Fotivda
(tivozanib)Dosage & Administration
Fotivda Prescribing Information
FOTIVDA is indicated for the treatment of adult patients with relapsed or refractory advanced renal cell carcinoma (RCC) following two or more prior systemic therapies.
Recommended Dosing
The recommended dosage of FOTIVDA is 1.34 mg taken orally once daily for 21 days on treatment followed by 7 days off treatment for a 28-day cycle.
Continue treatment until disease progression or until unacceptable toxicity occurs.
Take FOTIVDA with or without food. Swallow the FOTIVDA capsule whole with a glass of water. Do not open the capsule.
If a dose is missed, the next dose should be taken at the next scheduled time. Do not take two doses at the same time.
Dose Modifications for Adverse Reactions
Initiate medical management for diarrhea, nausea, or vomiting prior to dose interruption or reduction.
If dose modifications are required for adverse reactions, reduce the dosage of FOTIVDA to 0.89 mg for 21 days on treatment followed by 7 days off treatment for a 28-day cycle.
Recommendations for dosage modifications are provided in Table 1.
| Adverse Reaction | Severity * | Dosage Modifications for FOTIVDA |
|---|---|---|
| ||
| Hypertension [see Warnings and Precautions (5.1)] | Grade 3 |
|
| Grade 4 |
| |
| Cardiac Failure [see Warnings and Precautions (5.2)] | Grade 3 |
|
| Grade 4 |
| |
| Arterial Thromboembolic Events [see Warnings and Precautions (5.3)] | Any Grade |
|
| Hemorrhagic Events [see Warnings and Precautions (5.5)] | Grade 3 or 4 |
|
| Proteinuria [see Warnings and Precautions (5.6)] | 2 grams or greater proteinuria in 24 hours |
|
| Reversible Posterior Leukoencephalopathy Syndrome [see Warnings and Precautions (5.10)] | Any Grade |
|
| Other Adverse Reactions | Persistent or intolerable Grade 2 or 3 adverse reaction Grade 4 laboratory abnormality |
|
| Grade 4 adverse reaction |
| |
Dosage Modifications for Moderate Hepatic Impairment
Reduce the recommended dosage of FOTIVDA to 0.89 mg capsule taken orally once daily for 21 days on treatment followed by 7 days off treatment for a 28-day cycle for patients with moderate hepatic impairment [see USE IN SPECIFIC POPULATIONS (8.7)].
Capsules:
- 1.34 mg: bright yellow opaque cap imprinted with "TIVZ" in dark blue ink and a bright yellow opaque body imprinted with "SD" in dark blue ink.
- 0.89 mg: dark blue opaque cap imprinted with "TIVZ" in yellow ink and a bright yellow opaque body imprinted with "LD" in dark blue ink.
Pregnancy
Risk Summary
Based on findings in animal studies and its mechanism of action, FOTIVDA can cause fetal harm when administered to a pregnant woman [see CLINICAL PHARMACOLOGY (12.1)]. There are no available data on FOTIVDA use in pregnant woman to inform the drug-associated risk. In embryo-fetal developmental studies, oral administration of tivozanib to pregnant animals during the period of organogenesis caused maternal toxicity, fetal malformations and embryo- fetal death at doses below the maximum recommended clinical dose on a mg/m2 basis [see DATA] . Advise pregnant woman of the potential risk to a fetus.
The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically-recognized pregnancies is 2% to 4% and 15% to 20% respectively.
Data
Animal Data
In an embryo-fetal developmental study in pregnant rats, daily oral administration of tivozanib at doses ≥ 0.03 mg/kg/day (0.2 times the maximum recommended clinical dose on a mg/m2 basis) during the period of organogenesis resulted in maternal toxicity, increases in early and late resorptions, and an increase in fetal external malformations (body edema, short/kinked tail), and skeletal developmental delays.
In an embryo-fetal developmental study in pregnant rabbits, daily oral administration of tivozanib at 1 mg/kg/day (14.5 times the maximum recommended clinical dose on a mg/m2 basis) during the period of organogenesis resulted in fetal malformations including ventricular septal defects and major vessel anomalies. No maternal toxicity was reported at doses up to 1 mg/kg/day.
Lactation
Risk Summary
There are no data on the presence of tivozanib in human milk, or the effects of tivozanib on the breastfed child, or on milk production. Because of the potential for serious adverse reactions in a breastfed child, advise a lactating woman not to breastfeed during treatment with FOTIVDA and for one month after the last dose.
