BEXAROTENE- bexarotene_capsule

Bexarotene selectively binds and activates retinoid X receptor subtypes (RXRalpha, RXRbeta, RXRgamma). RXRs can form heterodimers with various receptor partners such as retinoic acid receptors (RARs), vitamin D receptor, thyroid receptor, and peroxisome proliferator activator receptors (PPARs). Once activated, these receptors function as transcription factors that regulate the expression of genes that control cellular differentiation and proliferation. Bexarotene inhibits the growth in vitro in vivo Terminal half-life of bexarotene is approximately seven hours. Studies in patients with advanced malignancies show approximate single dose linearity within the therapeutic range. Absorption After oral administration of bexarotene, bexarotene is absorbed with a T max max Distribution Bexarotene is highly bound (>99%) to plasma proteins. The plasma proteins to which bexarotene binds have not been elucidated, and the ability of bexarotene to displace drugs bound to plasma proteins and the ability of drugs to displace bexarotene binding have not been studied. Elimination Metabolism Four bexarotene metabolites have been identified in plasma: 6- and 7-hydroxy-bexarotene and 6- and 7-oxo-bexarotene. In vitro in vitro Excretion The renal elimination of bexarotene and its metabolites was examined in patients with Type 2 diabetes mellitus. Urinary elimination of bexarotene and its known metabolites is a minor excretory pathway (<1% of administered dose). Pharmacokinetics in Specific Populations Age: Based on the population pharmacokinetic analysis of data for 232 patients aged >=65 years and 343 patients aged <65 years, age has no statistically significant effect on bexarotene pharmacokinetics. Body Weight and Gender: Based on the population pharmacokinetics analysis of data for 614 patients with a weight range of 26 to 145 kg, the bexarotene apparent clearance increases with increasing body weight. Gender has no statistically significant effect on bexarotene pharmacokinetics. Race: Based on the population pharmacokinetic analysis of data for 540 Caucasian and 44 Black patients, bexarotene pharmacokinetics are similar in Blacks and Caucasians. There are insufficient data to evaluate potential differences in the pharmacokinetics of bexarotene for other races. Renal Impairment: No formal studies have been conducted with bexarotene in patients with renal impairment. Urinary elimination of bexarotene and its known metabolites is a minor excretory pathway (<1% of administered dose), but because renal impairment can result in significant protein binding changes, pharmacokinetics may be altered in patients with renal impairment. Hepatic Impairment: No specific studies have been conducted with bexarotene in patients with hepatic impairment. Because less than 1% of the dose is excreted in the urine unchanged and there is in vitro Drug Interactions Effect of Other Drugs on Bexarotene CYP3A4 Inhibitors/Inducers: In a clinical study, concomitant administration of multiple doses of ketoconazole with bexarotene did not alter bexarotene plasma concentrations. This suggests that bexarotene elimination is not dependent on CYP3A4 metabolism. Paclitaxel plus Carboplatin: The co-administration of paclitaxel (200 mg/m 2 2 0-24 max Atorvastatin: Bexarotene concentrations were not affected by concomitant atorvastatin administration. Effect of Bexarotene on Other Drugs Bexarotene did not significantly inhibit the following enzymes in human liver microsomes: CYP1A2, CYP2A6, CYP2C9, CYP2C19, CYP2D6, CYP2E1 and CYP3A4. In vitro Atorvastatin: The exposure (AUC) to atorvastatin (a substrate for CYP3A4) decreased by half when atorvastatin was co-administered with bexarotene (400 mg/m 2 Tamoxifen: Based on interim data, concomitant administration of bexarotene and tamoxifen resulted in approximately a 35% decrease in plasma concentrations of tamoxifen, possibly through induction of CYP3A4 by bexarotene. Paclitaxel: The exposure (AUC) to paclitaxel (a substrate for CYP3A4 and CYP2C8) decreased by 19% when paclitaxel (200 mg/m 2 2 Carboplatin: The co-administration of bexarotene (400 mg/m 2.

