Sorafenib Drug Information

Hepatocellular Carcinoma Sorafenib tablets are indicated for the treatment of patients with

unresectable hepatocellular carcinoma (HCC).

Differentiated Thyroid Carcinoma Sorafenib tablets are indicated for the treatment of patients

with locally recurrent or metastatic, progressive,differentiated thyroid carcinoma (DTC) that is refractory to radioactive iodine treatment.

Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The data described reflect exposure to sorafenib tablets in 504 patients who participated in placebo-controlled studies in hepatocellular carcinoma N=297), or differentiated thyroid carcinoma (N = 207). The most common adverse reactions (≥20%), which were considered to be related to sorafenib tablets, in patients with HCC or DTC are diarrhea, fatigue, infection, alopecia, hand-foot skin reaction, rash, weight loss, decreased appetite, nausea, gastrointestinal and abdominal pains, hypertension, and hemorrhage. Hepatocellular Carcinoma Table 4 shows the percentage of patients in the SHARP (HCC) study experiencing adverse reactions that were reported in at least 10% of patients and at a higher rate in the Sorafenib Tablets -treated group than in those eceiving placebo.

Table 4: Adverse Reactions Reported in at Least 10% of Patients and at a Higher Rate in Sorafenib Tablets Arm than the Placebo Arm–SHARP (HCC) Adverse Reaction 1 Sorafenib Tablets N = 297 Placebo N = 302 All Grades% Grade 3% Grade 4% All Grades % Grade 3% Grade 4% Any Adverse Reaction 98 39 6 96 24 8 Gastrointestinal Diarrhea 55 10 < 1 25 2 0 Anorexia 29 3 0 18 3 < 1 Nausea 24 1 0 20 3 0 Vomiting 15 2 0 11 2 0 Constipation 14 0 0 10 0 0 Constitutional symptoms Fatigue 46 9 1 45 12 2 Weight loss 30 2 0 10 1 0 Pain Pain, abdomen 31 9 0 26 5 1 Dermatology/skin Hand-foot skin reaction 21 8 0 3 < 1 0 Rash/desquamation 19 1 0 14 0 0 Alopecia 14 0 0 2 0 0 Pruritus 14 < 1 0 11 < 1 0 Dry skin 10 0 0 6 0 0 Hepatobiliary/pancreas Liver dysfunction 11 2 1 8 2 1 1Adverse reactions graded according to National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 (NCI CTCAE v3.0). Hypertension was reported in 9% of patients treated with sorafenib tablets and 4% of those receiving placebo. Grade 3 hypertension was reported in 4% of sorafenib tablets -treated patients and 1% of those receiving placebo. Hemorrhage/bleeding was reported in 18% of those receiving sorafenib tablets and 20% of patients receiving placebo.

The rates of Grade 3 and 4 bleeding were also higher in patients receiving placebo (Grade 3 – 3% sorafenib tablets and 5% placebo and Grade 4 – 2% sorafenib tablets and 4% placebo). Bleeding from esophageal varices was reported in 2.4% in sorafenib tablets -treated patients and 4% of patients receiving placebo. Renal failure was reported in <1% of patients treated with sorafenib tablets and 3% of patients receiving placebo. Clinical pancreatitis was reported in 1 of 297 sorafenib tablets -treated patients (Grade 2). The rate of adverse reactions (including those associated with progressive disease) resulting in permanent discontinuation was similar in both the sorafenib tablets -treated patients and those receiving placebo (32% of sorafenib tablets -treated patients and 35% of patients receiving placebo). Laboratory test abnormalities reported in SHARP are presented in Table 5. Table 5: Laboratory Test Abnormalities Reported in SHARP (HCC) Laboratory Parameter 1 Sorafenib Tablets N=297 Placebo N=302 All Grades(%) Grade 3 or 4(%) All Grades(%) Grade 3 or 4(%) Hypoalbuminemia 59 0 47 0 Elevated Lipase 40 9 37 9 Lymphopenia 47 NR 42 NR Thrombocytopenia 46 4 41 < 1 Elevated INR 42 4 34 2 Hypophosphatemia 35 11 11 2 Elevated Amylase 34 2 29 2 Hypocalcemia 27 2.4 15 1 Hypokalemia 10 < 1 6 < 1 1Laboratory parameters graded according to National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 (NCI CTCAE v3.0). NR = not reported Differentiated Thyroid Carcinoma The safety of sorafenib tablets was evaluated in DECISION in 416 patients with locally recurrent or metastatic, progressive differentiated thyroid carcinoma (DTC) refractory to radioactive iodine (RAI) treatment randomized to receive 400 mg twice daily sorafenib tablets (n=207) or matching placebo (n=209) until disease progression or intolerable toxicity in a double-blind trial.