Females and Males of Reproductive Potential
FOTIVDA can cause fetal harm when administered to a pregnant woman [see USE IN SPECIFIC POPULATIONS (8.1)].
Pregnancy Testing
Verify pregnancy status of females of reproductive potential prior to starting treatment with FOTIVDA.
Contraception
Females
Advise females of reproductive potential to use effective contraception during treatment with FOTIVDA and for one month after the last dose [see USE IN SPECIFIC POPULATIONS (8.1)].
Males
Advise males with female partners of reproductive potential to use effective contraception during treatment with FOTIVDA and for one month after the last dose [see NONCLINICAL TOXICOLOGY (13.1)].
Infertility
Females and Males
Based on findings in animal studies, FOTIVDA can impair fertility in females and males of reproductive potential [see NONCLINICAL TOXICOLOGY (13.1)].
Pediatric Use
The safety and effectiveness of FOTIVDA in pediatric patients have not been established.
Animal Data
Juvenile animal studies have not been conducted with tivozanib.
In a 13-week repeat-dose study, oral administration of tivozanib to young and growing cynomolgus monkeys resulted in growth plate hypertrophy, absence of active corpora lutea, and no maturing follicles at doses ≥ 0.3 mg/kg/day (4.4 times the maximum recommended clinical dose on a mg/m2 basis). In a 13-week repeat-dose study in rats, teeth abnormalities (thin, brittle teeth, tooth loss, malocclusions) and growth plate hypertrophy were observed following oral administration of tivozanib at doses ≥ 0.1 mg/kg/day (0.7 times the maximum recommended clinical dose on a mg/m2 basis).
Geriatric Use
Of the 1008 patients with advanced RCC treated with FOTIVDA, 29% were ≥ 65 years of age and 4% were ≥ 75 of age. No overall differences in safety were observed between patients ≥ 65 versus < 65 years of age.
Of the 175 patients with advanced RCC following two or more prior systemic therapies randomized to FOTIVDA, 44% were ≥ 65 years of age and 9% were ≥ 75 of age. No overall differences in effectiveness were observed between patients ≥ 65 versus < 65 years of age.
Renal Impairment
No dosage modification is recommended for patients with mild to severe renal impairment (creatinine clearance [CLcr] 15-89 mL/min, estimated by Cockcroft-Gault). The recommended dosage for patients with end-stage renal disease has not been established [see CLINICAL PHARMACOLOGY (12.3)].
Hepatic Impairment
Reduce the dosage when administering FOTIVDA in patients with moderate (total bilirubin greater than 1.5 to 3 times ULN with any AST) hepatic impairment [see DOSAGE AND ADMINSITARTION (2.3)]. No dosage modification is recommended for patients with mild (total bilirubin less than or equal to ULN with AST greater than ULN or total bilirubin greater than 1 to 1.5 times ULN with any AST) hepatic impairment. The recommended dosage of FOTIVDA in patients with severe (total bilirubin greater than 3 to 10 times ULN with any AST) hepatic impairment has not been established [see CLINICAL PHARMACOLOGY (12.3)].
None.
Hypertension and Hypertensive Crisis
FOTIVDA can cause severe hypertension and hypertensive crisis. Hypertension occurred in 45% of patients treated with FOTIVDA, with 22% of the events ≥ Grade 3. Median time to onset of hypertension was 2 weeks (range: 0 – 192 weeks).
Hypertensive crisis occurred in 0.8% of patients. One patient (0.1%) died due to hypertensive emergency after FOTIVDA overdose [see OVERDOSAGE (10)].
FOTIVDA has not been studied in patients with systolic blood pressure > 150 mmHg or diastolic blood pressure > 100 mmHg.
Control blood pressure prior to treatment with FOTIVDA. Monitor blood pressure after 2 weeks and at least monthly thereafter during treatment with FOTIVDA. Treat patients with anti- hypertensive therapy when hypertension occurs during treatment with FOTIVDA.
Withhold FOTIVDA for severe hypertension despite optimal anti-hypertensive therapy. For persistent hypertension despite use of anti-hypertensive medications, reduce the FOTIVDA dose [see DOSAGE AND ADMINISTRATION (2.2)].
Discontinue FOTIVDA if hypertension is severe and persistent despite anti-hypertensive therapy and dose reduction of FOTIVDA, or in patients who experience hypertensive crisis.
If FOTIVDA is interrupted, monitor patients receiving anti-hypertensive medications for hypotension.