Bexarotene capsules are indicated for the treatment of cutaneous manifestations of cutaneous T-cell lymphoma in patients who are refractory to at least one prior systemic therapy. Bexarotene capsules are a retinoid indicated for the treatment of cutaneous manifestations of cutaneous T-cell lymphoma in patients who are refractory to at least one prior systemic therapy.

The recommended initial dose of bexarotene capsules is 300 mg/m 2 [see Use in Specific Populations (8. 1) Table 1: Bexarotene Capsules Initial Dose Calculation According to Body Surface Area Initial Dose Level (300 mg/m 2 Number of 75 mg Body Surface Area (m 2 Total Daily Dose (mg/day) 0. 62 750 10 Dose Modification Guidelines: The 300 mg/m 2 2 2 2 2 Duration of Therapy: In clinical trials in CTCL, bexarotene capsules was administered for up to 97 weeks. Bexarotene capsules should be continued as long as the patient is deriving benefit. Recommended initial dose is 300 mg/m 2 (2) Take bexarotene capsules as a single oral daily dose with a meal. (2) Dose adjustment: may be adjusted to 200 mg/m 2 2 (2).

The following serious adverse reactions are discussed in greater detail in other sections of the prescribing information: Hyperlipidemia [see Warnings and Precautions (5. 1) Pancreatitis [see Warnings and Precautions (5. 2) Hepatotoxicity, cholestasis, and hepatic failure [see Warnings and Precautions (5. 3) Hypothyroidism [see Warnings and Precautions (5. 4) Neutropenia [see Warnings and Precautions (5. 5) Cataracts [see Warnings and Precautions (5. 6) Vitamin A Supplementation Hazard [see Warnings and Precautions (5. 7) Hypoglycemia Risk in Patients with Diabetes Mellitus [see Warnings and Precautions (5. 8) Photosensitivity [see Warnings and Precautions (5. 9) Laboratory Tests [see Warnings and Precautions (5. 10) Drug/Laboratory Test Interactions [see Warnings and Precautions (5. 11) The most common adverse reactions (greater than 10%) include: hyperlipidemia, hypercholesteremia, headache, hypothyroidism, asthenia, leukopenia, rash, nausea, infection, peripheral edema, abdominal pain, and dry skin. 1) To report SUSPECTED ADVERSE REACTIONS, contact AvKARE at 1-855-361-3993 or FDA at 1-800-FDA-1088 or www. gov/medwatch 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 safety of bexarotene has been evaluated in two clinical trials of 152 patients with CTCL who received bexarotene for up to 97 weeks and in 352 patients in other trials. The mean duration of therapy for the 152 patients with CTCL was 166 days. The most common adverse events reported with an incidence of at least 10% in patients with CTCL treated at an initial dose of 300 mg/m 2 2 Adverse reactions leading to bexarotene dose reduction or discontinuation in at least two patients were hyperlipemia, neutropenia/leukopenia, diarrhea, fatigue/lethargy, hypothyroidism, headache, liver function test abnormalities, rash, pancreatitis, nausea, anemia, allergic reaction, muscle spasm, pneumonia, and confusion. The NCI Grade 3 and NCI Grade 4 adverse reactions reported in two or more patients with CTCL treated at an initial dose of 300 mg/m 2 2 2 In patients with CTCL receiving an initial dose of 300 mg/m 2 2 In addition to the 152 patients enrolled in the two CTCL trials, 352 patients received bexarotene as monotherapy for various advanced malignancies at doses from 5 mg/m 2 2 In the 504 patients (CTCL and non-CTCL) who received bexarotene as monotherapy, drug-related serious adverse reactions that were fatal, in one patient each, were acute