Pharmacologic class: Receptor tyrosine kinase inhibitor
Therapeutic class: Antineoplastic
Pregnancy risk category D
Inhibits receptor tyrosine kinases, including ALK, hepatocyte growth factor receptor, and recepteur d'origine nantais. Translocations can affect the ALK gene, resulting in expression of oncogenic fusion proteins. Formation of ALK fusion proteins results in activation and dysregulation of the gene's expression and signaling, which can contribute to increased cell proliferation and survival in tumors expressing these proteins.
Capsules: 200 mg, 250 mg
⊘Indications and dosages
➣ Anaplastic lymphoma kinase-positive locally advanced or metastatic non-small-cell lung cancer (NSCLC)
Adults: 250 mg P.O. b.i.d. Dosing interruption or reduction to 200 mg P.O. b.i.d. may be required based on individual safety and tolerability; then 250 mg P.O. daily if further reduction is necessary.
• Hematologic toxicities
• Grade 3 QT interval prolongation
Use cautiously in:
• hepatic impairment, severe renal impairment (creatinine clearance less than 30 ml/minute), end-stage renal disease
• congenital long QT syndrome (avoid use), congestive heart failure, bradyarrhythmias, electrolyte abnormalities, pulmonary disease
• concurrent use of drugs known to prolong QT interval (such as alfuzosin, amiodarone, ibutilide, or quetiapine)
• concurrent use of moderate CYP3A inhibitors
• concurrent use of strong CYP3A inducers or inhibitors (avoid use)
• concurrent use of CYP3A substrates with narrow therapeutic indices (avoid use)
• grapefruit, grapefruit juice, St. John's wort (avoid use)
• pregnant or breastfeeding patients
• children (safety and efficacy not established).
• Be aware that detection of ALK-positive NSCLC using an FDA-approved test is necessary before starting drug.
• Administer with or without food. Don't crush, dissolve, or open capsules.
CNS: headache, fatigue, dizziness, neuropathy, insomnia
CV: bradycardia, prolonged
EENT: vision disorder
GI: nausea, vomiting, diarrhea, constipation, abdominal pain, esophageal disorder, stomatitis
GU: complex renal cysts
Hematologic: neutropenia, thrombocytopenia, lymphopenia
Musculoskeletal: arthralgia, back pain
Respiratory: upper respiratory tract infection, dyspnea, cough,
pneumonia, pulmonary embolism
Other: edema, chest pain or discomfort, fever, decreased appetite, dysgeusia
Drug-drug.CYP3A substrates with narrow therapeutic indices (such as alfentanil, cyclosporine, dihydroergotamine, ergotamine, fentanyl, pimozide, quinidine, sirolimus, tacrolimus): inhibited metabolism of these drugs, leading to potential for serious adverse reactions
Moderate CYP3A inhibitors (such as diltiazem): possible increased crizotinib plasma concentration
Strong CYP3A inducers (including but not limited to carbamazepine, phenobarbital, phenytoin, rifabutin, rifampin): decreased crizotinib plasma concentration
Strong CYP3A inhibitors (such as atazanavir, clarithromycin, indinavir, itraconazole, ketoconazole, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, troleandomycin, voriconazole): increased crizotinib plasma concentration
Drug-diagnostic tests.ALT, AST: increased levels
Lymphocytes, neutrophils, platelets: decreased levels
Drug-food.Grapefruit, grapefruit juice: increased crizotinib plasma concentration
High-fat meal: decreased crizotinib area under the curve and Cmax.
Drug-herbs.St. John's wort: decreased crizotinib plasma concentration
☞ Monitor liver function tests (including ALT and total bilirubin) monthly and as clinically indicated, with more frequent testing in patients who develop transaminase elevations. Temporarily suspend drug, reduce dosage, or permanently discontinue drug as indicated.
• Monitor CBC with differential and renal function tests closely.
☞ Monitor patient for pulmonary signs and symptoms indicative of pneumonitis; permanently discontinue drug in patients diagnosed with treatment-related pneumonitis.
☞ Consider periodic ECGs and electrolyte monitoring in patients who have QT-interval prolongation or predisposition for QT-interval prolongation, or who are taking drugs known to prolong QT interval. Withhold drug in patients with Grade 3 QT-interval prolongation until recovery to Grade 1 or less; then resume at prescribed reduced dosage. Permanently discontinue drug if Grade 3 QT-interval prolongation recurs and in patients with Grade 4 QT-interval prolongation.
• Tell patient to take drug with or without food, to avoid grapefruit and grapefruit juice, and not to crush, dissolve, or open capsules.
☞ Instruct patient to immediately report signs and symptoms of liver disorder (such as weakness, fatigue, nausea, vomiting, right upper abdominal pain, jaundice, yellowing of skin or eyes, or dark urine).
☞ Instruct patient to immediately report swelling of hands or feet, abnormal heartbeats, dizziness, or faintness.
• Inform patient that visual changes, such as perceived flashes of light, blurry vision, light sensitivity, and floaters, may occur and to report flashes or floaters to prescriber.
• Caution patient to use caution while driving and performing other hazardous activities, because of the risk of developing a vision disorder, dizziness, or fatigue while taking drug.
• Instruct patient to tell prescriber about all drugs he's taking, because some drugs have potential for serious drug interactions and shouldn't be taken with crizotinib.
• Advise patient not to use St. John's wort or other herbal supplements without consulting prescriber.
• Advise female patient of childbearing age to avoid becoming pregnant during treatment.
• Advise breastfeeding patient that she should decide whether to discontinue breastfeeding or discontinue drug, taking into account importance of drug for her treatment.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, foods, and herbs mentioned above.
