Dosing & Uses
Dosage Forms & Strengths
tablet
- 3mg
- 4mg
- 5mg
Urothelial Carcinoma
Indicated for locally advanced or metastatic urothelial carcinoma that has fibroblast growth factor receptor-2 (FGFR2) or FGFR3 genetic alterations and progressed during or following at least 1 line of prior platinum-containing chemotherapy, including within 12 months of neoadjuvant or adjuvant platinum-containing chemotherapy
8 mg PO qDay initially; increase to 9 mg PO qDay based on serum phosphate (PO4) levels and tolerability at 14-21 days
Continue until disease progression or unacceptable toxicity
Increase dose to 9 mg qDay if serum phosphate level <5.5 mg/dL and there are no ocular disorders or Grade ≥2 adverse reactions
Dosage Modifications
Dose reduction schedule
-
9 mg/day reduction schedule
- First: 8 mg/day
- Second: 6 mg/day
- Third: 5 mg/day
- Fourth: 4 mg/day
- Fifth: Stop drug if fifth reduction needed
-
8 mg/day reduction schedule
- First: 6 mg/day
- Second: 5 mg/day
- Third: 4 mg/day
- Fourth: Stop drug if fourth reduction needed
Hyperphosphatemia
- In all patients, restrict phosphate intake to 600-800 mg/day; if serum phosphate >7 mg/dL, consider adding oral phosphate binder until serum phosphate level returns to <5.5 mg/dL
-
Phosphate levels and dosage
- 5.6-6.9 mg/dL (1.8-2.3 mmol/L): Continue at current dose
- 7-9 mg/dL (2.3-2.9 mmol/L): Withhold; reassess weekly until phosphate <5.5 mg/dL (or baseline), then resume at same dose level; implement dose reduction if hyperphosphatemia lasts >1 week
- >9 mg/dL (>2.9 mmol/L): Withhold; reassess weekly until phosphate <5.5 mg/dL (or baseline), then restart at 1 dose level lower
- >10 mg/dL (>3.2 mmol/L) or significantly altered baseline renal function or Grade 3 hypercalcemia: Withhold; reassess weekly until phosphate <5.5 mg/dL (or baseline), then restart at 2 dose levels lower
Central serous retinopathy or retinal pigment epithelial detachment (CSR/RPED)
-
Grade 1
- Asymptomatic; clinical or diagnostic observations only
- Withhold drug until resolution
- If resolves within 4 weeks, resume at the next lower dose level; then, if no recurrence for a month, consider reescalation
- If stable for 2 consecutive eye examinations, but not resolved, resume at the next lower dose level
-
Grade 2
- Visual acuity 20/40 or better or ≤3 lines of decreased vision from baseline
- Withhold until resolution
- If resolves within 4 weeks, may resume at the next lower dose level
-
Grade 3
- Visual acuity worse than 20/40 or >3 lines of decreased vision from baseline
- Withhold until resolution
- If resolves within 4 weeks, may resume 2 dose levels lower
- If recurs, consider permanent discontinuation
-
Grade 4
- Visual acuity 20/200 or worse in affected eye
- Permanently discontinue
Other adverse reactions
- Grade 3: Withhold drug until resolves to Grade 1 or baseline, then may resume dose 1 level lower
- Grade 4: Permanently discontinue
Renal impairment
- Mild or moderate (eGFR 30-89 mL/min/1.73 m2): No clinically meaningful trends in the pharmacokinetics observed
- Severe or dialysis: Unknown
Hepatic impairment
- Mild (TB ≤ULN and AST >ULN or TB >1 to 1.5x ULN and any AST): No clinically meaningful trends in the pharmacokinetics observed
- Moderate or severe: Unknown
Dosing Considerations
Patient selection
- Selection based on the presence of susceptible FGFR genetic alterations in tumor specimens as detected by an FDA-approved companion diagnostic
- Information on FDA-approved tests for the detection of FGFR genetic alterations in urothelial cancer is available at: http://www.fda.gov/CompanionDiagnostics
Monitoring
- Assess serum phosphate levels 14-21 days after initiating
- Monitor phosphate levels monthly for hyperphosphatemia
Safety and efficacy not established
Interactions
Interaction Checker
No Results
Contraindicated
Serious - Use Alternative
