Dosage modifications1

Impaired wound healing can occur in patients who receive drugs that inhibit the VEGF signaling pathway. Therefore, NEXAVAR® (sorafenib) has the potential to adversely affect wound healing. Withhold NEXAVAR for at least 10 days prior to elective surgery. Do not administer for at least 2 weeks following major surgery and until adequate wound healing. The safety of resumption of NEXAVAR after resolution of wound healing complications has not been established.

Recommended dose reductions for adverse reactions
Dose ReductionHepatocellular Carcinoma and Renal Cell CarcinomaDifferentiated Thyroid Carcinoma
First dose reduction400 mg orally once daily400 mg orally in the morning and 200 mg orally in the evening about 12 hours apart
OR 200 mg orally in the morning and 400 mg orally in the evening about 12 hours apart
Second dose reduction200 mg orally once daily
OR 400 mg every other day		200 mg orally twice daily
Third dose reductionNone200 mg orally once daily
Financial assistance

The following may require temporary interruption or permanent discontinuation of NEXAVAR (see table below):

Recommended dosage modifications of NEXAVAR for adverse reactions
Adverse ReactionSeverity*NEXAVAR Dosage Modification
Cardiovascular events  
Cardiac ischemia and/or infarctionGrade 2 and abovePermanently discontinue
Congestive heart failureGrade 3Interrupt† until Grade 1 or less, resume at reduced dose by 1 dose level‡
Grade 4Permanently discontinue
HemorrhageGrade 2 and above requiring medical interventionPermanently discontinue
HypertensionGrade 2
(symptomatic/persistent) OR Grade 2 symptomatic increase by greater than 20 mm Hg (diastolic) or greater than 140/90 mm Hg if previously within normal limits OR Grade 3		Interrupt until symptoms resolve and diastolic blood pressure less than 90 mm Hg, then resume at reduced dose by 1 dose level‡ If needed, reduce another dose level‡
Grade 4Permanently discontinue
Gastrointestinal perforationAny gradePermanently discontinue
QT interval prolongationGreater than 500 milliseconds OR Increase from baseline of 60 milliseconds or greaterInterrupt and correct electrolyte abnormalities (magnesium, potassium, calcium)

