZolam. Risk C: Monitor therapy
Antithymocyte Globulin (Equine): Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the adverse/toxic effect of Antithymocyte Globulin (Equine). Specifically, these effects may be unmasked if the dose of immunosuppressive therapy is reduced. Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the immunosuppressive effect of Antithymocyte Globulin (Equine). Specifically, infections may occur with greater severity and/or atypical presentations. Risk C: Monitor therapy
Baricitinib: Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the immunosuppressive effect of Baricitinib. Risk X: Avoid combination
BCG (Intravesical): Myelosuppressive Agents may diminish the therapeutic effect of BCG (Intravesical). Risk X: Avoid combination
BCG Products: Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the adverse/toxic effect of BCG Products. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of BCG Products. Risk X: Avoid combination
Brincidofovir: Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of Brincidofovir. Risk C: Monitor therapy
Brivudine: May enhance the adverse/toxic effect of Immunosuppressants (Miscellaneous Oncologic Agents). Risk X: Avoid combination
Chikungunya Vaccine (Live): Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the adverse/toxic effect of Chikungunya Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of Chikungunya Vaccine (Live). Risk X: Avoid combination
Chloramphenicol (Ophthalmic): May enhance the adverse/toxic effect of Myelosuppressive Agents. Risk C: Monitor therapy
Chloramphenicol (Systemic): Myelosuppressive Agents may enhance the myelosuppressive effect of Chloramphenicol (Systemic). Risk X: Avoid combination
Cladribine: May enhance the myelosuppressive effect of Myelosuppressive Agents. Risk X: Avoid combination
Cladribine: Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the immunosuppressive effect of Cladribine. Risk X: Avoid combination
Clofazimine: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy
CloZAPine: Myelosuppressive Agents may enhance the adverse/toxic effect of CloZAPine. Specifically, the risk for neutropenia may be increased. Risk C: Monitor therapy
Coccidioides immitis Skin Test: Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the diagnostic effect of Coccidioides immitis Skin Test. Management: Consider discontinuing these oncologic agents several weeks prior to coccidioides immitis skin antigen testing to increase the likelihood of accurate diagnostic results. Risk D: Consider therapy modification
COVID-19 Vaccine (Adenovirus Vector): Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of COVID-19 Vaccine (Adenovirus Vector). Management: Administer a 2nd dose using an mRNA COVID-19 vaccine (at least 4 weeks after the primary vaccine dose) and a bivalent booster dose (at least 2 months after the additional mRNA dose or any other boosters). Risk D: Consider therapy modification
COVID-19 Vaccine (Inactivated Virus): Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of COVID-19 Vaccine (Inactivated Virus). Risk C: Monitor therapy
COVID-19 Vaccine (mRNA): Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of COVID-19 Vaccine (mRNA). Management: Give a 3-dose primary series for all patients aged 6 months and older taking immunosuppressive medications or therapies. Booster doses are recommended for certain age groups. See CDC guidance for details. Risk D: Consider therapy modification
COVID-19 Vaccine (Subunit): Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of COVID-19 Vaccine (Subunit). Risk C: Monitor therapy
COVID-19 Vaccine (Virus-like Particles): Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of COVID-19 Vaccine (Virus-like Particles). Risk C: Monitor therapy
CycloSPORINE (Systemic): CYP3A4 Inhibitors (Weak) may increase the serum concentration of CycloSPORINE (Systemic). Risk C: Monitor therapy
CYP3A4 Inducers (Moderate): May decrease the serum concentration of Palbociclib. Risk C: Monitor therapy
CYP3A4 Inducers (Strong): May decrease the serum concentration of Palbociclib. Risk X: Avoid combination
CYP3A4 Inhibitors (Moderate): May increase the serum concentration of Palbociclib. Risk C: Monitor therapy
CYP3A4 Inhibitors (Strong): May increase the serum concentration of Palbociclib. Management: Avoid concurrent use of strong CYP3A4 inhibitors with palbociclib when possible. If the use of a strong CYP3A4 inhibitor cannot be avoided, decrease the palbociclib dose to 75 mg/day. Risk D: Consider therapy modification
