Exkivity

 Recommended Evaluation and Testing Before Initiating EXKIVITY

Before initiating EXKIVITY, evaluate QTc and electrolytes and correct abnormalities in sodium, potassium, calcium, and magnesium [see Warnings and Precautions (5.1)].

 Patient Selection

Select patients with locally advanced or metastatic NSCLC for treatment with EXKIVITY based on the presence of EGFR exon 20 insertion mutations [see Clinical Studies (14)]. Information on FDA-approved tests is available at: http://www.fda.gov/CompanionDiagnostics.

 Recommended Dosage

The recommended dosage of EXKIVITY is 160 mg orally once daily until disease progression or unacceptable toxicity.

Take EXKIVITY with or without food [see Clinical Pharmacology 12.3], at the same time each day. Swallow EXKIVITY capsules whole. Do not open, chew or dissolve the contents of the capsules.

If a dose is missed by more than 6 hours, skip the dose and take the next dose the following day at its regularly scheduled time.

If a dose is vomited, do not take an additional dose. Take the next dose as prescribed the following day.

 Dosage Modifications for Adverse Reactions

EXKIVITY dose reduction levels for adverse reactions are summarized in Table 1.

Recommended dosage modifications of EXKIVITY for adverse reactions are provided in Table 2.

 Dosage Modifications for Moderate CYP3A Inhibitors

Avoid concomitant use of moderate CYP3A inhibitors with EXKIVITY. If concomitant use of a moderate CYP3A inhibitor cannot be avoided, reduce the EXKIVITY dose by approximately 50% (i.e., from 160 to 80 mg, 120 to 40 mg, or 80 to 40 mg) and monitor the QTc interval more frequently. After the moderate CYP3A inhibitor has been discontinued for 3 to 5 elimination half-lives, resume EXKIVITY at the dose taken prior to initiating the moderate CYP3A inhibitor [see Drug Interactions (7.1)].

2.6 Dosage Modifications for Patients with Severe Renal Impairment

Reduce the EXKIVITY dose by approximately 50% (i.e., from 160 to 80 mg, 120 to 40 mg, or 80 to 40 mg) and monitor the QTc interval more frequently for patients with severe renal impairment [see Use in Specific Populations (8.6)].

Pregnancy

Lactation

Females and Males of Reproductive Potential

EXKIVITY can cause fetal harm when administered to pregnant women [see Use in Specific Populations (8.1)].

Pediatric Use

The safety and effectiveness of EXKIVITY in pediatric patients have not been established.

Geriatric Use

Of the 114 patients [see Clinical Studies (14)] who received EXKIVITY in clinical studies, 37% were 65 years and over, and 7% were 75 years and over. No overall difference in effectiveness was observed between patients aged 65 and older and younger patients. Exploratory analysis suggests a higher incidence of Grade 3 and 4 adverse reactions (69% vs 47%) and serious adverse reactions (64% vs 35%) in patients 65 years and older as compared to those younger than 65 years.

Renal Impairment

Mobocertinib plasma concentrations are higher in patients with severe renal impairment [see Clinical Pharmacology (12.3)], which may increase the risk of adverse reactions. Reduce the recommended dosage of EXKIVITY for patients with severe renal impairment (estimated glomerular filtration rate [eGFR] <30 mL/min/1.73 m2 by Modification of Diet in Renal Disease [MDRD] equation) [see Dosage and Administration (2.6) and Clinical Pharmacology (12.3)]. No dosage adjustment of EXKIVITY is recommended for patients with mild-to-moderate renal impairment (eGFR 30 to 89 mL/min/1.73 m2 by MDRD equation).

Hepatic Impairment

No dosage adjustment of EXKIVITY is recommended for patients with mild (total bilirubin ≤ upper limit of normal [ULN] and aspartate aminotransferase [AST] > ULN or total bilirubin >1 to 1.5 times ULN and any AST)-to-severe (total bilirubin >3 times ULN and any AST) hepatic impairment [see Clinical Pharmacology (12.3)].

 QTc Prolongation and Torsades de Pointes

EXKIVITY can cause life-threatening heart rate-corrected QT (QTc) prolongation, including Torsades de Pointes, which can be fatal. In the 250 patient subset of the pooled EXKIVITY safety population who had scheduled and unscheduled electrocardiograms (ECGs) [see Adverse Reactions (6.1), Clinical Pharmacology (12.2)], 1.2% of patients had a QTc interval >500 msec and 11% of patients had a change-from-baseline QTc interval >60 msec. Grade 4 Torsades de Pointes occurred in 1 patient (0.4%). Clinical trials of EXKIVITY did not enroll patients with baseline QTc greater than 470 msec.

