bosutinib

General

High Alert Medication: This medication bears a heightened risk of causing significant patient harm when it is used in error.

Genetic Implications:

Pronunciation:
boe-sue-ti nib

Trade Name(s)

• Bosulif

Ther. Class.

antineoplastics

Pharm. Class.

kinase inhibitors

Indications

•  Chronic phase Philadelphia chromosome positive (Ph+) chronic myelogenous leukemia (CML) that is newly diagnosed or resistant/intolerant to previous therapies.
•  Accelerated/blast phase Ph+ CML that is resistant/intolerant to previous therapies.

Action

Acts as a kinase inhibitor, specifically inhibiting the kinase that promotes CML.

Therapeutic Effect(s):

Decreased progression of CML.

Pharmacokinetics

Absorption: 34% absorbed following oral administration; absorption ↑ with high-fat meal.

Distribution: Extensively distributed to tissues.

Protein Binding: 96%

Metabolism and Excretion: Mostly metabolized, mainly by the CYP3A4 isoenzyme; metabolites do not have antineoplastic activity.

Half-life: 22.5 hr

TIME/ACTION PROFILE (beneficial hematologic response)

Contraindication/Precautions

Contraindicated in:

• Hypersensitivity;
• OB:  Pregnancy;
• Lactation: Lactation.

Use Cautiously in:

• Renal impairment (dose ↓ recommended);
• Hepatic impairment (dose ↓ recommended);
• Rep:   Women of reproductive potential;
• Pedi:  Safety and effectiveness not established in children.

Adverse Reactions/Side Effects

CV: chest pain, HF, myocardial ischemia, pericardial effusion, pericarditis, peripheral edema, QT interval prolongation, tachycardia

Derm: itching, rash, acne, STEVENS-JOHNSON SYNDROME (SJS)

EENT: tinnitus

Endo: hypothyroidism

F and E: dehydration, hyperkalemia

GI: ↑ liver enzymes, abdominal pain, diarrhea, nausea, vomiting, gastritis, GI bleeding, HEPATOTOXICITY, pancreatitis

GU: ↓ fertility, renal impairment

Hemat: anemia, neutropenia, thrombocytopenia

Metabolic: ↓ appetite

MS: arthralgia, back pain, myalgia

Neuro: dizziness, fatigue, headache, dysgeusia

Resp: cough, pulmonary edema

Misc: fever, HYPERSENSITIVITY REACTIONS (including anaphylaxis)

* CAPITALS indicate life-threatening.
Underline indicate most frequent.

Interactions

Drug-Drug

•  Moderate or strong CYP3A4 inhibitors, including  aprepitant,  atazanavir,  ciprofloxacin,  clarithromycin,  conivaptan,  crizotinib,  darunavir,  diltiazem,  erythromycin,  fluconazole,  fosamprenavir,  imatinib,  itraconazole,  ketoconazole,  lopinavir/ritonavir,  nefazodone,  nelfinavir,  posaconazole,  ritonavir,  verapamil, and  voriconazole, ↑ levels and risk of toxicity; avoid concurrent use.
•  Moderate or strong CYP3A4 inducers, including  bosentan,  carbamazepine,  efavirenz,  etravirine,  modafinil,  nafcillin,  phenobarbital,  phenytoin,  rifabutin, and  rifampin, may ↓ levels and effectiveness; avoid concurrent use.
•  Proton pump inhibitors, including  esomeprazole,  dexlansoprazole,  lansoprazole,  omeprazole,  pantoprazole, and  rabeprazole, may ↓ levels and effectiveness; avoid concurrent use. Consider using short-acting antacids or histamine-H₂  receptor blockers instead (these should be taken 2 hr before or after bosutinib).
• May ↑  digoxin  levels and risk of toxicity.

Drug-Natural Products:

 St. John's wort  may ↓ levels and effectiveness; avoid concurrent use.

Drug-Food:

Grapefruit juice may ↑ levels and risk of toxicity; avoid concurrent use.