Cardiac Failure
FOTIVDA can cause serious, sometimes fatal, cardiac failure. Cardiac failure in FOTIVDA- treated patients occurred in 1.6%, with 1% of events ≥ Grade 3, and 0.6% events were fatal.
FOTIVDA has not been studied in patients with symptomatic cardiac failure within the preceding 6 months before FOTIVDA treatment initiation.
Periodically monitor patients for symptoms of cardiac failure throughout treatment with FOTIVDA.
Management of cardiac failure events may require interruption, dose reduction, or permanent discontinuation of FOTIVDA therapy [see DOSAGE AND ADMINISTRATION (2.2)].
Cardiac Ischemia and Arterial Thromboembolic Events
FOTIVDA can cause serious, sometimes fatal, cardiac ischemia and arterial thromboembolic events. Cardiac ischemia in FOTIVDA-treated patients occurred in 3.2%, with 1.5% of events ≥ Grade 3, and 0.4% events were fatal. Arterial thromboembolic events were reported in 2% of FOTIVDA-treated patients, including death due to ischemic stroke (0.1%).
FOTIVDA has not been studied in patients who had an arterial thrombotic event, myocardial infarction, or unstable angina within the preceding 6 months before FOTIVDA treatment initiation.
Closely monitor patients who are at risk for, or who have a history of these events (such as myocardial infarction and stroke), during treatment with FOTIVDA.
Discontinue FOTIVDA in patients who develop any severe or life-threatening arterial thromboembolic event [see DOSAGE AND ADMINISTRATION (2.2)].
Venous Thromboembolic Events
FOTIVDA can cause serious, sometimes fatal, venous thromboembolic events. Venous thromboembolic events occurred in 2.4% of patients treated with FOTIVDA, including death (0.3%).
Closely monitor patients who are at risk for, or who have a history of these events during treatment with FOTIVDA.
Discontinue FOTIVDA in patients who develop any severe or life-threatening venous thromboembolic event [see DOSAGE AND ADMINISTRATION (2.2)].
Hemorrhagic Events
FOTIVDA can cause serious, sometimes fatal, hemorrhagic events. Hemorrhagic events occurred in 11% of patients treated with FOTIVDA, including death (0.2%).
FOTIVDA has not been studied in patients with significant bleeding within the preceding 6 months before FOTIVDA treatment initiation.
Closely monitor patients who are at risk for or who have a history of bleeding during treatment with FOTIVDA.
Discontinue FOTIVDA in patients who develop severe or life-threatening hemorrhagic events [see DOSAGE AND ADMINISTRATION (2.2)].
Proteinuria
FOTIVDA can cause proteinuria. Proteinuria occurred in 8% of FOTIVDA-treated patients with 2% of events Grade 3. Of the patients who developed proteinuria, 3/81 (3.7%) had acute kidney injury either concurrently or later during treatment.
Monitor patients for proteinuria before initiation of, and periodically throughout, treatment with FOTIVDA.
For patients who develop moderate to severe proteinuria, reduce the dose or interrupt FOTIVDA treatment.
Discontinue FOTIVDA in patients who develop nephrotic syndrome [see DOSAGE AND ADMINISTRATION (2.2)].
Gastrointestinal Perforation and Fistula Formation
Gastrointestinal perforation including fatal cases, has been reported in patients receiving FOTIVDA. Monitor for symptoms of gastrointestinal perforation or fistula periodically throughout treatment with FOTIVDA. Permanently discontinue FOTIVDA in patients who develop severe or life-threatening gastrointestinal perforation.
Thyroid Dysfunction
FOTIVDA can cause thyroid dysfunction. Thyroid dysfunction events in FOTIVDA-treated patients occurred in 11%, with 0.3% Grade 3 or 4 events. Hypothyroidism was reported in 8% of patients and hyperthyroidism was reported in 1% of patients.
Monitor thyroid function before initiation of, and periodically throughout, treatment with FOTIVDA.
Treat hypothyroidism and hyperthyroidism to maintain euthyroid state before and during treatment with FOTIVDA.
Risk of Impaired Wound Healing
Impaired wound healing can occur in patients who receive drugs that inhibit the vascular endothelial growth factor (VEGF) signaling pathway, such as FOTIVDA. Therefore, FOTIVDA has the potential to adversely affect wound healing.
Withhold FOTIVDA for at least 24 days prior to elective surgery. Do not administer for at least 2 weeks following major surgery and until adequate wound healing. The safety of resumption of FOTIVDA after resolution of wound healing complications has not been established.