Use medical judgment before restarting
Drug-induced liver injuryGrade 3 ALT or higher in the absence of another cause§ OR AST/ALT greater than 3 x upper limit normal (ULN) with bilirubin greater than 2 x ULN in the absence of another cause§Permanently discontinue
Non-hematological toxicitiesGrade 2Continue treatment at reduced dose by 1 dose level
Grade 3 
1st occurrenceInterrupt until Grade 2 or less, then resume at reduced dose by 1 dose level
No improvement within 7 days OR 2nd or 3rd occurrenceInterrupt until Grade 2 or less, then resume at reduced dose by 2 dose levels
4th occurrenceInterrupt until Grade 2 or less, then resume at reduced dose by 2 dose levels for HCC and RCC or 3 dose levels for DTC
Grade 4Permanently discontinue
Adverse Reaction
Cardiovascular events
Adverse Reaction
Cardiac ischemia and/or infarction
Severity*NEXAVAR Dosage Modification
Grade 2 and abovePermanently discontinue
Adverse Reaction
Congestive heart failure
Severity*NEXAVAR Dosage Modification
Grade 3Interrupt† until Grade 1 or less, resume at reduced dose by 1 dose level‡
Severity*NEXAVAR Dosage Modification
Grade 4Permanently discontinue
Adverse Reaction
Hemorrhage
Severity*NEXAVAR Dosage Modification
Grade 2 and above requiring medical interventionPermanently discontinue
Adverse Reaction
Hypertension
Severity*NEXAVAR Dosage Modification
Grade 2
(symptomatic/persistent) OR Grade 2 symptomatic increase by greater than 20 mm Hg (diastolic) or greater than 140/90 mm Hg if previously within normal limits OR Grade 3		Interrupt until symptoms resolve and diastolic blood pressure less than 90 mm Hg, then resume at reduced dose by 1 dose level‡
If needed, reduce another dose level‡
Severity*NEXAVAR Dosage Modification
Grade 4Permanently discontinue
Adverse Reaction
Gastrointestinal perforation
Severity*NEXAVAR Dosage Modification
Any gradePermanently discontinue
Adverse Reaction
QT interval prolongation
Severity*NEXAVAR Dosage Modification
Greater than 500 milliseconds OR Increase from baseline of 60 milliseconds or greaterInterrupt and correct electrolyte abnormalities (magnesium, potassium, calcium) Use medical judgment before restarting
Adverse Reaction
Drug-induced liver injury
Severity*NEXAVAR Dosage Modification
Grade 3 ALT or higher in the absence of another cause§ OR AST/ALT greater than 3 x upper limit normal (ULN) with bilirubin greater than 2 x ULN in the absence of another cause§Permanently discontinue
Adverse Reaction
Non-hematological toxicities
Severity*NEXAVAR Dosage Modification
Grade 2Continue treatment at reduced dose by 1 dose level
Severity*
Grade 3
Severity*NEXAVAR Dosage Modification
1st occurrenceInterrupt until Grade 2 or less, then resume at reduced dose by 1 dose level
Severity*NEXAVAR Dosage Modification
No improvement within 7 days OR 2nd or 3rd occurrenceInterrupt until Grade 2 or less, then resume at reduced dose by 2 dose levels
Severity*NEXAVAR Dosage Modification
4th occurrenceInterrupt until Grade 2 or less, then resume at reduced dose by 2 dose levels for HCC and RCC or 3 dose levels for DTC
Severity*NEXAVAR Dosage Modification
Grade 4Permanently discontinue
Recommended dosage modifications for dermatologic toxicities
Dermatologic
Toxicity Grade		OccurrenceNEXAVAR Dosage Modification
  Hepatocellular and Renal Cell CarcinomaDifferentiated Thyroid Carcinoma
Grade 2:
Painful erythema and swelling of the hands or feet and/or discomfort affecting the patient’s normal activities		1st occurrenceContinue NEXAVAR and consider topical therapy for symptomatic relief
If no improvement within 7 days, see below		Decrease NEXAVAR to
600 mg daily
If no improvement within 7 days, see below
No improvement within 7 days at reduced dose

OR

2nd and 3rd occurrence		Interrupt NEXAVAR until resolved or improved to Grade 0 to 1Interrupt NEXAVAR until completely resolved or improved to Grade 1
When resuming treatment, decrease dose by 1 dose levelWhen resuming treatment, decrease dose by 1 dose level for 2nd occurrence and 2 dose levels for 3rd occurrence
4th occurrenceDiscontinue NEXAVAR treatment
Grade 3:
Moist desquamation, ulceration, blistering, or severe pain of the hands or feet, resulting in inability to work or perform activities of daily living		1st occurrenceInterrupt NEXAVAR until resolved or improved to Grade 0 to 1Interrupt NEXAVAR until completely resolved or improved to Grade 1
When resuming treatment, decrease dose by 1 dose levelWhen resuming treatment, decrease dose by 1 dose level
2nd occurrenceInterrupt NEXAVAR until resolved or improved to Grade 0 to 1Interrupt NEXAVAR until completely resolved or improved to Grade 1
When resuming treatment, decrease dose by 1 dose levelWhen resuming treatment, decrease dose by 2 dose levels
3rd occurrenceDiscontinue NEXAVAR treatment
Dermatologic
Toxicity Grade		OccurrenceNEXAVAR Dosage Modification
  Hepatocellular and Renal Cell Carcinoma
Grade 2:
Painful erythema and swelling of the hands or feet and/or discomfort affecting the patient’s normal activities		1st occurrenceContinue NEXAVAR and consider topical therapy for symptomatic relief
If no improvement within 7 days, see below
No improvement within 7 days at reduced dose

