Sotorasib (Monograph)

Brand name: Lumakras
Drug class: Antineoplastic Agents

Medically reviewed by Drugs.com on Mar 10, 2024. Written by ASHP.

Introduction

Antineoplastic agent; irreversible and selective inhibitor of mutated KRAS p.G12C (KRAS G12C).

Uses for Sotorasib

Non-small Cell Lung Cancer

Treatment of locally advanced or metastatic KRAS G12C mutation-positive (as detected by an FDA-approved diagnostic test) non-small cell lung cancer (NSCLC) previously treated with ≥1 prior systemic therapy (designated an orphan drug by FDA for this use).

Accelerated approval based on overall response rate and duration of response; continued approval may be contingent on verification and description of clinical benefit of sotorasib in confirmatory studies.

Sotorasib Dosage and Administration

General

Pretreatment Screening

Confirm the presence of KRAS G12C mutation (as determined by an FDA-approved test) in tumor or plasma specimens; if KRAS G12C mutation is not detected in a plasma specimen, retest with tumor tissue.
Baseline liver function tests (i.e., ALT, AST, total bilirubin).

Patient Monitoring

Monitor liver function tests (i.e., AST, ALT, total bilirubin) every 3 weeks for the first 3 months of therapy, then monthly or as clinically indicated; more frequent monitoring may be necessary in patients who develop hepatotoxicity.
Monitor for new or worsening pulmonary symptoms (e.g., dyspnea, cough, fever) indicative of interstitial lung disease or pneumonitis.

Administration

Oral Administration

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

Alternatively, for patients who are unable to swallow whole tablets, disperse tablets in 120 mL (4 ounces) of non-carbonated, room temperature water. Place total number of tablets for the dose (e.g., three 320 mg tablets or eight 120 mg tablets for total dose of 960 mg) into the water, without crushing, and stir or swirl for approximately 3 minutes to disperse the tablets into small pieces (complete dissolution will not occur). Resulting mixture may range in color from pale to bright yellow. Consume entire mixture immediately or within 2 hours of mixing without chewing residual tablet pieces. Rinse any residue remaining in the container with an additional 120 mL of water, stir or swirl again, and then consume immediately.

If a dose of sotorasib is missed by ≤6 hours, administer the prescribed dose as soon as it is remembered. If a dose is missed by >6 hours, administer the prescribed dose at the next scheduled time; do not administer an additional dose to replace the missed dose.

If vomiting occurs after taking a dose, administer the next dose at the next scheduled time; do not administer an additional dose to replace the vomited dose.

Dosage

Adults

Non-small Cell Lung Cancer

Oral

960 mg once daily. Continue until disease progression or unacceptable toxicity occurs.

Dosage Modification

Dosing interruption and/or dosage reduction of sotorasib may be necessary based on individual safety and tolerability.

If dosage reduction from 960 mg once daily is necessary, reduce dosage to 480 mg once daily. If toxicity recurs on a dosage of 480 mg once daily, reduce dosage to 240 mg once daily. If toxicity recurs on a dosage of 240 mg once daily, discontinue drug.

Hepatotoxicity

Oral

If symptomatic grade 2 serum AST/ALT elevations occur, withhold sotorasib therapy. When toxicity resolves or improves to grade 1 or less, resume therapy at next lower dosage.

If grade 3 or 4 serum AST/ALT elevations occur, withhold sotorasib therapy. When toxicity resolves or improves to grade 1 or less, resume therapy at next lower dosage.

If serum AST or ALT concentrations >3 times the ULN and serum total bilirubin concentrations >2 times the ULN in the absence of other etiology, permanently discontinue sotorasib therapy.

Interstitial Lung Disease/Pneumonitis

Oral

If interstitial lung disease/pneumonitis of any grade is suspected, withhold sotorasib therapy. If interstitial lung disease/pneumonitis is confirmed, permanently discontinue sotorasib therapy.

GI Effects

Oral

If grade 3 or 4 nausea, vomiting, or diarrhea occurs despite appropriate supportive care, withhold sotorasib therapy. When toxicity resolves or improves to grade 1 or less, resume therapy at next lower dosage.

Other Toxicity

Oral

If other grade 3 or 4 toxicities occur, withhold sotorasib therapy. When toxicity resolves or improves to grade 1 or less, resume therapy at next lower dosage.

Special Populations

Hepatic Impairment

No dosage adjustment recommended in mild to moderate (Child Pugh class A or B) hepatic impairment. No specific dosage recommendations in severe (Child Pugh class C) hepatic impairment.

Renal Impairment

No specific dosage recommendations.

Geriatric Patients

No specific dosage recommendations.

Cautions for Sotorasib

Contraindications

None.

Warnings/Precautions

Hepatotoxicity

Hepatotoxicity, including drug-induced liver injury and hepatitis, reported. Median time to onset of serum ALT/AST elevations is 9 weeks.