Reversible Posterior Leukoencephalopathy Syndrome
Reversible posterior leukoencephalopathy syndrome (RPLS), a syndrome of subcortical vasogenic edema diagnosed by MRI, can occur with FOTIVDA. Perform an evaluation for RPLS in any patient presenting with seizures, headaches, visual disturbances, confusion, or altered mental function.
Discontinue FOTIVDA in patients who develop RPLS [see DOSAGE AND ADMINISTRATION (2.2)].
Embryo-Fetal Toxicity
Based on findings from animal studies and its mechanism of action, FOTIVDA can cause fetal harm when administered to a pregnant woman. In embryo-fetal developmental studies, oral administration of tivozanib to pregnant animals during the period of organogenesis caused maternal toxicity, fetal malformations and embryo-fetal death at doses below the maximum recommended clinical dose on a mg/m2 basis.
Advise pregnant woman of the potential risk to the fetus. Advise females of reproductive potential to use effective contraception during treatment with FOTIVDA and for one month after the last dose. Advise males with female partners of reproductive potential to use effective contraception during treatment with FOTIVDA and for one month after the last dose [see USE IN SPECIFIC POPULATIONS (8.1), (8.3) and CLINICAL PHARMACOLOGY (12.1)].
Allergic Reactions to Tartrazine (FD&C Yellow No.5)
FOTIVDA 0.89 mg capsule contains FD&C Yellow No.5 (tartrazine) as an imprint ink which may cause allergic-type reactions (including bronchial asthma) in certain susceptible patients. Although the overall incidence of FD&C Yellow No.5 (tartrazine) sensitivity in the general population is low, it is frequently seen in patients who also have aspirin hypersensitivity.
The following clinically significant adverse reactions are also described elsewhere in the labeling:
- Hypertension and Hypertensive Crisis [see WARNINGS AND PRECAUTIONS (5.1)]
- Cardiac Failure [see WARNINGS AND PRECAUTIONS (5.2)]
- Cardiac Ischemia and Arterial Thromboembolic Events [see WARNINGS AND PRECAUTIONS (5.3)]
- Venous Thromboembolic Events [see WARNINGS AND PRECAUTIONS (5.4)]
- Hemorrhagic Events [see WARNINGS AND PRECAUTIONS (5.5)]
- Proteinuria [see WARNINGS AND PRECAUTIONS (5.6)]
- Gastrointestinal Perforation and Fistula Formation [see WARNINGS AND PRECAUTIONS (5.7)]
- Thyroid Dysfunction [see WARNINGS AND PRECAUTIONS (5.8)]
- Risk of Impaired Wound Healing [see WARNINGS AND PRECAUTIONS (5.9)]
- Reversible Posterior Leukoencephalopathy Syndrome (RPLS) [see WARNINGS AND PRECAUTIONS (5.10)]
Clinical Trial Experience
Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice.
The pooled safety population described in WARNINGS AND PRECAUTIONS reflects exposure to FOTIVDA administered at 1.34 mg orally once daily with or without food for 21 days on treatment followed by 7 days off treatment for a 28-day cycle in 1008 patients with advanced RCC in TIVO-3 and five other monotherapy studies. Among 1008 patients who received FOTIVDA, 52% were exposed for 6 months or longer and 34% were exposed for greater than one year.
Relapsed or Refractory Advanced RCC Following Two or More Prior Systemic Therapies
The safety of FOTIVDA was evaluated in TIVO-3, a randomized, open-label trial in 350 patients with relapsed or refractory advanced RCC who received 2 or 3 prior systemic treatments [see CLINICAL STUDIES (14)]. Patients were randomized (1:1) to receive FOTIVDA 1.34 mg orally once daily for 21 days on treatment followed by 7 days off treatment for a 28-day cycle, or to receive sorafenib 400 mg orally twice a day continuously until disease progression or unacceptable toxicity. Among patients who received FOTIVDA, 53% were exposed for 6 months or longer and 31% were exposed for greater than one year.
Serious adverse reactions occurred in 45% of patients who received FOTIVDA. Serious adverse reactions in > 2% of patients included bleeding (3.5%), venous thromboembolism (3.5%), arterial thromboembolism (2.9%), acute kidney injury (2.3%), and hepatobiliary disorders (2.3%). Fatal adverse reactions occurred in 8% of patients who received FOTIVDA, including pneumonia (1.7%), hepatobiliary disorders (1.2%), respiratory failure (1.2%), myocardial infarction (0.6%), cerebrovascular accident (0.6%), and subdural hematoma (0.6%).