pancreatitis, subdural hematoma, and liver failure. In the patients with CTCL receiving an initial dose of 300 mg/m 2 Body as a Whole: Cardiovascular: Digestive: Hemic and Lymphatic: Metabolic and Nutritional: Musculoskeletal: Nervous: Respiratory: Skin and Appendages: Special Senses: Urogenital: Table 2: Adverse Events with Incidence >=10% in CTCL Trials Initial Assigned Dose Group (mg/m 2 300 >300 Body System N=84 N=53 Adverse Event 1,2 N (%) N (%) METABOLIC AND NUTRITIONAL DISORDERS Hyperlipemia 66 (79) 42 (79) Hypercholesteremia 27 (32) 33 (62) Lactic dehydrogenase increased 6 (7) 7 (13) BODY AS A WHOLE Headache 25 (30) 22 (42) Asthenia 17 (20) 24 (45) Infection 11 (13) 12 (23) Abdominal pain 9 (11) 2 (4) Chills 8 (10) 7 (13) Fever 4 (5) 9 (17) Flu syndrome 3 (4) 7 (13) Back pain 2 (2) 6 (11) Infection bacterial 1 (1) 7 (13) ENDOCRINE Hypothyroidism 24 (29) 28 (53) SKIN AND APPENDAGES Rash 14 (17) 12 (23) Dry skin 9 (17) 5 (9) Exfoliative dermatitis 8 (10) 15 (28) Alopecia 3 (4) 6 (11) HEMIC AND LYMPHATIC SYSTEM Leukopenia 14 (17) 25 (47) Anemia 5 (6) 13 (25) Hypochromic anemia 3 (4) 7 (13) DIGESTIVE SYSTEM Nausea 13 (16) 4 (8) Diarrhea 6 (7) 22 (42) Vomiting 3 (4) 7 (13) Anorexia 2 (2) 12 (23) CARDIOVASCULAR SYSTEM Peripheral edema 11 (13) 6 (11) NERVOUS SYSTEM Insomnia 4 (5) 6 (11) 1 2 Table 3: Incidence of Moderately Severe and Severe Adverse Events Reported in at Least Two Patients (CTCL Trials) Initial Assigned Dose Group (mg/m 2 300 (N=84) >300 (N=53) Mod Sev Severe Mod Sev Severe Body System Adverse Event 1,2 N (%) N (%) N (%) N (%) BODY AS A WHOLE Asthenia 1 (1) 0 (0) 11 (21) 0 (0) Headache 3 (4) 0 (0) 5 (9) 1 (2) Infection bacterial 1 (1) 0 (0) 0 (0) 2 (4) CARDIOVASCULAR SYS. Peripheral edema 2 (2) 1 (1) 0 (0) 0 (0) DIGESTIVE SYSTEM Anorexia 0 (0) 0 (0) 3 (6) 0 (0) Diarrhea 1 (1) 1 (1) 2 (4) 1 (2) Pancreatitis 1 (1) 0 (0) 3 (6) 0 (0) Vomiting 0 (0) 0 (0) 2 (4) 0 (0) ENDOCRINE Hypothyroidism 1 (1) 1 (1) 2 (4) 0 (0) HEM. Leukopenia 3 (4) 0 (0) 6 (11) 1 (2) META. Bilirubinemia 0 (0) 1 (1) 2 (4) 0 (0) Hypercholesteremia 2 (2) 0 (0) 5 (9) 0 (0) Hyperlipemia 16 (19) 6 (7) 17 (32) 5 (9) SGOT/AST increased 0 (0) 0 (0) 2 (4) 0 (0) SGPT/ALT increased 0 (0) 0 (0) 2 (4) 0 (0) RESPIRATORY SYSTEM Pneumonia 0 (0) 0 (0) 2 (4) 2 (4) SKIN AND APPENDAGES Exfoliative dermatitis 0 (0) 1 (1) 3 (6) 1 (2) Rash 1 (1) 2 (2) 1 (2) 0 (0) 1 2 Table 4: Treatment-Emergent Abnormal Laboratory Values in CTCL Trials Initial Assigned Dose (mg/m 2 300 >300 N=83 1 N=53 1 Grade 3 2 Grade 4 2 Grade 3 Grade 4 Analyte (%) (%) (%) (%) Triglycerides 3 21 7 32 14 Total Cholesterol 3 19 7 16 30 Alkaline Phosphatase 1 0 0 2 Hyperglycemia 1 0 6 0 Hypocalcemia 1 0 0 0 Hyponatremia 1 0 9 0 SGPT/ALT 1 0 2 2 Hyperkalemia 0 0 2 0 Hypernatremia 0 1 0 0 SGOT/AST 0 0 2 2 Total Bilirubin 0 0 0 2 ANC decreased 12 4 19 8 ALC decreased 7 0 15 0 WBC decreased 4 0 11 0 Hemoglobin decreased 0 0 2 0 1 2 3 2 2 The safety profile from the one post-approval trial with 59 subjects was generally comparable to that of the pivotal trials with the exception of serious adverse events hypertriglyceridemia, neutropenia and bone marrow failure which were observed more frequently in the bexarotene 300 mg/m 2 2 Severe hypertriglyceridemia (>=800 mg/dL) was not seen in any subject in the lower dosage arm. The most common AEs by preferred term in either the bexarotene 300 or 150 mg/m 2 Higher percentage of subjects in the bexarotene 300 mg/m 2 2 Of the SAEs of special interest, there were more events in the bexarotene 300 mg/m 2 2.

