Drug Interactions between moxifloxacin / triamcinolone and vandetanib

MONITOR CLOSELY: Concomitant administration of corticosteroids may potentiate the risk of tendinitis and tendon rupture associated with fluoroquinolone treatment. The mechanism is unknown. Tendinitis and tendon rupture have most frequently involved the Achilles tendon, although cases involving the rotator cuff (the shoulder), the hand, the biceps, and the thumb have also been reported. Some have required surgical repair or resulted in prolonged disability. Tendon rupture can occur during or up to several months after completion of fluoroquinolone therapy.

MANAGEMENT: Caution is recommended if fluoroquinolones are prescribed in combination with corticosteroids, particularly in patients with other concomitant risk factors (e.g., age over 60 years; recipient of kidney, heart, and/or lung transplant). Patients should be advised to stop taking the fluoroquinolone, avoid exercise and use of the affected area, and promptly contact their physician if they experience pain, swelling, or inflammation of a tendon. In general, fluoroquinolones should only be used to treat conditions that are proven or strongly suspected to be caused by bacteria and only if the benefits outweigh the risks.

GENERALLY AVOID: Vandetanib can cause concentration-dependent prolongation of the QT interval. Theoretically, coadministration with other agents that can prolong the QT interval may result in additive effects and increased risk of ventricular arrhythmias including torsade de pointes and sudden death. In a phase 3 clinical trial where 231 medullary thyroid cancer patients were randomized to receive vandetanib 300 mg once daily, mean change in QTcF (Fridericia-corrected QT interval) from baseline based on the exposure-response relationship was 35 ms for the 300 mg dose. The QTcF increase remained above 30 ms for the duration of the trial (up to 2 years). In addition, 36% of patients experienced greater than 60 ms QTcF increases from baseline and 4.3% had QTcF greater than 500 ms. Vandetanib treatment alone has been associated with reported cases of torsade de pointes, ventricular tachycardia, and sudden death. In general, the risk of an individual agent or a combination of agents causing ventricular arrhythmia in association with QT prolongation is largely unpredictable but may be increased by certain underlying risk factors such as congenital long QT syndrome, cardiac disease, and electrolyte disturbances (e.g., hypokalemia, hypomagnesemia, hypocalcemia). Moreover, the extent of drug-induced QT prolongation is dependent on the particular drug(s) involved and dosage(s) of the drug(s).

MANAGEMENT: The use of vandetanib in combination with other medications that can prolong the QT interval should generally be avoided. Should treatment with other QT-prolonging drugs be required, the manufacturer recommends more frequent monitoring of the ECG as well as serum potassium, magnesium, and calcium levels. Given vandetanib's half-life of 19 days, ECGs and serum electrolytes should typically be obtained at baseline, at 2 to 4 weeks and 8 to 12 weeks after starting treatment, and every 3 months thereafter. Vandetanib should not be started if baseline QTcF is greater than 450 ms, and treatment should be interrupted if QTcF is greater than 500 ms. Treatment may resume when QTcF returns to less than 450 ms, but at a reduced dosage. In addition, hypokalemia, hypomagnesemia, and/or hypocalcemia must be corrected prior to vandetanib administration. Since diarrhea is a common side effect of vandetanib and may cause electrolyte imbalances, ECG and electrolyte levels should also be monitored more frequently when diarrhea develops. Vandetanib treatment should be stopped in the presence of severe diarrhea. Treatment may resume when diarrhea improves, but at a reduced dosage. Following any dosage reduction, or any interruption of treatment greater than 2 weeks, QT assessment and serum electrolytes should be conducted as described previously. Patients should be advised to seek medical attention if they experience symptoms that could indicate the occurrence of torsade de pointes such as dizziness, lightheadedness, fainting, palpitations, irregular heartbeat, shortness of breath, or syncope. Because of the drug's long half-life, adverse reactions including a prolonged QT interval may not resolve quickly, thus appropriate monitoring is necessary.