(vis moe DEG ib)
Basal cell carcinoma, metastatic or locally advanced: Treatment of metastatic basal cell carcinoma, or locally-advanced basal cell carcinoma that has recurred following surgery or in patients who are not candidates for surgery, and not candidates for radiation therapy
US labeling: There are no contraindications listed in the manufacturer 's labeling.
Canadian labeling: Hypersensitivity to vismodegib or any component of the formulation; pregnancy or females at risk of becoming pregnant; breast-feeding; male patients or female patients of childbearing potential who do not comply with the Erivedge Pregnancy Prevention Program; children and adolescents <18 years of age.
Vismodegib can cause embryofetal death or severe birth defects when administered to a pregnant woman. Vismodegib is embryotoxic, fetotoxic, and teratogenic in animals. Teratogenic effects included severe midline defects, missing digits, and other irreversible malformations.
Verify pregnancy status of females of reproductive potential within 7 days prior to initiating vismodegib therapy. Advise females of reproductive potential to use effective contraception during and after vismodegib therapy. Advise males of the potential risk of vismodegib exposure through semen and to use condoms with a pregnant partner or a female partner of reproductive potential. Advise pregnant women of the potential risks to a fetus.
Basal cell carcinoma, metastatic or locally advanced: Oral: 150 mg once daily until disease progression or unacceptable toxicity.
Missed doses: If a dose is missed, do not make up; resume dosing with the next scheduled dose.
No dosage adjustment necessary.
US labeling: No dosage adjustment necessary.
Canadian labeling:
Mild to moderate impairment: No dosage adjustment necessary; use with caution.
Severe impairment: Use is not recommended due to limited data in this patient population.
Oral: May be taken with or without food. Swallow capsules whole; do not open or crush.
Hazardous agent; use appropriate precautions for handling and disposal (meets NIOSH 2014 criteria). NIOSH recommends single gloving for administration of intact capsules (NIOSH 2014).
Store at 20 ‚ °C to 25 ‚ °C (68 ‚ °F to 77 ‚ °F); excursions permitted to 15 ‚ °C to 30 ‚ °C (59 ‚ °F to 86 ‚ °F).
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Capsule, Oral:
Erivedge: 150 mg
There are no known significant interactions.
Pregnancy test within 1 week prior to treatment initiation.
Canadian labeling: Pregnancy testing (minimum sensitivity of 25 milliunits/mL) within 1 week prior to treatment initiation, monthly during treatment (including during treatment interruptions), and for 24 months after discontinuation; CBC with differential and comprehensive metabolic panel at baseline and every 4 weeks thereafter; liver function tests; skin examination routinely during therapy.
>10%:
Central nervous system: Fatigue (40%)
Dermatologic: Alopecia (64%)
Endocrine & metabolic: Amenorrhea (30%)
Gastrointestinal: Dysgeusia (55%), weight loss (45%), nausea (30%), diarrhea (29%), decreased appetite (25%), constipation (21%), vomiting (14%), ageusia (11%)
Neuromuscular & skeletal: Muscle spasm (72%), arthralgia (16%)
1% to 10%:
Endocrine & metabolic: Hyponatremia (grade 3: 4%), hypokalemia (grade 3: 1%)
Renal: Azotemia (grade 3: 2%)
<1% (Limited to important or life-threatening): Cholestasis, hepatic injury, hepatitis, rhabdomyolysis
In patients with mild hepatic impairment (normal total bilirubin and AST >ULN or total bilirubin >1 to 1.5 times ULN), the mean systemic vismodegib exposure was increased 24% as compared to patients with normal hepatic function. Systemic exposure was increased 31% in patients with moderate impairment (total bilirubin >1.5 to 3 times ULN) and decreased 14% in patients with severe impairment (total bilirubin >3 to 10 times ULN), respectively, compared to patients with normal hepatic function.
Concerns related to adverse effects:
- Amenorrhea: Amenorrhea was observed in women of reproductive potential; it is unknown if this is reversible.
- Cardiovascular events: Cardiovascular events (eg, cardiac failure, atrial fibrillation, left ventricular dysfunction, restrictive cardiomyopathy, myocardial infarction, hypertension, and orthostatic hypotension) have been observed during treatment (Erivedge Canadian product monograph 2016). All cardiac events ≥ grade 3 occurred in patients with a history of significant cardiac disease.
- Cutaneous squamous cell cancer (cuSCC): Cases of cuSCC have been reported. Patients with advanced basal cell carcinoma are at risk for developing cuSCC; monitor during treatment.
- Gastrointestinal toxicity: Nausea, vomiting, diarrhea, constipation, abdominal pain, and decreased appetite may occur (usually grade 1 or 2).
Disease-related concerns:
- Hepatic impairment: Vismodegib metabolism and elimination are primarily hepatic. Elevated liver function tests (ALT, AST, total bilirubin, and alkaline phosphatase) have been observed; cases of cholestasis, hepatitis, and hepatocellular injury have also been reported. Preexisting hepatic impairment, malignancy, concomitant hepatotoxic medications, and systemic infection may be risk factors for hepatotoxicity. Monitor liver function tests; may require treatment interruption or discontinuation (Erivedge Canadian product monograph 2016).