Deferiprone: Myelosuppressive Agents may enhance the neutropenic effect of Deferiprone. Management: Avoid the concomitant use of deferiprone and myelosuppressive agents whenever possible. If this combination cannot be avoided, monitor the absolute neutrophil count more closely. Risk D: Consider therapy modification
Dengue Tetravalent Vaccine (Live): Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the adverse/toxic effect of Dengue Tetravalent Vaccine (Live). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of Dengue Tetravalent Vaccine (Live). Risk X: Avoid combination
Denosumab: May enhance the immunosuppressive effect of Immunosuppressants (Miscellaneous Oncologic Agents). Management: Consider the risk of serious infections versus the potential benefits of coadministration of denosumab and immunosuppressants. If combined, monitor patients for signs/symptoms of serious infections. Risk D: Consider therapy modification
Deucravacitinib: May enhance the immunosuppressive effect of Immunosuppressants (Miscellaneous Oncologic Agents). Risk X: Avoid combination
Dipyrone: May enhance the adverse/toxic effect of Myelosuppressive Agents. Specifically, the risk for agranulocytosis and pancytopenia may be increased Risk X: Avoid combination
Dofetilide: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Dofetilide. Risk C: Monitor therapy
Etrasimod: May enhance the immunosuppressive effect of Immunosuppressants (Miscellaneous Oncologic Agents). Risk X: Avoid combination
Fexinidazole: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination
Fexinidazole: Myelosuppressive Agents may enhance the myelosuppressive effect of Fexinidazole. Risk X: Avoid combination
Filgotinib: May enhance the immunosuppressive effect of Immunosuppressants (Miscellaneous Oncologic Agents). Risk X: Avoid combination
Finerenone: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Finerenone. Risk C: Monitor therapy
Flibanserin: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Flibanserin. Risk C: Monitor therapy
Fusidic Acid (Systemic): May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination
Grapefruit Juice: May increase the serum concentration of Palbociclib. Risk X: Avoid combination
Inebilizumab: Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the immunosuppressive effect of Inebilizumab. Risk C: Monitor therapy
Influenza Virus Vaccines: Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of Influenza Virus Vaccines. Management: Administer influenza vaccines at least 2 weeks prior to initiating immunosuppressants if possible. If vaccination occurs less than 2 weeks prior to or during therapy, revaccinate at least 3 months after therapy discontinued if immune competence restored. Risk D: Consider therapy modification
Inhibitors of the Proton Pump (PPIs and PCABs): May diminish the therapeutic effect of Palbociclib. Specifically, this has been reported with the use of palbociclib capsules. Inhibitors of the Proton Pump (PPIs and PCABs) may decrease the serum concentration of Palbociclib. Specifically, this may occur with the use of palbociclib capsules, and to the greatest extent when taken without food. Management: Carefully evaluate potential risks and benefits of coadministration of palbociclib capsules and proton pump inhibitors or potassium-competitive acid blockers due to the risk of reduced palbociclib efficacy. Palbociclib capsules should be taken with food. Risk D: Consider therapy modification
Ixabepilone: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Ixabepilone. Risk C: Monitor therapy
Leflunomide: Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the immunosuppressive effect of Leflunomide. Management: Increase the frequency of chronic monitoring of platelet, white blood cell count, and hemoglobin or hematocrit to monthly, instead of every 6 to 8 weeks, if leflunomide is coadministered with immunosuppressive agents. Risk D: Consider therapy modification
Lemborexant: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Lemborexant. Management: The maximum recommended dosage of lemborexant is 5 mg, no more than once per night, when coadministered with weak CYP3A4 inhibitors. Risk D: Consider therapy modification
