Medically reviewed on Nov 15, 2018
(tra ME ti nib)
- Trametinib Dimethyl Sulfoxide
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Mekinist: 0.5 mg, 2 mg
Brand Names: U.S.
- Antineoplastic Agent, MEK Inhibitor
Trametinib reversibly and selectively inhibits mitogen-activated extracellular kinase (MEK) 1 and 2 activation and kinase activity. MEK is a downstream effector of the protein kinase B-raf (BRAF); BRAF V600 mutations result in constitutive activation of the BRAF pathway (including MEK1 and MEK2). Through inhibition of MEK 1 and 2 kinase activity, trametinib causes decreased cellular proliferation, cell cycle arrest, and increased apoptosis (Kim 2013). The combination of trametinib and dabrafenib allows for greater inhibition of the MAPK pathway, resulting in BRAF V600 melanoma cell death (Flaherty 2012). Trametinib plus dabrafenib has been reported to synergistically inhibit cell growth in lung cancer cell lines which are BRAF V600E-mutant (Planchard 2016).
Rapid; decreased with a high-fat, high-calorie meal (~1,000 calories)
Predominantly deacetylation (via hydrolytic enzymes) alone or with mono-oxygenation or in combination with glucuronidation
Feces (>80%); urine (<20% with <0.1% as unchanged drug)
Time to Peak
1.5 hours; delayed with a high-fat, high-calorie meal (~1,000 calories)
~4 to 5 days
~97% to plasma proteins
Use: Labeled Indications
Adjuvant treatment of melanoma (in combination with dabrafenib) in patients with a BRAF V600E or BRAF V600K mutation (as detected by an approved test), and lymph node involvement, following complete resection.
Treatment of unresectable or metastatic melanoma in patients with a BRAF V600E or BRAF V600K mutation (as detected by an approved test), either as a single-agent or in combination with dabrafenib.
Limitations of use: Trametinib is not indicated for use in melanoma patients who have received prior BRAF-inhibitor therapy.
Non-small cell lung cancer (metastatic): Treatment of metastatic non-small cell lung cancer (NSCLC) in patients with BRAF V600E mutation as detected by an approved test (in combination with dabrafenib).
Thyroid cancer, anaplastic, locally advanced or metastatic: Treatment of locally advanced or metastatic anaplastic thyroid cancer (in combination with dabrafenib) in patients with BRAF V600E mutation and with no satisfactory locoregional treatment options.
There are no contraindications listed in the manufacturer's US labeling.
Canadian labeling: Hypersensitivity to trametinib or any component of the formulation.
Note: Confirm BRAF V600 mutation status prior to treatment initiation.
Melanoma, adjuvant treatment (with BRAF V600E or BRAF V600K mutations): Oral: 2 mg once daily (in combination with dabrafenib); continue for up to 1 year in the absence of disease progression or unacceptable toxicity (Long 2017).
Melanoma, metastatic or unresectable (with BRAF V600E or BRAF V600K mutations): Oral: 2 mg once daily (either as a single-agent or in combination with dabrafenib), continue until disease progression or unacceptable toxicity.
Non-small cell lung cancer, metastatic (with BRAF V600E mutation): Oral: 2 mg once daily (in combination with dabrafenib); continue until disease progression or unacceptable toxicity (Planchard 2016).
Thyroid cancer, anaplastic, locally advanced or metastatic (with BRAF V600E mutation): Oral: 2 mg once daily (in combination with dabrafenib); continue until disease progression or unacceptable toxicity (Subbiah 2018)
Missed doses: Do not take a missed dose within 12 hours of the next dose.
Dosing: Renal Impairment
Mild to moderate impairment (GFR ≥30 mL/minute/1.73 m2): No dosage adjustment necessary.
Severe impairment (GFR <30 mL/minute/1.73 m2): There are no dosage adjustments provided in the manufacturer's labeling (has not been studied); however, renal excretion is low and is unlikely to affect drug exposure.
Dosing: Hepatic Impairment
Mild impairment (total bilirubin ≤ ULN and AST > ULN or total bilirubin >1 to 1.5 times ULN with any AST): No dosage adjustment necessary.