OR

2nd and 3rd occurrence		Interrupt NEXAVAR until resolved or improved to Grade 0 to 1
When resuming treatment, decrease dose by 1 dose level
4th occurrenceDiscontinue NEXAVAR treatment
Grade 3:
Moist desquamation, ulceration, blistering, or severe pain of the hands or feet, resulting in inability to work or perform activities of daily living		1st occurrenceInterrupt NEXAVAR until resolved or improved to Grade 0 to 1
When resuming treatment, decrease dose by 1 dose level
2nd occurrenceInterrupt NEXAVAR until resolved or improved to Grade 0 to 1
When resuming treatment, decrease dose by 1 dose level
3rd occurrenceDiscontinue NEXAVAR treatment
Dermatologic
Toxicity Grade		OccurrenceNEXAVAR Dosage Modification
  Differentiated Thyroid Carcinoma
Grade 2:
Painful erythema and swelling of the hands or feet and/or discomfort affecting the patient’s normal activities		1st occurrenceDecrease NEXAVAR to 600 mg daily
If no improvement within 7 days, see below
No improvement within 7 days at reduced dose

OR

2nd and 3rd occurrence		Interrupt NEXAVAR until completely resolved or improved to Grade 1
When resuming treatment, decrease dose by 1 dose level for 2nd occurrence and 2 dose levels for 3rd occurrence
4th occurrenceDiscontinue NEXAVAR treatment
Grade 3:
Moist desquamation, ulceration, blistering, or severe pain of the hands or feet, resulting in inability to work or perform activities of daily living		1st occurrenceInterrupt NEXAVAR until completely resolved or improved to Grade 1
When resuming treatment, decrease dose by 1 dose level
2nd occurrenceInterrupt NEXAVAR until completely resolved or improved to Grade 1
When resuming treatment, decrease dose by 2 dose levels
3rd occurrenceDiscontinue NEXAVAR treatment

Following improvement of Grade 2 or 3 dermatologic toxicity to Grade 0 or 1 for at least 28 days on a reduced dose of NEXAVAR, the dose of NEXAVAR may be increased 1 dose level from the reduced dose. Approximately 50% of patients requiring a dose reduction for dermatologic toxicity are expected to meet these criteria for resumption of the higher dose and roughly 50% of patients resuming the previous dose are expected to tolerate the higher dose (that is, maintain the higher dose level without recurrent Grade 2 or higher dermatologic toxicity).

Learn more about AE management

Indications for NEXAVAR

NEXAVAR is indicated for the treatment of patients with unresectable hepatocellular carcinoma (HCC).

NEXAVAR is indicated for the treatment of patients with advanced renal cell carcinoma (RCC).

NEXAVAR is indicated for the treatment of patients with locally recurrent or metastatic, progressive, differentiated thyroid carcinoma (DTC) that is refractory to radioactive iodine treatment.

See More

Important Safety Information

Contraindications: NEXAVAR is contraindicated in patients with known severe hypersensitivity to sorafenib or any other component of NEXAVAR.

NEXAVAR in combination with carboplatin and paclitaxel is contraindicated in patients with squamous cell lung cancer.

Cardiovascular Events: In the SHARP (HCC) study, the incidence of cardiac ischemia/infarction was 2.7% in NEXAVAR-treated patients compared with 1.3% for placebo-treated group. In the TARGET (RCC) study, the incidence of cardiac ischemia/infarction was higher in the NEXAVAR-treated group (2.9%) compared with the placebo-treated group (0.4%). In the DECISION (DTC) study, the incidence of cardiac ischemia/infarction was 1.9% in the NEXAVAR-treated group compared with 0% in the placebo-treated group. Patients with unstable coronary artery disease or recent myocardial infarction were excluded from this study. Consider temporary or permanent discontinuation of NEXAVAR in patients who develop cardiovascular events.

