XOSPATA is indicated for the treatment of adult patients who have relapsed or refractory acute myeloid leukemia (AML) with a FMS-like tyrosine kinase 3 (FLT3) mutation as detected by an FDA-approved test.
Ritchie EK, Cella D, Fabbiano F, et al. Leuk Lymphoma 2023;64(5):938-50.
The information below is not included in the US Prescribing Information for XOSPATA® (gilteritinib) and is a summary of the publication.
Because adjustments for multiple comparisons were not made in the analysis of the PRO data, the results shown here need cautious interpretation and should not be used to make comparisons between treatment arms.
Results were not powered or statistically significant. Additionally, early discontinuation resulted in the use of descriptive statistics. These results may represent chance findings and should be understood as descriptive and exploratory.
A conceptual model was developed and used to conduct interviews of adult patients with AML. During the interviews, patients rated the level of disturbance of their symptoms and associated impacts, which enabled the identification of salient symptoms and impacts.1
Salient symptoms were nausea, vomiting, anemia, pain, fatigue, weakness, shortness of breath, fever, infection, mouth sores, and vision problems; salient impacts included anxiety, depression, fear, worry about remission, and decreased ability to maintain social/familial roles. These symptoms informed the selection of the PRO instruments.1
For all PRO instruments, the completion rate at each study visit was calculated as the number of patients returning evaluable forms divided by the total number of patients expected to complete the PRO assessment at the study visit. Limited data in the salvage chemotherapy (SC) arm past 2 cycles prevented longitudinal comparison.
Note: Due to treatment discontinuation, the number of patients who completed PRO questionnaires decreased substantially by Cycle 6 in the XOSPATA arm and by Cycle 2 in the SC arm. As a result, PRO data collection for patients receiving high-intensity salvage chemotherapy did not extend beyond 2 cycles, with only 15 patients in the SC arm having PRO data at Cycle 2.1
*Post-baseline item scores and domain scores were classified as “improvement,” “no change” or “deterioration” relative to baseline scores at each cycle according to the change threshold, which was based on published values denoting clinically meaningful change or on a distribution-based method in the absence of a published value.1
References: 1. Ritchie EK, Cella D, Fabbiano F, et al. Patient-reported outcomes from the phase 3 ADMIRAL trial in patients with FLT3-mutated relapsed/refractory AML. Leuk Lymphoma. 2023;64(5):938-950. 2. Supplement to: Ritchie EK, Cella D, Fabbiano F, et al. Patient-reported outcomes from the phase 3 ADMIRAL trial in patients with FLT3-mutated relapsed/refractory AML. Leuk Lymphoma. 2023;64(5):938-950. 3. Peipert JD, Yount SE, Efficace F, et al. Validation of the Functional Assessment of Cancer Therapy-Leukemia instrument in patients with acute myeloid leukemia who are not candidates for intensive therapy. Cancer 2020;126(15):3542-51.
The information below is not included in the US Prescribing Information for XOSPATA® (gilteritinib) and is a summary of the publication. Because adjustments for multiple comparisons were not made in the analysis of the PRO data, the results shown here need cautious interpretation and should not be used to make comparisons between treatment arms. Results were not powered or statistically significant. Additionally, early discontinuation resulted in the use of descriptive statistics. These results may represent chance findings and should be understood as descriptive and exploratory.
Based on evaluable BFI questionnaires on Day 8 and Day 15 of Cycle 1: Patients in the XOSPATA arm experienced directionally less fatigue compared to the SC arm according to the BFI worst level of fatigue rating.1
All statistical analyses of PRO data were performed on the ITT population,† all of whom provided PRO data at baseline.1
†Defined as all patients who were randomly assigned to treatment.1
The information below is not included in the US Prescribing Information for XOSPATA® (gilteritinib) and is a summary of the publication. Because adjustments for multiple comparisons were not made in the analysis of the PRO data, the results shown here need cautious interpretation and should not be used to make comparisons between treatment arms. Results were not powered or statistically significant. Additionally, early discontinuation resulted in the use of descriptive statistics. These results may represent chance findings and should be understood as descriptive and exploratory.
