encorafenib

General

Genetic Implications: Genetic Implications

Pronunciation:
en-koe-raf-e-nib

Trade Name(s)

  • Braftovi

Ther. Class.
antineoplastics

Pharm. Class.
kinase inhibitors

Indications

Genetic implication Treatment of metastatic or unresectable melanoma in patients with the BRAF V600E or V600K mutation (in combination with binimetinib).

Action

Kinase inhibitor that targets BRAF V600E, a mutated enzyme that promotes tumor cell proliferation.

Therapeutic Effect(s):

Improvement in progression-free survival and overall survival in patients with melanoma.

Pharmacokinetics

Absorption: Well absorbed (86%) following oral administration.

Distribution: Extensively distributed to tissues.

Metabolism and Excretion: Mostly metabolized by CYP3A4 and CYP2C19 enzyme systems. Primarily excreted as metabolites in feces (42%) and urine (45%).

Half-life: 3.5 hr

TIME/ACTION PROFILE (plasma concentrations)

ROUTEONSETPEAKDURATION
POunknown2 hr24 hr

Contraindication/Precautions

Contraindicated in:

  • Genetic implicationWild-type BRAF melanoma (may ↑ proliferation);
  • Long QT syndrome, bradyarrhythmias, severe or decompensated HF, hypokalemia, or hypomagnesemia (↑ risk of QT interval prolongation)
  • Concurrent use of QT-interval prolonging medications
  • Baseline QTc interval >500 msec
  • Concurrent use of strong or moderate CYP3A4 inhibitors or inducers (may significantly alter levels and effects);
  • OB: Pregnancy (may cause fetal harm);
  • Lactation: Breastfeeding should be avoided.

Use Cautiously in:

  • Moderate or severe hepatic impairment;
  • Severe renal impairment;
  • Rep: Women of reproductive potential;
  • Pedi: Safety and effectiveness not established.

Adverse Reactions/Side Effects

CNS: INTRACRANIAL HEMORRHAGE, dizziness, headache, fatigue, facial paralysis

CV: QT interval prolongation

Derm: BASAL CELL CARCINOMA, CUTANEOUS SQUAMOUS CELL CARCINOMA, alopecia, dry skin, hyperkeratosis, pruritus, rash, nodule formation

EENT: uveitis

Endo: hyperglycemia

F and E: hypermagnesemia, hyponatremia

GU: ↑ serum creatinine, ↓ fertility (males)

GI: GI HEMORRHAGE, PANCREATITIS, abdominal pain, constipation, ↑ liver enzymes, nausea, vomiting

Hemat: BLEEDING, anemia, leukopenia, lymphopenia, neutropenia

MS: arthralgia, myalgia

Neuro: peripheral neuropathy

Misc: HYPERSENSITIVITY REACTIONS, MALIGNANCY, fever

* CAPITALS indicate life-threatening.
Underline indicate most frequent.

Interactions

Drug-Drug

  • QT interval prolonging drugs may ↑ the risk of QT interval prolongation and torsades de pointes; avoid concurrent use.
  • Strong or moderate CYP3A4 inhibitors, including diltiazem and posaconazole may ↑ levels and risk of toxicity; avoid concurrent use, if possible (if must use concurrently, ↓ encorafenib dose).
  • Strong or moderate CYP3A4 inducers may ↓ levels and effectiveness; avoid concurrent use.
  • May ↓ effectiveness of hormonal contraceptives; use non-hormonal method of contraception.

Drug-Natural Products:

St. John's wort may ↓ levels and effectiveness; avoid concurrent use.

Drug-Food:

Grapefruit juice may ↑ levels and risk of toxicity; avoid concurrent use.

Route/Dosage

PO (Adults) 450 mg once daily, continued until disease progression or unacceptable toxicity. Concurrent use of moderate CYP3A4 inhibitor–↓ dose by 50%; Concurrent use of strong CYP3A4 inhibitor–↓ dose by 2/3 (66%).