Moderate to severe impairment: There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
Dosing: Adjustment for Toxicity
Recommended trametinib dose reductions for toxicity:
First dose reduction: 1.5 mg once daily
Second dose reduction: 1 mg once daily
Subsequent modification (if unable to tolerate 1 mg once daily): Permanently discontinue
Note: If using combination therapy, refer to dabrafenib monograph for recommended dabrafenib dose reductions
Asymptomatic, 10% or greater absolute decrease in LVEF from baseline and LVEF is below institutional lower limits of normal (LLN) from pretreatment value: Interrupt trametinib therapy for up to 4 weeks. If LVEF improves to normal within 4 weeks following therapy interruption, resume at a lower dose level. If LVEF does not improve to normal within 4 weeks following therapy interruption, permanently discontinue trametinib.
>20% absolute decrease in LVEF from baseline and LVEF is below institutional LLN: Permanently discontinue trametinib.
Symptomatic heart failure: Permanently discontinue trametinib.
Intolerable Grade 2 toxicity or Grade 3 or 4 toxicity: Interrupt trametinib therapy for up to 3 weeks. If toxicity improves within 3 weeks, resume at a lower dose level. If toxicity does not improve within 3 weeks following therapy interruption, permanently discontinue trametinib.
New primary cutaneous malignancies: No trametinib dosage modification is necessary.
Fever: Fever >40°C (104°F) or fever (any severity) complicated by rigors, hypotension, dehydration, or renal failure: Interrupt trametinib therapy until fever resolves, then resume at the same or a lower dose level. May require prophylactic antipyretics (secondary prophylaxis) upon resumption. Administer corticosteroids (eg, prednisone 10 mg daily or equivalent) for at least 5 days for second or subsequent pyrexia if temperature does not return to baseline within 3 days of onset of fever, or for fever associated with complications (eg, dehydration, hypotension, severe chills/rigors with no evidence of active infection).
Grade 3 hemorrhage: Interrupt trametinib therapy. If hemorrhage improves, resume at a lower dose level. If hemorrhage does not improve following therapy interruption, permanently discontinue trametinib.
Grade 4 hemorrhage: Permanently discontinue trametinib.
Uveitis and iritis: No trametinib dosage modification necessary.
Retinal pigment epithelial detachments (RPED): Interrupt trametinib therapy for up to 3 weeks. If improves within 3 weeks following therapy interruption, resume at the same or lower dose level. If RPED does not improve within 3 weeks following therapy interruption, reduce dose or permanently discontinue trametinib.
Retinal vein occlusion: Permanently discontinue trametinib.
Pulmonary: Interstitial lung disease or pneumonitis: Permanently discontinue trametinib.
Uncomplicated DVT or PE: Interrupt trametinib therapy for up to 3 weeks. If improves to ≤ grade 1 within 3 weeks following therapy interruption, resume at a lower dose level. If toxicity does not improve within 3 weeks following therapy interruption, permanently discontinue trametinib.
Life-threatening PE: Permanently discontinue trametinib.
Intolerable Grade 2 adverse reaction or any Grade 3 adverse reaction: Interrupt therapy. If toxicity improves to ≤ grade 1 following therapy interruption, resume at a lower dose level. If toxicity does not improve following therapy interruption, permanently discontinue trametinib.
Grade 4 adverse reaction:
First occurrence: Interrupt trametinib therapy until improves to ≤grade 1, then resume at a lower dose level or permanently discontinue trametinib.
Recurrence: Permanently discontinue trametinib.
New primary noncutaneous malignancy: No trametinib dosage modification is necessary.
Oral: Administer at least 1 hour before or 2 hours after a meal. Administer dose at the same time each day (trametinib doses should be administered ~24 hours apart), whether administered as a single agent or in combination with dabrafenib (when administered in combination with dabrafenib, take the once daily trametinib dose either with the morning or with the evening dabrafenib dose).
Store refrigerated at 2°C to 8°C (36°F to 46°F). Dispense in original bottle; do not remove desiccant. Protect from light and moisture. Do not transfer to pill boxes.