Route/Dosage

Chronic Phase Ph+ CML Resistant/Intolerant to Previous Therapies

PO (Adults and Children ≥1 yr and BSA ≥1.1 m2): 500 mg once daily; if hematologic, cytogenetic, or molecular response is not achieved or maintained and there has been no occurrence of ≥Grade 3 adverse reactions, consider ↑ dose in 100-mg/day increments up to maximum dose of 600 mg once daily. Continue until disease progression or unacceptable toxicity.

PO (Children ≥1 yr and BSA 0.9–<1.1 m2): 400 mg once daily; if hematologic, cytogenetic, or molecular response is not achieved after 3 mo, consider ↑ dose in 50-mg/day increments up to maximum dose of 500 mg once daily. Continue until disease progression or unacceptable toxicity.

PO (Children ≥1 yr and BSA 0.75–<0.9 m2): 350 mg once daily; if hematologic, cytogenetic, or molecular response is not achieved after 3 mo, consider ↑ dose in 50-mg/day increments up to maximum dose of 450 mg once daily. Continue until disease progression or unacceptable toxicity.

PO (Children ≥1 yr and BSA 0.63–<0.75 m2): 300 mg once daily; if hematologic, cytogenetic, or molecular response is not achieved after 3 mo, consider ↑ dose in 50-mg/day increments up to maximum dose of 400 mg once daily. Continue until disease progression or unacceptable toxicity.

PO (Children ≥1 yr and BSA 0.55–<0.63 m2): 250 mg once daily; if hematologic, cytogenetic, or molecular response is not achieved after 3 mo, consider ↑ dose in 50-mg/day increments up to maximum dose of 350 mg once daily. Continue until disease progression or unacceptable toxicity.

PO (Children ≥1 yr and BSA <0.55 m2): 200 mg once daily; if hematologic, cytogenetic, or molecular response is not achieved after 3 mo, consider ↑ dose in 50-mg/day increments up to maximum dose of 300 mg once daily. Continue until disease progression or unacceptable toxicity.

Renal Impairment 
PO (Adults and Children ≥1 yr and BSA ≥1.1 m2): CCr 30–50 mL/min: 400 mg once daily;  CCr <30 mL/min: 300 mg once daily.

Renal Impairment 
(Children ≥1 yr and BSA 0.9–<1.1 m2): CCr 30–50 mL/min: 300 mg once daily;  CCr <30 mL/min: 250 mg once daily.

Renal Impairment 
(Children ≥1 yr and BSA 0.75–<0.9 m2): CCr 30–50 mL/min: 250 mg once daily;  CCr <30 mL/min: 200 mg once daily.

Renal Impairment 
(Children ≥1 yr and BSA 0.63–<0.75 m2): CCr 30–50 mL/min: 200 mg once daily;  CCr <30 mL/min: 200 mg once daily.

Renal Impairment 
(Children ≥1 yr and BSA 0.55–<0.63 m2): CCr 30–50 mL/min: 200 mg once daily;  CCr <30 mL/min: 150 mg once daily.

Renal Impairment 
(Children ≥1 yr and BSA <0.55 m2): CCr 30–50 mL/min: 150 mg once daily;  CCr <30 mL/min: 100 mg once daily.

Hepatic Impairment 
PO (Adults and Children ≥1 yr and BSA ≥1.1 m2): Mild, moderate, or severe hepatic impairment: 200 mg once daily.

Hepatic Impairment 
(Children ≥1 yr and BSA 0.9–<1.1 m2): Mild, moderate, or severe hepatic impairment: 200 mg once daily.

Hepatic Impairment 
(Children ≥1 yr and BSA 0.63–<0.9 m2): Mild, moderate, or severe hepatic impairment: 150 mg once daily.

Hepatic Impairment 
(Children ≥1 yr and BSA <0.63 m2): Mild, moderate, or severe hepatic impairment: 100 mg once daily.

Newly Diagnosed Chronic Phase Ph+ CML

PO (Adults and Children ≥1 yr and BSA ≥1.1 m2): 400 mg once daily; if hematologic, cytogenetic, or molecular response is not achieved or maintained and there has been no occurrence of ≥Grade 3 adverse reactions, consider ↑ dose in 100-mg/day increments up to maximum dose of 600 mg once daily. Continue until disease progression or unacceptable toxicity.