Patients in both the XOSPATA and SC arms had similar mean FACT-Leu total scores at baseline, and the FACT-Leu subscale scores were generally stable at Day 1 of Cycle 2 in the XOSPATA arm.1
All statistical analyses of PRO data were performed on the ITT population,† all of whom provided PRO data at baseline.1
†Defined as all patients who were randomly assigned to treatment.1
‡A higher score indicates a better PRO result.1,2
§An mEOT assessment was established and defined as either the EOT assessment which occurred within 7 days of the last PRO assessment if the patient discontinued or died, or as the last PRO assessment before the data cutoff date for patients still on treatment.1
The information below is not included in the US Prescribing Information for XOSPATA® (gilteritinib) and is a summary of the publication. Because adjustments for multiple comparisons were not made in the analysis of the PRO data, the results shown here need cautious interpretation and should not be used to make comparisons between treatment arms. Results were not powered or statistically significant. Additionally, early discontinuation resulted in the use of descriptive statistics. These results may represent chance findings and should be understood as descriptive and exploratory.
At baseline, mean EQ-5D-5L visual analogue scale (VAS) values were similar between groups.1
Patients in both arms had stable EQ-5D-5L VAS scores throughout the first 2 treatment cycles.1
All statistical analyses of PRO data were performed on the ITT population,† all of whom provided PRO data at baseline.1
†Defined as all patients who were randomly assigned to treatment.1
‡A higher score indicates a better PRO result.1,2
§An mEOT assessment was established and defined as either the EOT assessment which occurred within 7 days of the last PRO assessment if the patient discontinued or died, or as the last PRO assessment before the data cutoff date for patients still on treatment.1
The information below is not included in the US Prescribing Information for XOSPATA® (gilteritinib) and is a summary of the publication. Because adjustments for multiple comparisons were not made in the analysis of the PRO data, the results shown here need cautious interpretation and should not be used to make comparisons between treatment arms. Results were not powered or statistically significant. Additionally, early discontinuation resulted in the use of descriptive statistics. These results may represent chance findings and should be understood as descriptive and exploratory.
Patients in both arms had similar mean dyspnea scores and functional limitation scores at baseline, indicating mild shortness of breath and minimal functional impact of dyspnea, respectively.1
All statistical analyses of PRO data were performed on the ITT population,† all of whom provided PRO data at baseline.1
†Defined as all patients who were randomly assigned to treatment.1
§An mEOT assessment was established and defined as either the EOT assessment which occurred within 7 days of the last PRO assessment if the patient discontinued or died, or as the last PRO assessment before the data cutoff date for patients still on treatment.1
||A higher score indicates a worse PRO result.1,2
The information below is not included in the US Prescribing Information for XOSPATA® (gilteritinib) and is a summary of the publication. Because adjustments for multiple comparisons were not made in the analysis of the PRO data, the results shown here need cautious interpretation and should not be used to make comparisons between treatment arms. Results were not powered or statistically significant. Additionally, early discontinuation resulted in the use of descriptive statistics. These results may represent chance findings and should be understood as descriptive and exploratory.
Patients entering the ADMIRAL trial had mild symptoms of dizziness and mouth sores. Although more patients in the XOSPATA arm (50%) than in the SC arm (10%) reported an increase in dizziness at the mEOT assessment, most patients in both treatment arms reported no change in dizziness (62.9%) and/or mouth sores (73.3%) after 2 treatment cycles.1
All statistical analyses of PRO data were performed on the ITT population,† all of whom provided PRO data at baseline.1
†Defined as all patients who were randomly assigned to treatment.1
§An mEOT assessment was established and defined as either the EOT assessment which occurred within 7 days of the last PRO assessment if the patient discontinued or died, or as the last PRO assessment before the data cutoff date for patients still on treatment.1
||A higher score indicates a worse PRO result.1,2
EOT=end-of-treatment; ITT=intention-to-treat; mEOT=modified end-of-treatment.
The information below is not included in the US Prescribing Information for XOSPATA® (gilteritinib) and is a summary of the publication. Because adjustments for multiple comparisons were not made in the analysis of the PRO data, the results shown here need cautious interpretation and should not be used to make comparisons between treatment arms. Results were not powered or statistically significant. Additionally, early discontinuation resulted in the use of descriptive statistics. These results may represent chance findings and should be understood as descriptive and exploratory.
