ceritinib

ceritinib

(se-ri-ti-nib),

Zykadia

(trade name)

Classification

Therapeutic: antineoplastics
Pharmacologic: kinase inhibitors
Pregnancy Category: D

Indications

Treatment of anaplastic lymphoma kinase (ALK)-positive metastatic non-small cell lung cancer (NSCLC) that has progressed despite treatment with or intolerance to crizotinib.

Action

Acts as a tyrosine kinase inhibitor, inhibiting anaplastic lymphoma kinase as well as other kinases, resulting in decreased growth of certain malignant cell lines.

Therapeutic effects

Slowed progression of metastatic NSCLC.

Pharmacokinetics

Absorption: Absorption follows oral administration; food significantly ↑ absorption and may ↑ risk of adverse reactions.
Distribution: Slight preference to distribute from plasma into red blood cells.
Metabolism and Excretion: Metabolized in the liver (mostly by CYP3A) and is a substrate of P-glucoprotein (P-gp); 68% eliminated unchanged in feces, 1.3% in urine.
Half-life: 41 hr.

Time/action profile (clinical response)

ROUTEONSETPEAKDURATION
POunknown4–6 hr (blood level)7.1–7.4 mos

Contraindications/Precautions

Contraindicated in: Obstetric: Pregnancy (may cause fetal harm); Lactation: Discontinue ceritinib or discontinue breastfeeding.
Use Cautiously in: Females with reproductive potential (effective contraception required); Moderate to severe hepatic impairment/severe renal impairment (CCr <30 mL/min; Pediatric: Safe and effective use in children has not been established.

Adverse Reactions/Side Effects

Central nervous system

  • fatigue (most frequent)

Respiratory

  • interstitial lung disease/pneumonitis (life-threatening)

Cardiovascular

  • Qtc prolongation (life-threatening)
  • bradycardia (life-threatening)

Gastrointestinal

  • GI toxicity (life-threatening)
  • hepatotoxicity (life-threatening)
  • abdominal pain (most frequent)
  • ↓ appetite (most frequent)
  • constipation (most frequent)
  • diarrhea (most frequent)
  • esophagitis/reflux/dysphagia (most frequent)
  • ↑ liver enzymes (most frequent)
  • nausea (most frequent)
  • vomiting (most frequent)
  • hepatotoxicity

Dermatologic

  • rash (most frequent)

Endocrinologic

  • hyperglycemia (life-threatening)

Fluid and Electrolyte

  • hypophosphatemia (most frequent)

Genitourinary

  • ↑ creatinine (most frequent)

Hematologic

  • anemia (most frequent)

Metabolic

  • ↑ lipase (most frequent)

Interactions

Drug-Drug interaction

Concurrent use of strong inhibitors of CYP3A including ketoconazole, nefazodone, and telithromycin ↑ blood levels and the risk of toxicities (if unavoidable, dose reduction is necessary). Strong inducers of CYP3A including carbamazepine, phenytoin, and rifampin may ↓ blood levels and effectiveness; concurrent use should be avoided.Ceritinib inhibits CYP3A and CYP2C9 enzymes and may ↑ blood levels and the risk of toxicity from alfentanil, cyclosporine, dihyroergotamine, ergotamine, fentanyl, phenytoin, pimozide, quinidine, sirolimus, tacrolimus, and warfarin ; dose of these medications may need to be decreased/adjusted.Grapefruit/grapefruit juice ↑ blood levels and the risk of toxicity; concurrent ingestion should be avoided.St. John's wort ↓ blood levels and effectiveness; concurrent use should be avoided.

Route/Dosage

Oral (Adults) 750 mg once daily; dose reduction/modifcation/discontinuation required for GI toxicity, ↑ liver enzymes, hyperglycemia, QT prolongation or bradycardia; Concurrent use of strong CYP3A inhibitors—↓ dose by 1/3 rounded to the nearest 150 mg strength.

Availability

Capsules: 150 mg

Nursing implications

Nursing assessment

  • Assess for signs and symptoms of interstitial lung disease or pneumonitis (trouble breathing, shortness of breath, fever, cough with or without mucus, chest pain). If these symptoms occur, discontinue therapy permanently.
  • Monitor ECG periodically during therapy. If QTc interval is >500 msec on at least 2 separate ECGs, withhold ceritinib until QTc interval <481 msec or recovery to baseline if QTc ≥481 msec, resume ceritinib with a 150 mg dose reduction. If QTc interval prolongation in combination Torsades de pointes or polymorphic ventricular tachycardia or signs and symptoms of serious arrhythmia, discontinue ceritinib permanently.
    • If symptomatic bradycardia that is not life-threatening occurs, withhold ceritinib until recovery to asymptomatic bradycardia or a heart rate ≥ 60 bpm, evaluate concurrent medications causing bradycardia, and adjust dose of ceritinib. If clinically significant bradycardia requiring intervention or life-threatening bradycardia in patients taking concurrent medication known to cause bradycardia or a medication known to cause hypotension occurs withhold ceritinib until asymptomatic bradycardia recovers to ≥60 bpm. If concurrent medication can be adjusted or discontinued, resume ceritinib with a 150 mg dose reduction and frequent monitoring. If life-threatening bradycardia occurs in patients not taking medications known to cause bradycardia or hypotension, discontinue ceritinib permanently.
  • Assess for nausea, vomiting, diarrhea. If severe or intolerable nausea, vomiting, or diarrhea continue despite optimal antiemetic or antidiarrheal therapy, withhold ceritinib until improved; then resume with a 150 mg dose reduction.
  • Lab Test Considerations: Monitor liver function tests at least monthly. If ALT or AST >5 times the upper limit of normal and total bilirubin is ≤2 times the upper limit of normal, withhold ceritinib until recovery to baseline or less than or equal to 3 times the upper limit of normal, then resume ceritinib with a 150 mg dose reduction. If ALT or AST >3 times the upper limit of normal and total bilirubin is >2 times the upper limit of normal in the absence of cholestasis or hemolysis, permanently discontinue ceritinib.
    • Monitor blood glucose periodically during therapy. If persistent hyperglycemia >250 mg/dL despite anti-hyperglycemic therapy, withhold ceritinib until hyperglycemia is adequately controlled, then resume with a 150 mg dose reduction. If adequate hyperglycemic control cannot be achieved, discontinue therapy.
    • May cause decreased hemoglobin and serum phosphate; increased creatinine, glucose, lipase, and total bilirubin.