PO (Children ≥1 yr and BSA 0.9–<1.1 m2): 300 mg once daily; if hematologic, cytogenetic, or molecular response is not achieved after 3 mo, consider ↑ dose in 50-mg/day increments up to maximum dose of 400 mg once daily. Continue until disease progression or unacceptable toxicity.

PO (Children ≥1 yr and BSA 0.75–<0.9 m2): 250 mg once daily; if hematologic, cytogenetic, or molecular response is not achieved after 3 mo, consider ↑ dose in 50-mg/day increments up to maximum dose of 350 mg once daily. Continue until disease progression or unacceptable toxicity.

PO (Children ≥1 yr and BSA 0.55–<0.75 m2): 200 mg once daily; if hematologic, cytogenetic, or molecular response is not achieved after 3 mo, consider ↑ dose in 50-mg/day increments up to maximum dose of 300 mg once daily. Continue until disease progression or unacceptable toxicity.

PO (Children ≥1 yr and BSA <0.55 m2): 150 mg once daily; if hematologic, cytogenetic, or molecular response is not achieved after 3 mo, consider ↑ dose in 50-mg/day increments up to maximum dose of 250 mg once daily. Continue until disease progression or unacceptable toxicity.

Renal Impairment 
(Adults and Children ≥1 yr and BSA ≥1.1 m2): CCr 30–50 mL/min: 300 mg once daily;  CCr <30 mL/min: 200 mg once daily.

Renal Impairment 
(Children ≥1 yr and BSA 0.9–<1.1 m2): CCr 30–50 mL/min: 200 mg once daily;  CCr <30 mL/min: 200 mg once daily.

Renal Impairment 
(Children ≥1 yr and BSA 0.75–<0.9 m2): CCr 30–50 mL/min: 200 mg once daily;  CCr <30 mL/min: 150 mg once daily.

Renal Impairment 
(Children ≥1 yr and BSA 0.63–<0.75 m2): CCr 30–50 mL/min: 150 mg once daily;  CCr <30 mL/min: 100 mg once daily.

Renal Impairment 
(Children ≥1 yr and BSA 0.55–<0.63 m2): CCr 30–50 mL/min: 150 mg once daily;  CCr <30 mL/min: 100 mg once daily.

Renal Impairment 
(Children ≥1 yr and BSA <0.55 m2): CCr 30–50 mL/min: 100 mg once daily;  CCr <30 mL/min: 100 mg once daily.

Hepatic Impairment 
(Adults and Children ≥1 yr and BSA ≥1.1 m2): Mild, moderate, or severe hepatic impairment: 200 mg once daily.

Hepatic Impairment 
(Children ≥1 yr and BSA 0.9–<1.1 m2): Mild, moderate, or severe hepatic impairment: 150 mg once daily.

Hepatic Impairment 
(Children ≥1 yr and BSA <0.9 m2): Mild, moderate, or severe hepatic impairment: 100 mg once daily.

Accelerated/Blast Phase Ph+ CML Resistant/Intolerant to Previous Therapies

PO (Adults): 500 mg once daily; if hematologic, cytogenetic, or molecular response is not achieved or maintained and there has been no occurrence of ≥Grade 3 adverse reactions, consider ↑ dose in 100-mg/day increments up to maximum dose of 600 mg once daily. Continue until disease progression or unacceptable toxicity.

Renal Impairment 
PO (Adults): CCr 30–50 mL/min: 400 mg once daily;  CCr <30 mL/min: 300 mg once daily.

Hepatic Impairment 
PO (Adults): Any degree of hepatic impairment: 200 mg once daily.

