Cabozantinib(Cometriq )

Cabozantinib (Cometriq®)

Pronounced: [cabo-ZAN-ti-nib]

About Your Medication

Cabozantinib (Cometriq®) is an oral medicine that your doctor prescribed for the treatment of your cancer. Please take Cabozantinib as directed by your prescriber.

How to Take Your Medication

 Take your cabozantinib at approximately the same time each day

 Do not eat for at least 2 hours before and at least 1 hour after taking your Cabozantinib. Take the tablets whole – do not crush or break them.

 If you miss a dose of cabozantinib, take your next dose at the usual scheduled time.

 Do not take two doses on the same day to make up for a missed dose.

 Contact your cancer clinic if you are unable to take cabozantinib as prescribed, including if you are unable to swallow the tablet.

Tell Your Healthcare Provider if you have any trouble taking your cabozantinib, including:

 Trouble swallowing pills

 Forgetting to take doses

 Trouble affording your medications

 Throwing up pills

 Side effects

Important Precautions

 Cabozantinib may be harmful to an unborn child. If sexually active with a partner that is pregnant or who may become pregnant during and for several weeks after treatment, two forms of contraception must be used (a condom and another effective form of birth control).

 It is not known whether cabozantinib passes into breast milk. Nursing mothers should discuss with their healthcare providers whether to discontinue nursing or to discontinue cabozantinib.

 Gastrointestinal perforations have occurred in a small number of patients taking this medication

 Severe, sometimes fatal bleeding events have occurred in patients taking cabozantinib. Monitor signs and symptoms of bleeding while on this medication.

Copyright 2017 Michigan Oncology Quality Consortium, All rights reserved. V.12-14 MOQC makes no representations or warranties and explicitly disclaims the appropriateness or applicability of the MOQC Content to any specific patient's care or treatment. Any clinician seeking to treat a patient using the MOQC Content is expected to use independent medical judgment in the context of individual clinical circumstances of a specific patient's care or treatment.  Wound healing may be impaired while on cabozantinib. It is recommended that this medication be stopped at least 28 days prior to a scheduled surgery.

 Damage to the jaw bone called osteonecrosis of the jaw (ONJ) has been observed with cabozantinib. This risk may be increased if other medicines to support your bones are used. Notify your cancer clinic if you have jaw pain immediately.

What foods and drugs may interact with my cabozantinib?

Please talk to your healthcare provider at your cancer clinic before starting or stopping any medications, vitamins, or herbal supplements, because some of these may interact with your cabozantinib. Some examples of products that interact with cabozantinib include:

 Grapefruit or grapefruit juice

 Certain anti-infectives such as rifampin (Rifadin®)

 Anti-seizure medicines, including carbamazepine (Tegretol®), phenobarbital (Luminal®), and phenytoin (Dilantin®)

 Antivirals like ritonavir (Norvir®), nelfinavir (Viracept®), and saquinavir (Invirase®)

 Some medications for mood, like St. John’s Wort and nefazodone (Serzone®)

 Certain antifungals, such as itraconazole (Sporanox®), ketoconazole (Nizoral®), posaconazole (Noxafil®), and voriconazole (Vfend®)

 Antibiotics like ciprofloxacin (Cipro®) and levofloxacin (Levaquin®)

 Heart rhythm medications like quinidine, verapamil (Calan®) and amiodarone (Cordarone®) or dronedarone (Multaq®)

 Blood thinning medicines such as warfarin (Coumadin®) and dabigatran (Pradaxa®)

Storage, Handling, and Disposal

It is important to keep these safeguards in mind when storing and handling oral anticancer therapy to keep you and your caregivers safe.

 Keep your cabozantinib in a safe place, away from other family members’ medications and away from any food or drinks.

 Store the medication at room temperature in a dry location – avoid storing your medication in the bathroom.

 Store cabozantinib in its original container.

Copyright 2017 Michigan Oncology Quality Consortium, All rights reserved. V.12-14 MOQC makes no representations or warranties and explicitly disclaims the appropriateness or applicability of the MOQC Content to any specific patient's care or treatment. Any clinician seeking to treat a patient using the MOQC Content is expected to use independent medical judgment in the context of individual clinical circumstances of a specific patient's care or treatment.  Keep the medication out of reach from children and pets.