¶The association between PRO measures and OS was evaluated based on the HR for the PRO variable and was calculated as the HR for death per X-point change in the PRO score, with X corresponding to the threshold value denoting a clinically meaningful change.1
INDICATION
IMPORTANT SAFETY INFORMATION
INDICATION
XOSPATA is indicated for the treatment of adult patients who have relapsed or refractory acute myeloid leukemia (AML) with a FMS-like tyrosine kinase 3 (FLT3) mutation as detected by an FDA-approved test.
WARNING: DIFFERENTIATION SYNDROME
Patients treated with XOSPATA have experienced symptoms of differentiation syndrome, which can be fatal or life-threatening if not treated. Symptoms may include fever, dyspnea, hypoxia, pulmonary infiltrates, pleural or pericardial effusions, rapid weight gain or peripheral edema, hypotension, or renal dysfunction. If differentiation syndrome is suspected, initiate corticosteroid therapy and hemodynamic monitoring until symptom resolution.
Contraindications
XOSPATA is contraindicated in patients with hypersensitivity to gilteritinib or any of the excipients. Anaphylactic reactions have been observed in clinical trials.
Warnings and Precautions
Differentiation Syndrome (See BOXED WARNING) 3% of 319 patients treated with XOSPATA in the clinical trials experienced differentiation syndrome. Differentiation syndrome is associated with rapid proliferation and differentiation of myeloid cells and may be life-threatening or fatal if not treated. Symptoms and other clinical findings of differentiation syndrome in patients treated with XOSPATA included fever, dyspnea, pleural effusion, pericardial effusion, pulmonary edema, hypotension, rapid weight gain, peripheral edema, rash, and renal dysfunction. Some cases had concomitant acute febrile neutrophilic dermatosis. Differentiation syndrome occurred as early as 1 day and up to 82 days after XOSPATA initiation and has been observed with or without concomitant leukocytosis. If differentiation syndrome is suspected, initiate dexamethasone 10 mg IV every 12 hours (or an equivalent dose of an alternative oral or IV corticosteroid) and hemodynamic monitoring until improvement. Taper corticosteroids after resolution of symptoms and administer corticosteroids for a minimum of 3 days. Symptoms of differentiation syndrome may recur with premature discontinuation of corticosteroid treatment. If severe signs and/or symptoms persist for more than 48 hours after initiation of corticosteroids, interrupt XOSPATA until signs and symptoms are no longer severe.
Posterior Reversible Encephalopathy Syndrome (PRES) 1% of 319 patients treated with XOSPATA in the clinical trials experienced posterior reversible encephalopathy syndrome (PRES) with symptoms including seizure and altered mental status. Symptoms have resolved after discontinuation of XOSPATA. A diagnosis of PRES requires confirmation by brain imaging, preferably magnetic resonance imaging (MRI). Discontinue XOSPATA in patients who develop PRES.
Prolonged QT Interval XOSPATA has been associated with prolonged cardiac ventricular repolarization (QT interval). 1% of the 317 patients with a post-baseline QTc measurement on treatment with XOSPATA in the clinical trial were found to have a QTc interval greater than 500 msec and 7% of patients had an increase from baseline QTc greater than 60 msec. Perform electrocardiogram (ECG) prior to initiation of treatment with XOSPATA, on days 8 and 15 of cycle 1, and prior to the start of the next two subsequent cycles. Interrupt and reduce XOSPATA dosage in patients who have a QTcF >500 msec. Hypokalemia or hypomagnesemia may increase the QT prolongation risk. Correct hypokalemia or hypomagnesemia prior to and during XOSPATA administration.
Pancreatitis 4% of 319 patients treated with XOSPATA in the clinical trials experienced pancreatitis. Evaluate patients who develop signs and symptoms of pancreatitis. Interrupt and reduce the dose of XOSPATA in patients who develop pancreatitis.