Hemorrhage: An increased risk of bleeding may occur following NEXAVAR administration. In the SHARP (HCC) study, the rates of bleeding from esophageal varices (2.4% and 4%) and of bleeding with a fatal outcome from any site (2.4% and 4%) were similar in NEXAVAR-treated patients and those receiving placebo, respectively. In the TARGET (RCC) study, bleeding was reported in 15.3% of patients in the NEXAVAR-treated group and 8.2% of patients receiving placebo. The incidence of Grade 3 and 4 bleeding was 2% and 0%, respectively, in NEXAVAR-treated patients, and 1.3% and 0.2%, respectively, in those receiving placebo. There was one fatal hemorrhage in each treatment group in the TARGET (RCC) study. In the DECISION (DTC) study, bleeding was reported in 17.4% of NEXAVAR-treated patients and 9.6% of those receiving placebo; however, the incidence of Grade 3 bleeding was similar (1% and 1.4%) in NEXAVAR-treated patients and in those receiving placebo. If any bleeding necessitates medical intervention, consider permanent discontinuation of NEXAVAR.

Hypertension: In the SHARP (HCC) study, hypertension was reported in 9.4% of NEXAVAR-treated patients and 4.3% of patients in the placebo-treated group. In the TARGET (RCC) study, hypertension was reported in 16.9% of NEXAVAR-treated patients and 1.8% of patients in the placebo-treated group. In the DECISION (DTC) study, hypertension was reported in 40.6% of NEXAVAR-treated patients and 12.4% of placebo-treated patients. Hypertension was usually mild to moderate, occurred early in the course of treatment, and was managed with standard antihypertensive therapy. Monitor blood pressure weekly during the first 6 weeks of NEXAVAR. Thereafter, monitor blood pressure and treat hypertension, if required, in accordance with standard medical practice. In cases of severe or persistent hypertension despite institution of antihypertensive therapy, consider temporary or permanent discontinuation of NEXAVAR.

Dermatologic Toxicities: Hand-foot skin reaction and rash are the most common adverse reactions attributed to NEXAVAR. Management of dermatologic toxicities may include topical therapies for symptomatic relief, temporary treatment interruption and/or dose modification of NEXAVAR, or in severe or persistent cases, permanent discontinuation of NEXAVAR. There have been reports of severe dermatologic toxicities, including Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). These cases may be life-threatening. Discontinue NEXAVAR if SJS or TEN are suspected.

Gastrointestinal Perforation: Gastrointestinal perforation has been reported in less than 1% of patients taking NEXAVAR. In the event of a gastrointestinal perforation, permanently discontinue NEXAVAR.

Increased Risk of Bleeding with Concomitant Use of Warfarin: Infrequent bleeding or elevations in the International Normalized Ratio (INR) have been reported in some patients taking warfarin while on NEXAVAR. Monitor patients taking concomitant warfarin regularly for changes in prothrombin time (PT), INR, or clinical bleeding episodes.

Risk of Impaired Wound Healing: Impaired wound healing can occur in patients who receive drugs that inhibit the VEGF signaling pathway. Therefore, NEXAVAR has the potential to adversely affect wound healing. Withhold NEXAVAR for at least 10 days prior to elective surgery. Do not administer for at least 2 weeks following major surgery and until adequate wound healing. The safety of resumption of NEXAVAR after resolution of wound healing complications has not been established.

Increased Mortality, Concomitant Administration with Carboplatin/Paclitaxel & Gemcitabine/Cisplatin in Squamous Cell Lung Cancer: In a subset analysis of two randomized controlled trials in chemo-naïve patients with Stage IIIB-IV non-small cell lung cancer, patients with squamous cell carcinoma experienced higher mortality with the addition of NEXAVAR compared to those treated with carboplatin/paclitaxel alone (HR 1.81, 95% CI 1.19-2.74) and gemcitabine/cisplatin alone (HR 1.22, 95% CI 0.82-1.80). NEXAVAR, in combination with gemcitabine/cisplatin, is not recommended in patients with squamous cell lung cancer. The safety and effectiveness of NEXAVAR has not been established in patients with non-small cell lung cancer.

