For:
Metastatic Non-Small Cell Lung Cancer (NSCLC) With BRAF V600E Mutation
Important Safety Information

New Primary Malignancies. Cutaneous Malignancies: In the COMBI-d study in patients with unresectable or metastatic melanoma, the incidence of basal cell carcinoma in patients receiving TAFINLAR wit...

See More

Indication TAFINLAR® (dabrafenib) capsules, in combination with MEKINIST® (trametinib) tablets, is indicated for the treatment of patients with metastatic non-small cell lung cancer (NSCLC) with BRAF V600E mutation as detected by an FDA-approved test.

Limitation of Use: TAFINLAR is not indicated for the treatment of patients with wild-type BRAF NSCLC.

Efficacy

Study Design

TAFINLAR + MEKINIST: THE FIRST AND ONLY FDA-APPROVED TARGETED COMBINATION THERAPY FOR PATIENTS WITH BRAF V600E MUTATION-POSITIVE METASTATIC NSCLC1,2

A phase 2, multicenter, 3-cohort, nonrandomized, noncomparative, open-label trial assessed the efficacy and safety of TAFINLAR® (dabrafenib) capsules, alone or in combination with MEKINIST® (trametinib) tablets, in patients with BRAF V600E mutation-positive NSCLC (N=171)1-3*

The 3 cohorts were sequentially enrolled and studied in the following order: Cohort A (previously treated monotherapy), Cohort B (previously treated combination therapy), followed by Cohort C (first-line combination therapy).

TAFINLAR + MEKINIST study design

Major efficacy outcomes studied: ORR and DOR1-3†
Additional efficacy outcomes: DCR and PFS

TAFINLAR + MEKINIST: Your first choice for patients with BRAF V600E mutation-positive metastatic NSCLC

bid, twice daily; DCR, disease control rate; DOR, duration of response; FDA, Food and Drug Administration; NSCLC, non-small cell lung cancer; ORR, overall response rate; PFS, progression-free survival; qd, once daily.
*Patients had no prior exposure to BRAF or mitogen-activated extracellular signal-regulated kinase (MEK) inhibitors and did not have epidermal growth factor receptor (EGFR) mutation or anaplastic lymphoma kinase (ALK) rearrangement (unless they had progression on prior tyrosine kinase inhibitor therapy).1,2
The major efficacy outcomes were ORR per Response Evaluation Criteria In Solid Tumors version 1.1 (RECIST v1.1) as assessed by blinded independent review committee and DOR.1,2

Patient Characteristics

PROFILE OF PATIENTS IN TAFINLAR + MEKINIST NSCLC STUDY

Patient characteristics across all 3 cohorts1,2

Profile of patients in TAFINLAR + MEKINIST NSCLC study

ECOG, Eastern Cooperative Oncology Group.

Efficacy in First-Line Patients

PROVEN RESPONSE RATES TO FIRST-LINE, ORAL TARGETED COMBINATION THERAPY IN PATIENTS WITH METASTATIC NSCLC

Efficacy in first-line patients of TAFINLAR + MEKINIST (n=36)1,2

Based on independent review:

TAFINLAR + MEKINIST efficacy in treatment-naïve patients

 

 

Updated non-prespecified analysis (n=36)4,b

  • ORR: 64% (95% CI, 46, 79)
    • CR: 6%
    • PR: 58%
  • Median DOR: 15.2 months (95% CI, 7.8, 23.5)
    • Responders with DOR ≥6 months: 82% (95% CI, 59, 93)5

DCR (exploratory results) (n=36)

  • DCR: 72.2% (95% CI, 54.8, 85.8)5,a
  • Updated non-prespecified analysis
    • DCR: 72% (95% CI, 55, 86)4,b
  • DCR was an exploratory end point that takes into account CR + PR + SD, which may reflect the natural history of disease in an individual patient rather than the therapeutic effect of the treatment