Permanent discontinuation of FOTIVDA due to an adverse reaction occurred in 21% of patients. Adverse reactions which resulted in permanent discontinuation of FOTIVDA in > 2 patients included hepatobiliary disorders, fatigue, and pneumonia.
Dosage interruptions of FOTIVDA due to an adverse reaction occurred in 48% of patients. Adverse reactions which required dosage interruption in > 5% of patients included fatigue, hypertension, decreased appetite, and nausea.
Dose reductions of FOTIVDA due to an adverse reaction occurred in 24% of patients. Adverse reactions which required dose reductions in > 3% of patients included fatigue, diarrhea, and decreased appetite.
The most common (≥ 20%) adverse reactions were fatigue, hypertension, diarrhea, decreased appetite, nausea, dysphonia, hypothyroidism, cough, and stomatitis, and the most common Grade 3 or 4 laboratory abnormalities (≥ 5%) were sodium decreased, lipase increased, and phosphate decreased.
Table 2 summarizes the adverse reactions in TIVO-3.
| Adverse Reaction | FOTIVDA (n = 173) | Sorafenib (n = 170) | ||
|---|---|---|---|---|
| All Grades (%) | Grade 3 or 4 (%) | All Grades (%) | Grade 3 or 4 (%) | |
| ||||
| Any | 99 | 67 | 100 | 72 |
| General | ||||
| Fatigue * | 67 | 13 | 48 | 12 |
| Vascular | ||||
| Hypertension † | 44 | 24 | 31 | 17 |
| Bleeding ‡ | 17 | 3 | 12 | 1 |
| Gastrointestinal | ||||
| Diarrhea § | 43 | 2 | 54 | 11 |
| Nausea | 30 | 0 | 18 | 4 |
| Stomatitis | 21 | 2 | 23 | 2 |
| Vomiting | 18 | 1 | 17 | 2 |
| Metabolism and nutrition | ||||
| Decreased appetite | 39 | 5 | 30 | 4 |
| Respiratory, thoracic, and mediastinal | ||||
| Dysphonia | 27 | 1 | 9 | 0 |
| Cough | 22 | 0 | 15 | 1 |
| Dyspnea | 15 | 3 | 11 | 1 |
| Endocrine | ||||
| Hypothyroidism ¶ | 24 | 1 | 11 | 0 |
| Musculoskeletal | ||||
| Back pain | 19 | 2 | 16 | 2 |
| Skin and subcutaneous tissue disorders | ||||
| Rash # | 18 | 1 | 52 | 15 |
| Palmar-plantar erythrodysesthesia syndrome | 16 | 1 | 41 | 17 |
| Investigations | ||||
| Weight decreased | 17 | 3 | 22 | 3 |
Clinically relevant adverse reactions in < 15% of patients who received FOTIVDA included proteinuria, venous thromboembolism, arterial thromboembolism, hyperthyroidism, hepatobiliary disorders, osteonecrosis, cardiac failure, and delirium.
Table 3 summarizes the laboratory abnormalities in TIVO-3.
| Laboratory Abnormality | FOTIVDA * (n = 173) | Sorafenib * (n = 170) | ||
|---|---|---|---|---|
| All Grades (%) | Grade 3 or 4 (%) | All Grades (%) | Grade 3 or 4 (%) | |
| ||||
| Hematology | ||||
| Lymphocytes decreased | 25 | 5 | 42 | 6 |
| Hemoglobin increased | 19 | 0 | 8 | 0 |
| Platelets decreased | 19 | 0 | 18 | 1 |
| Hemoglobin decreased | 16 | 1 | 27 | 4 |
| Chemistry | ||||
| Creatinine increased | 50 | 0 | 37 | 1 |
| Glucose increased | 50 | 3 | 40 | 0 |
| Phosphate decreased | 38 | 5 | 63 | 31 |
| Sodium decreased | 36 | 9 | 30 | 11 |
| Lipase increased | 32 | 9 | 36 | 10 |
| ALT increased | 30 | 4 | 29 | 2 |
| Alkaline phosphatase increased | 30 | 4 | 32 | 2 |
| AST increased | 28 | 1 | 31 | 2 |
| Potassium increased | 26 | 3 | 23 | 0 |
| Magnesium decreased | 26 | 0 | 23 | 1 |
| Amylase increased | 23 | 2 | 28 | 3 |
| Calcium increased | 15 | 2 | 7 | 2 |
| Bilirubin increased | 11 | 3 | 11 | 0 |
| Coagulation | ||||
| Activated partial thromboplastin time prolonged | 26 | 1 | 18 | 0 |
Postmarketing Experience
The following adverse reactions have been identified during post-approval use of FOTIVDA. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
- Gastrointestinal disorders: Gastrointestinal perforation and pancreatitis
Effect of Other Drugs on FOTIVDA
Strong CYP3A Inducers
Concomitant use of FOTIVDA with a strong CYP3A inducer decreases tivozanib exposure [see CLINICAL PHARMACOLOGY (12.3)], which may reduce FOTIVDA anti-tumor activity.