Significant - Monitor Closely
Minor
Adverse Effects
>10% (All Grades)
Phosphate increased (76%)
Stomatitis (56%)
Fatigue (54%)
Creatinine increased (52%)
Diarrhea (47%)
Dry mouth (45%)
ALT increased (41%)
Alkaline phosphatase increased (41%)
Onycholysis (41%)
Sodium decreased (40%)
Decreased appetite (38%)
Albumin decreased (37%)
Dysgeusia (37%)
Hemoglobin decreased (35%)
Dry skin (34%)
AST increased (30%)
Magnesium decreased (30%)
Constipation (28%)
Dry eye (28%)
Palmar-plantar erythrodysesthesia (26%)
Alopecia (26%)
Phosphate decreased (24%)
Abdominal pain (23%)
Calcium increased (22%)
Nausea (21%)
Musculoskeletal pain (20%)
Platelets decreased (19%)
Leukocytes decreased (17%)
Blurred vision (17%)
Paronychia (17%)
Urinary tract infection (17%)
Potassium increased (16%)
Weight decreased (16%)
Pyrexia (14%)
Vomiting (13%)
Nail discoloration (11%)
Conjunctivitis (11%)
Oropharyngeal pain (11%)
Hematuria (11%)
Arthralgia (11%)
>10% (Grades 3-4)
Sodium decreased (16%)
1-10% (All Grades)
Neutrophils decreased (10%)
Fasting glucose increased (10%)
Lacrimation increased (10%)
Dyspnea (10%)
1-10% (Grades 3-4)
Fatigue (10%)
Onycholysis (10%)
Phosphate decreased (9%)
Stomatitis (9%)
Palmar-plantar erythrodysesthesia (6%)
Urinary tract infection (6%)
Dry eye (6%)
Creatinine increased (5%)
Hemoglobin decreased (3%)
Calcium increased (3%)
Paronychia (3%)
Neutrophils decreased (2%)
Diarrhea (2%)
Abdominal pain (2%)
Vomiting (2%)
Dyspnea (2%)
Hematuria (2%)
Platelets decreased (1%)
Phosphate increased (1%)
ALT increased (1%)
Alkaline phosphatase increased (1%)
Magnesium decreased (1%)
Constipation (1%)
Nausea (1%)
Pyrexia (1%)
Dysgeusia (1%)
Oropharyngeal pain (1%)
Warnings
Contraindications
None
Cautions
Based on mechanism of action and animal studies, can cause fetal harm if administered to pregnant women
Ocular disorders
- Can cause ocular disorders, including central serous retinopathy/retinal pigment epithelial detachment (CSR/RPED), resulting in visual-field defect
- Perform monthly ophthalmological examinations during first 4 months of treatment and then every 3 months afterwards, and urgently at any time for visual symptoms
- Dry eye symptoms are common; all patients should receive dry eye prophylaxis with ocular demulcents as needed
Hyperphosphatemia
- Increases in serum phosphate levels are a pharmacodynamic effect as a consequence of FGFR inhibition
- Median onset time for any grade event of hyperphosphatemia was 20 days
- Monitor for hyperphosphatemia and follow dose modifications when required
- Patients may require phosphate binders during treatment
Drug interaction overview
-
Moderate CYP2C9 or strong CYP3A4 inhibitors
- Coadministration increases erdafitinib plasma concentrations
- Consider alternant therapiesIf coadministration is unavoidable, monitor closely for adverse reactions and consider dose modifications accordingly
- If the moderate CYP2C9 or strong CYP3A4 inhibitor is discontinued, erdafitinib dose may be increased
-
Strong CYP2C9 or CYP3A4 inducers
- Coadministration may significantly decrease erdafitinib plasma concentrations and efficacy
- Avoid coadministration
-
Moderate CYP2C9 or CYP3A4 inducers
- Coadministration may significantly decrease erdafitinib plasma concentrations and efficacyIf moderate inducer must be coadministered at start of treatment, start at 8-mg/day dose, with potential to increase to 9 mg/day based on serum phosphate levels on Days 14-21 and tolerability
- If moderate inducer must be coadministered after the initial dose increase period based on serum phosphate levels and tolerability, increase erdafitinib dose up to 9 mg
- When a moderate inducer discontinued, continue erdafitinib at same dose, in absence of drug-related toxicity
-
Serum phosphate level-altering drugs
- Coadministration with other serum phosphate level-altering agents may increase or decrease serum phosphate levels