QT Interval Prolongation: NEXAVAR can prolong the QT/QTc interval. QT/QTc interval prolongation increases the risk for ventricular arrhythmias. Avoid use in patients with congenital long QT syndrome. Monitor electrolytes and electrocardiograms in patients with congestive heart failure, bradyarrhythmias, drugs known to prolong the QT interval, including Class Ia and III antiarrhythmics. Correct electrolyte abnormalities (magnesium, potassium, calcium). Interrupt NEXAVAR if QTc interval is greater than 500 milliseconds or for an increase from baseline of 60 milliseconds or greater.

Drug-Induced Liver Injury: Sorafenib-induced hepatitis is characterized by a hepatocellular pattern of liver damage with significant increases of transaminases which may result in hepatic failure and death. Increases in bilirubin and INR may also occur. Liver function tests should be monitored regularly and in cases of increased transaminases without alternative explanation NEXAVAR should be discontinued.

Embryo-Fetal Toxicity: Based on its mechanism of action and findings in animals, NEXAVAR may cause fetal harm when administered to a pregnant woman. Sorafenib caused embryo-fetal toxicities in animals at maternal exposures that were significantly lower than the human exposures at the recommended dose of 400 mg twice daily. Advise pregnant women and females of reproductive potential of the potential risk to a fetus. Verify the pregnancy status of females of reproductive potential prior to initiation of NEXAVAR. Advise females of reproductive potential to use effective contraception during treatment and for 6 months following the last dose of NEXAVAR. Advise male patients with female partners of reproductive potential and pregnant partners to use effective contraception during treatment and for 3 months following the last dose of NEXAVAR.

Impairment of Thyroid Stimulating Hormone Suppression in Differentiated Thyroid Carcinoma: NEXAVAR impairs exogenous thyroid suppression. In the DECISION (DTC) study, 99% of patients had a baseline thyroid stimulating hormone (TSH) level less than 0.5 mU/L. Elevation of TSH level above 0.5 mU/L was observed in 41% of NEXAVAR-treated patients as compared with 16% of placebo-treated patients. For patients with impaired TSH suppression while receiving NEXAVAR, the median maximal TSH was 1.6 mU/L and 25% had TSH levels greater than 4.4 mU/L. Monitor TSH levels monthly and adjust thyroid replacement medication as needed in patients with DTC.

Laboratory Abnormalities: In the HCC study, the most common laboratory abnormalities observed in the NEXAVAR arm versus the placebo arm, respectively, were hypoalbuminemia (59% vs. 47%), lymphopenia (47% vs. 42%), thrombocytopenia (46% vs. 41%), elevation in INR (42% vs. 34%), elevated lipase (40% vs. 37%), hypophosphatemia (35% vs. 11%), elevated amylase (34% vs. 29%), hypocalcemia (27% vs. 15%), and hypokalemia (10% vs. 6%).

In the RCC study, the most common laboratory abnormalities observed in the NEXAVAR arm versus the placebo arm, respectively, were hypophosphatemia (45% vs. 11%), anemia (44% vs. 49%), elevated lipase (41% vs. 30%), elevated amylase (30% vs. 23%), lymphopenia (23% vs. 13%), neutropenia (18% vs. 10%), thrombocytopenia (12% vs. 5%), hypocalcemia (12% vs. 8%), and hypokalemia (5% vs. <1%).

In the DTC study, the most common laboratory abnormalities observed in the NEXAVAR arm versus the placebo arm, respectively, were elevated ALT (59% vs. 24%), elevated AST (54% vs. 15%), and hypocalcemia (36% vs. 11%). The relative increase for the following laboratory abnormalities observed in NEXAVAR-treated DTC patients as compared to placebo-treated patients is similar to that observed in the RCC and HCC studies: lipase, amylase, hypokalemia, hypophosphatemia, neutropenia, lymphopenia, anemia, and thrombocytopenia.