Pharmacologic: kinase inhibitors
Time/action profile (blood levels)
Adverse Reactions/Side Effects
Central nervous system
Ear, Eye, Nose, Throat
- visual disturbances (most frequent)
- pneumonitis (life-threatening)
- QTc interval prolongation (life-threatening)
- bradycardia (most frequent)
- edema (most frequent)
- chest pain
- hepatotoxicity (life-threatening)
- constipation (most frequent)
- diarrhea (most frequent)
- nausea (most frequent)
- vomiting (most frequent)
- abdominal pain
- ↓ appetite
Drug-Drug interactionConcurrent use of strong CYP3A inhibitors including atazanavir, clarithromycin, indinavir, itraconazole, ketoconazole, nefazodone, nelfinavir, ritonavir, saquinavir, telithromycin, troleandomycin, and voriconazole may ↑ levels and should be avoided.Concurrent use of strong CYP3A inducers including carbamazepine, phenobarbital, phenytoin, rifabutin, and rifampin may ↓ levels and effectiveness and should be avoided.Antacids, H2 blockers, and proton pump inhibitors may ↓ levelsBeta-blockes, verapamil, diltiazem, digoxin, and clonidine may ↑ risk of bradycardia; avoid concurrent use, if possibleConcurrent use of St. John's wort may ↓ levels and effectiveness and should be avoided.Grapefruit or grapefruit juice may ↑ levels and should be avoided.
Renal ImpairmentOral (Adults) CCr <30 mL/min (not on dialysis)—250 mg once daily
- Assess respiratory function (lung sounds, dyspnea, oxygen saturation) periodically during therapy.
- Monitor for signs and symptoms of pneumonitis (difficulty breathing, shortness or breath, cough with or without mucus, fever) periodically during therapy. If any Grade of pneumonitis occurs, permanently discontinue.
- Assess for signs and symptoms of neuropathy (burning, dysesthesia, hyperesthesia, hypoesthesia, neuralgia, paresthesia, peripheral neuropathy sensory and motor) periodically during therapy. Usually Grade 1.
- Monitor ECG periodically during therapy in patients with HF, bradyarrhythmias, electrolyte imbalances, or taking medications than may prolong QT interval. If Grade 3 QTc prolongation occurs, withhold until recovery to Grade ≤1, then resume at 200 mg twice daily. If Grade 4 QTc prolongation occurs, permanently discontinue. If symptomatic bradycardia occurs, withhold dose until heart rate return to ≥60 bpm. Evaluate concomitant medications, if contributing medication is identified and dose reduced or discontinued, return to previous dose of crizotinib once heart rate is ≥60 bpm and/or bradycardia is asymptomatic. If no contributing medication is identified or dose modifications are not made, resume crizotinib at a reduced dose once heart rate ≥60 bpm and/or bradycardia is asymptomatic. If bradycardia is life-threatening and no contributing medication identified, discontinue crizotinib. If contributing medication is identified and dose is reduced or discontinued, reduce crizotinib dose to 250 mg once daily with frequent monitoring once heart rate ≥60 bpm and/or bradycardia is asymptomatic.
- Lab Test Considerations: Monitor CBC with differential monthly and as clinically indicated; more frequently if Grade 3 or 4 toxicities occur. If Grade 3 hematologic toxicity occurs, withhold dose until recovery to Grade ≤2, then resume same dose schedule. If Grade 4 hematologic toxicity occurs, withhold until recovery to Grade ≤2, then resume at 200 mg twice daily. May also cause Grade 3 or 4 neutropenia, thrombocytopenia, and lymphopenia.
- Monitor liver function tests monthly and as clinically indicated; more frequently if Grade 2, 3, 4 abnormalities occur. If Grade 3 or 4 AST or ALT ↑ with Grade ≤1 total bilirubin occurs, withhold until recovery to Grade ≤1 or baseline, then resume at 200 mg twice daily. If Grade 2, 3, or 4 AST or ALT ↑ with concurrent Grade 2, 3, or 4 total bilirubin ↑ (with no cholestasis or hemolysis), permanently discontinue.
Potential Nursing DiagnosesImpaired gas exchange (Indications)
- Oral: Administer twice daily without regard to food. Swallow capsules whole, do not crush, dissolve, or open.
- Instruct patient to take crizotinib as directed; do not change dose or stop taking without consulting health care professional. Take missed doses as soon as remembered unless <6 hr until next dose. If <6 hr to next dose, skip dose and return to regular schedule; do not double doses. Advise patient to read the Patient Information leaflet before starting and with each Rx refill in case of changes.
- Advise patient to avoid eating grapefruit or drinking grapefruit juice during therapy.
- Caution patient that dizziness and visual disorders may occur. Advise patient to avoid driving or other activities requiring alertness until response to medication is known. Visual disturbances generally start within 2 wk of therapy. Instruct patient to notify health care professional if flashes of light or new or worse vitreous floaters occur; ophthalmological evaluation should be considered.
- Advise patient to notify health care professional immediately if symptoms of weakness, fatigue, anorexia, nausea, vomiting, abdominal pain (especially RUQ abdominal pain), jaundice, dark urine, generalized pruritus, and bleeding occur, especially in combination with fever and rash
- Inform patient that nausea, diarrhea, vomiting, and constipation are common side effects. Standard anti-emetic, antidiarrheal, and laxative medications are usually effective.
- Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications.
- Instruct women of childbearing age and their partners to use effective contraception during and for at least 90 days following discontinuation of therapy and to avoid breast feeding during therapy.
- Decrease spread of lung cancer.