Embryo-Fetal Toxicity XOSPATA can cause embryo-fetal harm when administered to a pregnant woman. Advise females of reproductive potential to use effective contraception during treatment with XOSPATA and for 6 months after the last dose of XOSPATA. Advise males with female partners of reproductive potential to use effective contraception during treatment with XOSPATA and for 4 months after the last dose of XOSPATA. Pregnant women, patients becoming pregnant while receiving XOSPATA or male patients with pregnant female partners should be apprised of the potential risk to the fetus.
Adverse Reactions
Fatal adverse reactions occurred in 2% of patients receiving XOSPATA. These were cardiac arrest (1%) and one case each of differentiation syndrome and pancreatitis. The most frequent (≥5%) nonhematological serious adverse reactions reported in patients were fever (13%), dyspnea (9%), renal impairment (8%), transaminase increased (6%) and noninfectious diarrhea (5%).
7% discontinued XOSPATA treatment permanently due to an adverse reaction. The most common (>1%) adverse reactions leading to discontinuation were aspartate aminotransferase increased (2%) and alanine aminotransferase increased (2%).
The most frequent (≥5%) grade ≥3 nonhematological adverse reactions reported in patients were transaminase increased (21%), dyspnea (12%), hypotension (7%), mucositis (7%), myalgia/arthralgia (7%), and fatigue/malaise (6%).
Other clinically significant adverse reactions occurring in ≤10% of patients included: electrocardiogram QT prolonged (9%), hypersensitivity (8%), pancreatitis (5%), cardiac failure (4%), pericardial effusion (4%), acute febrile neutrophilic dermatosis (3%), differentiation syndrome (3%), pericarditis/myocarditis (2%), large intestine perforation (1%), and posterior reversible encephalopathy syndrome (1%).
Lab Abnormalities Shifts to grades 3-4 nonhematologic laboratory abnormalities in XOSPATA treated patients included phosphate decreased (14%), alanine aminotransferase increased (13%), sodium decreased (12%), aspartate aminotransferase increased (10%), calcium decreased (6%), creatine kinase increased (6%), triglycerides increased (6%), creatinine increased (3%), and alkaline phosphatase increased (2%).
Drug Interactions
Combined P-gp and Strong CYP3A Inducers Concomitant use of XOSPATA with a combined P-gp and strong CYP3A inducer decreases XOSPATA exposure which may decrease XOSPATA efficacy. Avoid concomitant use of XOSPATA with combined
P-gp and strong CYP3A inducers.
Strong CYP3A inhibitors Concomitant use of XOSPATA with a strong CYP3A inhibitor increases XOSPATA exposure. Consider alternative therapies that are not strong CYP3A inhibitors. If the concomitant use of these inhibitors is considered essential for the care of the patient, monitor patient more frequently for XOSPATA adverse reactions. Interrupt and reduce XOSPATA dosage in patients with serious or life-threatening toxicity.
Drugs that Target 5HT2B Receptor or Sigma Nonspecific Receptor Concomitant use of XOSPATA may reduce the effects of drugs that target the 5HT2B receptor or the sigma nonspecific receptor (e.g., escitalopram, fluoxetine, sertraline). Avoid concomitant use of these drugs with XOSPATA unless their use is considered essential for the care of the patient.
P-gp, BCRP, and OCT1 Substrates Based on in vitro data, gilteritinib is a P-gp, breast cancer resistant protein (BCRP), and organic cation transporter 1 (OCT1) inhibitor. Coadministration of gilteritinib may increase the exposure of P-gp, BCRP, and OCT1 substrates, which may increase the incidence and severity of adverse reactions of these substrates. For P-gp, BCRP, or OCT1 substrates where small concentration changes may lead to serious adverse reactions, decrease the dose or modify the dosing frequency of such substrate and monitor for adverse reactions as recommended in the respective prescribing information.
Specific Populations
Lactation Advise women not to breastfeed during treatment with XOSPATA and for 2 months after the last dose.
Please see Full Prescribing Information including BOXED WARNING for additional safety information.
References: 1. Ritchie EK, Cella D, Fabbiano F, et al. Patient-reported outcomes from the phase 3 ADMIRAL trial in patients with FLT3-mutated relapsed/refractory AML. Leuk Lymphoma 2023;64(5):938-50. 2. Supplement to: Ritchie EK, Cella D, Fabbiano F, et al. Patient-reported outcomes from the phase 3 ADMIRAL trial in patients with FLT3-mutated relapsed/refractory AML. Leuk Lymphoma 2023;64(5):938-50.