 Return expired, damaged, or unused cabozantinib to a pharmacy or hospital for disposal. Do not discard into the garbage or toilet, or anywhere that children or pets may have access.

Copyright 2017 Michigan Oncology Quality Consortium, All rights reserved. V.12-14 MOQC makes no representations or warranties and explicitly disclaims the appropriateness or applicability of the MOQC Content to any specific patient's care or treatment. Any clinician seeking to treat a patient using the MOQC Content is expected to use independent medical judgment in the context of individual clinical circumstances of a specific patient's care or treatment. Cabozantinib (Cometriq®) Side Effect Summary

This list does not include all possible side effects of cabozantinib. If you have an unusual symptom, call the clinic. Below are the most common side effects:

 Diarrhea – frequent and/or watery bowel movements What are your symptoms? What can you do…

Mild diarrhea – stools are more  Stay well hydrated loose/watery or you are having 1-3 more  Avoid fatty, greasy, spicy foods that may increase your risk for stools per day than usual diarrhea  Avoid caffeine and alcohol  Eat small, frequent meals; foods that are easy on the stomach include bananas, rice, applesauce, and toast  Use your antidiarrheal medicine, loperamide (Imodium®) 4 mg at the onset of diarrhea, then 2 mg every 2 hours until diarrhea- free for 12 hours  If diarrhea is not improving after 48 hours of treatment with your antidiarrheal medicine, or you are having trouble staying hydrated, call the clinic Moderate diarrhea - you are having 4-6  Try to manage using the measures listed above. more stools per day than usual; you are  If diarrhea is not improving within 24 hours, or you are having still able to perform your normal daily trouble staying hydrated, call the clinic activities Severe diarrhea – you are having 7 or more stools per day than usual, or you are having trouble staying hydrated or  Stop taking the cabozantinib and call the clinic performing normal daily activities, or you are not making it to the bathroom in time

 Nausea/Vomiting What are your symptoms? What can you do…

Mild nausea – loss of appetite without  Stay well-hydrated alteration of eating habits  Use anti-nausea medication prescribed by the clinic  Eat smaller, more frequent meals/snacks Mild vomiting - you experience 1-2  avoid empty stomach episodes in 24 hours  Eat bland foods Moderate nausea – decreased oral intake  Try to manage using the measures listed above. without significant weight loss,  If nausea/vomiting is not improving within 24 hours, or you are dehydration, or malnutrition having trouble staying hydrated, call the clinic

Moderate vomiting – you experience 3-5

Copyright 2017 Michigan Oncology Quality Consortium, All rights reserved. V.12-14 MOQC makes no representations or warranties and explicitly disclaims the appropriateness or applicability of the MOQC Content to any specific patient's care or treatment. Any clinician seeking to treat a patient using the MOQC Content is expected to use independent medical judgment in the context of individual clinical circumstances of a specific patient's care or treatment. episodes in 24 hours Severe nausea – you have inadequate oral intake of calories or fluids  Unable to stay hydrated or hold down fluid (not able to drink 8- Severe vomiting – you experience 6 or 10 cups of liquid per day) – contact the clinic IMMEDIATELY more episodes in 24 hours  The anti-nausea medication prescribed is not working  Stop taking cabozantinib and call the clinic

 Anorexia – decreased appetite/inability to eat What Can I Do? When to Call the Clinic?

 Stay well-hydrated  Unable to stay hydrated-CONTACT IMMEDIATELY  Eat smaller, more frequent meals/snacks that  Unable to eat are high in calories  If you have had a rapid increase in weight (i.e. 5 pounds or more in one week)

 Skin Conditions – hand-foot syndrome (swelling and redness of the skin on the palms of the hands and soles of the feet What are your symptoms? What can you do…

Mild hand-foot syndrome –  Apply non-scented lotion to affected areas to avoid Minimal skin changes (e.g., redness or swelling) dryness without pain  Use moisturizing products with lactic acid  Use gloves/socks at night

Moderate hand-foot syndrome –  If symptoms do not improve with above measures Skin changes (e.g., peeling, blisters, bleeding, call the clinic. edema, or abnormal thickening of the outer skin layer) with pain or which limit your ability to perform some activities

Copyright 2017 Michigan Oncology Quality Consortium, All rights reserved. V.12-14 MOQC makes no representations or warranties and explicitly disclaims the appropriateness or applicability of the MOQC Content to any specific patient's care or treatment. Any clinician seeking to treat a patient using the MOQC Content is expected to use independent medical judgment in the context of individual clinical circumstances of a specific patient's care or treatment. Severe hand-foot syndrome –  Stop taking the axitinib and call the clinic Severe skin changes (e.g., peeling, blisters, bleeding, edema, or abnormal thickening of the outer skin layer) with pain or which limit your ability to perform daily activities

 Hair color changes – No self-care measures are recommended as this change is temporary and not harmful.

