Drug Interaction Report

MONITOR: Coadministration with inhibitors of the organic cation 2 (OCT2) or multidrug and toxin extrusion 1 (MATE1) transporters may theoretically increase the plasma concentrations of tipiracil, an in vitro substrate of these transporters. Tipiracil is a thymidine phosphorylase inhibitor and is administered in combination with the antineoplastic thymidine-based nucleoside analog, trifluridine, to increase the systemic exposure of trifluridine. Increased levels of tipiracil may therefore further increase the systemic exposure of trifluridine, and the risk of adverse effects such as myelosuppression and gastrointestinal toxicity.

MANAGEMENT: Although the clinical significance is unknown, caution is advised if the combination of tipiracil and trifluridine is used concomitantly with drugs that are inhibitors of OCT2 and/or MATE1. Patients should be monitored for adverse effects including excessive bone marrow suppression and gastrointestinal toxicity. Patients should be advised to contact their physician if they develop signs and symptoms of myelosuppression such as pallor, dizziness, fatigue, lethargy, fainting, easy bruising or bleeding, or signs of infection such as fever, chills, sore throat, body aches, and other influenza-like symptoms.

GENERALLY AVOID: Alcohol may potentiate some of the pharmacologic effects of CNS-active agents. Use in combination may result in additive central nervous system depression and/or impairment of judgment, thinking, and psychomotor skills.

MANAGEMENT: Patients receiving CNS-active agents should be warned of this interaction and advised to avoid or limit consumption of alcohol. Ambulatory patients should be counseled to avoid hazardous activities requiring complete mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.

ADJUST DOSING INTERVAL: Administration of trifluridine-tipiracil with a standardized high-fat, high-calorie meal has been shown to decrease trifluridine peak plasma concentration (Cmax) as well as tipiracil Cmax and systemic exposure (AUC) by approximately 40% compared to administration in a fasting state in patients with cancer given a single 35 mg/m2 dose. No change in trifluridine AUC was observed.

MANAGEMENT: Based on the observed correlation between increases in the Cmax of trifluridine and decreases in neutrophil counts, trifluridine-tipiracil should be taken within one hour after completion of the morning and evening meals.