INDICATION
IMPORTANT SAFETY INFORMATION
INDICATION
XOSPATA is indicated for the treatment of adult patients who have relapsed or refractory acute myeloid leukemia (AML) with a FMS-like tyrosine kinase 3 (FLT3) mutation as detected by an FDA-approved test.
WARNING: DIFFERENTIATION SYNDROME
Patients treated with XOSPATA have experienced symptoms of differentiation syndrome, which can be fatal or life-threatening if not treated. Symptoms may include fever, dyspnea, hypoxia, pulmonary infiltrates, pleural or pericardial effusions, rapid weight gain or peripheral edema, hypotension, or renal dysfunction. If differentiation syndrome is suspected, initiate corticosteroid therapy and hemodynamic monitoring until symptom resolution.
Contraindications
XOSPATA is contraindicated in patients with hypersensitivity to gilteritinib or any of the excipients. Anaphylactic reactions have been observed in clinical trials.
Warnings and Precautions
Differentiation Syndrome (See BOXED WARNING) 3% of 319 patients treated with XOSPATA in the clinical trials experienced differentiation syndrome. Differentiation syndrome is associated with rapid proliferation and differentiation of myeloid cells and may be life-threatening or fatal if not treated. Symptoms and other clinical findings of differentiation syndrome in patients treated with XOSPATA included fever, dyspnea, pleural effusion, pericardial effusion, pulmonary edema, hypotension, rapid weight gain, peripheral edema, rash, and renal dysfunction. Some cases had concomitant acute febrile neutrophilic dermatosis. Differentiation syndrome occurred as early as 1 day and up to 82 days after XOSPATA initiation and has been observed with or without concomitant leukocytosis. If differentiation syndrome is suspected, initiate dexamethasone 10 mg IV every 12 hours (or an equivalent dose of an alternative oral or IV corticosteroid) and hemodynamic monitoring until improvement. Taper corticosteroids after resolution of symptoms and administer corticosteroids for a minimum of 3 days. Symptoms of differentiation syndrome may recur with premature discontinuation of corticosteroid treatment. If severe signs and/or symptoms persist for more than 48 hours after initiation of corticosteroids, interrupt XOSPATA until signs and symptoms are no longer severe.
Posterior Reversible Encephalopathy Syndrome (PRES) 1% of 319 patients treated with XOSPATA in the clinical trials experienced posterior reversible encephalopathy syndrome (PRES) with symptoms including seizure and altered mental status. Symptoms have resolved after discontinuation of XOSPATA. A diagnosis of PRES requires confirmation by brain imaging, preferably magnetic resonance imaging (MRI). Discontinue XOSPATA in patients who develop PRES.
Prolonged QT Interval XOSPATA has been associated with prolonged cardiac ventricular repolarization (QT interval). 1% of the 317 patients with a post-baseline QTc measurement on treatment with XOSPATA in the clinical trial were found to have a QTc interval greater than 500 msec and 7% of patients had an increase from baseline QTc greater than 60 msec. Perform electrocardiogram (ECG) prior to initiation of treatment with XOSPATA, on days 8 and 15 of cycle 1, and prior to the start of the next two subsequent cycles. Interrupt and reduce XOSPATA dosage in patients who have a QTcF >500 msec. Hypokalemia or hypomagnesemia may increase the QT prolongation risk. Correct hypokalemia or hypomagnesemia prior to and during XOSPATA administration.
Pancreatitis 4% of 319 patients treated with XOSPATA in the clinical trials experienced pancreatitis. Evaluate patients who develop signs and symptoms of pancreatitis. Interrupt and reduce the dose of XOSPATA in patients who develop pancreatitis.
Embryo-Fetal Toxicity XOSPATA can cause embryo-fetal harm when administered to a pregnant woman. Advise females of reproductive potential to use effective contraception during treatment with XOSPATA and for 6 months after the last dose of XOSPATA. Advise males with female partners of reproductive potential to use effective contraception during treatment with XOSPATA and for 4 months after the last dose of XOSPATA. Pregnant women, patients becoming pregnant while receiving XOSPATA or male patients with pregnant female partners should be apprised of the potential risk to the fetus.
