Drug Interaction Report

MONITOR: Fostemsavir can cause dose-related 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. At therapeutic doses, fostemsavir did not prolong the QT interval to any clinically relevant extent. At 4 times the recommended dosage (2400 mg twice daily), the mean QTcF increase was 11.2 milliseconds (upper 90% confidence interval 13.3 milliseconds). The observed increase in QTcF was concentration-dependent on temsavir, the active moiety of fostemsavir. Therefore, the risk may be increased during concomitant treatment with potent CYP450 3A4 and/or P-glycoprotein (P-gp) inhibitors, which may increase systemic exposure to temsavir. 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). 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: Caution is recommended if fostemsavir is used in combination with other drugs that can prolong the QT interval. Consider obtaining electrocardiogram and serum electrolyte levels prior to initiating fostemsavir therapy and periodically thereafter, particularly in patients with risk factors for torsade de pointes and/or receiving one or more potent CYP450 3A4 inhibitors (e.g., azole antifungal agents; cobicistat; protease inhibitors; ketolide and certain macrolide antibiotics; ceritinib; idelalisib; nefazodone) or P-gp inhibitors (e.g., cyclosporine; diltiazem; quinidine; quinine; tacrolimus; verapamil). Correct hypokalemia and/or hypomagnesemia before starting treatment and as indicated during treatment, as they may be risk factors for ventricular arrhythmias. 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.

GENERALLY AVOID: Grapefruit juice may significantly increase the plasma concentrations of midostaurin. The proposed mechanism is inhibition of CYP450 3A4-mediated first-pass metabolism in the gut wall by certain compounds present in grapefruit. In general, the effect of grapefruit juice is concentration-, dose- and preparation-dependent, and can vary widely among brands. Certain preparations of grapefruit juice (e.g., high dose, double strength) have sometimes demonstrated potent inhibition of CYP450 3A4, while other preparations (e.g., low dose, single strength) have typically demonstrated moderate inhibition. Ketoconazole, a potent CYP450 3A4 inhibitor, has been shown to increase midostaurin systemic exposure (AUC) by greater than 10-fold in healthy volunteers. Increased exposure to midostaurin may increase the risk of adverse effects such as nausea, vomiting, diarrhea, edema, hyperglycemia, hyperuricemia, QT prolongation, neutropenia, lymphopenia, thrombocytopenia, and anemia.

ADJUST DOSING INTERVAL: Food enhances the oral bioavailability of midostaurin. Relative to fasting conditions, midostaurin systemic exposure (AUC) increased by approximately 1.2-fold when administered with a standard meal (457 calories; 50 g fat, 21 g proteins, 18 g carbohydrates) and 1.6-fold when administered with a high-fat meal (1007 calories; 66 g fat, 32 g proteins, 64 g carbohydrates), while midostaurin peak plasma concentration (Cmax ) decreased by 20% and 27%, respectively.

MANAGEMENT: The manufacturer recommends taking midostaurin with food. Midostaurin was administered with food in clinical trials. Patients should avoid consumption of grapefruit and grapefruit juice during treatment with midostaurin.