Avoid concomitant use of strong CYP3A inducers with FOTIVDA.
Tivozanib is a kinase inhibitor. Tivozanib hydrochloride, the active ingredient, has the chemical name 1-{2-chloro-4-[(6,7-dimethoxyquinolin-4-yl)oxy]phenyl}-3-(5-methylisoxazol-3-yl)urea hydrochloride hydrate. The molecular formula is C22H19ClN4O5 ∙ HCl ∙ H2O and the molecular weight is 509.34 Daltons. The chemical structure is:
Tivozanib hydrochloride is a white to light brown crystalline powder that is practically insoluble in water (0.09 mg/mL).
FOTIVDA 1.34 mg capsule contains 1.5 mg of tivozanib hydrochloride (equivalent to 1.34 mg tivozanib) with inactive ingredients: mannitol and magnesium stearate. Capsule composition: gelatin, titanium dioxide, FDA yellow iron oxide, and Blue SB-6018 (ink).
FOTIVDA 0.89 mg capsule contains 1.0 mg of tivozanib hydrochloride (equivalent to 0.89 mg tivozanib) with inactive ingredients: mannitol and magnesium stearate. Capsule composition: gelatin, titanium dioxide, FDA yellow iron oxide, FD&C Blue #2, Blue SB-6018 (ink) and Yellow SB-3017 (ink). The Yellow SB-3017 ink contains FD&C Yellow No.5 (tartrazine).
Mechanism of Action
Tivozanib is a tyrosine kinase inhibitor. In vitro cellular kinase assays demonstrated that tivozanib inhibits phosphorylation of vascular endothelial growth factor receptor (VEGFR)-1, VEGFR-2 and VEGFR-3 and inhibits other kinases including c-kit and PDGFR β at clinically relevant concentrations. In tumor xenograft models in mice and rats, tivozanib inhibited angiogenesis, vascular permeability, and tumor growth of various tumor cell types including human renal cell carcinoma.
Pharmacodynamics
Exposure-Response Relationship
Tivozanib exposure-response relationships and the time course of pharmacodynamic response have not been fully characterized.
Cardiac Electrophysiology
At the recommended dose of FOTIVDA, no large mean increases (i.e., 20 msec) in QTc interval were observed.
Pharmacokinetics
The pharmacokinetics of tivozanib were evaluated in patients with solid tumors administered 1.34 mg once daily unless otherwise specified. Steady-state tivozanib AUC and Cmax increased in a dose-proportional manner over the dose range of 0.89 to 1.78 mg once daily (0.67 to 1.3 times the recommended dose).
Steady-state was reached by 14 days and the accumulation ratio after administration of 1.34 mg once daily was approximately 6- to 7- fold. Mean steady-state tivozanib [coefficient of variation (CV%)] Cmax was 86.9 (44.7%) ng/mL and AUC0-24h was 1510 (46.1%) ng*h/mL.
Absorption
The median Tmax of tivozanib is 10 hours with a range of 3 to 24 hours.
Effect of Food
No clinically significant differences in tivozanib AUC or Cmax were observed following administration of a high fat meal (approximately 500-600 fat calories, 250 carbohydrate calories and 150 protein calories) in healthy subjects.
Distribution
The apparent volume of distribution (V/F) of tivozanib is 123 L.
Protein binding of tivozanib is ≥ 99%, primarily to albumin in vitro and is independent of concentration. The mean blood-to-plasma concentration ratios ranged from 0.495 to 0.615 in healthy subjects.
Elimination
The apparent clearance (CL/F) of tivozanib is 0.75 L/h and the half-life is 111 hours.