- Renal impairment: Population pharmacokinetic analyses demonstrate that creatinine clearance (range: 30 to 80 mL/minute) does not have a clinically meaningful effect on systemic exposure; urinary excretion is <5%.
Concurrent drug therapy issues:
- Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
Special populations:
- Pregnancy: [US Boxed Warnings]: May result in severe birth defects or embryo-fetal death. Teratogenic effects (severe midline defects, missing digits, and other irreversible malformations), embryotoxic, and fetotoxic events were observed in animal reproduction studies. Verify pregnancy status (in females of reproductive potential) within 7 days prior to initiating treatment and advise patients (female and male) of the risk of birth defects, the need for contraception and risk of exposure through semen and to use condoms with a pregnant partner or a female partner of childbearing potential.
Special handling:
- Hazardous agent: Use appropriate precautions for handling and disposal (meets NIOSH 2014 criteria).
Other warnings/precautions:
- Blood donations: Advise patients not to donate blood or blood products during vismodegib treatment and for at least 7 months after the last vismodegib dose. The Canadian labeling recommends patients not donate blood or blood products during treatment (including treatment interruptions) and for 24 months after discontinuation.
- Semen donations: Vismodegib is present in semen, although the amount of drug in semen that may cause embryotoxicity and/or fetotoxicity is not known. Advise patients not to donate sperm during vismodegib treatment and for 3 months after the last vismodegib dose.
- Toxicity duration: In a study of vismodegib in patients with basal cell nevus syndrome (not an approved use), with discontinuation of vismodegib treatment, taste alteration and muscle cramps abated within 1 month, and scalp and body hair began to regrow within 3 months (Tang 2012).
[US Boxed Warning]: May result in severe birth defects or embryo-fetal death. Teratogenic effects (severe midline defects, missing digits, and other irreversible malformations), embryotoxic, and fetotoxic events were observed in animal reproduction studies when administered in doses less than the normal human dose. Based on its mechanism of action adverse effects on pregnancy would be expected. [US Boxed Warning]: Verify pregnancy status (in females of reproductive potential) within 7 days prior to initiating treatment and advise patients (female and male) of the risk of birth defects, the need for contraception and risk of exposure through semen and to use condoms with a pregnant partner or a female partner of childbearing potential. In females of childbearing potential, obtain pregnancy test within 7 days prior to treatment initiation; after the negative pregnancy test, initiate highly effective contraception prior to the first vismodegib dose and continue during treatment and for 7 months after the final dose. During treatment (including treatment interruptions) and for 3 months after treatment, male patients should not donate sperm and should use condoms with spermicide (even after vasectomy) if their partner is of childbearing potential.
Women exposed to vismodegib during pregnancy (directly or via seminal fluid) are encouraged to participate in the Erivedge Pregnancy Pharmacovigilance program by contacting the Genentech Adverse Event Line (1-888-835-2555). Pregnancies occurring during or within 7 months after treatment should be reported to the Genentech Adverse Event Line.
Canadian labeling: Females of childbearing potential should use 2 simultaneous forms of effective contraception beginning at least 4 weeks prior to treatment initiation, during treatment (including treatment interruptions), and for 24 months after discontinuation. Pregnancy testing should be performed within 7 days prior to treatment initiation, monthly during treatment (including treatment interruptions) and for 24 months after discontinuation. For females of child bearing potential, a new prescription is required each month to allow for monthly pregnancy testing. Any suspected exposure (directly or via seminal fluid) during pregnancy should be immediately reported to the Erivedge Pregnancy Prevention Program (EPPP) at 1-888-748-8926.
Basal cell cancer is associated with mutations in Hedgehog pathway components. Hedgehog regulates cell growth and differentiation in embryogenesis; while generally not active in adult tissue, Hedgehog mutations associated with basal cell cancer can activate the pathway resulting in unrestricted proliferation of skin basal cells. Vismodegib is a selective Hedgehog pathway inhibitor which binds to and inhibits Smoothened homologue (SMO), the transmembrane protein involved in Hedgehog signal transduction.
Vd: 16.4 to 26.6 L
Males: In a small pharmacokinetic study, the average vismodegib concentration in semen was 6.5% of the average steady state plasma concentration on day 8
Metabolized by oxidation, glucuronidation, and pyridine ring cleavage, although >98% of circulating components are as the parent drug
Feces (82%); urine (4%)
~2.4 days (Graham, 2011)
Continuous daily dosing: ~4 days; Single dose: ~12 days
>99%; primarily to serum albumin and alpha1 acid glycoprotein (AAG)
- Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
- Patient may experience nausea, vomiting, alopecia, constipation, lack of appetite, loss of strength and energy, weight loss, diarrhea, muscle pain, joint pain, or change in taste (HCAHPS).
- Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.