Pregnancy (Boxed Warning 4. 1) Known hypersensitivity to bexarotene (4. 2) Bexarotene can cause fetal harm when administered to a pregnant female. Bexarotene is a member of the retinoid class of drugs that is associated with birth defects in humans and is contraindicated in females who are pregnant. Bexarotene was also teratogenic and caused developmental mortality when administered orally to pregnant rats. If this drug is used during pregnancy or if the patient becomes pregnant while taking this drug, the patient should be advised of the potential risk to a fetus. Bexarotene capsules are contraindicated in patients with a known serious hypersensitivity to bexarotene or other components of the product.

Risk Summary Bexarotene, a retinoid, can cause fetal harm based on findings from animal studies when administered to a pregnant female and is contraindicated during pregnancy. Bexarotene was teratogenic and caused developmental mortality in rats following oral administration during organogenesis [see Data] The background risk of major birth defects and miscarriage for the indicated populations are unknown. However, the background risk in the U. general population of major birth defects is 2% to 4% and of miscarriage is 15% to 20% of clinically recognized pregnancies. Data Animal Data Bexarotene caused malformations when administered orally to pregnant rats during days 7 to 17 of gestation. Developmental abnormalities included incomplete ossification at 4 mg/kg/day and cleft palate, depressed eye bulge/microphthalmia, and small ears at 16 mg/kg/day. The plasma AUC of bexarotene in rats at 4 mg/kg/day is approximately one third the AUC in humans at the recommended daily dose. At doses greater than 10 mg/kg/day, bexarotene caused developmental mortality. The no effect dose for fetal effects in rats was 1 mg/kg/day (producing an AUC approximately one sixth of the AUC at the recommended human daily dose). Risk Summary There is no information regarding the presence of bexarotene in human milk, the effects on the breast fed infant, or the effects on milk production. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from bexarotene, discontinue breastfeeding during treatment with bexarotene. Pregnancy Testing Obtain a negative serum pregnancy test (e. , serum beta-human chorionic gonadotropin [beta-HCG]) with a sensitivity of at least 50 mlU/L within one week prior to bexarotene therapy. Obtain another pregnancy test at monthly intervals while the patient remains on bexarotene. Contraception Females Bexarotene can cause fetal harm when administered to a pregnant female [see Use in Specific Populations (8. 1) [see Drug Interactions (7) Males Male patients with sexual partners who are pregnant, possibly pregnant, or who could become pregnant must use condoms during sexual intercourse while taking bexarotene and for at least one month after the last dose of drug. Safety and effectiveness of bexarotene in pediatric patients have not been established. Of the total patients with CTCL in clinical trials of bexarotene, 64% were 60 years or older, while 33% were 70 years or older. No overall differences in safety were observed between patients 70 years or older and younger patients, but greater sensitivity of some older individuals to bexarotene cannot be ruled out. Responses to bexarotene were observed across all age group decades, without preference for any individual age group decade. No specific studies have been conducted with bexarotene in subjects with hepatic impairment. Hepatic impairment is expected to lead to decreased clearance [see Clinical Pharmacology (12.