Dabrafenib: Trametinib may enhance the adverse/toxic effect of Dabrafenib. Monitor therapy
Adverse reactions reported with monotherapy:
Cardiovascular: Hypertension (15%), cardiomyopathy (7% to 11%)
Dermatologic: Skin toxicity (87%, most commonly dermatitis acneiform rash, palmar-plantar erythrodysesthesia, erythema, skin rash; severe: 12%; severe toxicity and secondary skin infection requiring hospitalization: 6%), skin rash (57%), acneiform eruption (19%), xeroderma (11%)
Endocrine & metabolic: Hypoalbuminemia (42%)
Gastrointestinal: Diarrhea (43%), stomatitis (15%), abdominal pain (13%)
Hematologic & oncologic: Anemia (38%), lymphedema (32%), hemorrhage (13%; grades 3/4: <1%)
Hepatic: Increased serum aspartate aminotransferase (60%), increased serum alanine aminotransferase (39%), increased serum alkaline phosphatase (24%)
1% to 10%:
Cardiovascular: Decreased left ventricular ejection fraction (5%, ≥20% below baseline), bradycardia
Central nervous system: Dizziness
Dermatologic: Paronychia (10%), pruritus (10%), cellulitis, folliculitis, pustular rash
Gastrointestinal: Dysgeusia, xerostomia
Neuromuscular & skeletal: Rhabdomyolysis
Ophthalmic: Blurred vision, dry eye syndrome
Respiratory: Interstitial pulmonary disease (≤2%), pneumonitis (≤2%)
<1%, postmarketing, and/or case reports: Retinal detachment, retinal vein occlusion
Adverse reactions reported with dual therapy (trametinib plus dabrafenib):
Cardiovascular: Hypertension (25% to 26%), peripheral edema (21% to 25%; includes edema and lymphedema; grades 3/4: ≤1% ), prolonged Q-T Interval on ECG (4% QTcF increased >60 msec; <1% QTcF prolongation to >500 msec)
Central nervous system: Fatigue (51% to 59%), headache (30% to 39%), chills (23% to 37%), dizziness (11% to 14%)
Dermatologic: Skin toxicity (55%; severe toxicity: <1%), skin rash (28% to 42%), xeroderma (10% to 31%)
Endocrine & metabolic: Hyperglycemia (60% to 71%), hyponatremia (24% to 57%), hypoalbuminemia (25% to 53%), hypophosphatemia (36% to 42%), exacerbation of diabetes mellitus (27%)
Gastrointestinal: Nausea (34% to 45%), vomiting (25% to 33%), diarrhea (30% to 33%), decreased appetite (29%), abdominal pain (18% to 26%), constipation (13%)
Hematologic & oncologic: Neutropenia (44% to 50%; grades 3/4: 6% to 8%), leukopenia (48%; grades 3/4: 8%), anemia (25% to 46%; grades 3/4: ≤10%), lymphocytopenia (26% to 42%; grades 3/4: 5% to 14%), hemorrhage (18% to 23%; grades 3/4: 2% to 3%; includes hepatic hematoma, duodenal ulcer hemorrhage), thrombocytopenia (19% to 21%; grades 3/4: <1%), malignant neoplasm (1%)
Hepatic: Increased serum alkaline phosphatase (38% to 64%), increased serum aspartate aminotransferase (57% to 61%), increased serum alanine aminotransferase (32% to 48%)
Neuromuscular & skeletal: Arthralgia (25% to 28%), myalgia (13% to 20%)
Renal: Increased serum creatinine (21%)
Respiratory: Cough (20% to 22%), dyspnea (20%)
Miscellaneous: Fever (54% to 63%), febrile reaction (complicated with dehydration: 2%, complicated with severe chills/rigors: <1%, complicated with renal failure: <1%, complicated with syncope: <1%)
1% to 10%:
Cardiovascular: Bradycardia (<10%), cardiomyopathy (6%), reduced ejection fraction (5%), venous thromboembolism (3%; deep vein thrombosis, pulmonary embolism), hypertension
Central nervous system: Intracranial hemorrhage (1%)
Gastrointestinal: Gastrointestinal hemorrhage (6%), pancreatitis
Hematologic & oncologic: Basal cell carcinoma (3%), squamous cell carcinoma of skin (3%; including keratoacanthoma)
Neuromuscular & skeletal: Rhabdomyolysis (<10%)
Ophthalmic: Blurred vision (6%)
Respiratory: Pneumonitis (≤2%)
<1%, postmarketing, and/or case reports: Malignant melanoma
Concerns related to adverse effects:
• Bone marrow suppression: Neutropenia (including grade 3 and 4 events) has been observed when used in combination with dabrafenib.
• Cardiac events: Cardiac events such as heart failure, left ventricular dysfunction, or decreased left ventricular ejection fraction (LVEF) were observed in clinical trials (for single-agent trametinib and when used in combination with dabrafenib). Assess LVEF (by echocardiogram or MUGA scan) prior to therapy initiation, at one month, and then every 2 to 3 months while on therapy. Cardiac dysfunction may require treatment interruption, dosage reduction, or discontinuation; such measures resulted in resolution of cardiomyopathy in some patients.