The data described below reflect a median exposure to sorafenib tablets for 46 weeks (range 0.3 to 135). The population exposed to sorafenib tablets was 50% male, and had a median age of 63 years. Dose interruptions for adverse reactions were required in 66% of patients receiving sorafenib tablets and dose reductions were required in 64% of patients. Adverse reactions that resulted in treatment discontinuation were reported in 14% of sorafenib tablets -treated patients compared to 1.4% of patients receiving placebo.

Table 8 shows the percentage of DTC patients experiencing adverse reactions at a higher rate in sorafenib tablets -treated patients than in patients receiving placebo in the double-blind phase of the DECISION study. Grade 3 adverse reactions occurred in 53% of sorafenib tablets -treated patients compared to 23% of patients receiving placebo. Grade 4 adverse reactions occurred in 12% of sorafenib tablets-treated patients compared to 7% of patients receiving placebo.

Table 8: Selected Adverse Reactions Occurring at a Higher Incidence in Sorafenib Tablets -Treated Patients Adverse Reaction Sorafenib Tablets N = 207 Placebo N = 209 All Grades (%) Grades 3 and 4 (%) All Grades (%) Grades 3 and 4 (%) Skin and subcutaneous tissue disorders PPES 5 69 19 8 0 Alopecia 67 0 8 0 Rash 35 5 7 0 Pruritus 20 0.5 11 0 Dry skin 13 0.5 5 0 Erythema 10 0 0.5 0 Hyperkeratosis 7 0 0 0 Gastrointestinal disorders Diarrhea 68 6 15 1 Stomatitis 3 24 2 3 0 Nausea 21 0 12 0 Abdominal pain 2 20 1 7 1 Constipation 16 0 8

Oral pain 4 14 0.5 6 0 Vomiting 11 0 3 0

Investigations Weight loss 49 6 14 1 General disorders and administration site conditions Fatigue 41 5 20 1 Asthenia 12 0 7 0 Pyrexia 11 1 5 0 Vascular disorders Hypertension 6 41 10 12 2 Metabolism and nutrition disorders Decreased appetite 30 2 5 0 Nervous system disorders Headache 17 0 6 0 Dysgeusia 6 0 0 0 Musculoskeletal and connective tissue disorders Pain in extremity 15 1 7 0 Muscle spasms 10 0 3 0 Respiratory, thoracic and mediastinal disorders Dysphonia 13 0.5 3 0 Epistaxis 7 0 1 0 Neoplasms benign, malignant and unspecified Squamous cell carcinoma of skin 3 3 0 0 1 National Cancer Institute Common Terminology Criteria for Adverse Events Version 3.0 2 Includes the following terms: abdominal pain, abdominal discomfort, hepatic pain, esophageal pain, esophageal discomfort, abdominal pain lower, abdominal pain upper, abdominal tenderness, abdominal rigidity 3 Includes the following terms: stomatitis, aphthous stomatitis, mouth ulceration, mucosal inflammation 4 Includes the following terms: oral pain, oropharyngeal discomfort, glossitis, burning mouth syndrome, glossodynia 5 Palmar-plantar erythrodysesthesia syndrome (Hand-foot skin reaction) 6 Includes the following terms: hypertension, blood pressure increased, blood pressure systolic increased The relative increase for the following laboratory abnormalities observed in sorafenib-treated patients as compared to patients receiving placebo in the DECISION study is similar to that observed in the RCC and HCC studies: lipase, amylase, hypokalemia, hypophosphatemia, neutropenia, lymphopenia, anemia, and thrombocytopenia. Hypocalcemia was more frequent and more severe in patients with DTC, especially those with a history of hypoparathyroidism, compared to patients with RCC or HCC. Other laboratory test abnormalities reported in DECISION are presented in Table 9. Table 9: Laboratory Test Abnormalities Reported in DECISION (DTC) Laboratory Parameter 1 Sorafenib Tablets N=207 Placebo N=209 All Grades (%) Grade 3 or 4 (%) All Grades (%) Grade 3 or 4 (%) Elevated ALT 59 4 24 0 Elevated AST 54 2 15 0 Hypocalcemia 36 10 11 3 1Laboratory parameters graded according to National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 (NCI CTCAE v3.0). Additional Data from Multiple Clinical Trials The following additional drug-related adverse reactions and laboratory abnormalities were reported from clinical trials of sorafenib tablets (very common 10% or greater, common 1 to less than 10%, uncommon 0.1% to less than 1%, rare less than 0.1 %): Cardiovascular:Common: congestive heart failure*†, myocardial ischemia and/or infarction Uncommon: hypertensive crisis* Rare: QT prolongation* Dermatologic:Very common: erythema Common: exfoliative dermatitis, acne, flushing, folliculitis, hyperkeratosis Uncommon: eczema, erythema multiforme Digestive:Very common: increased lipase, increased amylase Common: mucositis, stomatitis (including dry mouth and glossodynia), dyspepsia, dysphagia, gastrointestinal reflux Uncommon: pancreatitis, gastritis, gastrointestinal perforations*, cholecystitis, cholangitis Note that elevations in lipase are very common (41%, see below); a diagnosis of pancreatitis should not be made solely on the basis of abnormal laboratory values General Disorders:Very common: infection, hemorrhage (including gastrointestinal* and respiratory tract* and uncommon cases of cerebral hemorrhage*), asthenia, pain (including mouth, bone, and tumor pain), pyrexia, decreased appetite Common: influenza-like illness Hematologic:Very common: leukopenia, lymphopenia Common: anemia, neutropenia, thrombocytopenia Uncommon: INR abnormal Hepatobiliary disorders:Rare: drug-induced hepatitis (including hepatic failure and death) Hypersensitivity:Uncommon: hypersensitivity reactions (including skin reactions and urticaria), anaphylactic reaction Metabolic and Nutritional:Very common: hypophosphatemia Common: transient increases in transaminases, hypocalcemia, hypokalemia, hyponatremia, hypothyroidism Uncommon: dehydration, transient increases in alkaline phosphatase, increased bilirubin (including jaundice), hyperthyroidism Musculoskeletal:Very common: arthralgia Common: myalgia, muscle spasms Nervous System and Psychiatric:Common: depression, dysgeusia Uncommon: tinnitus, reversible posterior leukoencephalopathy* Renal and Genitourinary:Common: renal failure, proteinuria Rare: nephrotic syndrome Reproductive:Common: erectile dysfunction Uncommon: gynecomastia Respiratory:Common: rhinorrhea Uncommon: interstitial lung disease-like events (includes reports of pneumonitis, radiation pneumonitis, acute respiratory distress, interstitial pneumonia, pulmonitis and lung inflammation) In addition, the following medically significant adverse reactions were uncommon during clinical trials of sorafenib tablets: transient ischemic attack, arrhythmia, and thromboembolism. For these adverse reactions, the causal relationship to sorafenib tablets has not been established. *adverse reactions may have a life-threatening or fatal outcome. †reported in 1.9% of patients treated with sorafenib tablets (N= 2276).