Lomitapide: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Lomitapide. Management: Patients on lomitapide 5 mg/day may continue that dose. Patients taking lomitapide 10 mg/day or more should decrease the lomitapide dose by half. The lomitapide dose may then be titrated up to a max adult dose of 30 mg/day. Risk D: Consider therapy modification
Lonafarnib: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Lonafarnib. Management: Avoid concurrent use of lonafarnib with weak CYP3A4 inhibitors. If concurrent use is unavoidable, reduce the lonafarnib dose to or continue at a dose of 115 mg/square meter. Monitor for evidence of arrhythmia, syncope, palpitations, or similar effects. Risk D: Consider therapy modification
Midazolam: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Midazolam. Risk C: Monitor therapy
Mumps- Rubella- or Varicella-Containing Live Vaccines: May enhance the adverse/toxic effect of Immunosuppressants (Miscellaneous Oncologic Agents). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination
Nadofaragene Firadenovec: Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the adverse/toxic effect of Nadofaragene Firadenovec. Specifically, the risk of disseminated adenovirus infection may be increased. Risk X: Avoid combination
Natalizumab: Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the immunosuppressive effect of Natalizumab. Risk X: Avoid combination
NiMODipine: CYP3A4 Inhibitors (Weak) may increase the serum concentration of NiMODipine. Risk C: Monitor therapy
Ocrelizumab: Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the immunosuppressive effect of Ocrelizumab. Risk C: Monitor therapy
Ofatumumab: Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the immunosuppressive effect of Ofatumumab. Risk C: Monitor therapy
Olaparib: Myelosuppressive Agents may enhance the myelosuppressive effect of Olaparib. Risk C: Monitor therapy
Pidotimod: Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of Pidotimod. Risk C: Monitor therapy
Pimecrolimus: May enhance the immunosuppressive effect of Immunosuppressants (Miscellaneous Oncologic Agents). Risk X: Avoid combination
Pimozide: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Pimozide. Risk X: Avoid combination
Pneumococcal Vaccines: Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of Pneumococcal Vaccines. Risk C: Monitor therapy
Poliovirus Vaccine (Live/Trivalent/Oral): Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the adverse/toxic effect of Poliovirus Vaccine (Live/Trivalent/Oral). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of Poliovirus Vaccine (Live/Trivalent/Oral). Risk X: Avoid combination
Polymethylmethacrylate: Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the potential for allergic or hypersensitivity reactions to Polymethylmethacrylate. Management: Use caution when considering use of bovine collagen-containing implants such as the polymethylmethacrylate-based Bellafill brand implant in patients who are receiving immunosuppressants. Consider use of additional skin tests prior to administration. Risk D: Consider therapy modification
Promazine: May enhance the myelosuppressive effect of Myelosuppressive Agents. Risk C: Monitor therapy
Rabies Vaccine: Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of Rabies Vaccine. Management: Complete rabies vaccination at least 2 weeks before initiation of immunosuppressant therapy if possible. If combined, check for rabies antibody titers, and if vaccination is for post exposure prophylaxis, administer a 5th dose of the vaccine. Risk D: Consider therapy modification
Ritlecitinib: Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the immunosuppressive effect of Ritlecitinib. Risk X: Avoid combination
Ropeginterferon Alfa-2b: Myelosuppressive Agents may enhance the myelosuppressive effect of Ropeginterferon Alfa-2b. Management: Avoid coadministration of ropeginterferon alfa-2b and other myelosuppressive agents. If this combination cannot be avoided, monitor patients for excessive myelosuppressive effects. Risk D: Consider therapy modification
Ruxolitinib (Topical): Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the immunosuppressive effect of Ruxolitinib (Topical). Risk X: Avoid combination
Simvastatin: CYP3A4 Inhibitors (Weak) may increase serum concentrations of the active metabolite(s) of Simvastatin. CYP3A4 Inhibitors (Weak) may increase the serum concentration of Simvastatin. Risk C: Monitor therapy
