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
Warning
Fetal/Neonatal Morbidity and Mortality
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May cause embryofetal death or severe birth defects. Embryotoxic, fetotoxic, and teratogenic in animals.
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In women of childbearing potential, a pregnancy test must be obtained prior to treatment initiation. Advise such women to use effective methods of contraception during therapy and for at least 30 days after drug discontinuance. (See Fetal/Neonatal Morbidity and Mortality under Cautions.)
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Potential risk of exposure through semen; advise male patients to use condoms during sexual encounters with a pregnant partner or a female partner of reproductive potential during therapy and for at least 30 days after drug discontinuance. (See Fetal/Neonatal Morbidity and Mortality under Cautions.)
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
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Verify pregnancy status in women of childbearing potential ≤7 days prior to initiating glasdegib.
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Assess ECG and serum electrolyte concentrations.
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CBC.
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Renal and hepatic function.
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Serum CK.
Patient Monitoring
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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.
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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.
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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
OralRecommended 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.)
Adverse Effect |
Patient Monitoring |
Dosage Modification |
---|---|---|
QTc interval >480 to ≤500 msec on at least 2 separate ECGs |
Assess electrolyte concentrations and correct as clinically indicated |
Evaluate concomitant drugs known to prolong QTc interval; adjust therapy as needed |
After QTc interval returns to ≤480 msec, monitor ECG at least weekly for 2 weeks |
||
QTc interval >500 msec on at least 2 separate ECGs |
Assess electrolyte concentrations and correct as clinically indicated |
Interrupt glasdegib |
After QTc interval returns to ≤480 msec, monitor ECG at least weekly for 2 weeks |
After QTc interval returns to within 30 msec of baseline or is ≤480 msec, resume glasdegib at reduced dosage of 50 mg once daily |
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Evaluate concomitant drugs known to prolong QTc interval; adjust therapy as needed |
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Consider resuming glasdegib 100 mg once daily if alternative etiology for QTc interval prolongation identified |
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QTc interval prolongation occurring with life-threatening arrhythmias |
Permanently discontinue glasdegib |
Hematologic Toxicity
OralAdverse effects related to hematologic toxicity with glasdegib and low-dose cytarabine therapy may require discontinuance of treatment as described in Table 2.
Adverse Effect |
Dosage Modification |
---|---|
Platelet count <10,000/mm3 for >42 days in absence of disease |
Permanently discontinue glasdegib and low-dose cytarabine |
ANC <500/mm3 for >42 days in absence of disease |
Permanently discontinue glasdegib and low-dose cytarabine |
Nonhematologic Toxicity
OralAdverse 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.
Adverse Effect |
Dosage Modification |
---|---|
Grade 3 |
Interrupt glasdegib and/or low-dose cytarabine until symptoms reduce to grade 1 or baseline |
Grade 3 |
After resolution of toxicity, resume glasdegib at original dosage or at reduced dosage of 50 mg daily and resume low-dose cytarabine at original dosage or at reduced dosage of 15 mg or 10 mg twice daily |
Grade 3 |
If grade 3 toxicity recurs, discontinue glasdegib and low-dose cytarabine |
Grade 3 |
If toxicity is attributable to glasdegib only (e.g., dysgeusia, muscle spasm, alopecia), low-dose cytarabine may be continued |
Grade 4 |
Permanently discontinue glasdegib and low-dose cytarabine |
Concomitant Use with CYP3A4 Inducers
OralAvoid 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
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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
QTc 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
Drug |
Interaction |
Comments |
---|---|---|
Efavirenz |
Decreased glasdegib peak concentrations and AUC expected |
Avoid concomitant use; if concomitant use cannot be avoided, increase glasdegib dosage from 100 mg to 200 mg once daily or from 50 mg to 100 mg once daily Resume previous glasdegib dosage 7 days after efavirenz discontinued |
Ketoconazole |
Substantially increased glasdegib peak concentration and AUC |
Avoid concomitant use; if concomitant use cannot be avoided, monitor for glasdegib adverse effects |
Rabeprazole |
Decreased glasdegib peak concentration, but no effect on glasdegib AUC; not considered clinically important |
|
Rifampin |
Substantially decreased glasdegib peak concentration and AUC |
Avoid concomitant use |
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 (Clcr 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
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Inhibits the hedgehog pathway by selectively binding to and inhibiting smoothened, a transmembrane protein involved in hedgehog signal transduction.
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Hedgehog signaling pathway plays important role during embryonic organ and tissue development; also key regulator of maintenance of tissues and stem cells in adults.
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Aberrant activation of the hedgehog pathway implicated in development of several malignancies, including hematologic malignancies.
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Activation of smoothened results in activation of glioma (GLI) zinc finger transcription factors, which regulate gene transcription.
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Glasdegib inhibits expression of activating transcription factor GLI1 via inhibition of smoothened.
Advice to Patients
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Importance of instructing patients to read the manufacturer's patient information.
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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.
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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.
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Importance of advising patients to avoid donating blood or blood products while receiving glasdegib and for at least 30 days after discontinuance.
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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.
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Importance of advising men of reproductive potential that glasdegib may cause fertility problems and to discuss any concerns about fertility with their clinician.
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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.
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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.
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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.
Routes |
Dosage Forms |
Strengths |
Brand Names |
Manufacturer |
---|---|---|---|---|
Oral |
Tablets, film-coated |
25 mg (of glasdegib) |
Daurismo |
Pfizer |
100 mg (of glasdegib) |
Daurismo |
Pfizer |
AHFS DI Essentials™. © Copyright 2023, Selected Revisions December 13, 2021. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.
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