Most Frequently Observed Adverse Drug Reactions (≥20%): The most common adverse reactions reported in ≥20% of patients and at a higher rate in the NEXAVAR arm versus the placebo arm, respectively, in the SHARP (HCC) study included: diarrhea (55% vs. 25%), fatigue (46% vs. 45%), abdominal pain (31% vs. 26%), weight loss (30% vs. 10%), anorexia (29% vs. 18%), nausea (24% vs. 20%), and hand-foot skin reaction (21% vs. 3%). Grade 3/4 adverse reactions were 45% vs. 32%.

The most common adverse reactions reported in ≥20% of patients and at a higher rate in the NEXAVAR arm versus the placebo arm, respectively, in the TARGET (RCC) study included: diarrhea (43% vs. 14%), rash/desquamation (40% vs. 16%), fatigue (37% vs. 28%), hand-foot skin reaction (30% vs. 7%), alopecia (27% vs. 3%), and nausea (23% vs. 19%), anorexia (29% vs. 18%), nausea (23% vs. 19%). Grade 3/4 adverse reactions were 38% vs. 28%.

The most common adverse reactions reported in ≥20% of patients and at a higher rate in the NEXAVAR arm versus the placebo arm, respectively, in the DECISION (DTC) study included: palmar-plantar erythrodysesthesia syndrome (PPES) (69% vs. 8%), diarrhea (68% vs. 15%), alopecia (67% vs. 8%), weight loss (49% vs. 14%), fatigue (41% vs. 20%), hypertension (41% vs. 12%), rash (35% vs. 7%), decreased appetite (30% vs. 5%), stomatitis (24% vs. 3%), nausea (21% vs. 12%), pruritus (20% vs. 11%), and abdominal pain (20% vs. 7%). Grade 3/4 adverse reactions were 65% vs 30%.

Drug Interactions: Avoid concomitant use of NEXAVAR with strong CYP3A4 inducers, when possible, because these drugs can decrease the systemic exposure to sorafenib. Avoid concomitant use of NEXAVAR with neomycin. The effects of other antibiotics on the pharmacokinetics of sorafenib have not been studied. The concomitant use of NEXAVAR and warfarin may increase the risk of bleeding or increased the INR. Monitor INR and for clinical bleeding episodes in patients taking warfarin while receiving NEXAVAR. NEXAVAR is associated with QTc interval prolongation. Avoid coadministration of NEXAVAR with medicinal products with a known potential to prolong QT/QTc interval.

Lactation: Because of the potential for serious adverse reactions in a breastfed child from NEXAVAR, advise lactating women not to breastfeed during treatment with NEXAVAR and for 2 weeks after the last dose.

For important risk and use information about NEXAVAR, please see the full Prescribing Information.

Indication and Important Safety Information for STIVARGA® (regorafenib)

Indication for STIVARGA

STIVARGA is indicated for the treatment of patients with hepatocellular carcinoma (HCC) who have been previously treated with sorafenib.

Important Safety Information

WARNING: HEPATOTOXICITY

  • Severe and sometimes fatal hepatotoxicity has occurred in clinical trials.

  • Monitor hepatic function prior to and during treatment.

  • Interrupt and then reduce or discontinue STIVARGA for hepatotoxicity as manifested by elevated liver function tests or hepatocellular necrosis, depending upon severity and persistence.

Hepatotoxicity: Severe drug-induced liver injury with fatal outcome occurred in STIVARGA-treated patients across all clinical trials. In most cases, liver dysfunction occurred within the first 2 months of therapy and was characterized by a hepatocellular pattern of injury. In hepatocellular carcinoma (HCC), there was no increase in the incidence of fatal hepatic failure as compared to placebo.

