RYDAPT SIDE EFFECTS

Generic Name: midostaurin capsules
Brand Name: Rydapt
Drug Class: Antineoplastic Tyrosine Kinase Inhibitors

Last updated on MDtodate: 10/10/2022

SIDE EFFECTS

The following serious adverse reactions are described elsewhere in the labeling:

Pulmonary Toxicity

Clinical Trials Experience

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.

Acute Myeloid Leukemia

The safety evaluation of RYDAPT (50 mg twice daily with food) in patients with newly diagnosed FLT3 mutated AML is based on a randomized, double-blind, trial of RYDAPT (n = 345) or placebo (n = 335) with chemotherapy [see Clinical Studies]. The overall median duration of exposure was 42 days (range 2 to 576 days) for patients in the RYDAPT plus chemotherapy arm versus 34 days (range 1 to 465 days) for patients in the placebo plus chemotherapy arm. On the RYDAPT plus chemotherapy arm, 35% of patients completed induction and consolidation therapy, compared to 25% of patients on the placebo plus chemotherapy arm.

The most frequent (incidence greater than or equal to 20%) adverse drug reactions (ADRs) in the RYDAPT plus chemotherapy arm were febrile neutropenia, nausea, mucositis, vomiting, headache, petechiae, musculoskeletal pain, epistaxis, device-related infection, hyperglycemia, and upper respiratory tract infections. The most frequent Grade 3/4 adverse reactions (incidence ≥ 10%) were febrile neutropenia, device-related infection and mucositis.

The most frequent serious adverse reaction (≥ 10%) in patients in the RYDAPT plus chemotherapy arm was febrile neutropenia (16%), which occurred at a similar rate in the placebo arm (16%).

Discontinuation due to any adverse reaction occurred in 9% of patients in the RYDAPT arm versus 6% in the placebo arm. The most frequent (> 1%) Grade 3/4 adverse reactions leading to discontinuation in the RYDAPT arm was renal insufficiency (1%).

Excluding deaths due to disease progression, no fatal adverse reactions occurred in the study. Overall, the most frequent non-treatment related cause of death in the RYDAPT plus chemotherapy arm was sepsis (2%) and occurred at a similar rate in the placebo arm (2%).

Table 1 presents the frequency category of adverse reactions reported in the randomized trial in patients with newly diagnosed FLT3 mutated AML. Adverse reactions are listed according to body system. Within each body system, the adverse reactions are ranked by frequency, with the most frequent reactions first. Table 3 presents the key laboratory abnormalities from the same randomized trial in patients with newly diagnosed FLT3 mutated AML.

Table 1: Common Adverse Reactions (≥ 10% Incidence and ≥ 2% More Frequent on the Midostaurin Arm) of Patients With Acute Myeloid Leukemia in Study 1

Adverse Reactions	All Grades		Grades ≥ 3
Adverse Reactions	RYDAPT + chemo n = 229¹ %	Placebo + chemo n = 226¹ %	RYDAPT + chemo n = 345¹ %	Placebo + chemo n = 335¹ %
Gastrointestinal disorders
Nausea	83	70	6	10
Mucositis^a	66	62	11	13
Vomiting	61	53	3	5
Hemorrhoids	15	11	1	0
Blood and lymphatic system disorders
Febrile neutropenia	83	81	84	83
Petechiae	36	27	1	1
Nervous system disorders
Headache^a	46	38	3	3
Musculoskeletal and connective tissue disorders
Musculoskeletal pain^a	33	31	5	2
Arthralgia	14	8	<1	<1
Respiratory, thoracic and mediastinal disorders
Epistaxis	28	24	3	1
Infections and infestations
Device-related infection	24	17	16	10
Upper respiratory tract infection^a	20	15	4	3
Investigations
Hyperglycemia^a	20	17	7	6
Activated partial thromboplastin time prolonged	13	8	3	2
Skin and subcutaneous tissue disorders
Hyperhidrosis	14	8	0	0
Renal and urinary disorders
Renal insufficiency^a	12	9	5	3
Psychiatric disorders
Insomnia	12	8	0	<1
¹For trial sites in North America, only Grades 3 and 4 were collected. ^aGrouped terms: Upper respiratory tract infections: e.g., nasopharyngitis, upper respiratory tract infections, sinusitis. Mucositis: e.g., radiation mucositis, stomatitis, laryngeal pain. Musculoskeletal pain: e.g., back pain, bone pain, pain in extremity. Renal insufficiency: e.g., blood creatinine increased, renal failure, acute kidney injury. Hyperglycemia: mainly hyperglycemia.