Metabolism
Tivozanib is metabolized predominantly by CYP3A4. Following oral administration of a single radiolabeled 1.34 mg dose of tivozanib to healthy subjects, unchanged tivozanib constituted 90% of the radioactive drug components in serum.
Excretion
Following oral administration of a single radiolabeled 1.34 mg dose of tivozanib to healthy subjects, 79% of the administered dose was recovered in feces (26% unchanged) and 12% in urine (unchanged tivozanib not detected).
Specific Populations
No clinically significant differences in the pharmacokinetics of tivozanib were observed based on age (18 years to 88 years), sex, race (93% Caucasian, 3% African American, 2% Asian, 2% others), body weight (39 kg to 158 kg), mild to severe renal impairment (CLcr 15-89 mL/min as estimated by Cockcroft-Gault) or mild hepatic impairment (total bilirubin less than or equal to ULN with AST greater than ULN or total bilirubin greater than 1 to 1.5 times ULN with any AST). The effect of end-stage renal disease or severe hepatic impairment on tivozanib pharmacokinetics is unknown [see USE IN SPECIFIC POPULATIONS (8.6) and (8.7)].
Patients with Hepatic Impairment
Compared to subjects with normal hepatic function, tivozanib AUCtau increased by 1% in patients with mild (total bilirubin less than or equal to ULN with AST greater than ULN or total bilirubin greater than 1 to 1.5 times ULN with any AST) hepatic impairment. Compared to subjects with normal hepatic function, tivozanib AUCtau increased by 62% in patients with moderate (total bilirubin greater than 1.5 to 3 times ULN with any AST) hepatic impairment. The effect of severe (total bilirubin greater than 3 to 10 times ULN with any AST) hepatic impairment on tivozanib pharmacokinetics has not been studied [see DOSAGE AND ADMINISTRATION (2.3) and USE IN SPECIFIC POPLATIONS (8.7)].
Drug Interaction Studies
Clinical Studies
Strong CYP3A Inducers: Concomitant use of multiple doses of rifampin (strong CYP3A inducer) did not change tivozanib Cmax but decreased tivozanib AUC0-INF by 52%.
Strong CYP3A Inhibitors: No clinically significant differences in the pharmacokinetics of tivozanib were observed when multiple doses of ketoconazole (strong CYP3A inhibitor) was co-administered with tivozanib.
In Vitro Studies
Cytochrome P450 (CYP) Enzymes: Tivozanib does not inhibit CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6 or CYP3A4 at clinically relevant concentrations. Tivozanib does not induce CYP1A, CYP2B6, CYP2C9, CYP2C19, or CYP3A at clinically relevant concentrations.
Uridine Diphosphate (UDP)-glucuronosyl Transferase (UGT) Enzymes: Tivozanib does not inhibit UGT at clinically relevant concentrations.
Transporter Systems: Tivozanib inhibits BCRP but does not inhibit P-gp, OCT1, OATP1B1, OATP1B3, BSEP, OAT1, OAT3, OCT2, MATE1 or MATE2-K at clinically relevant concentrations. Tivozanib is not a substrate for P-gp, MRP2, BCRP, OCT1, OATP1B1, OATP1B3, or BSEP.
Carcinogenesis, Mutagenesis, Impairment of Fertility
Carcinogenicity studies have not been conducted with tivozanib.
Tivozanib was not mutagenic in a bacterial reverse mutation (Ames) assay and was not clastogenic in an in vitro cytogenetic assay in Chinese hamster ovary cells or in an in vivo mouse bone marrow micronucleus assay.
In animal studies assessing mating and fertility parameters, oral doses ≥ 0.03 mg/kg/day (0.2 times the maximum recommended clinical dose on a mg/m2 basis) in rats were associated with increased epididymis and testis weights, and doses ≥ 0.3 mg/kg/day (2 times the maximum recommended clinical dose on a mg/m2 basis) reduced mating and produced infertility. An increase in embryo lethality was noted at doses ≥ 0.1 mg/kg/day (0.7 times the maximum recommended clinical dose on a mg/m2 basis).
