Drug Interactions between PC-CAP and quizartinib

GENERALLY AVOID: Quizartinib can cause dose- and concentration-dependent prolongation of the QT interval. Theoretically, coadministration with other agents that can prolong the QT interval may increase the risk of ventricular arrhythmias including torsade de pointes and sudden death. In a clinical study where 265 patients with newly diagnosed FLT3-ITD-positive acute myeloid leukemia (AML) were treated with quizartinib (38% for >=6 months; 30% for >1 year) in combination with chemotherapy, 2.3% had a Fridericia-corrected QT interval (QTcF) greater than 500 ms and 10% had a QTcF increase from baseline greater than 60 ms. Overall, QT prolongation of any grade occurred in 14% of the quizartinib patients (compared to 4.1% of patients treated with placebo and chemotherapy), and 4% required dose reductions of quizartinib due to QT prolongation. The study excluded patients with a QTcF >=450 ms or other risk factors for QT prolongation or arrhythmic events. Based on an analysis of the exposure-response relationship, quizartinib is predicted to produce a median increase of 18 and 24 ms in the QTcF at steady-state peak plasma concentration during maintenance therapy at the 26.5 mg and 53 mg dose levels, respectively. Across premarketing clinical trials, torsade de pointes arrhythmia was reported in approximately 0.2%, cardiac arrest in 0.6% (including 0.4% with a fatal outcome), and ventricular fibrillation in 0.1% of the total 1,081 patients with AML treated with quizartinib. These severe cardiac events occurred predominantly during the induction phase. 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, hypomagnesemias). In addition, the extent of drug-induced QT prolongation is dependent on the particular drug(s) involved and dosage(s) of the drug(s).

MANAGEMENT: Coadministration of quizartinib with other drugs that can prolong the QT interval should generally be avoided. If concomitant use is required, more frequent monitoring with electrocardiograms (ECGs) is recommended to guide continued treatment. All patients treated with quizartinib should have ECGs performed as well as potassium and magnesium serum levels measured prior to initiation of treatment, at regular intervals during treatment, and when clinically indicated such as following dose escalation or during episodes of diarrhea or vomiting. Do not initiate quizartinib or escalate the dose if QTcF interval is greater than 450 ms. In addition, hypokalemia and hypomagnesemia should be corrected before and during treatment. If QTcF increases to greater than 480 ms during treatment, reduce the dose, interrupt therapy, or permanently discontinue quizartinib as clinically appropriate in accordance with the prescribing information. Patients should be advised to seek prompt medical attention if they experience symptoms that could indicate the occurrence of torsade de pointes such as dizziness, lightheadedness, fainting, palpitation, irregular heart rhythm, shortness of breath, or syncope. Quizartinib should be permanently discontinued in patients who experience torsade de pointes, polymorphic ventricular tachycardia, or QT prolongation with signs or symptoms of life-threatening arrhythmia.

One study has reported that coadministration of caffeine and aspirin lead to a 25% increase in the rate of appearance and 17% increase in maximum concentration of salicylate in the plasma. A significantly higher area under the plasma concentration time curve of salicylate was also reported when both drugs were administered together. The exact mechanism of this interaction has not been specified. Physicians and patients should be aware that coadministration of aspirin and caffeine may lead to higher salicylate levels faster.