Other notable adverse reactions occurring in < 10% of patients treated with RYDAPT but at least 2% more frequently than in the placebo group included:

Infections and infestations: Cellulitis^a (7%), fungal infection^a (7%)
Metabolism and nutrition disorders: Hyperuricemia (8%)
Nervous system disorders: Tremor (4%)
Eye disorders: Eyelid edema (3%)
Cardiac disorders: Hypertension^a (8%), pericardial effusion (4%)
Respiratory, thoracic and mediastinal disorders: pleural effusion (6%)
Skin and subcutaneous tissue disorders: Dry skin (7%)
General disorders and administration site conditions: Thrombosis^a (5%)
Investigations: Weight increased (7%), hypercalcemia (3%)

^aGrouped terms:

Thrombosis: e.g., thrombosis in device, thrombosis.
Cellulitis: e.g., cellulitis, erysipelas.
Fungal infection: e.g., Bronchopulmonary aspergillosis, pneumonia fungal, splenic infection fungal, hepatic candidiasis.

Table 2: New or Worsening Laboratory Abnormalities (≥ 10% Incidence and ≥ 2% More Frequent on the Midostaurin Arm) Reported in Patients With Acute Myeloid Leukemia on Study 1

Laboratory Abnormality	RYDAPT (50 mg twice daily) N = 345 All Grades %	RYDAPT (50 mg twice daily) N = 345 Grade 3/4 %	Placebo N = 335 All Grades %	Placebo N = 335 Grade 3/4 %
Alanine aminotransferase increased	71	20	69	16
Hypernatremia	21	1	15	2
Hypocalcemia	74	7	70	8

In Study 1, 205 patients (120 in RYDAPT arm and 85 in placebo arm) who remained in remission following completion of consolidation continued to receive either single agent RYDAPT or placebo for a median of 11 months (range 0.5 to 17 months) with 69 in the RYDAPT arm and 51 in the placebo completing 12 treatment cycles. Common adverse reactions (greater than or equal to 5% difference between the RYDAPT and placebo arms) reported for these patients included nausea (47% vs 18%), hyperglycemia (20% vs 13%) and vomiting (19% vs 5%).

Systemic Mastocytosis

Two single-arm, open-label multicenter trials (Study 2 and Study 3) evaluated the safety of RYDAPT (100 mg twice daily with food) as a single agent in 142 adult patients total with ASM, SM-AHN, or MCL. The median age was 63 (range 24 to 82), 63% had an ECOG performance status of 0 or 1, and 75% had no hepatic impairment (bilirubin and AST ≤ ULN) at baseline. The median duration of exposure to RYDAPT was 11.4 months (range 0 to 81 months), with 34% treated for ≥ 24 months.

The most frequent adverse reactions (≥ 20%), excluding laboratory terms, were nausea, vomiting, diarrhea, edema, musculoskeletal pain, abdominal pain, fatigue, upper respiratory tract infection, constipation, pyrexia, headache, and dyspnea (Table 4). Grade≥ 3 adverse reactions reported in ≥ 5%, excluding laboratory terms, were fatigue, sepsis, gastrointestinal hemorrhage, pneumonia, diarrhea, febrile neutropenia, edema, dyspnea, nausea, vomiting, abdominal pain, and renal insufficiency (Table 4).

Adverse reactions led to dose modifications (interruption or reduction) in 56% of patients. Among these, the most frequent adverse reactions (> 5%) were gastrointestinal symptoms, QT prolongation, neutropenia, pyrexia, thrombocytopenia, gastrointestinal hemorrhage, lipase increase, and fatigue. The median time to first dose modification for toxicity was 1.6 months, with 75% of dose modifications first occurring within 5 months of starting treatment.

Treatment discontinuation due to adverse reactions occurred in 21% of patients. The most frequent adverse reactions causing treatment discontinuation included infection, nausea or vomiting, QT prolongation, and gastrointestinal hemorrhage.

Serious adverse reactions were reported in 68% of patients, most commonly (≥ 20%) due to infections and gastrointestinal disorders.

On-treatment deaths unrelated to the underlying malignancy occurred in 16 patients (11%), most commonly from infection (sepsis or pneumonia), followed by cardiac events. Of the on-treatment deaths from disease progression, 4 were also attributable to infection.

Table 3 summarizes the adverse reactions reported in ≥ 10% of the patients with advanced SM.

Table 3: Adverse Reactions Reported in ≥ 10% of Patients With Advanced Systemic Mastocytosis (Study 2 and Study 3)

