Note: Select patients for selpercatinib treatment based on the presence of a rearranged during transfection (RET) gene fusion (thyroid cancer) or based on specific RET gene mutation (medullary thyroid cancer) in tumor specimens or plasma. Withhold selpercatinib for at least 7 days prior to elective surgery; do not administer for at least 2 weeks following major surgery and until adequate wound healing has occurred. Optimize BP prior to initiating treatment; do not initiate selpercatinib in patients with uncontrolled hypertension. Correct hypokalemia, hypomagnesemia, and hypocalcemia prior to selpercatinib initiation and during treatment. Consider appropriate tumor lysis syndrome prophylaxis (including hydration) as clinically necessary.
Thyroid cancer, medullary, RET-mutant:
Children ≥12 years and Adolescents:
<50 kg: Oral: 120 mg twice daily (approximately 12 hours apart) until disease progression or unacceptable toxicity.
≥50 kg: Oral: 160 mg twice daily (approximately 12 hours apart) until disease progression or unacceptable toxicity.
Thyroid cancer, RET fusion-positive:
Children ≥12 years and Adolescents:
<50 kg: Oral: 120 mg twice daily (approximately 12 hours apart) until disease progression or unacceptable toxicity.
≥50 kg: Oral: 160 mg twice daily (approximately 12 hours apart) until disease progression or unacceptable toxicity.
Dosing adjustment for toxicity:
Children ≥12 years and Adolescents: Oral:
Dosage Reduction Levels | ||
---|---|---|
Dose reduction level |
<50 kg |
≥50 kg |
Initial dosage |
120 mg twice daily |
160 mg twice daily |
First dose reduction level |
80 mg twice daily |
120 mg twice daily |
Second dose reduction level |
40 mg twice daily |
80 mg twice daily |
Third dose reduction level |
40 mg once daily |
40 mg twice daily |
Permanently discontinue in patients unable to tolerate 3 dose reductions. |
Dose modifications for toxicities:
Toxicity |
Severity |
Selpercatinib dose modification |
---|---|---|
Hemorrhagic events |
Grade 3 or 4 |
Withhold selpercatinib until recovery to baseline or grade 0 or 1. Discontinue selpercatinib (permanently) for severe or life-threatening hemorrhagic events. |
Hypersensitivity reactions |
All grades |
Withhold selpercatinib and initiate corticosteroids (at a dose of 1 mg/kg prednisone [or equivalent]). After resolution, resume selpercatinib with the dose reduced by 3 dose levels while continuing corticosteroids. Increase dose by 1 dose level each week until achieving the dose administered prior to the onset of hypersensitivity, then taper corticosteroids. |
Recurrent hypersensitivity |
Permanently discontinue selpercatinib. | |
Hypertension |
Grade 3 |
Initiate or optimize hypertensive therapy. Withhold selpercatinib for grade 3 hypertension that persists despite management with optimal antihypertensive therapy. Resume selpercatinib at a reduced dose when hypertension is controlled. |
Grade 4 |
Discontinue selpercatinib. | |
Hypothyroidism |
Grade 3 or 4 |
Withhold selpercatinib until resolution to grade 1 or baseline. Discontinue selpercatinib based on severity. Manage with thyroid hormone replacement therapy as clinically appropriate. |
Pulmonary toxicity (interstitial lung disease [ILD]/pneumonitis) |
Grade 2 |
Withhold selpercatinib until resolution, then resume at a reduced dose. Discontinue selpercatinib permanently for recurrent ILD/pneumonitis. |
Grade 3 or 4 |
Discontinue selpercatinib permanently for confirmed ILD/pneumonitis. | |
QT interval prolongation |
Grade 3 |
Withhold selpercatinib until recovery to baseline or grade 0 or 1, then resume selpercatinib at a reduced dose. |
Grade 4 |
Discontinue selpercatinib. | |
Other adverse reactions |
Grade 3 or 4 |
Withhold selpercatinib until recovery to baseline or grade 0 or 1, then resume selpercatinib at a reduced dose. |
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Altered kidney function:
Note: Kidney function estimated by Modification of Diet in Renal Disease (MDRD) equation.
Children ≥12 years and Adolescents: Oral:
eGFR ≥15 mL/minute: No dosage adjustment recommended.