Monitor liver function tests (i.e., serum ALT, AST, total bilirubin concentrations) prior to initiation of sotorasib, every 3 weeks for the first 3 months of treatment, then once a month or as clinically indicated. More frequent monitoring may be necessary in patients who develop elevated aminotransferase and/or total bilirubin concentrations. If hepatotoxicity occurs, temporary interruption of sotorasib therapy, dosage reduction, or discontinuance of therapy may be necessary.

Interstitial Lung Disease/Pneumonitis

Interstitial lung disease/pneumonitis, sometimes fatal, reported. Median time to onset is 2 weeks.

Monitor patients for new or worsening pulmonary symptoms indicative of interstitial lung disease/pneumonitis (e.g., dyspnea, cough, fever). If interstitial lung disease/pneumonitis is suspected, promptly withhold sotorasib. Permanently discontinue drug if no other etiology is identified.

Specific Populations

Pregnancy

No available data in pregnant women.

No adverse developmental effects or embryo-lethality observed in animal studies.

Lactation

Not known whether sotorasib or its metabolites distribute into human milk or if the drug has any effect on milk production or the breast-fed infant. Because of the potential for adverse reactions to sotorasib in breast-fed infants, advise females not to breast-feed while receiving the drug and for 7 days after the drug is discontinued.

Pediatric Use

Safety and efficacy of sotorasib not established in pediatric patients.

Geriatric Use

Although data are limited, no clinically important differences in safety or efficacy observed between geriatric patients and younger adults.

Age (28–86 years) does not appear to have clinically important effects on pharmacokinetics of sotorasib.

Hepatic Impairment

Patients with hepatic impairment may experience more frequent adverse reactions.

Mild to moderate hepatic impairment (Child Pugh class A or B): dosage adjustments not necessary. Severe hepatic impairment (Child Pugh class C): safety of sotorasib unknown.

Renal Impairment

Mild to moderate renal impairment (estimated GFR ≥30 mL/minute per 1.73 m²): Pharmacokinetics not substantially altered; no dosage adjustment needed.

Severe renal impairment: Pharmacokinetics not studied.

Common Adverse Effects

Adverse effects (≥20%) include diarrhea, musculoskeletal pain, nausea, fatigue, hepatotoxicity, and cough. Laboratory abnormalities (≥25%) include decreased lymphocytes, decreased hemoglobin, increased ALT and/or AST concentrations, decreased calcium, increased alkaline phosphatase, increased urine protein, and decreased sodium concentrations.

Drug Interactions

Metabolized principally by nonenzymatic conjugation and oxidative metabolism with CYP3A.

Sotorasib is a CYP3A4 substrate and inducer and a P-glycoprotein inhibitor. In vitro, may induce CYP2C8, CYP2C9, and CYP2B6. Inhibits breast cancer resistance protein (BCRP).

Does not inhibit CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, or CYP2D6.

Drugs Affecting or Affected by Hepatic Microsomal Enzymes

Potent Inducers of CYP3A4: Possible decrease in systemic exposure to sotorasib and reduced sotorasib efficacy. Avoid concomitant use.

Substrates of CYP3A4: Possible decrease in plasma concentrations of CYP3A4 substrate drug and reduced efficacy of the CYP3A4 substrate. Avoid concomitant use with sensitive CYP3A4 substrates that have a narrow therapeutic index. If concomitant administration cannot be avoided, consult manufacturer's labeling of the sensitive CYP3A4 substrate drug for dosage adjustments of the CYP3A4 substrate.

Drugs Affecting or Affected by Transport Systems

Substrates of P-gp: Possible increase in plasma concentrations of the P-gp substrate drug and increased toxicity of the P-gp substrate. Avoid concomitant use with P-gp substrates where minimal concentration changes may lead to serious toxicities. If concomitant administration cannot be avoided, consult manufacturer's labeling of the P-gp substrate drug for dosage adjustments of the P-gp substrate.

Substrates of BCRP

Possible increase in plasma concentrations of the BCRP substrate drug and increased toxicity of the BCRP substrate. Monitor for adverse reactions of the BCRP substrate and potentially reduce the dosage if coadministered with sotorasib.

Drugs Affecting Gastric Acidity

Possible decrease in systemic exposure to sotorasib.

Avoid concomitant use with proton-pump inhibitors, H₂-receptor antagonists, and locally acting antacids. If concomitant use of a locally-acting antacid cannot be avoided, administer sotorasib 4 hours before or 10 hours after the locally-acting antacid.