Sipuleucel-T: Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of Sipuleucel-T. Management: Consider reducing the dose or discontinuing the use of immunosuppressants prior to initiating sipuleucel-T therapy. Risk D: Consider therapy modification
Sirolimus (Conventional): CYP3A4 Inhibitors (Weak) may increase the serum concentration of Sirolimus (Conventional). Risk C: Monitor therapy
Sirolimus (Protein Bound): CYP3A4 Inhibitors (Weak) may increase the serum concentration of Sirolimus (Protein Bound). Management: Reduce the dose of protein bound sirolimus to 56 mg/m2 when used concomitantly with a weak CYP3A4 inhibitor. Risk D: Consider therapy modification
Sphingosine 1-Phosphate (S1P) Receptor Modulator: May enhance the immunosuppressive effect of Immunosuppressants (Miscellaneous Oncologic Agents). Risk C: Monitor therapy
St John's Wort: May decrease the serum concentration of Palbociclib. Risk X: Avoid combination
Tacrolimus (Systemic): CYP3A4 Inhibitors (Weak) may increase the serum concentration of Tacrolimus (Systemic). Risk C: Monitor therapy
Tacrolimus (Topical): Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the immunosuppressive effect of Tacrolimus (Topical). Risk X: Avoid combination
Talimogene Laherparepvec: Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the adverse/toxic effect of Talimogene Laherparepvec. Specifically, the risk of infection from the live, attenuated herpes simplex virus contained in talimogene laherparepvec may be increased. Risk X: Avoid combination
Tertomotide: Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of Tertomotide. Risk X: Avoid combination
Tofacitinib: Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the immunosuppressive effect of Tofacitinib. Risk X: Avoid combination
Triazolam: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Triazolam. Risk C: Monitor therapy
Typhoid Vaccine: Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the adverse/toxic effect of Typhoid Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of Typhoid Vaccine. Risk X: Avoid combination
Ublituximab: Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the immunosuppressive effect of Ublituximab. Risk C: Monitor therapy
Ubrogepant: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Ubrogepant. Management: In patients taking weak CYP3A4 inhibitors, the initial and second dose (given at least 2 hours later if needed) of ubrogepant should be limited to 50 mg. Risk D: Consider therapy modification
Upadacitinib: Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the immunosuppressive effect of Upadacitinib. Risk X: Avoid combination
Vaccines (Inactivated/Non-Replicating): Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of Vaccines (Inactivated/Non-Replicating). Management: Give inactivated vaccines at least 2 weeks prior to initiation of immunosuppressants when possible. Patients vaccinated less than 14 days before initiating or during therapy should be revaccinated at least 3 after therapy is complete. Risk D: Consider therapy modification
Vaccines (Live): Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the adverse/toxic effect of Vaccines (Live). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of Vaccines (Live). Risk X: Avoid combination
Yellow Fever Vaccine: Immunosuppressants (Miscellaneous Oncologic Agents) may enhance the adverse/toxic effect of Yellow Fever Vaccine. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of Yellow Fever Vaccine. Risk X: Avoid combination
Coadministration with grapefruit may increase palbociclib plasma concentrations. Management: Avoid concomitant administration with grapefruit.
Food effect: Tablets: Compared to overnight fasted conditions, AUC and Cmax increased 22% and 26%, respectively, when administered with a high-fat, high-calorie meal (~800 to 1,000 calories; with 500 to 600 calories from fat); AUC and Cmax increased 9% and 10%, respectively, when administered with a moderate-fat, standard-calorie meal (~500 to 700 calories; with 175 to 245 calories from fat).
Evaluate pregnancy status prior to treatment in patients who could become pregnant. Patients who could become pregnant should use effective contraception during treatment and for at least 3 weeks after the last dose. Patients with partners who could become pregnant should use effective contraception during treatment and for 3 months after the last dose.