Potential Nursing Diagnoses

Ineffective airway clearance (Indications)
Deficient knowledge, related to medication regimen (Patient/Family Teaching)

Implementation

  • Oral: Administer on an empty stomach, at least 2 hr before or after meals.

Patient/Family Teaching

  • Instruct patient to take ceritinib as directed. Take missed doses as soon as remembered unless within 12 hrs of next dose. Instruct patient to read Patient Information prior to starting therapy and with each Rx refill in case of changes.
  • Inform patient to avoid consuming grapefruit and grapefruit juice during therapy.
  • Advise patient to notify health care professional if nausea, vomiting, and diarrhea is severe or persistent; if signs and symptoms of hepatotoxicity (feeling tired, itchy skin, skin or whites of eyes turn yellow, nausea and vomiting, decreased appetite, pain on right side of stomach, dark or brown, tea-colored urine, bleed or bruise easily); pneumonitis; QTc interval prolongation or bradycardia (new chest pain, changes in heartbeat, palpitations, dizziness, fainting, or changes in or use of a new heart or blood pressure medication); hyperglycemia (increased thirst, increased hunger, headaches, trouble thinking or concentration, urinating often, blurred vision, tiredness, breath smells like fruit)
  • Advise female patient to use effective contraceptives during and for at least 2 wks following completion of therapy and to notify health care provider if pregnancy is planned or suspected or if breastfeeding.

Evaluation/Desired Outcomes

  • Slowed progression of metastatic NSCLC.
References in periodicals archive ?
Patients may benefit from treatment with crizotinib, ceritinib, or alectinib, depending on previous therapies.
Results from ASCEND-4 trial show patients receiving first-line ceritinib experienced a 45 percent risk reduction of disease progression compared to chemotherapy.
Recently, next-generation ALK-TK inhibitors, such as ceritinib (Zykadia, Novartis Pharmaceuticals Corp, Cambridge, Massachusetts), were approved by FDA (3) to combat crizotinib-resistant tumors.
In a draft recommendation, which is to be put out for consultation, the National Institute for Health and Care Excellence (Nice) has recommended ceritinib, called Zykadia, for treating lung cancer patients.
20) In April 2014, the FDA granted accelerated approval to Ceritinib (ZYKADIA[R]) for treating patients with ALK-positive, metastatic non-small cell lung cancer (NSCLC) who have had disease progression while on or are intolerant to Crizotinib.
For multiple compounds, Dugan focused on lung cancer development, where she was instrumental in several key advancements including a breakthrough therapy status for ceritinib from the Food and Drug Administration in 2013, helping the drug reach approval with four months of filing.
27) Such second-generation ALK inhibitors that have already undergone clinical trials include ceritinib, alectinib, AP26113, PF-06463922, TSR-011, RXDX-101, X396, and CEP-37440, with EML4-ALK(L1196M) being sensitive to all of these compounds.
The nine new antineoplastic agents and their indications are belinostat (Beleodaq) for peripheral T-cell lymphoma; blinatumomab (Blincyto) for acute lymphoblastic leukemia; ceritinib (Zykadia) for non-small cell lung cancer; idelalisib (Zydelig) for some types of leukemia and lymphoma; nivolumab (Opdivo) for metastatic melanoma; olaparib (Lynparza) for ovarian cancer; pembrolizumab (Keytruda) for unresectable or metastatic melanoma; ramucirumab (Cyramza) for gastric or gastroesophageal adenocarcinoma and metastatic non-small cell lung cancer; and siltuximab (Sylvant) for multicentric Castleman disease.
Phase 1 clinical trials of the 20-fold more potent ALK inhibitor ceritinib demonstrated an overall response rate of 58% among patients with non-small cell lung carcinoma who had previously received crizotinib.
Limited Tenders are invited for Supply of Ceritinib 150mg Cap, Declatasavir 60mg Tab, and Sofosbuvir 400mg Tab.
Circulogene's ALK and ROS1 tests cover more than 90 % of clinically relevant gene fusions associated with treatment decision-making for targeted therapy (crizotinib, ceritinib and brigatinib) for NSCLC patients.
Seoul National University Hospital lead investigator, Dong-Wan Kim, stated that ceritinib indicated a high level of activity in patients with ALK+ NSCLC, regardless of whether or not they were previously treated with an ALK inhibitor.