Specific Drugs

Drug	Interaction	Comments
Antacid, locally acting	Possible decrease in systemic exposure to sotorasib	Avoid concomitant use; if concomitant use cannot be avoided, administer sotorasib 4 hours before or 10 hours after the locally-acting antacid
Digoxin	P-gp substrate: Increased peak plasma concentrations and AUC of digoxin by 91 and 21%, respectively	Avoid concomitant use; if concomitant use cannot be avoided, adjust dosage of digoxin as needed
Famotidine	When famotidine was administered 10 hours before and 2 hours after a single dose of sotorasib under fed conditions, peak plasma concentrations or AUC of sotorasib decreased by 35 or 38%, respectively	Avoid concomitant use
Metformin	Multidrug and toxin extrusion (MATE) transporter 1 and MATE2-K substrate: No meaningful change in metformin exposure
Midazolam	Sensitive CYP3A4 substrate: Decreased peak plasma concentrations and AUC of midazolam by 48 and 53%, respectively	Avoid concomitant use; if concomitant use cannot be avoided, adjust dosage of midazolam as needed
Omeprazole	Decreased peak plasma concentrations or AUC of sotorasib by 65 or 57%, respectively, under fed conditions, and by 57 or 42%, respectively, under fasted conditions	Avoid concomitant use
Rifampin	Potent CYP3A4 inducer: Decreased peak plasma concentrations and AUC of sotorasib by 35 and 51%, respectively	Avoid concomitant use
Rosuvastatin	BCRP substrate: Increased peak plasma concentrations and AUC of rosuvastatin by 70% and 34%, respectively	Monitor for adverse reactions and adjust dosage of rosuvastatin as needed

Sotorasib Pharmacokinetics

Absorption

Bioavailability

Pharmacokinetics are non-linear and time-dependent across the dosage range of 180–960 mg once daily.

Peak plasma concentrations attained at a median of 1 hour.

Steady state plasma concentrations achieved within 22 days.

Systemic exposure is comparable between film-coated tablets and film-coated tablets dispersed in water when administered under fasted conditions.

Food

Administration with a high-fat, high-calorie meal did not substantially affect pharmacokinetics of sotorasib.

Special Populations

Mean AUC of single 960 mg dose of sotorasib decreased by 25% in patients with moderate hepatic impairment (Child-Pugh class B) and increased by 4% in patients with severe hepatic impairment (Child-Pugh class C) compared to those with normal hepatic function.

Mild to moderate renal impairment (estimated GFR ≥30 mL/minute per 1.73 m²): Pharmacokinetics not substantially altered.

Severe renal impairment: Not studied.

Age (26–86 years), sex, race/ethnicity, and body weight (36.8–157.9 kg) do not substantially affect sotorasib pharmacokinetics.

Distribution

Extent

Not known whether sotorasib or its metabolites distribute into human milk.

Plasma Protein Binding

89%.

Elimination

Metabolism

Metabolized principally by nonenzymatic conjugation and oxidative metabolism with CYP3A.

Elimination Route

Eliminated in feces (74%; 53% as unchanged drug) and urine (6%; 1% as unchanged drug).

Half-life

5 hours.

Stability

Storage

Oral

Tablets

20–25ºC (excursions permitted between 15–30ºC).

When tablets have been dispersed in non-carbonated, room temperature water, the entire mixture must be consumed immediately or within 2 hours of mixing.

Actions

Irreversible and selective inhibitor of KRAS G12C mutation.
In vitro, inhibits KRAS signaling and cell growth, and promotes apoptosis selectively in KRAS G12C-positive cell lines.
Rapidly and irreversibly binds to KRAS G12C to provide durable suppression of the mitogen-activated protein kinase (MAPK) signaling pathway.
Tumor regression, prolonged survival, and anti-tumor immunity demonstrated in mouse tumor xenograft KRAS G12C models.
In vitro and in vivo, inhibits KRAS G12C with minimal detectable off-target activity.

Advice to Patients

Advise the patient to read the FDA-approved patient labeling (Patient Information).
Advise patients to immediately contact their healthcare provider for signs and symptoms of liver dysfunction.
Advise patients to contact their healthcare provider immediately to report new or worsening respiratory symptoms.
Advise women not to breast-feed during treatment with sotorasib and for 1 week after the final dose.
Advise patients to inform their healthcare provider of all concomitant medications, including prescription medicines, over-the-counter drugs, vitamins, dietary and herbal products. Inform patients to avoid proton pump inhibitors, and H₂-receptor antagonists while taking sotorasib.
If coadministration with an acid-reducing agent cannot be avoided, inform patients to take sotorasib 4 hours before or 10 hours after a locally-acting antacid.
If a dose of sotorasib is missed by greater than 6 hours, resume treatment as prescribed the next day.

Additional Information

The American Society of Health-System Pharmacists, Inc. represents that the information provided in the accompanying monograph was formulated with a reasonable standard of care, and in conformity with professional standards in the field. Readers are advised that decisions regarding use of drugs are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and that the information contained in the monograph is provided for informational purposes only. The manufacturer’s labeling should be consulted for more detailed information. The American Society of Health-System Pharmacists, Inc. does not endorse or recommend the use of any drug. The information contained in the monograph is not a substitute for medical care. For further information on the handling of antineoplastic agents, see the ASHP Guidelines on Handling Hazardous Drugs at [Web].

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.

Sotorasib can only be obtained through designated specialty pharmacies and distributors. Contact manufacturer for additional information.