Glasdegib (Monograph)

Brand name: Daurismo
Drug class: Antineoplastic Agents
- Hedgehog Pathway Inhibitors
- Smoothened Inhibitors
Chemical name: 1-[(2R,4R)-2-(1H-benzimidazol-2-yl)-1-methylpiperidin-4-yl]-3-(4-cyanophenyl)urea
Molecular formula: C₂₁H₂₂N₆O
CAS number: 1095173-27-5

Medically reviewed by Drugs.com on Dec 13, 2021. Written by ASHP.

Introduction

Antineoplastic agent; a hedgehog signaling pathway inhibitor.

Uses for Glasdegib

Acute Myeloid Leukemia

Used in conjunction with low-dose cytarabine for treatment of newly diagnosed acute myeloid leukemia (AML) in patients ≥75 years of age or in those with comorbidities that preclude use of intensive induction chemotherapy; designated an orphan drug by FDA for treatment of AML.

Glasdegib Dosage and Administration

General

Pretreatment Screening

• Verify pregnancy status in women of childbearing potential ≤7 days prior to initiating glasdegib.

• Assess ECG and serum electrolyte concentrations.

• CBC.

• Renal and hepatic function.

• Serum CK.

Patient Monitoring

• Assess ECG approximately 1 week after initiation, and then once monthly for the next 2 months. Monitor ECG more frequently in patients with congenital long QT syndrome, CHF, or electrolyte abnormalities and in those who are receiving drugs known to prolong the QT interval.

• Monitor CBC, serum electrolyte concentrations, and renal and hepatic function at least once weekly for the first month of therapy. Monitor serum electrolyte concentrations and renal function monthly thereafter.

• Monitor serum CK as clinically indicated (e.g., if musculoskeletal symptoms reported).

Administration

Oral Administration

Administer orally once daily without regard to food, at approximately the same time each day. Swallow tablets whole; do not split, crush, or chew.

If a dose is missed, advise the patient to take the dose as soon as it is remembered unless it is <12 hours until the next dose; if <12 hours remain before the next scheduled dose, skip the missed dose and take the next dose at the regularly scheduled time. Do not administer 2 doses within 12 hours.

If vomiting occurs after a dose is administered, take the next dose at the regularly scheduled time. Do not administer an additional dose to replace a dose that is vomited.

Dosage

Available as glasdegib maleate; dosage expressed in terms of glasdegib.

Adults

Acute Myeloid Leukemia

Oral

100 mg daily on days 1–28, in conjunction with cytarabine 20 mg sub-Q twice daily on days 1–10 of each 28-day cycle.

Continue therapy until disease progression or unacceptable toxicity occurs. Manufacturer recommends treatment for a minimum of 6 cycles to allow for clinical response.

Dosage Modification for Toxicity or Drug Interactions

Adverse effects may require temporary interruption and/or dosage reduction or discontinuance of glasdegib and/or cytarabine.

Prolongation of QT Interval

Oral

Recommended dosage modifications for QT-interval prolongation with glasdegib and low-dose cytarabine therapy are described in Table 1. (Also see Prolongation of QT Interval under Cautions.)

Hematologic Toxicity

Oral

Adverse effects related to hematologic toxicity with glasdegib and low-dose cytarabine therapy may require discontinuance of treatment as described in Table 2.

Nonhematologic Toxicity

Oral

Adverse effects related to grade 3 or 4 nonhematologic toxicity with glasdegib and low-dose cytarabine therapy may require temporary interruption and/or dosage reduction or discontinuance of treatment as described in Table 3.

Concomitant Use with CYP3A4 Inducers

Oral

Avoid concomitant use with moderate or potent CYP3A4 inducers; if a moderate CYP3A4 inducer cannot be avoided, increase dosage of glasdegib. (See Drugs Affecting Hepatic Microsomal Enzymes under Interactions.)

Special Populations

No specific dosage recommendations based on age, sex, race, or body weight.

Hepatic Impairment

No specific dosage recommendations for patients with hepatic impairment. (See Hepatic Impairment under Cautions.)

Renal Impairment

No specific dosage recommendations for patients with mild to severe renal impairment. Not studied in patients with end-stage renal disease (ESRD) requiring hemodialysis. (See Renal Impairment under Cautions.)

Geriatric Patients

No specific dosage recommendations for geriatric patients. (See Geriatric Use under Cautions.)

Cautions for Glasdegib

Contraindications

• Manufacturer states none known.

Warnings/Precautions

Warnings

Fetal/Neonatal Morbidity and Mortality.