Noncomparative analysis of PFS

  • mPFS: NE (95% CI, 7.0, NE)5,a
    • Percentage of patients with 6-month PFS: 69% (95% CI, 51, 82)a
  • Updated non-prespecified analysis
    • mPFS: 14.6 months (95% CI, 7.0, 22.1)4,b
    • Percentage of patients with 6-month PFS: 69% (95% CI, 51, 82)5,b
  • Due to the nonrandomized, noncomparative nature of the NSCLC study, PFS results are difficult to interpret

aAugust 2016 data cutoff.
bApril 2017 data cutoff.
CR, complete response; DCR, disease control rate; DOR, duration of response; mPFS, median progression-free survival; NE, not estimable; NSCLC, non-small cell lung cancer; ORR, overall response rate; PFS, progression-free survival; PR, partial response; SD, stable disease.

Efficacy in Previously Treated Patients

PROVEN RESPONSE RATES TO ORAL TARGETED COMBINATION THERAPY IN PREVIOUSLY TREATED PATIENTS

Efficacy in previously treated patients (n=57)1,2

Based on independent review:

TAFINLAR + MEKINIST efficacy in previously treated patients 

DCR (exploratory results) (n=57)

  • DCR: 75.4% (95% CI, 62.2, 85.9)5,a
  • DCR was an exploratory end point that takes into account CR + PR + SD, which may reflect the natural history of disease in an individual patient rather than the therapeutic effect of the treatment

Noncomparative analysis of PFS

  • mPFS: 8.6 months (95% CI, 5.2, 16.8)5,a
    • Percentage of patients with 6-month PFS: 56% (95% CI, 42, 68)
  • Due to the nonrandomized, noncomparative nature of the NSCLC study, PFS results are difficult to interpret

TAFINLAR monotherapy in previously treated patients (n=78)1,2

  • ORR was 27% (95% CI, 18, 38), with 1% CR and 26% PR
  • Median DOR was 9.9 months (95% CI, 4.2, NE) among 21 responders, with 52% experiencing DOR ≥6 months

aAugust 2016 data cutoff.
CR, complete response; DCR, disease control rate; DOR, duration of response; mPFS, median progression-free survival; NE, not estimable; NSCLC, non-small cell lung cancer; ORR, overall response rate; PFS, progression-free survival; PR, partial response; SD, stable disease.

References: 1. Tafinlar [prescribing information]. East Hanover, NJ: Novartis Pharmaceuticals Corp; 2018. 2. Mekinist [prescribing information]. East Hanover, NJ: Novartis Pharmaceuticals Corp; 2018. 3. Planchard D, Besse B, Groen HJ, et al. Dabrafenib plus trametinib in patients with previously treated BRAF V600E-mutant metastatic non-small cell lung cancer: an open-label, multicentre phase 2 trial. Lancet Oncol. 2016;17(7):984-993. 4. Planchard D, Smit EF, Groen HJM, et al. Dabrafenib plus trametinib in patients with previously untreated BRAFV600E-mutant metastatic non-small cell lung cancer: an open-label, multicentre phase 2 trial. Lancet Oncol. 2017;18(10):1307-1316. 5. Data on file. Novartis Pharmaceuticals Corp; 2017.

INDICATION

TAFINLAR® (dabrafenib) capsules, in combination with MEKINIST® (trametinib) tablets, is indicated for the treatment of patients with metastatic non-small cell lung cancer (NSCLC) with BRAF V600E mutation as detected by an FDA-approved test.

Limitation of Use: TAFINLAR is not indicated for the treatment of patients with wild-type BRAF NSCLC.

IMPORTANT SAFETY INFORMATION

New Primary Malignancies.

Cutaneous Malignancies: In the COMBI-d study in patients with unresectable or metastatic melanoma, the incidence of basal cell carcinoma in patients receiving TAFINLAR with MEKINIST was 3.3% compared with 6% of patients receiving single-agent TAFINLAR. Among the 7 patients receiving TAFINLAR with MEKINIST who developed basal cell carcinoma, 2 experienced more than 1 occurrence (range: 1 to 3).