Adverse Reactions
Fatal adverse reactions occurred in 2% of patients receiving XOSPATA. These were cardiac arrest (1%) and one case each of differentiation syndrome and pancreatitis. The most frequent (≥5%) nonhematological serious adverse reactions reported in patients were fever (13%), dyspnea (9%), renal impairment (8%), transaminase increased (6%) and noninfectious diarrhea (5%).
7% discontinued XOSPATA treatment permanently due to an adverse reaction. The most common (>1%) adverse reactions leading to discontinuation were aspartate aminotransferase increased (2%) and alanine aminotransferase increased (2%).
The most frequent (≥5%) grade ≥3 nonhematological adverse reactions reported in patients were transaminase increased (21%), dyspnea (12%), hypotension (7%), mucositis (7%), myalgia/arthralgia (7%), and fatigue/malaise (6%).
Other clinically significant adverse reactions occurring in ≤10% of patients included: electrocardiogram QT prolonged (9%), hypersensitivity (8%), pancreatitis (5%), cardiac failure (4%), pericardial effusion (4%), acute febrile neutrophilic dermatosis (3%), differentiation syndrome (3%), pericarditis/myocarditis (2%), large intestine perforation (1%), and posterior reversible encephalopathy syndrome (1%).
Lab Abnormalities Shifts to grades 3-4 nonhematologic laboratory abnormalities in XOSPATA treated patients included phosphate decreased (14%), alanine aminotransferase increased (13%), sodium decreased (12%), aspartate aminotransferase increased (10%), calcium decreased (6%), creatine kinase increased (6%), triglycerides increased (6%), creatinine increased (3%), and alkaline phosphatase increased (2%).
Drug Interactions
Combined P-gp and Strong CYP3A Inducers Concomitant use of XOSPATA with a combined P-gp and strong CYP3A inducer decreases XOSPATA exposure which may decrease XOSPATA efficacy. Avoid concomitant use of XOSPATA with combined
P-gp and strong CYP3A inducers.
Strong CYP3A inhibitors Concomitant use of XOSPATA with a strong CYP3A inhibitor increases XOSPATA exposure. Consider alternative therapies that are not strong CYP3A inhibitors. If the concomitant use of these inhibitors is considered essential for the care of the patient, monitor patient more frequently for XOSPATA adverse reactions. Interrupt and reduce XOSPATA dosage in patients with serious or life-threatening toxicity.
Drugs that Target 5HT2B Receptor or Sigma Nonspecific Receptor Concomitant use of XOSPATA may reduce the effects of drugs that target the 5HT2B receptor or the sigma nonspecific receptor (e.g., escitalopram, fluoxetine, sertraline). Avoid concomitant use of these drugs with XOSPATA unless their use is considered essential for the care of the patient.
P-gp, BCRP, and OCT1 Substrates Based on in vitro data, gilteritinib is a P-gp, breast cancer resistant protein (BCRP), and organic cation transporter 1 (OCT1) inhibitor. Coadministration of gilteritinib may increase the exposure of P-gp, BCRP, and OCT1 substrates, which may increase the incidence and severity of adverse reactions of these substrates. For P-gp, BCRP, or OCT1 substrates where small concentration changes may lead to serious adverse reactions, decrease the dose or modify the dosing frequency of such substrate and monitor for adverse reactions as recommended in the respective prescribing information.
Specific Populations
Lactation Advise women not to breastfeed during treatment with XOSPATA and for 2 months after the last dose.
Please see Full Prescribing Information including BOXED WARNING for additional safety information.
References: 1. Ritchie EK, Cella D, Fabbiano F, et al. Patient-reported outcomes from the phase 3 ADMIRAL trial in patients with FLT3-mutated relapsed/refractory AML. Leuk Lymphoma 2023;64(5):938-50. 2. Supplement to: Ritchie EK, Cella D, Fabbiano F, et al. Patient-reported outcomes from the phase 3 ADMIRAL trial in patients with FLT3-mutated relapsed/refractory AML. Leuk Lymphoma 2023;64(5):938-50.