Liver Function Monitoring: Obtain liver function tests (ALT, AST, and bilirubin) before initiation of STIVARGA and monitor at least every 2 weeks during the first 2 months of treatment. Thereafter, monitor monthly or more frequently as clinically indicated. Monitor liver function tests weekly in patients experiencing elevated liver function tests until improvement to less than 3 times the upper limit of normal (ULN) or baseline values. Temporarily hold and then reduce or permanently discontinue STIVARGA, depending on the severity and persistence of hepatotoxicity as manifested by elevated liver function tests or hepatocellular necrosis.

Infections: STIVARGA caused an increased risk of infections. The overall incidence of infection (Grades 1-5) was higher (32% vs 17%) in 1142 STIVARGA-treated patients as compared to the control arm in randomized placebo-controlled trials. The incidence of grade 3 or greater infections in STIVARGA treated patients was 9%. The most common infections were urinary tract infections (5.7%), nasopharyngitis (4.0%), mucocutaneous and systemic fungal infections (3.3%) and pneumonia (2.6%). Fatal outcomes caused by infection occurred more often in patients treated with STIVARGA (1.0%) as compared to patients receiving placebo (0.3%); the most common fatal infections were respiratory (0.6% vs 0.2%). Withhold STIVARGA for Grade 3 or 4 infections, or worsening infection of any grade. Resume STIVARGA at the same dose following resolution of infection.

Hemorrhage: STIVARGA caused an increased incidence of hemorrhage. The overall incidence (Grades 1-5) was 18.2% in 1142 patients treated with STIVARGA vs 9.5% with placebo in randomized, placebo-controlled trials. The incidence of grade 3 or greater hemorrhage in patients treated with STIVARGA was 3.0%. The incidence of fatal hemorrhagic events was 0.7%, involving the central nervous system or the respiratory, gastrointestinal, or genitourinary tracts. Permanently discontinue STIVARGA in patients with severe or life-threatening hemorrhage and monitor INR levels more frequently in patients receiving warfarin.

Gastrointestinal Perforation or Fistula: Gastrointestinal perforation occurred in 0.6% of 4518 patients treated with STIVARGA across all clinical trials of STIVARGA administered as a single agent; this included eight fatal events. Gastrointestinal fistula occurred in 0.8% of patients treated with STIVARGA and in 0.2% of patients in the placebo arm across randomized, placebo-controlled trials. Permanently discontinue STIVARGA in patients who develop gastrointestinal perforation or fistula.

Dermatological Toxicity: In randomized, placebo-controlled trials, adverse skin reactions occurred in 71.9% of patients with STIVARGA and 25.5% of patients in the placebo arm including hand-foot skin reaction (HFSR) (also known as palmar-plantar erythrodysesthesia syndrome [PPES]) and severe rash, requiring dose modification. In the randomized, placebo-controlled trials, the overall incidence of HFSR was higher in 1142 STIVARGA-treated patients (53% vs 8%) than in the placebo-treated patients. Most cases of HFSR in STIVARGA-treated patients appeared during the first cycle of treatment. The incidences of Grade 3 HFSR (16% vs <1%), Grade 3 rash (3% vs <1%), serious adverse reactions of erythema multiforme (<0.1% vs 0%), and Stevens-Johnson syndrome (<0.1% vs 0%) were higher in STIVARGA-treated patients. Across all trials, a higher incidence of HFSR was observed in Asian patients treated with STIVARGA (all grades: 72%; Grade 3:18%). Toxic epidermal necrolysis occurred in 0.02% of 4518 STIVARGA-treated patients across all clinical trials of STIVARGA administered as a single agent. Withhold STIVARGA, reduce the dose, or permanently discontinue depending on the severity and persistence of dermatologic toxicity.