In the NSCLC study, cutaneous squamous cell carcinoma (cuSCC) occurred in 3.2% of patients receiving TAFINLAR with MEKINIST.

Perform dermatologic evaluations prior to initiation of therapy, every 2 months while on therapy and for up to 6 months following discontinuation of TAFINLAR. No dose modifications are required in patients who develop new primary cutaneous malignancies.

Noncutaneous Malignancies: In the NSCLC study, noncutaneous malignancies occurred in 1.1% of patients receiving TAFINLAR with MEKINIST. Monitor patients closely for signs or symptoms of noncutaneous malignancies. Permanently discontinue TAFINLAR for monomeric G protein (RAS)-mutation–positive noncutaneous malignancies. No dose modification of MEKINIST is required for patients who develop noncutaneous malignancies.

Tumor Promotion in BRAF Wild-type NSCLC. In vitro experiments have demonstrated paradoxical activation of mitogen-activated protein kinase (MAPK) signaling and increased cell proliferation in BRAF wild-type cells that are exposed to BRAF inhibitors. Confirm evidence of BRAF V600E mutation status prior to initiation of therapy.

Hemorrhage. Hemorrhages, including major hemorrhages defined as symptomatic bleeding in a critical area or organ, can occur. In the COMBI-d study, the incidence of hemorrhagic events in patients treated with the combination was 19% compared with 15% of patients receiving single-agent TAFINLAR. Gastrointestinal hemorrhage occurred in 6% of patients treated with the combination compared with 3% of patients receiving single-agent TAFINLAR. In the NSCLC study, fatal hemorrhagic events occurred in 2.2% of patients receiving TAFINLAR with MEKINIST.

Permanently discontinue TAFINLAR and MEKINIST for all grade 4 hemorrhagic events and for any grade 3 hemorrhagic events that do not improve. Withhold TAFINLAR and MEKINIST for grade 3 hemorrhagic events; if improved, resume at the next lower dose level.

Colitis and Gastrointestinal Perforation. Colitis and gastrointestinal perforation, including fatal outcomes, can occur. Across clinical trials with MEKINIST, colitis occurred in 0.6% of patients and gastrointestinal perforation occurred in 0.3% of patients, respectively. Monitor patients closely for colitis and gastrointestinal perforations.

Venous Thromboembolism. In the NSCLC study, deep venous thrombosis (DVT) and pulmonary embolism (PE) occurred in 4.3% (4/93) of patients receiving TAFINLAR with MEKINIST.

Advise patients to immediately seek medical care if they develop symptoms of DVT or PE such as shortness of breath, chest pain, or arm or leg swelling. Permanently discontinue MEKINIST and TAFINLAR for life-threatening PE. Withhold MEKINIST for uncomplicated DVT or PE for up to 3 weeks; if improved, MEKINIST may be resumed at a lower dose.

Cardiomyopathy. Cardiomyopathy, including cardiac failure, can occur. In the NSCLC clinical trial, cardiomyopathy, defined as a decrease in left ventricular ejection fraction (LVEF) below the institutional lower limit of normal (LLN) with an absolute decrease in LVEF >10% below baseline, occurred in 9% of patients receiving TAFINLAR with MEKINIST and resulted in dose interruption and permanent discontinuation of MEKINIST in 5% and 2.2% of patients, respectively. Dose interruption and permanent discontinuation of TAFINLAR occurred in 3.2% and 2.2% of patients, respectively. Cardiomyopathy resolved in 4 of 8 patients receiving TAFINLAR with MEKINIST.