End-stage renal disease: There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).
Children ≥12 years and Adolescents: Oral:
Hepatic impairment at treatment initiation:
Mild impairment (total bilirubin ≤ ULN with AST > ULN or total bilirubin >1 to 1.5 times ULN with any AST): No initial dosage adjustment necessary. Monitor for adverse reactions.
Moderate impairment (total bilirubin >1.5 to 3 times ULN with any AST): No initial dosage adjustment necessary. Monitor for adverse reactions.
Severe impairment (bilirubin >3 to 10 times ULN with any AST): For current dose of 120 mg twice daily or 160 mg twice daily: Reduce dose to 80 mg twice daily. Monitor for adverse reactions.
Hepatotoxicity during treatment: Grade 3 or 4: Withhold selpercatinib and monitor AST and ALT once weekly. When AST/ALT return to grade 1 or baseline, resume at dose reduced by 2 dose levels; monitor AST and ALT once weekly. After a minimum of 2 weeks without recurrence, increase selpercatinib dose by 1 dose level. Then after a minimum of 4 weeks without recurrence, increase selpercatinib to dose taken prior to onset of grade 3 or 4 AST or ALT elevation. Continue monitoring AST and ALT once weekly until 4 weeks after reaching dose taken prior to the onset of grade 3 or 4 AST or ALT elevation. See recommended selpercatinib dosage reduction levels in "Dosing Adjustment for Toxicity."
(For additional information see "Selpercatinib: Drug information")
Note: Select patients for selpercatinib treatment based on the presence of a RET gene fusion (with non-small cell lung cancer, other solid tumors, or thyroid cancer) or based on specific RET gene mutation (medullary thyroid cancer) in tumor specimens. Withhold selpercatinib for at least 7 days prior to elective surgery; do not administer for at least 2 weeks following major surgery and until adequate wound healing has occurred. Optimize BP prior to initiating treatment; do not initiate selpercatinib in patients with uncontrolled hypertension. Correct hypokalemia, hypomagnesemia, and hypocalcemia prior to selpercatinib initiation and during treatment. Consider appropriate tumor lysis syndrome prophylaxis (including hydration) as clinically necessary.
Non–small cell lung cancer, locally advanced or metastatic, RET fusion-positive :
Patients ≥50 kg: Oral: 160 mg twice daily (approximately every 12 hours) until disease progression or unacceptable toxicity (Drilon 2020).
Patients <50 kg: Oral: 120 mg twice daily (approximately every 12 hours) until disease progression or unacceptable toxicity.
Solid tumors, RET fusion-positive:
Patients ≥50 kg: Oral: 160 mg twice daily (approximately every 12 hours) until disease progression or unacceptable toxicity (Subbiah 2022).
Patients <50 kg: Oral: 120 mg twice daily (approximately every 12 hours) until disease progression or unacceptable toxicity.
Thyroid cancer, medullary, RET-mutant:
Patients ≥50 kg: Oral: 160 mg twice daily (approximately every 12 hours) until disease progression or unacceptable toxicity (Wirth 2020).
Patients <50 kg: Oral: 120 mg twice daily (approximately every 12 hours) until disease progression or unacceptable toxicity.
Thyroid cancer, RET fusion-positive:
Patients ≥50 kg: Oral: 160 mg twice daily (approximately every 12 hours) until disease progression or unacceptable toxicity (Wirth 2020).
Patients <50 kg: Oral: 120 mg twice daily (approximately every 12 hours) until disease progression or unacceptable toxicity.
Missed dose: Do not administer a missed dose unless it is >6 hours until next scheduled dose. If vomiting occurs after selpercatinib administration, do not administer an additional dose and continue to the next scheduled time for the next dose.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Note: Kidney function estimated by Modification of Diet in Renal Disease equation.
eGFR ≥15 mL/minute: No dosage adjustment necessary.
End-stage renal disease: There are no dosage adjustments provided in the manufacturer's labeling (has not been established).
Hepatic impairment at treatment initiation:
Mild (total bilirubin ≤ ULN with AST > ULN or total bilirubin >1 to 1.5 times ULN with any AST) or moderate (total bilirubin >1.5 to 3 times ULN and any AST) impairment: No initial dosage adjustment necessary. Monitor for adverse reactions.