Adverse effects to male reproductive function and fertility were observed in animal toxicology studies; males of reproductive potential may want to consider sperm preservation prior to palbociclib therapy.
Based on the mechanism of action and data from animal reproduction studies, in utero exposure to palbociclib may cause fetal harm.
It is not known if palbociclib is present in breast milk.
Due to the potential for serious adverse reactions in the breastfed infant, breastfeeding is not recommended by the manufacturer during treatment and for 3 weeks after the last palbociclib dose.
Avoid grapefruit.
CBC with differential (prior to treatment initiation, every 2 weeks for first 2 cycles, then prior to each cycle, and as clinically indicated; if neutropenia is limited to grades 1 or 2 in the first 6 cycles, monitor every 3 months [prior to the beginning of a cycle] and as clinically indicated for subsequent cycles). Evaluate pregnancy status prior to treatment initiation (in patients who could become pregnant). Monitor closely for signs/symptoms of interstitial lung disease/pneumonitis (eg, hypoxia, cough, dyspnea, interstitial infiltrates on radiologic exam); exclude infectious, neoplastic, and other causes of pulmonary toxicity. Monitor for signs/symptoms of infection. 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.
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]). Consider baseline and periodic QTc monitoring in patients with QTc above the normal range or other conditions that may prolong the QTc interval (ESC [Lyon 2022]).
Palbociclib is a reversible small molecule cyclin-dependent kinase (CDK) inhibitor which is selective for CDK 4 and 6. CDKs have a role in regulating progression through the cell cycle at the G1/S phase by blocking retinoblastoma (Rb) hyperphosphorylation (Finn 2015). Palbociclib reduces proliferation of breast cancer cell lines by preventing progression from the G1 to the S cell cycle phase. The combination of palbociclib with an antiestrogen provides for increased inhibition of Rb phosphorylation, downstream signaling, and tumor growth compared with each agent alone.
Absorption: Tablets: Compared to overnight fasted conditions, AUC and Cmax increased 22% and 26%, respectively, when administered with a high-fat, high-calorie meal (~800 to 1,000 calories; with 500 to 600 calories from fat); AUC and Cmax increased 9% and 10%, respectively, when administered with a moderate-fat, standard-calorie meal (~500 to 700 calories; with 175 to 245 calories from fat).
Distribution: Vd (mean): 2,583 L.
Protein binding: ~85%.
Metabolism: Extensively hepatic; Major pathways: Oxidation and sulfonation, primarily by CYP3A and sulfotransferase (SULT) enzyme SULT2A1; Minor pathways: Acylation and glucuronidation.
Bioavailability: Mean absolute bioavailability: 46%.
Half-life elimination: 29 ± 5 hours.
Time to peak: Tablets: 4 to 12 hours; Capsules: 6 to 12 hours.
Excretion: Feces (~74%, primarily as metabolites); Urine (~18%; primarily as metabolites).
Altered kidney function: Total palbociclib exposure (AUCINF) is increased by 39%, 42%, and 31% with mild (CrCl 60 to <90 mL/minute), moderate (CrCl 30 to <60 mL/minute), and severe (CrCl <30 mL/minute) impairment, respectively, relative to subjects with normal renal function. Peak palbociclib exposure (Cmax) was increased by 17%, 12%, and 15% for mild, moderate, and severe impairment, respectively, relative to subjects with normal renal function.
Hepatic function impairment: Palbociclib unbound exposure (unbound AUCINF) is decreased by 17% in subjects with mild impairment (Child-Pugh class A), and increased by 34% and 77% in subjects with moderate and severe (Child-Pugh classes B and C) impairment, respectively, relative to subjects with normal hepatic function. The mean fraction of unbound (fu) palbociclib in human plasma increased incrementally in patients with worsening hepatic function. Peak palbociclib unbound exposure (unbound Cmax) increased by 7%, 38%, and 72% for mild, moderate, and severe impairment, respectively, relative to subjects with normal hepatic function.
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