Postmarketing Experience

The following adverse reactions have been identified during postapproval use of sorafenib tablets. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Blood and lymphatic disorders: Thrombotic microangiopathy (TMA) Dermatologic:Stevens-Johnson syndrome and toxic epidermal necrolysis (TEN) Hypersensitivity: Angioedema Musculoskeletal: Rhabdomyolysis, osteonecrosis of the jaw Respiratory: Interstitial lung disease-like events (which may have a life-threatening or fatal outcome) Vascular: Arterial (including aortic) aneurysms, dissections, and rupture

Effect of Other Drugs on Sorafenib Tablets Strong

CYP3A4 Inducers The concomitant use of sorafenib tablets with rifampin, a strong CYP3A4 inducer decreased the mean AUC of sorafenib, which may decrease the antitumor activity. Avoid concomitant use of sorafenib tablets with strong CYP3A4 inducers, when possible, because these drugs can decrease the systemic exposure to sorafenib. Neomycin The concomitant use of sorafenib tablets with neomycin decreased the mean AUC of sorafenib, which may decrease the antitumor activity.

Avoid concomitant use of sorafenib tablets with neomycin. The effects of other antibiotics on the pharmacokinetics of sorafenib have not been studied.

Concomitant Use of Warfarin

The concomitant use of sorafenib tablets 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 sorafenib tablets.

Drugs That Prolong the QT Interval Sorafenib tablets are associated with QTc

interval prolongation. Avoid coadministration of sorafenib tablets with medicinal products with a known potential to prolong QT/QTc interval.

Hepatic Impairment No dose adjustment is necessary for patients with mild or

moderate hepatic impairment. The pharmacokinetics of sorafenib have not been studied in patients with severe (Child-Pugh C) hepatic impairment.

Sorafenib tablets are contraindicated in patients with known severe hypersensitivity to sorafenib or any other component of sorafenib tablets. Sorafenib tablets in combination with carboplatin and paclitaxel is contraindicated in patients with squamous cell lung cancer. 4 CONTRAINDICATIONS Sorafenib tablets are contraindicated in patients with known severe hypersensitivity to sorafenib or any other component of sorafenib tablets. Sorafenib tablets in combination with carboplatin and paclitaxel are contraindicated in patients with squamous cell lung cancer.

The adverse reactions observed at a dose of 800 mg twice daily (2 times the recommended dose) were primarily diarrhea and dermatologic. No information is available on symptoms of acute overdose in animals because of the saturation of absorption in oral acute toxicity studies conducted in animals. In cases of suspected overdose, withhold sorafenib tablets and institute supportive care.