Severe impairment (total bilirubin >3 to 10 times ULN and any AST): Current dose of 120 mg twice daily or 160 mg twice daily: Reduce dose to 80 mg twice daily. Monitor for adverse reactions.
Hepatotoxicity during treatment: Grade 3 or 4: Withhold selpercatinib and monitor AST and ALT once weekly until resolves to grade 1 or baseline. Resume selpercatinib with the dose reduced by 2 dose levels; monitor AST and ALT once weekly. After a minimum of 2 weeks without recurrence, increase selpercatinib dose by 1 dose level. Then, after a minimum of 4 weeks without recurrence, increase selpercatinib to dose taken prior to the onset of grade 3 or 4 AST or ALT elevation. Continue monitoring AST and ALT once weekly until 4 weeks after reaching dose taken prior to the onset of grade 3 or 4 AST or ALT elevation. See recommended selpercatinib dosage reduction levels in "Dosing Adjustment for Toxicity."
Selpercatinib may cause grade ≥3 hemorrhage; serious and fatal hemorrhagic events have occurred, including cerebral hemorrhage, tracheostomy site hemorrhage, and hemoptysis.
Selpercatinib may cause hepatotoxicity, including severe hepatic disease; laboratory evidence may include increased serum alanine aminotransferase (ALT), increased serum alkaline phosphatase, and increased serum aspartate aminotransferase (AST). Hepatoxicity may require dosage interruption, reduction, and/or discontinuation.
Onset: Varied; median time to first onset of elevated ALT was 5.8 weeks (range: 1 day to 2.5 years) and AST was 6 weeks (range: 1 day to 3.4 years) in clinical trials.
Risk factors:
• Preexisting severe hepatic impairment
Hypersensitivity reactions have occurred (including grade 3 events); reactions include signs/symptoms of fever, skin rash, and arthralgias or myalgias with concurrent thrombocytopenia or transaminitis.
Mechanism: Non–dose-related; immunologic.
Onset: Varied; median time to onset was 1.9 weeks (range: 5 days to 2 years).
Hypertension may occur, including grade 3 and grade 4 events; some patients may require dose interruption, dose reduction, and/or anti-hypertensive treatment.
Risk factors:
• Preexisting uncontrolled hypertension
Severe or life-threatening interstitial lung disease (ILD)/pneumonitis may occur with selpercatinib; grade 3 or 4 events and fatal cases have been reported.
Selpercatinib may cause concentration-dependent prolonged QT interval on ECG with observed increases in QTcF interval to >500 msec and increases in the QTcF interval of at least 60 msec over baseline; some patients require dose interruption or reduction.
Mechanism: Dose-related (concentration dependent); exact mechanism is unknown.
Onset: Varied; effect is concentration-dependent; therefore, timing may be impacted by high doses or accumulation.
Risk factors:
In general, risk factors for drug-induced QT prolongation include (Ref):
• Females
• Age >65 years
• Structural heart disease (eg, history of myocardial infarction or heart failure with reduced ejection fraction)
• Genetic defects of cardiac ion channels
• History of drug-induced torsades de pointes
• Congenital long QT syndrome
• Baseline QTc interval prolongation (eg, >500 msec) or lengthening of the QTc by ≥60 msec
• Electrolyte disturbances (eg, hypocalcemia, hypokalemia, or hypomagnesemia)
• Bradycardia
• Hepatic impairment
• Kidney impairment
• Loop diuretic use
• Sepsis
• Concurrent use of strong and moderate CYP3A inhibitors
• Concurrent administration of multiple medications (≥2) that prolong the QT interval or drug interactions that increase serum drug concentrations of QT-prolonging medications
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Adverse reactions reported in children, adolescents, and adults.