Assess QTc and electrolytes at baseline and correct abnormalities in sodium, potassium, calcium, and magnesium prior to initiating EXKIVITY. Monitor QTc and electrolytes periodically during treatment. Increase monitoring frequency in patients with risk factors for QTc prolongation, such as patients with congenital long QT syndrome, heart disease, severe renal impairment, or electrolyte abnormalities. Avoid use of concomitant drugs which are known to prolong the QTc interval. Avoid concomitant use of strong or moderate CYP3A inhibitors with EXKIVITY [see Drug Interactions (7.1)], which may further prolong the QTc [see Drug Interactions (7.3)].

Withhold, reduce the dose, or permanently discontinue EXKIVITY based on the severity of the QTc prolongation [see Dosage and Administration (2.4)].

 Interstitial Lung Disease (ILD)/Pneumonitis

EXKIVITY can cause ILD/pneumonitis, which can be fatal. In the pooled EXKIVITY safety population [see Adverse Reactions (6.1)], ILD/pneumonitis occurred in 4.3% of patients including 0.8% Grade 3 events and 1.2% fatal events.

Monitor patients for new or worsening pulmonary symptoms indicative of ILD/pneumonitis. Immediately withhold EXKIVITY in patients with suspected ILD/pneumonitis and permanently discontinue EXKIVITY if ILD/pneumonitis is confirmed [see Dosage and Administration (2.4)].

 Cardiac Toxicity

EXKIVITY can cause cardiac toxicity (including decreased ejection fraction, cardiomyopathy, and congestive heart failure) resulting in heart failure which can be fatal. In the pooled EXKIVITY safety population [see Adverse Reactions (6.1)], heart failure occurred in 2.7% of patients including 1.2% Grade 3 reactions, 0.4% Grade 4 reactions, and one (0.4%) fatal case of heart failure.

EXKIVITY can cause QTc prolongation resulting in Torsades de Pointes [see Warnings and Precautions (5.1)]. Atrial fibrillation (1.6%), ventricular tachycardia (0.4%), first degree atrioventricular block (0.4%), second degree atrioventricular block (0.4%), left bundle branch block (0.4%), supraventricular extrasystoles (0.4%) and ventricular extrasystoles (0.4%) also occurred in patients receiving EXKIVITY.

Monitor cardiac function, including assessment of left ventricular ejection fraction at baseline and during treatment. Withhold, reduce the dose, or permanently discontinue EXKIVITY based on the severity [see Dosage and Administration (2.4)].

 Diarrhea

EXKIVITY can cause diarrhea, which can be severe. In the pooled EXKIVITY safety population [see Adverse Reactions (6.1)], diarrhea occurred in 93% of patients, including 20% Grade 3 and 0.4% Grade 4. The median time to first onset of diarrhea was 5 days but diarrhea has occurred within 24 hours after administration of EXKIVITY. In the 48% of patients whose diarrhea resolved, the median time to resolution was 3 days. Diarrhea may lead to dehydration or electrolyte imbalance, with or without renal impairment. Treat diarrhea promptly.

Advise patients to start an antidiarrheal agent (e.g., loperamide) at first sign of diarrhea or increased bowel movement frequency and to increase fluid and electrolyte intake.

Monitor electrolytes and withhold, reduce the dose or permanently discontinue EXKIVITY based on the severity [see Dosage and Administration (2.4)].

 Embryo-Fetal Toxicity

Based on findings from animal studies and its mechanism of action, EXKIVITY can cause fetal harm when administered to a pregnant woman. Oral administration of mobocertinib to pregnant rats during the period of organogenesis resulted in embryolethality at maternal exposures approximately 1.7 times the human exposure based on area under the curve (AUC) at the 160 mg once daily clinical dose.

Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective non-hormonal contraception during treatment with EXKIVITY [see Drug Interactions (7.2)] and for 1 month after the last dose. Advise males with female partners of reproductive potential to use effective contraception during treatment with EXKIVITY and for 1 week after the last dose of EXKIVITY [see Use in Specific Populations (8.1, 8.3)].

 Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

The pooled safety population described in WARNINGS AND PRECAUTIONS reflects exposure to EXKIVITY as a single agent at a dose of 160 mg orally once daily in 256 patients, including 114 patients with EGFR exon 20 insertion mutation-positive locally advanced or metastatic NSCLC from Study AP32788-15-101, and patients with other solid tumors. Forty-eight percent (48%) were exposed for 6 months or longer and 12% were exposed for greater than one year. The most common (>20%) adverse reactions were diarrhea, rash, nausea, stomatitis, vomiting, decreased appetite, paronychia, fatigue, dry skin, and musculoskeletal pain. The most common (≥2%) Grade 3 or 4 laboratory abnormalities were decreased lymphocytes, increased amylase, increased lipase, decreased potassium, decreased hemoglobin, increased creatinine, and decreased magnesium.

 Effect of Other Drugs on EXKIVITY

 Effect of EXKIVITY on Other Drugs

 Drugs that Prolong the QTc Interval

Mechanism of Action

Mobocertinib is a kinase inhibitor of the epidermal growth factor receptor (EGFR) that irreversibly binds to and inhibits EGFR exon 20 insertion mutations at lower concentrations than wild type (WT) EGFR. Two pharmacologically-active metabolites (AP32960 and AP32914) with similar inhibitory profiles to mobocertinib have been identified in the plasma after oral administration of mobocertinib. In vitro, mobocertinib also inhibited the activity of other EGFR family members (HER2 and HER4) and one additional kinase (BLK) at clinically relevant concentrations (IC50 values <2 nM).

In cultured cell models, mobocertinib inhibited the proliferation of cells driven by different EGFR exon 20 insertion mutation variants at 1.5- to 10-fold lower concentrations than WT-EGFR signaling inhibition.

In animal tumor implantation models, mobocertinib exhibited anti-tumor activity against xenografts with the EGFR exon 20 insertions NPH or ASV.

Pharmacodynamics

Mobocertinib exposure-response relationships and the time course of pharmacodynamic response are unknown.

Pharmacokinetics

After single- and multiple-dose administration, combined molar Cmax and AUC0-24h of mobocertinib and its active metabolites, AP32960 and AP32914, was dose-proportional over the dose range of 5 to 180 mg once daily (0.03 to 1.1 times the approved recommended dosage). No clinically meaningful accumulation was observed after administration of EXKIVITY 160 mg once daily based on the AUC ratio of mobocertinib.

Carcinogenesis, Mutagenesis, Impairment of Fertility

Carcinogenicity studies were not performed with mobocertinib. Mobocertinib was not mutagenic in an in vitro bacterial reverse mutation (Ames) assay and did not induce chromosomal aberrations in an in vitro chromosome aberration assay in human peripheral blood lymphocytes. Mobocertinib was not clastogenic in an in vivo bone marrow micronucleus test in rats.

Fertility, early embryonic development, and pre- and post-natal toxicology studies were not conducted with mobocertinib; however, in 4- and 13-week repeat-dose toxicology studies in rats and dogs, there were generally reversible changes that included decreases in organ weights affecting multiple reproductive organs (including ovaries, seminal vesicle/prostate gland, and/or uterus) at exposures ≥0.3 times the AUC observed at the recommended clinical dose of 160 mg once daily, as well as microscopic changes of decreased epithelial thickness/inflammation of the cervix/vagina and atrophy of the uterus, prostate gland, or mammary gland (males only) at exposures ≥0.2 times the AUC at the 160 mg once daily clinical dose in rats and/or dogs. Based on these findings, mobocertinib may impair fertility in males and females of reproductive potential. These effects may be reversible.

 Animal Toxicology and/or Pharmacology

In rats, mobocertinib administration resulted in histological findings of decreased corneal epithelial thickness in the 4- and 13-week repeat-dose toxicology studies at doses ≥0.8 times the human exposure (AUC) at the 160 mg once daily clinical dose. In the 4-week repeat-dose study in dogs, mobocertinib administration resulted in discharge from the eye, sclera injection, partial or complete closure of the eye and histological findings of corneal epithelial atrophy at doses ≥0.3 times the AUC at the 160 mg once daily clinical dose. In the 13-week repeat-dose study in dogs, mobocertinib administration resulted in discharge, conjunctival hyperemia, and corneal opacity correlating histologically with decreased corneal epithelial thickness at doses ≥0.2 times the AUC at the 160 mg once daily clinical dose. The clinical relevance of these findings is unknown.

Store at 20°C to 25°C (68°F to 77°F); excursions permitted from 15°C to 30°C (59°F to 86°F) [see USP Controlled Room Temperature].