Adverse Reaction^a	RYDAPT (100 mg twice daily) N = 142
Adverse Reaction^a	All Grades %	Grade ≥ 3 %
Gastrointestinal disorders
Nausea	82	6
Vomiting	68	6
Diarrhea^a	54	8
Abdominal pain^a	34	6
Constipation	29	<1
Gastrointestinal hemorrhage^a	14	9
General disorders and administration site conditions
Edema^a	40	7
Fatigue^a	34	9
Pyrexia	27	4
Infections and infestations
Upper respiratory tract infection^a	30	1
Urinary tract infection^a	16	3
Pneumonia^a	10	8
Herpesvirus infection^a	10	1
Musculoskeletal and connective tissue disorders
Musculoskeletal pain^a	35	4
Arthralgia	19	2
Nervous system disorders
Headache^a	26	1
Dizziness	13	0
Respiratory, thoracic and mediastinal disorders
Dyspnea^a	23	7
Cough^a	18	<1
Pleural effusion	13	4
Epistaxis	12	3
Skin and subcutaneous disorders
Rash^a	14	3
Investigations
QT prolonged	11	<1
Psychiatric disorders
Insomnia	11	0
Renal disorders
Renal insufficiency^a	11	5
Toxicity was graded per National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE) version 3. Represents adverse reactions, excluding laboratory terms, occurring up to 28 days after last midostaurin dose, regardless of baseline grade. ^aGrouped terms: Upper respiratory tract infection: e.g., nasopharyngitis, upper respiratory tract infections. Urinary tract infection: e.g., urinary tract infection, cystitis. Pneumonia: e.g., pneumonia, lung infection. Herpesvirus infection: e.g., oral herpes, herpes zoster. Headache: e.g., headache, sinus headache. Dyspnea: e.g., dyspnea, bronchospasm, respiratory failure. Cough: e.g., cough, productive cough. Diarrhea: e.g., diarrhea, gastroenteritis, colitis. Abdominal pain: e.g., abdominal pain, abdominal pain upper. Gastrointestinal hemorrhage: e.g., gastrointestinal hemorrhage, hemorrhoidal hemorrhage, duodenal ulcer hemorrhage. Fatigue: e.g., fatigue, asthenia. Rash: e.g., rash, rash maculo-papular, erythema multiforme. Musculoskeletal pain: e.g., back pain, musculoskeletal pain, pain in extremity. Renal insufficiency: e.g., blood creatinine increased, renal failure, acute kidney injury. Edema: e.g., edema, edema peripheral.

Gastrointestinal Toxicities Leading to Treatment Modification

In patients with advanced SM, the median time to onset of nausea was 9 days, with 75% of cases beginning within the first 3 months. The median time to onset of vomiting was 1 month.

Other clinically significant adverse reactions occurring in ≤ 10% of patients included:

Infections and infestations: Sepsis (9%)^a, bronchitis (6%), cellulitis or erysipelas (5%)

Blood and lymphatic system disorders: Febrile neutropenia (8%)

Cardiac disorders: Cardiac failure (6%), myocardial infarction or ischemia (4%)^a

Immune system disorders: Hypersensitivity (4%)^a

Nervous system disorders: Disturbance in attention (7%), tremor (6%), mental status changes (4%)

Ear and labyrinth disorders: Vertigo (5%)

Vascular disorders: Hypotension (9%), hematoma (6%)

Respiratory, thoracic and mediastinal disorders: Oropharyngeal pain (4%), interstitial lung disease or pneumonitis (2%), pulmonary edema (3%)a

Gastrointestinal disorders: Dyspepsia (6%), gastritis (3%)^a

General disorders and administration site conditions: Chills (5%)

Investigations: Weight increased (6%)

Injury, poisoning and procedural complications: Contusion (6%)

^aGrouped terms:

Sepsis: e.g., sepsis, staphylococcal/Enterobacter/Escherichia sepsis
Hypersensitivity: includes one report of anaphylactic shock
Myocardial infarction or ischemia: e.g., myocardial infarction and acute myocardial infarction, angina pectoris
Gastritis: gastritis, gastritis erosive, gastritis hemorrhagic
Pulmonary edema: pulmonary edema, pulmonary congestion

Table 5 summarizes new or worsening laboratory abnormalities. Common (≥ 10%) Grade 3 or higher non-hematologic laboratory abnormalities were hyperglycemia (non-fasting), lipase increase, and hyperuricemia. The most common (≥ 20%) Grade 3 or higher hematologic laboratory abnormalities were lymphopenia, anemia, thrombocytopenia, and neutropenia. Grade 4 hematologic abnormalities occurring in ≥ 5% were thrombocytopenia (13%), neutropenia (8%), anemia (6%), and lymphopenia (6%).

Table 4: Most Common (≥ 20%) New or Worsening Laboratory Abnormalities Reported in Patients With Advanced Systemic Mastocytosis (Study 2 and Study 3)

Test	RYDAPT (100 mg twice daily) N = 142
Test	All Grades %	Grade ≥ 3 %
Hematology
Lymphopenia	66	42
Leukopenia	61	19
Anemia	60	38
Thrombocytopenia	50	27
Neutropenia	49	22
Chemistry
Hyperglycemia^a	80	18
Alk phos increase	39	9
Hypocalcemia	39	2
Lipase increase	37	18
Hyperuricemia	37	11
GGT increase^b	35	9
Hyponatremia	34	5
AST increase	32	3
ALT increase	31	4
Hyperbilirubinemia	29	4
Hypoalbuminemia	27	1
Hypokalemia	25	6
Creatinine increase	25	<1
Hyperkalemia	23	4
Hypophosphatemia	22	1
Amylase increase	20	7
Hypomagnesemia	20	0
Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; GGT, gamma glutamyltransferase. Includes abnormalities occurring up to 28 days after last midostaurin dose, if new or worsened from baseline or if baseline was unknown. ^aNon-fasting. ^bAmong 116 evaluable patients.

SRC: NLM .

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