>10%:
Cardiovascular: Edema (49%), hypertension (41%), prolonged QT interval on ECG (21%)
Dermatologic: Skin rash (33%)
Endocrine & metabolic: Decreased serum albumin (56%), decreased serum calcium (59%), decreased serum glucose (34%), decreased serum magnesium (33%), decreased serum sodium (42%), hypothyroidism (grades 1/2: 13%), increased serum cholesterol (35%), increased serum glucose (53%), increased serum potassium (34%)
Gastrointestinal: Abdominal pain (34%), constipation (33%), diarrhea (47%; grade 3: 5%), nausea (31%; grade 3: 1%), vomiting (22%; grade 3: 2%), xerostomia (43%)
Hematologic & oncologic: Decreased hemoglobin (28%; grades 3/4: 4%), decreased neutrophils (25%; grades 3/4: 3%), decreased platelet count (37%; grades 3/4: 3%), hemorrhage (22%; grades 3/4: 3%), lymphocytopenia (52%; grades 3/4: 20%)
Hepatic: Increased serum alanine aminotransferase (56%), increased serum alkaline phosphatase (40%), increased serum aspartate aminotransferase (59%), increased serum bilirubin (30%)
Nervous system: Fatigue (46%), headache (28%)
Neuromuscular & skeletal: Arthralgia (21%)
Renal: Increased serum creatinine (47%)
Respiratory: Cough (24%), dyspnea (22%)
1% to 10%:
Hepatic: Severe hepatic disease (3%)
Hypersensitivity: Hypersensitivity reaction (6%)
Respiratory: Interstitial lung disease (≤2%), pleural effusion (≥2%), pneumonia (serious: ≥2%), pneumonitis (≤2%)
Frequency not defined: Infection: Sepsis
There are no contraindications listed in the manufacturer's US labeling.
Canadian labeling: Hypersensitivity to selpercatinib or any component of the formulation.
Concerns related to adverse effects:
• Tumor lysis syndrome: Tumor lysis syndrome (TLS) has been reported rarely when used for the treatment of medullary thyroid carcinoma. Risk factors for TLS include rapidly proliferating tumors, a high tumor burden, renal dysfunction, and dehydration.
Disease-related concerns:
• Renal function: Elevations in serum creatinine were noted after 10 days (in healthy patients). If persistent serum creatinine elevations are observed, consider alternative markers for renal function evaluation.
Other warnings/precautions:
• RET gene status: Select patients for selpercatinib treatment based on the presence of a RET gene fusion (with non-small cell lung cancer, other solid tumors, or thyroid cancer) or based on specific RET gene mutation (medullary thyroid cancer) in tumor specimens. Information on approved test(s) for the detection of RET gene fusions and mutations is available at https://www.fda.gov/CompanionDiagnostics.
Retevmo tablets: FDA approved April 2024; anticipated availability currently unknown. Information pertaining to this product within the monograph is pending revision. Retevmo tablets are indicated for treatment of RET gene fusion-positive non-small lung cancer or other solid tumors in adults; Ret gene fusion positive thyroid cancer or Ret gene mutant medullary thyroid cancer in adults and pediatric patients ≥ 12 years of age. Retevmo tablets are bioequivalent to Retevmo capsules. Consult the prescribing information for additional information.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Capsule, Oral:
Retevmo: 40 mg
Retevmo: 80 mg [contains brilliant blue fcf (fd&c blue #1)]
No
Capsules (Retevmo Oral)
40 mg (per each): $150.65
80 mg (per each): $225.98
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Capsule, Oral:
Retevmo: 40 mg
Retevmo: 80 mg [contains fd&c blue #1 (brilliant blue)]
Oral: May administer with or without food (unless administered with a proton pump inhibitor [PPI]). Swallow whole; do not crush or chew. If vomiting occurs after administration, do not take an additional dose; continue to the next scheduled dose.
Administration with acid-reducing agents: Avoid concomitant use of a PPI, a histamine-2 (H2) receptor antagonist, or a locally-acting antacid with selpercatinib. If concomitant use cannot be avoided, administer selpercatinib with food when coadministered with a PPI; administer selpercatinib 2 hours before or 10 hours after administration of an H2 receptor antagonist; administer selpercatinib 2 hours before or 2 hours after administration of a locally-acting antacid.
Missed dose: Do not take a missed dose unless it is more than 6 hours until next scheduled dose.
Oral: May administer with or without food (unless coadministered with a proton pump inhibitor [PPI]). Swallow whole; do not crush or chew.