May cause fetal harm, including embryofetal death or severe birth defects; teratogenicity, embryotoxicity, and fetotoxicity demonstrated in animals at exposures lower than those achieved in humans at the recommended daily dosage. (See Boxed Warning.)

Avoid pregnancy during therapy. Verify pregnancy status in women of childbearing potential ≤7 days prior to initiating glasdegib. Advise women of childbearing potential to use effective methods of contraception during treatment and for at least 30 days following drug discontinuance.

Because of the potential risk of exposure through semen, advise male patients (including those who have undergone vasectomy) to use a condom for each sexual encounter with a pregnant woman or woman of childbearing potential during and for at least 30 days after drug discontinuance. Advise men not to donate semen during and for at least 30 days after drug discontinuance.

Because of the potential risk of exposure in pregnant women through blood transfusion, advise patients not to donate blood or blood products during and for at least 30 days after drug discontinuance.

Report any drug exposure during pregnancy to the manufacturer by calling 800-438-1985.

Other Warnings and Precautions

Prolongation of QT Interval

QT_c prolongation and ventricular arrhythmias, including ventricular fibrillation and ventricular tachycardia, may occur. The prolongation appears to occur in a plasma concentration-dependent manner.

Monitor ECGs and serum electrolytes periodically and promptly manage any abnormalities. Monitor ECG more frequently in patients with congenital long QT syndrome, CHF, or electrolyte abnormalities and in those who are receiving drugs known to prolong the QT interval. (See Interactions.)

Impairment of Male Fertility

Based on animal studies, may impair male fertility. Some effects on male fertility are potentially irreversible. (See Advice to Patients.)

Specific Populations

Pregnancy

May cause fetal harm. (See Boxed Warning and see Fetal/Neonatal Morbidity and Mortality under Cautions.)

Lactation

Not known whether distributed into milk. Discontinue nursing during therapy and for at least 30 days after drug discontinuance.

Effects on nursing infants or milk production unknown.

Pediatric Use

Safety and efficacy not established.

Geriatric Use

Most patients in the principal efficacy study were ≥65 years of age. Insufficient experience in patients <65 years of age to determine whether geriatric patients respond differently than younger adults.

Hepatic Impairment

Pharmacokinetics not substantially altered by mild hepatic impairment. Glasdegib pharmacokinetics altered in moderate and severe hepatic impairment. (See Special Populations under Pharmacokinetics.)

No specific dosage recommendations for hepatic impairment.

Renal Impairment

Pharmacokinetics not substantially altered by mild renal impairment. (See Special Populations under Pharmacokinetics.)

No dosage adjustment necessary in patients with renal impairment; however, monitor patients with severe renal impairment for adverse reactions.

Not studied in patients with ESRD requiring hemodialysis.

Common Adverse Effects

Adverse effects reported in ≥20% of patients: Anemia, fatigue, hemorrhage, febrile neutropenia, musculoskeletal pain, nausea, edema, thrombocytopenia, dyspnea, decreased appetite, dysgeusia, mucositis, constipation, rash.

Interactions for Glasdegib

Metabolized principally by CYP3A4, with minor contributions by CYP2C8 and UGT1A9.

Substrate of P-glycoprotein (P-gp) and breast cancer resistance protein (BCRP) in vitro.

Does not inhibit CYP1A2, 2B6, 2C8, 2C9, 2C19, 2D6, or 3A, and does not induce CYP1A2, 2B6, or 3A.

In vitro, inhibits P-gp, BCRP, multidrug and toxin extrusion transporters (MATE) 1, and MATE2K; does not inhibit organic anion transport protein (OATP) 1B1, OATP1B3, organic anion transporter (OAT) 1, OAT3, or organic cation transporter (OCT) 2.

Drugs Affecting Hepatic Microsomal Enzymes

Potent CYP3A inhibitors: Possible pharmacokinetic interaction (increased plasma concentrations of glasdegib and risk of adverse effects). Consider alternative therapy with drugs that are not potent CYP3A inhibitors; if concomitant use cannot be avoided, monitor for glasdegib adverse effects.

Moderate or potent CYP3A inducers: Possible pharmacokinetic interaction (decreased plasma concentrations of glasdegib and possible reduced efficacy). Avoid concomitant use. If concomitant use of a moderate CYP3A4 inducer cannot be avoided, increase glasdegib dosage from 100 mg to 200 mg once daily or from 50 mg to 100 mg once daily. May resume previous glasdegib dosage 7 days after discontinuance of the moderate CYP3A4 inducer.