The efficacy of FOTIVDA was evaluated in TIVO-3 (NCT02627963), a randomized (1:1), open- label, multicenter trial of FOTIVDA versus sorafenib in patients with relapsed or refractory advanced RCC who received 2 or 3 prior systemic treatments including at least one VEGFR kinase inhibitor other than sorafenib or tivozanib. Patients were randomized to receive FOTIVDA 1.34 mg orally once daily for 21 days on treatment followed by 7 days off treatment for a 28-day cycle, or to receive sorafenib 400 mg orally twice a day continuously, until disease progression or unacceptable toxicity. Randomization was stratified by prior therapy [two kinase inhibitors (KIs), a KI plus an immune checkpoint inhibitor, or a KI plus other systemic agents] and by International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) prognostic score. Patients were excluded if they had more than 3 prior treatments or Central Nervous System metastases. The main efficacy outcome measure was progression-free survival (PFS) assessed by a blinded independent radiology review committee. Other efficacy endpoints were objective response rate (ORR) and overall survival (OS).
The median age was 63 years (range: 30 to 90 years), 73% were male, 95% were Caucasian, ECOG performance status was 0 in 48% and 1 in 49% of patients (respectively), and 98% of patients had clear cell or clear cell component histology. Prior therapy included two KIs (45%), a KI plus an immune checkpoint inhibitor (26%), and a KI plus another systemic agent (29%). At the time of study entry, 20% of patients had favorable, 61% intermediate, and 19% poor IMDC prognoses.
Efficacy results are summarized in Table 4 and Figure 1.
| Endpoint | FOTIVDA N= 175 | Sorafenib N= 175 |
|---|---|---|
| CI: Confidence interval; HR: Hazard ratio (FOTIVDA/sorafenib); NE: not estimable. | ||
| ||
| Progression Free Survival (PFS) * | ||
| Events, n (%) | 123 (70) | 123 (70) |
| Progressive Disease | 103 (59) | 109 (62) |
| Death | 20 (11) | 14 (8) |
| Median (95% CI), months | 5.6 (4.8, 7.3) | 3.9 (3.7, 5.6) |
| HR (95% CI) † | 0.73 (0.56, 0.95) | |
| P-value ‡ | 0.016 | |
| Overall Survival | ||
| Deaths, n (%) | 125 (71) | 126 (72) |
| Median (95% CI), months | 16.4 (13.4, 21.9) | 19.2 (14.9, 24.2) |
| HR (95% CI) † | 0.97 (0.75, 1.24) | |
| Objective Response Rate % (95% CI) * | 18 (12, 24) | 8 (4, 13) |
| Median duration of response in months (95% CI) | NE (9.8, NE) | 5.7 (5.6, NE) |
Figure 1. Kaplan-Meier Plot of PFS in TIVO-3
How Supplied
FOTIVDA (tivozanib) capsules, for oral use are supplied as follows:
| Capsule Strength | Opaque Capsule Color | Capsule Markings | Pack Size | NDC Code |
|---|---|---|---|---|
| Tivozanib 1.34 mg (equivalent to 1.5 mg tivozanib hydrochloride) | Bright yellow cap and body | "TIVZ" imprinted with dark blue ink on cap; "SD" imprinted with dark blue ink on body | Bottle of 21 | NDC 45629-134-01 |
| Tivozanib 0.89 mg (equivalent to 1.0 mg tivozanib hydrochloride) | Dark blue cap and bright yellow body | "TIVZ" imprinted with yellow ink on cap; "LD" imprinted with dark blue ink on body | Bottle of 21 | NDC 45629-089-01 |
| Tivozanib 1.34 mg (equivalent to 1.5 mg tivozanib hydrochloride) | Bright yellow cap and body | "TIVZ" imprinted with dark blue ink on cap; "SD" imprinted with dark blue ink on body | Bottle of 21 in a Carton | NDC 45629-134-02 |
| Tivozanib 0.89 mg (equivalent to 1.0 mg tivozanib hydrochloride) | Dark blue cap and bright yellow body | "TIVZ" imprinted with yellow ink on cap; "LD" imprinted with dark blue ink on body | Bottle of 21 in a Carton | NDC 45629-089-02 |
Storage and Handling
Store at 20°C to 25°C (68°F to 77°F); excursions permitted between 15°C to 30°C (59°F to 86° F) [see USP CONTROLLED ROOM TEMPERATURE].
Keep out of reach of children.
Mechanism of Action
Tivozanib is a tyrosine kinase inhibitor. In vitro cellular kinase assays demonstrated that tivozanib inhibits phosphorylation of vascular endothelial growth factor receptor (VEGFR)-1, VEGFR-2 and VEGFR-3 and inhibits other kinases including c-kit and PDGFR β at clinically relevant concentrations. In tumor xenograft models in mice and rats, tivozanib inhibited angiogenesis, vascular permeability, and tumor growth of various tumor cell types including human renal cell carcinoma.