Hypertension: Hypertensive crisis occurred in 0.2% in STIVARGA-treated patients and in none of the patients in placebo arm across all randomized, placebo-controlled trials. STIVARGA caused an increased incidence of hypertension (31% vs. 6% in HCC). The onset of hypertension occurred during the first cycle of treatment in most patients who developed hypertension (67% in randomized, placebo controlled trials). Do not initiate STIVARGA until blood pressure is adequately controlled. Monitor blood pressure weekly for the first 6 weeks of treatment and then every cycle, or more frequently, as clinically indicated. Temporarily or permanently withhold STIVARGA for severe or uncontrolled hypertension.

Cardiac Ischemia and Infarction: STIVARGA increased the incidence of myocardial ischemia and infarction (0.9% vs 0.2%) in randomized placebo-controlled trials. Withhold STIVARGA in patients who develop new or acute cardiac ischemia or infarction, and resume only after resolution of acute cardiac ischemic events if the potential benefits outweigh the risks of further cardiac ischemia.

Reversible Posterior Leukoencephalopathy Syndrome (RPLS): Reversible posterior leukoencephalopathy syndrome (RPLS), a syndrome of subcortical vasogenic edema diagnosed by characteristics finding on MRI, occurred in one of 4800 STIVARGA-treated patients across all clinical trials. Perform an evaluation for RPLS in any patient presenting with seizures, severe headache, visual disturbances, confusion, or altered mental function. Discontinue STIVARGA in patients who develop RPLS.

Wound Healing Complications: Impaired wound healing complications can occur in patients who receive drugs that inhibit the VEGF signaling pathway. Therefore, STIVARGA has the potential to adversely affect wound healing. Withhold STIVARGA for at least 2 weeks prior to elective surgery. Do not administer for at least 2 weeks following major surgery and until adequate wound healing. The safety of resumption of STIVARGA after resolution of wound healing complications has not been established.

Embryo-Fetal Toxicity: STIVARGA can cause fetal harm when administered to a pregnant woman. There are no available data on STIVARGA use in pregnant women. Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential and males with female partners of reproductive potential to use effective contraception during treatment with STIVARGA and for 2 months after the final dose.

Nursing Mothers: Because of the potential for serious adverse reactions in breastfed infants from STIVARGA, do not breastfeed during treatment with STIVARGA and for 2 weeks after the final dose.

Most Frequently Observed Adverse Drug Reactions in HCC (≥30%): The most frequently observed adverse drug reactions (≥30%) in STIVARGA-treated patients vs placebo-treated patients in HCC, respectively, were: pain (55% vs 44%), HFSR/PPE (51% vs 7%), asthenia/fatigue (42% vs 33%), diarrhea (41% vs 15%), hypertension (31% vs 6%), infection (31% vs 18%), decreased appetite and food intake (31% vs 15%).

For important risk and use information about STIVARGA, please see the full Prescribing Information including the Boxed Warning.

You are encouraged to report negative side effects or quality complaints of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088. For Bayer products you can report these directly to Bayer by clicking here.

INR, International Normalized Ratio; VEGF, vascular endothelial growth factor.

*Adverse reactions graded according to National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 (NCI CTCAE v3.0).

†If no recovery after 30 day interruption, discontinue treatment unless the patient is deriving clinical benefit.

‡If more than 2 dose reductions are required, permanently discontinue treatment.

§In addition, any grade increased alkaline phosphatase in the absence of known bone pathology and Grade 2 or worse increased bilirubin; any 1 of the following: INR of 1.5 or greater, ascites and/or encephalopathy in the absence of underlying cirrhosis or other organ failure considered to be due to drug-induced liver injury.

Reference:

  • NEXAVAR. Prescribing information. Whippany, NJ: Bayer HealthCare Pharmaceuticals Inc; July 2020. Return to content

© 2021 Bayer. All rights reserved. Bayer, the Bayer Cross, NEXAVAR, and STIVARGA are registered trademarks of Bayer. Access Services by Bayer is a trademark of Bayer.

This site is intended for US audiences only.

Last updated on March 2021