Availability

Capsules: 50 mg, 100 mg

Tablets: 100 mg, 400 mg, 500 mg

Assessment

• Monitor for diarrhea, nausea, vomiting, and abdominal pain. Usually occurs within 4 days of therapy and lasts for about 3 days.  For Grade 3–4 diarrhea (↑ of ≥7 stools/day over baseline/pretreatment),  hold bosutinib until recovery to Grade ≤1.
• Assess for signs and symptoms fluid retention (swelling in hands, ankles, or feet; weight gain; shortness of breath; cough; chest pain). May manifest as pericardial effusion, pleural effusion, pulmonary edema, and/or peripheral edema. Interrupt, reduce dose, or discontinue bosutinib as necessary.
• Monitor for signs of allergic reaction (rash, shortness of breath, respiratory tract infections, loss of appetite, headache, dizziness, back pain, joint pain, itching).
• Assess patient for skin rash frequently during therapy. Discontinue bosutinib at first sign of rash; may be life-threatening. SJS may develop. Treat symptomatically; may recur once treatment is stopped.
• Monitor for signs and symptoms of cardiac failure (shortness of breath; weight gain; swelling in hands, ankles, or feet.) Interrupt therapy, reduce dose, or discontinue therapy as needed.

Lab Test Considerations:

Verify negative pregnancy test prior to starting therapy.

Monitor CBC weekly for first mo, then monthly thereafter. May cause thrombocytopenia, anemia, and neutropenia. If ANC <1000 × 10⁶ /L or platelets <50,000 × 10⁶ /L, withhold bosutinib until ANC ≥1000 × 10⁶ /L and platelets ≥50,000 × 10⁶ /L. Resume treatment with bosutinib at same dose if recovery occurs within 2 wk. If blood counts remain low for >2 wk, upon recovery, ↓ dose by 100 mg (or by 50 mg in pediatric patients with BSA <1.1 m² ) and resume treatment. If cytopenia recurs, ↓ dose by an additional 100 mg (or by 50 mg in pediatric patients with BSA <1.1 m² ) upon recovery and resume treatment.

• Monitor hepatic function monthly for first 3 mo, then periodically during therapy as clinically indicated.  If ↑ liver transaminases >5 times upper limit of normal (ULN) occur,  hold bosutinib until recovery to ≤2.5 times ULN and resume at 400 mg once daily thereafter. If recovery takes longer than 4 wk, discontinue bosutinib.  If transaminase ↑ ≥3 times ULN occur concurrently with bilirubin ↑ >2 times ULN and alkaline phosphatase <2 times ULN,  discontinue bosutinib.
• Monitor renal function prior to and periodically during therapy, especially in patients with pre-existing renal impairment and other risk factors. May require dose adjustments.

Implementation

• PO Administer once daily with food.  DNC: Swallow tablets and capsules whole; do not crush, break, or chew. Do not handle crushed or broken tablets.  For patients unable to swallow whole capsules, each capsule can be opened and the contents mixed with applesauce or yogurt. Mixing the capsule contents with applesauce or yogurt cannot be considered a substitute of a proper meal.

Patient/Family Teaching

• Instruct patient to take bosutinib as directed. Take missed doses as soon as remembered if within 12 hr; if longer than 12 hr, skip dose and take usual prescribed dose on the following day. Do not stop taking bosutinib without consulting health care professional. Advise patient to read  Patient Information  before starting therapy and with each Rx refill in case of changes.
• Advise patient to avoid grapefruit and grapefruit juice during therapy.
• Advise patient to immediately report fever, jaundice (skin or the white part of the eyes turns yellow or dark "tea color" urine), symptoms of infection, fluid retention, anaphylaxis, rash, unexpected bleeding or bruising, or blood in urine or stools occur. Advise patient to notify health care professional if diarrhea, nausea, vomiting, or abdominal pain occur.
• Inform patient to take medications that ↓ stomach acid (antacids and H₂  blockers) 2 hr before or 2 hr after bosutinib and to consult health care professional if taking a proton pump inhibitor.
• Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications, especially St. John's wort.
• Rep:  May cause fetal harm. Advise females of reproductive potential to use effective contraception and to avoid breastfeeding during and for at least 2 wk after last dose of therapy. Advise patient to notify health care professional immediately if pregnancy is suspected. May impair fertility in male and female patients.

Evaluation/Desired Outcomes

Decreased progression of CML.