Availability

Capsules: 75 mg

Assessment

  • Assess skin for lesions prior to starting, every 2 months during, and for up to 6 months following discontinuation of therapy. Manage suspicious skin lesions with excision and dermatopathologic evaluation. For Grade 2 lesion, if no improvement in 2 wks, hold encorafenib until Grade 0-1. Resume at same dose. For Grade 3, hold encorafenib until Grade 0-1. Resume at same dose if first occurrence or reduce dose if recurrent. For Grade 4, discontinue encorafenib permanently.
  • Monitor for Non-Cutaneous RAS Mutation-positive Malignancies. Permanently discontinue encorafenib if these malignancies occur.
  • Monitor for signs and symptoms of hemorrhage (bleeding GI, rectal, anal, hemorrhoidal) periodically during therapy. If Grade 2 or 1st occurrence of Grade 3: Withhold encorafenib up to 4 wks. If improves to Grade 0-1 or to pretreatment level, resume at reduced dose. If no improvement, permanently discontinue encorafenib. If 1st occurrence of Grade 4: Discontinue encorafenib permanently or withhold up to 4 wks. If improves to Grade 0-1 or to pretreatment level, resume at reduced dose. If no improvement, permanently discontinue encorafenib. If recurrent Grade 3: Consider permanently discontinuing encorafenib. If recurrent Grade 4: permanently discontinue encorafenib.
  • Monitor ECG in patients who already have or are at risk of QTc prolongation, including patients with known long QT syndromes, clinically significant bradyarrhythmias, severe or uncontrolled heart failure and those taking other medications leading to QT prolongation. If QTcF >500 ms and ≤60 ms increase from baseline, hold encorafenib until QTcF ≤500 ms. Resume at reduced dose. If occurs more than once, permanently discontinue encorafenib. If QTcF >500 ms and >60 ms increase from baseline, discontinue encorafenib permanently.
  • Assess for signs and symptoms of uveitis (visual changes, eye pain) during therapy. Perform ophthalmologic exam regularly and for new or worsening visual disturbances; follow new or persistent ophthalmologic findings.If Grade 1 or 2 does not respond to ocular therapy, or for Grade 3 uveitis, withhold encorafenib for up to 6 wks. If improved, resume at same or reduced dose. If not improved, permanently discontinue encorafenib. If Grade 4 uveitis occurs, permanently discontinue encorafenib.

Lab Test Considerations: Verify the pregnancy status of females of reproductive potential prior to starting therapy.

  • Monitor serum electrolytes periodically during therapy. Correct hypokalemia and hypomagnesemia prior to and during therapy. May also cause hyponatremia and hyperglycemia.
  • May cause anemia, leukopenia, lymphopenia, and neutropenia.
  • May cause ↑ serum creatinine, GGT, AST, ALT, and alkaline phosphatase.

Potential Diagnoses

Implementation

  • Genetic implicationConfirm the presence of a BRAF V600E or V600K mutation in tumor specimens prior to initiating therapy. Information on FDA-approved tests for the detection of BRAF V600E and V600K mutations in melanoma is available at http://www.fda.gov/CompanionDiagnostics.
  • PO Administer once daily without regard to food in combination with binimetinib. If binimetinib is held, reduce encorafenib to maximum dose of 300 mg once daily until binimetinib is resumed. Store in original, tightly capped bottle at room temperature; do not remove desiccant, protect from moisture.

Patient/Family Teaching

  • Instruct patient to take encorafenib as directed. Take missed dose within 12 hr of missed dose; do not take dose within 12 hr of next dose. Advise patient to read Medication Guide before starting therapy and with each Rx refill in case of changes.
  • Inform patient that grapefruit products may increase amount of encorafenib in the body. Avoid grapefruit and grapefruit juice during therapy.
  • Inform patient that encorafenib increases risk of developing new cutaneous malignancies. Notify health care professional immediately if new lesions (wart, skin sore or reddish bump that bleeds or does not heal) or changes in size or color of existing moles or lesions occur.
  • Advise patient to notify health care professional immediately if signs and symptoms of bleeding (headaches, dizziness, weakness, coughing up blood or blood clots, vomiting blood or vomit looks like "coffee grounds", red or black stools that look like tar); liver dysfunction (yellow skin or whites of eyes; feeling tired; urine turns dark or brown; nausea or vomiting; loss of appetite; pain on right side of stomach); changes heart rhythm (feeling faint, lightheaded, dizzy, heart beating irregularly or fast); or eye problems (blurred vision, loss of vision, other vision changes, seeing colored dots, seeing halos or blurred outline around objects, eye pain, swelling, redness) occur.
  • Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications, especially St. John's wort.
  • Rep: Advise female patient to use a highly effective form of contraception and avoid breastfeeding during and for at least 2 wks after last dose of encorafenib. Use a non-hormonal form of contraception; encorafenib may decrease effectiveness of hormonal contraceptives. Advise patient to notify health care professional if pregnancy is suspected and to avoid breast feeding. Advise patients to seek counseling on fertility and family planning prior to beginning therapy; may impair fertility in males.
  • Inform patient that regular assessments of skin and assessments for signs and symptoms of other malignancies must be done every 2 mo during and for up to 6 mo after therapy. Advise patient to notify health care professional immediately if any changes in skin occur.

Evaluation/Desired Outcomes

Decreased spread of melanoma.

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