Drugs that Prolong QT Interval

Potential pharmacologic interaction (increased risk of QT-interval prolongation). Consider alternative therapy with drugs that do not prolong the QT interval. If concomitant use cannot be avoided, monitor for QT-interval prolongation. (See Prolongation of QT Interval under Cautions.)

Specific Drugs

Glasdegib Pharmacokinetics

Absorption

Bioavailability

77%.

Systemic exposure and peak concentrations are dose-proportional over dosage range of 5–600 mg once daily.

Peak concentrations attained 1.3–1.8 hours after oral administration.

Steady-state concentrations achieved within 8 days with a median accumulation ratio of 1.2–2.5.

Food

Administration with high-fat, high-calorie meal reduces peak concentration and AUC; not considered clinically important.

Special Populations

Mild hepatic impairment (total bilirubin concentration between 1–1.5 times ULN or AST concentration exceeding ULN with total bilirubin concentration not exceeding ULN): No clinically important effects on glasdegib pharmacokinetics.

Moderate hepatic impairment (Child-Pugh class B): Glasdegib AUC increased by 11%.

Severe hepatic impairment (Child-Pugh class C): Glasdegib AUC decreased by 24%.

Mild renal impairment (Cl_cr 60–89 mL/minute): No clinically important effects on glasdegib pharmacokinetics.

Moderate (eGFR 30–59 mL/minute per 1.73 m²) or severe (eGFR 15–29 mL/minute per 1.73 m²) renal impairment: Glasdegib AUC increased 2.1-fold.

ESRD requiring hemodialysis: Not studied.

Distribution

Plasma Protein Binding

91%.

Elimination

Metabolism

Principally metabolized by CYP3A4 (60–80%), with minor contributions by CYP2C8 (2–20%) and UGT1A9.

Unchanged drug is the major component circulating in plasma; no active metabolites identified.

Elimination Route

Eliminated in urine (49%, 17% as unchanged drug) and feces (42%, 20% as unchanged drug).

Half-life

17.4 hours.

Stability

Storage

Oral

Tablets

20–25°C (may be exposed to 15–30°C).

Actions

• Inhibits the hedgehog pathway by selectively binding to and inhibiting smoothened, a transmembrane protein involved in hedgehog signal transduction.

• Hedgehog signaling pathway plays important role during embryonic organ and tissue development; also key regulator of maintenance of tissues and stem cells in adults.

• Aberrant activation of the hedgehog pathway implicated in development of several malignancies, including hematologic malignancies.

• Activation of smoothened results in activation of glioma (GLI) zinc finger transcription factors, which regulate gene transcription.

• Glasdegib inhibits expression of activating transcription factor GLI1 via inhibition of smoothened.

Advice to Patients

• Importance of instructing patients to read the manufacturer's patient information.

• Risk of fetal harm. Necessity of advising women of childbearing potential to use effective methods of contraception during glasdegib therapy and for at least 30 days after discontinuance (see Fetal/Neonatal Morbidity and Mortality under Cautions); importance of obtaining pregnancy tests prior to initiation of therapy. Advise female patients and female partners of men receiving glasdegib to contact clinician if pregnancy is suspected or confirmed.

• Risk of exposure of pregnant women or women of childbearing potential to glasdegib through semen. Necessity of advising men receiving glasdegib (including those who have undergone vasectomy) to use a condom during sexual encounters with pregnant women or women of childbearing potential; these contraceptive measures are required during glasdegib therapy and for at least 30 days after discontinuance. Advise men not to donate semen during glasdegib therapy and for at least 30 days after discontinuance.

• Importance of advising patients to avoid donating blood or blood products while receiving glasdegib and for at least 30 days after discontinuance.

• Risk of serious adverse reactions in nursing infants. Importance of advising women to avoid breast-feeding during glasdegib therapy and for at least 30 days after discontinuance.

• Importance of advising men of reproductive potential that glasdegib may cause fertility problems and to discuss any concerns about fertility with their clinician.

• Risk of QT-interval prolongation. Importance of informing patients of signs and symptoms that may be indicative of QT-interval prolongation; advise patients to contact a clinician immediately if they experience syncope, presyncope, dizziness, or cardiac palpitations.

• Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs and dietary or herbal supplements, as well as any concomitant illnesses.

• Importance of informing patients of other important precautionary information. (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Distribution of glasdegib is restricted. Contact manufacturer for additional information.

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Frequently asked questions

• What type of cancer is Daurismo (glasdegib) used to treat?

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