Effect of Other Drugs on Bexarotene Gemfibrozil: Concomitant administration of bexarotene and gemfibrozil resulted in increases in plasma concentrations of bexarotene. Concomitant administration of gemfibrozil with bexarotene is not recommended. Effect of Bexarotene on Other Drugs Bexarotene may be an inducer for the CYP3A4 enzymes, and may reduce plasma concentrations of other substrates metabolized by CYP3A4. Drug products which may be affected include oral or other systemic hormonal contraceptives. Thus, if treatment with bexarotene is intended for a female with reproductive potential, it is strongly recommended that a non-hormonal contraception be considered [see Use in Specific Populations (8.3) Clinical Pharmacology (12.3) Laboratory Test Interference CA125 assay values in patients with ovarian cancer may be increased by bexarotene therapy.

OVERDOSAGE
Doses up to 1000 mg/m 2 2
NONCLINICAL TOXICOLOGY
Long-term studies in animals to assess the carcinogenic potential of bexarotene have not been conducted. Bexarotene is not mutagenic to bacteria (Ames assay) or mammalian cells (mouse lymphoma assay). Bexarotene was not clastogenic in vivo No formal fertility studies were conducted with bexarotene. Bexarotene caused testicular degeneration when oral doses of 1.5 mg/kg/day were given to dogs for 91 days (producing an AUC of approximately one fifth the AUC at the recommended human daily dose).
CLINICAL STUDIES
Bexarotene was evaluated in two clinical trials in 152 patients with advanced and early stage cutaneous T-cell lymphoma (CTCL) in two multicenter, open-label, historically-controlled clinical trials conducted in the U.S., Canada, Europe, and Australia. The advanced disease patients had disease refractory to at least one prior systemic therapy (median of two, range one to six prior systemic therapies) and had been treated with a median of five (range 1 to 11) prior systemic, irradiation, and/or topical therapies. Early disease patients were intolerant to, had disease that was refractory to, or had reached a response plateau of six months on, at least two prior therapies. The patients entered had been treated with a median of 3.5 (range 2 to 12) therapies (systemic, irradiation, and/or topical). The two clinical trials enrolled a total of 152 patients, 102 of whom had disease refractory to at least one prior systemic therapy, 90 with advanced disease and 12 with early disease. This is the patient population for whom bexarotene is indicated. Patients were initially treated with a starting dose of 650 mg/m 2 2 2 2 2 Tumor response was assessed in both trials by observation of up to five baseline-defined index lesions using a Composite Assessment of Index Lesion Disease Severity (CA). This endpoint was based on a summation of the grades, for all index lesions, of erythema, scaling, plaque elevation, hypopigmentation or hyperpigmentation, and area of involvement. Also considered in response assessment was the presence or absence of cutaneous tumors and extracutaneous disease manifestations. All tumor responses required confirmation over at least two assessments separated by at least four weeks. A partial response was defined as an improvement of at least 50% in the index lesions without worsening, or development of new cutaneous tumors or non-cutaneous manifestations. A complete clinical response required complete disappearance of all manifestations of disease, but did not require confirmation by biopsy. At the initial dose of 300 mg/m 2 In one post-approval clinical trial with a total of 59 subjects (29 in 300 mg/m 2 2 2 2 The median duration of response in the bexarotene 300 mg/m 2 2 The median time to cutaneous tumor response (the time to cutaneous tumor response for a given subject is defined as the time interval from the first day of bexarotene treatment to the time of the first observation when the subject with subsequent confirmation of response meets criteria for CR, CCR or PR) in the bexarotene 300 mg/m 2 2 2 2

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BEXAROTENE- bexarotene_capsule Product manual source documgent