• Dermatologic toxicity: Dermatologic toxicity (eg, rash, dermatitis, acneiform rash, palmar-plantar erythrodysesthesia syndrome, and erythema) was commonly observed in trametinib-treated patients (either as a single-agent or when used in combination with dabrafenib); some patients required hospitalization for severe toxicity or for secondary skin infections. Monitor for dermatologic toxicity and signs/symptoms of secondary infections. Treatment interruption, dose reduction, and/or therapy discontinuation may be necessary.
• Febrile reactions: Serious febrile reactions and fever (any severity) accompanied by hypotension, rigors/chills, dehydration, or renal failure may occur when trametinib is used in combination with dabrafenib. Withhold trametinib for fever >104°F (if using in combination, withhold dabrafenib for fever ≥101.3°F), for serious febrile reactions, or for any fever with rigors/chills, hypotension, dehydration, or renal failure (evaluate for infection; also monitor serum creatinine and other evidence of renal function during and after serious fever); may require prophylactic antipyretics as secondary prophylaxis upon therapy resumption. Administer corticosteroids (eg, prednisone 10 mg daily or equivalent) for at least 5 days for second or subsequent episodes of pyrexia if temperature does not return to baseline within 3 days of fever onset, or for pyrexia associated with complications (eg, dehydration, hypotension, severe chills/rigors with no evidence of active infection).
• Gastrointestinal events: Colitis and GI perforation, including fatal cases, have been reported with monotherapy and when administered concomitantly with dabrafenib; monitor closely for development of colitis and GI perforations.
• Hemorrhage: Hemorrhage, including symptomatic bleeding in a critical area/organ, may occur with trametinib, either as a single agent or in combination with dabrafenib. Major bleeding events (some fatal) included intracranial, subarachnoid, retroperitoneal, or gastrointestinal hemorrhage. May require treatment interruption and dosage reduction; permanently discontinue trametinib (and dabrafenib) for all grade 4 hemorrhagic events and any grade 3 event that does not improve with therapy interruption.
• Hepatotoxicity: Elevated liver function tests have been reported with trametinib, including grade 3 and 4 events. Monitor hepatic function as clinically necessary.
• Hyperglycemia: While not reported with single-agent trametinib, hyperglycemia may occur while on combination therapy with dabrafenib; may require initiation of insulin or oral hypoglycemic agent therapy (or an increased dose if already taking). Monitor serum glucose at baseline and as clinically necessary in patients with preexisting diabetes or hyperglycemia.
• Hypertension: May cause hypertension; monitor blood pressure.
• Malignancy: New primary cutaneous malignancies (which are associated with dabrafenib as single-agent therapy) may occur when trametinib is given in combination with dabrafenib. The incidence of basal cell carcinoma (BCC) in melanoma patients is ~3% for combination therapy versus 6% for single-agent dabrafenib; although rare, some patients experienced more than one BCC occurrence. Cutaneous squamous cell carcinomas (cuSCC), including keratoacanthoma, occurred at a lower rate for combination therapy in melanoma patients compared to single-agent dabrafenib. Cases of cuSCC also occurred in patients with NSCLC. New primary melanoma occurred rarely in patients receiving trametinib. Dermatologic exams should be performed prior to initiation of combination therapy, every 2 months while receiving combination treatment, and for up to 6 months following discontinuation. There are case reports of noncutaneous malignancies with combination therapy; monitor for signs/symptoms of noncutaneous malignancies. No trametinib dosage modification is necessary for new primary cutaneous and noncutaneous malignancies; dabrafenib should be permanently discontinued if RAS mutation-positive noncutaneous malignancies develop.
• Ocular toxicity: Retinal pigment epithelial detachments (RPED) and retinal vein occlusion were seen in clinical trials (rare). Detachments were typically bilateral and multifocal and occurred in the central macular area of the retina. Retinal vein occlusion may lead to macular edema, decreased visual function, neovascularization, and glaucoma. Promptly (within 24 hours) refer patients for ophthalmological evaluations if loss of vision or other visual disturbances occur. Ophthalmic exams (including retinal evaluation) should be performed periodically during treatment and with visual disturbances. Interrupt trametinib therapy for RPED; may resume if resolves within 3 weeks; reduce the dose or discontinue if not resolved within 3 weeks. Permanently discontinue if retinal vein occlusion develops. Uveitis and iritis have been reported when trametinib is used in combination with dabrafenib and are managed symptomatically with ophthalmic steroid and mydriatic drops (does not require alteration in trametinib therapy).