 High blood pressure (onset within 3 weeks) What Can I Do?  When to Call the Clinic?

 Depending on your specific treatment plan, you  Blood pressure over 150/90 or less than 100/60 or as may be instructed by your clinic to monitor your instructed by your clinic provider blood pressure daily at home, especially during the first 6 weeks of therapy

 Mouth sores (mucositis) - Sores in the mouth and throat or on the lips which may be painful What are your symptoms? What can you do…

Mild mucositis – None or mild  Gently use a soft toothbrush symptoms; Pain treatments not needed.  Rinse 3-4 times daily with a solution of 1/8 tsp baking soda + 1/4 tsp salt in 1 cup warm water  Use pain medications as prescribed

Moderate mucositis – Moderate pain; but not  If symptoms do not improve with above measures interfering with eating or drinking significantly (may call the clinic include modifications in diet)

Severe mucositis - Severe pain; interfering with  Stop taking the cabozantinib and call the clinic eating or drinking (not able to drink 8-10 cups of liquid per day)

Copyright 2017 Michigan Oncology Quality Consortium, All rights reserved. V.12-14 MOQC makes no representations or warranties and explicitly disclaims the appropriateness or applicability of the MOQC Content to any specific patient's care or treatment. Any clinician seeking to treat a patient using the MOQC Content is expected to use independent medical judgment in the context of individual clinical circumstances of a specific patient's care or treatment. Below are some less common side effects of cabozantinib. Less Common Side What Can I Do?  When to Call the Clinic? Effects Gastrointestinal  There are no self-  If you have sudden, severe general abdominal or Perforations/ Fistulas care measures intestinal pain – contact the clinic IMMEDIATELY that can be taken (tears or holes in the intestine) Bleeding  Be careful with  Large unexplained bruises sharp objects  Bleeding that doesn’t stop after a few minutes  Wear shoes  Coughing up blood  Use a soft  Blood in your urine or stools toothbrush  If you are planning to have surgery, call with the date  Blow your nose gently Blood Clots  Your doctor may  Shortness of breath prescribe a  Chest pain (Deep Vein medication to  Swelling/tenderness/redness in the leg or arm Thrombosis/Pulmonary help decrease Embolism; Formation of a your risk of blood blood clot that plugs the clots blood vessel) Osteonecrosis of the Jaw  Notify the clinic of  If you have pain in your jaw while at rest, during the upcoming dental night or caused by chewing. appointments/ procedures Liver Dysfunction  The clinic will  Yellowing of eyes or skin monitor your labs to assess

Who to Call With Questions?

If you are having an emergency, call 911

Copyright 2017 Michigan Oncology Quality Consortium, All rights reserved. V.12-14 MOQC makes no representations or warranties and explicitly disclaims the appropriateness or applicability of the MOQC Content to any specific patient's care or treatment. Any clinician seeking to treat a patient using the MOQC Content is expected to use independent medical judgment in the context of individual clinical circumstances of a specific patient's care or treatment. Information to have ready for each appointment:

 Number of missed doses per month:____

 Problems receiving your medication (cost, insurance issues, etc; circle one): Yes / No

 New medications (Please call clinic before starting or stopping any medications): ______

 Symptoms and what you’ve done to address them: ______

______

Who to Call With Questions?

If you are having an emergency, call 911

Copyright 2017 Michigan Oncology Quality Consortium, All rights reserved. V.12-14 MOQC makes no representations or warranties and explicitly disclaims the appropriateness or applicability of the MOQC Content to any specific patient's care or treatment. Any clinician seeking to treat a patient using the MOQC Content is expected to use independent medical judgment in the context of individual clinical circumstances of a specific patient's care or treatment.