Assess LVEF by an echocardiogram or a multigated acquisition (MUGA) scan before initiation of therapy, 1 month after initiation then at 2- to 3-month intervals while on treatment. Withhold MEKINIST for up to 4 weeks, and continue TAFINLAR at the same dose if absolute LVEF value decreases by 10% from pretreatment values and is <LLN. For symptomatic cardiomyopathy or persistent asymptomatic LV dysfunction of >20% from baseline that is below LLN that does not resolve within 4 weeks, permanently discontinue MEKINIST and withhold TAFINLAR. Resume TAFINLAR at the same dose on the recovery of cardiac function to at least the institutional LLN for LVEF and absolute decrease ≤10% compared with baseline.

Ocular Toxicities.

Retinal Vein Occlusion (RVO): Across all clinical trials including MEKINIST, the incidence of RVO was 0.2%. RVO may lead to macular edema, decreased visual function, neovascularization, and glaucoma.

Urgently (within 24 hours) perform ophthalmologic evaluation for patient-reported loss of vision or other visual disturbances. Permanently discontinue MEKINIST in patients with documented RVO.

Retinal Pigment Epithelial Detachment (RPED): RPED can occur. Retinal detachments may be bilateral and multifocal, occurring in the central macular region of the retina or elsewhere in the retina. In the COMBI-d study, routine monitoring of patients to detect asymptomatic RPED was not conducted; therefore, the true incidence of this finding is unknown.

Perform ophthalmologic evaluation periodically, and at any time a patient reports visual disturbances. Withhold MEKINIST if RPED is diagnosed. If resolution of the RPED is documented on repeat ophthalmologic evaluation within 3 weeks, resume MEKINIST. Reduce the dose or discontinue MEKINIST if no improvement after 3 weeks.

Uveitis: Uveitis occurred in 2% of patients treated with the combination across metastatic melanoma trials. Treatment employed in clinical trials included steroid and mydriatic ophthalmic drops.

Monitor patients for visual signs and symptoms of uveitis (eg, change in vision, photophobia, and eye pain). If iritis is diagnosed, administer ocular therapy and continue TAFINLAR without dose modification; for severe uveitis or iridocyclitis, interrupt TAFINLAR and treat as clinically indicated. Permanently discontinue TAFINLAR for persistent grade 2 or greater uveitis of >6 weeks duration.

Interstitial Lung Disease (ILD). In clinical trials of MEKINIST as a single agent, ILD or pneumonitis occurred in 2% of patients. In the NSCLC study, 2.2% of patients receiving TAFINLAR with MEKINIST developed pneumonitis.

Withhold MEKINIST in patients presenting with new or progressive pulmonary symptoms and findings including cough, dyspnea, hypoxia, pleural effusion, or infiltrates pending clinical investigations. Permanently discontinue MEKINIST for patients diagnosed with treatment-related ILD or pneumonitis.

Serious Febrile Drug Reactions. The incidence and severity of pyrexia are increased when the combination is used compared with TAFINLAR as a single agent.

In patients treated with the combination in the metastatic melanoma studies, the incidence of fever was 54% and serious febrile reactions and fever of any severity complicated by severe rigors/chills, hypotension, dehydration, renal failure, or syncope occurred in 17%. About half of the patients on combination therapy who experienced pyrexia had 3 or more discrete episodes. Fever was complicated by severe chills/rigors in 0.4%, dehydration in 1.8%, renal failure in 0.5%, and syncope in 0.7% in patients receiving the combination.

Withhold TAFINLAR for fever of 101.3ºF or higher. Withhold MEKINIST for fever higher than 104ºF. Withhold TAFINLAR and MEKINIST for any serious febrile reaction or fever complicated by hypotension, rigors or chills, dehydration, or renal failure, and evaluate for signs and symptoms of infection. Monitor serum creatinine and other evidence of renal function during and following severe pyrexia. Refer to the Prescribing Information for either agent for recommended dose modifications. Administer antipyretics as secondary prophylaxis when resuming TAFINLAR and/or MEKINIST if the patient had a prior episode of severe febrile reaction or fever associated with complications. Administer corticosteroids (eg, prednisone 10 mg daily) for at least 5 days for second or subsequent pyrexia if temperature does not return to baseline within 3 days of onset of pyrexia, or for pyrexia associated with complications such as dehydration, hypotension, renal failure, or severe chills/rigors, and there is no evidence of active infection.