• Pulmonary toxicity: Interstitial lung disease (ILD) and pneumonitis were observed in clinical trials. Monitor for new or progressive pulmonary symptoms (eg, cough, dyspnea, hypoxia, pleural effusion, infiltrates); withhold treatment if symptoms occur; permanently discontinue with diagnosis of ILD or pneumonitis.
• Venous thromboembolism: Venous thromboembolic events (some fatal) may occur (was observed when used in combination with dabrafenib). DVT and PE occurred at an increased incidence with combination therapy. Patients should seek immediate medical attention with symptoms of DVT or PE (shortness of breath, chest pain, arm/leg swelling). Withhold trametinib for uncomplicated DVT or PE; may resume at a lower dose if improves within 3 weeks; permanently discontinue trametinib for life-threatening PE.
Concurrent drug therapy issues:
• Combination therapy with dabrafenib: Serious adverse reactions (tumor promotion, hemolytic anemia), which occur with single-agent dabrafenib, may also occur when trametinib is administered in combination with dabrafenib. Refer to Dabrafenib monograph for further information.
• Appropriate use: Prior to initiating therapy, confirm BRAF V600K and BRAF V600E mutation status with an approved test. Information on approved tests for detection of BRAF V600 mutations is available at www.fdacompaniondiagnostics.com.
BRAF V600K or V600E mutation status (prior to treatment); liver function tests at baseline and periodically; assess LVEF (by echocardiogram or MUGA scan) at baseline, 1 month after therapy initiation, and then at 2- to 3-month intervals; ophthalmological evaluation periodically during treatment and with visual disturbances; monitor for signs/symptoms of pulmonary toxicity (eg, cough dyspnea, hypoxia, pleural effusion, or infiltrates); monitor for dermatologic toxicity and secondary skin infections; blood pressure; diarrhea; signs/symptoms of bleeding, colitis, and GI perforations.
For patients receiving combination therapy with dabrafenib: Blood glucose (baseline and periodically in patients with preexisting diabetes or hyperglycemia); dermatologic exams should be performed prior to treatment initiation, every 2 months while receiving combination treatment, and for up to 6 months following therapy discontinuation. Monitor for signs/symptoms of cutaneous and noncutaneous malignancies and uveitis/iritis.
Based on its mechanism of action, and on findings in animal reproduction studies trametinib may cause fetal harm if administered to a pregnant female. Females of reproductive potential should use a highly effective contraceptive during therapy and for 4 months after treatment is complete. When trametinib is used in combination with dabrafenib, a highly effective nonhormonal contraceptive method should be used (dabrafenib may diminish efficacy of hormonal contraceptives). Fertility may also be impaired in females. Due to a risk for impaired spermatogenesis, males who may want to father a child should seek fertility/family planning counseling prior to initiating combination therapy with dabrafenib.
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience dry skin, nail changes, mouth sores, mouth irritation, lack of appetite, or vomiting. Have patient report immediately to prescriber signs of blood clots (numbness or weakness on one side of the body; pain, redness, tenderness, warmth, or swelling in the arms or legs; change in color of an arm or leg; angina; shortness of breath; tachycardia; or coughing up blood), signs of bleeding (vomiting blood or vomit that looks like coffee grounds; coughing up blood; hematuria; black, red, or tarry stools; bleeding from the gums; abnormal vaginal bleeding; bruises without a reason or that get bigger; or any severe or persistent bleeding), signs of fluid and electrolyte problems (mood changes, confusion, muscle pain or weakness, abnormal heartbeat, severe dizziness, passing out, tachycardia, increased thirst, seizures, loss of strength and energy, lack of appetite, urinary retention or change in amount of urine passed, dry mouth, dry eyes, or nausea or vomiting), signs of kidney problems (urinary retention, hematuria, change in amount of urine passed, or weight gain), signs of heart problems (cough or shortness of breath that is new or worse, swelling of the ankles or legs, abnormal heartbeat, weight gain of more than five pounds in 24 hours, dizziness, or passing out), acne, severe skin redness, persistent skin rash, redness or irritation of palms of hands or soles of feet, signs of a severe pulmonary disorder (lung or breathing problems like difficulty breathing, shortness of breath, or a cough that is new or worse), severe loss of strength and energy, chills, severe dizziness, passing out, severe headache, severe nausea, severe diarrhea, severe abdominal pain, severe abdominal cramps, blurred vision, blindness, vision changes, or visual halos or bright colors around lights (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
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- Drug class: multikinase inhibitors
Other brands: Mekinist