- Avoid coadministration before initial dose increase period (Days 14-21)
-
CYP3A4 substrates
- Erdafitinib may altered plasma concentrations of CYP3A4 substrates, leading to either loss of activity or increased toxicity of the substrate
- Avoid coadministration with sensitive CYP3A4 substrates with narrow therapeutic indices
-
OCT2 substrates
- Erdafitinib may increase plasma concentrations of OCT2 substrates
- Consider alternant therapies
-
P-gp substrates
- Erdafitinib may increase plasma concentrations of P-gp substrates
- If coadministration unavoidable, separate administration by at least 6 hr before or after administration of P-gp substrates with narrow therapeutic index
Pregnancy
Pregnancy
Based on the mechanism of action and findings in animal reproduction studies, can cause fetal harm when administered to pregnant women
Animal studies: Administration to pregnant rats during organogenesis caused malformations and embryofetal death at maternal exposures that were less than the human exposures at the maximum recommended human dose based on AUC
Pregnancy testing recommended for females of reproductive potential before initiating erdafitinib
Infertility: Based on findings in animal studies, may impair fertility in females of reproductive potential
Contraception
- Females: Advise females of reproductive potential to use effective contraception during treatment and for 1 month after last dose
- Males: Advise male patients with female partners of reproductive potential to use effective contraception during treatment and for 1 month after last dose
Lactation
No data are available on presence in human milk, effects on breastfed children, or on milk production
Owing to potential serious adverse reactions in breastfed children, advise lactating women not to breastfeed during treatment and for 1 month following last dose
Pregnancy Categories
A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk. C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done. D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk. X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist. NA: Information not available.Pharmacology
Mechanism of Action
Fibroblast growth factor receptor (FGFR) inhibitor; FGFRs are a family of receptor tyrosine kinases
In vitro, erdafitinib inhibits FGFR phosphorylation and signaling and decreases cell viability in cell lines expressing FGFR genetic alterations, including point mutations, amplifications, and fusions
Absorption
Peak plasma time: 2.5 hr
Peak plasma concentration: 1399 ng/mL
AUC: 29,268 ng·hr/mL
Distribution
Vd: 29 L
Protein bound: 99.8%; primarily to alpha-1-acid glycoprotein
Metabolism
Primarily metabolized by CYP2C9 and CYP3A4
Contribution of CYP2C9 and CYP3A4 in total clearance of erdafitinib is estimated to be 39% and 20%, respectively
Unchanged erdafitinib was the major drug-related moiety in plasma; there were no circulating metabolites
Elimination
Half-life: 59 hr
Total clearance: 0.362 L/hr
Excretion: 69% feces (19% unchanged); 19% urine (19% unchanged)
Pharmacogenomics
CYP2C9 poor metabolizers
- CYP2C9*3/*3 genotype: Erdafitinib systemic exposure predicted to be 50% higher
- Estimated to be present in 0.4-3% of the population among various ethnic groups
Administration
Oral Administration
May take with or without food
Swallow tablets whole; do not chew or crush
Vomited dose: If vomiting occur any time after taking erdafitinib, the next dose should be taken the next day
Missed dose
- Take missed dose as soon as possible on the same day
- Resume regular daily dose schedule the next day
- Extra tablets should not be taken to make up for the missed dose
Storage
Store at 20-25ºC (68-77ºF); excursions permitted to 15-30ºC (59-86ºF)
Images
Patient Handout
Formulary
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