Serious Skin Toxicity. Across clinical trials of the combination in unresectable metastatic melanoma, serious skin toxicity occurred in 0.7% of patients.

In the COMBI-d study, the overall incidence of any skin toxicity was 55% for patients receiving the combination. No serious or severe cases of skin toxicity occurred in patients treated with the combination. Reductions in the dose of MEKINIST were required in 5% of patients receiving the combination, and no patient required permanent discontinuation of TAFINLAR or MEKINIST for skin toxicity.

Withhold TAFINLAR and MEKINIST for intolerable or severe skin toxicity. TAFINLAR and MEKINIST may be resumed at lower doses in patients with improvement or recovery from skin toxicity within 3 weeks.

Hyperglycemia. In the COMBI-d study, 27% of patients with a history of diabetes receiving the combination and 13% of patients receiving single-agent TAFINLAR required more intensive hypoglycemic therapy. The incidence of grade 3 and grade 4 hyperglycemia based on laboratory values was 5% and 0.5% of patients treated with the combination, respectively. For patients receiving single-agent TAFINLAR, 4.3% of patients had grade 3 hyperglycemia based on laboratory values and no patients had grade 4 hyperglycemia.

Monitor serum glucose levels upon initiation, and as clinically appropriate in patients with preexisting diabetes or hyperglycemia.

Glucose-6-Phosphate Dehydrogenase Deficiency. TAFINLAR, which contains a sulfonamide moiety, confers a potential risk of hemolytic anemia in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Closely observe patients with G6PD deficiency for signs of hemolytic anemia.

Embryo-fetal Toxicity. TAFINLAR and MEKINIST both can cause fetal harm when administered to a pregnant woman. Advise female patients of reproductive potential to use highly effective nonhormonal contraception during treatment, and for 4 months after treatment, since TAFINLAR can render hormonal contraceptives ineffective. Advise patients to contact their health care provider if they become pregnant, or if pregnancy is suspected, while taking TAFINLAR and MEKINIST.

Most Common Adverse Reactions. In the NSCLC clinical trial, the most commonly occurring adverse reactions (≥20%) in patients receiving the combination were pyrexia (55%), fatigue (51%), nausea (45%), vomiting (33%), diarrhea (32%), dry skin (31%), decreased appetite (29%), edema (28%), rash (28%), chills (23%), hemorrhage (23%), cough (22%), and dyspnea (20%). The most common grade 3 or 4 adverse reactions (incidence ≥2%) were pyrexia (5%), fatigue (5%), dyspnea (5%), hemorrhage (3.2%), rash (3.2%), vomiting (3.2%), and diarrhea (2.2%).

Other Clinically Important Adverse Reactions. The other clinically important adverse reactions observed in ≤10% of patients with NSCLC receiving the combination were pancreatitis and tubulointerstitial nephritis.

Laboratory Abnormalities. In the NSCLC clinical trial, the most common treatment-emergent laboratory abnormalities occurring at ≥20% of patients receiving the combination were hyperglycemia (71%), increased blood alkaline phosphatase (64%), increased aspartate aminotransferase (61%), hyponatremia (57%), leukopenia (48%), anemia (46%), neutropenia (44%), lymphopenia (42%), hypophosphatemia (36%), increased alanine aminotransferase (32%), and creatinine (21%). The most common grade 3 or 4 laboratory abnormalities (incidence ≥10%) were hyponatremia (17%), lymphopenia (14%), and anemia (10%).

Please see full Prescribing Information for TAFINLAR and full Prescribing Information for MEKINIST.