Administration with acid-reducing agents: Avoid concomitant use of a PPI, a histamine-2 (H2) receptor antagonist, or a locally-acting antacid with selpercatinib. If concomitant use cannot be avoided, administer selpercatinib with food when coadministered with a PPI; administer selpercatinib 2 hours before or 10 hours after administration of an H2 receptor antagonist; administer selpercatinib 2 hours before or 2 hours after administration of a locally acting antacid.
This medication is not on the NIOSH (2016) list; however, it may meet the criteria for a hazardous drug. Selpercatinib may cause reproductive toxicity and teratogenicity.
Use appropriate precautions for receiving, handling, storage, preparation, dispensing, transporting, administration, and disposal. Follow NIOSH and USP 800 recommendations and institution-specific policies/procedures for appropriate containment strategy (NIOSH 2016; USP-NF 2020).
Note: Facilities may perform risk assessment of some hazardous drugs to determine if appropriate for alternative handling and containment strategies (USP-NF 2020). Refer to institution-specific handling policies/procedures.
Store at 20°C to 25°C (68°F to 77°F); excursions permitted between 15°C and 30°C (59°F to 86°F).
Treatment of advanced or metastatic thyroid cancer with a rearranged during transfection (RET) gene fusion, as detected by an approved test, in patients who require systemic therapy and who are radioactive iodine-refractory (if radioactive iodine is appropriate) (FDA approved in ages ≥12 years and adults); treatment of advanced or metastatic medullary thyroid cancer (MTC) with a RET mutation, as detected by an approved test, in patients who require systemic therapy (FDA approved in ages ≥12 years and adults); treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC) with a RET gene fusion, as detected by an approved test (FDA approved in adults); treatment of locally advanced or metastatic solid tumors with a RET gene fusion with progression on or following prior systemic treatment or who have no satisfactory alternative treatment options (FDA approved in adults).
Retevmo may be confused with Retrovir.
Selpercatinib may be confused with pralsetinib, selinexor, selumetinib, sunitinib, tucatinib.
The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drug classes (chemotherapeutic agent, parenteral and oral) which have a heightened risk of causing significant patient harm when used in error (High-Alert Medications in Acute Care, Community/Ambulatory Care, and Long-Term Care Settings).
Substrate of BCRP/ABCG2, CYP3A4 (major); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential; Inhibits CYP2C8 (moderate), CYP3A4 (weak), P-glycoprotein/ABCB1
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program
Afatinib: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Afatinib. Management: If combined, administer the P-gp inhibitor simultaneously with, or after, the dose of afatinib. Monitor closely for signs and symptoms of afatinib toxicity and if the combination is not tolerated, reduce the afatinib dose by 10 mg. Risk D: Consider therapy modification
Aliskiren: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Aliskiren. Risk C: Monitor therapy
ALPRAZolam: CYP3A4 Inhibitors (Weak) may increase the serum concentration of ALPRAZolam. Risk C: Monitor therapy
Amiodarone: QT-prolonging Kinase Inhibitors (Highest Risk) may enhance the QTc-prolonging effect of Amiodarone. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Amisulpride (Oral): QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Amisulpride (Oral). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even greater risk. Risk D: Consider therapy modification
Amodiaquine: CYP2C8 Inhibitors (Moderate) may increase the serum concentration of Amodiaquine. Risk X: Avoid combination
Androgens: Hypertension-Associated Agents may enhance the hypertensive effect of Androgens. Risk C: Monitor therapy
Antacids: May decrease the serum concentration of Selpercatinib. Management: Coadministration of selpercatinib and antacids should be avoided. If coadministration cannot be avoided, selpercatinib should be administered 2 hours before or 2 hours after antacids. Risk D: Consider therapy modification
Azithromycin (Systemic): QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Azithromycin (Systemic). Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification
Berotralstat: Selpercatinib may increase the serum concentration of Berotralstat. Berotralstat may increase the serum concentration of Selpercatinib. Management: Avoid this combination if possible. If unavoidable, decrease berotralstat dose to 110 mg daily, and reduce selpercatinib dose from 120 mg twice daily to 80 mg twice daily, or from 160 mg twice daily to 120 mg twice daily. Risk D: Consider therapy modification
Bilastine: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Bilastine. Risk X: Avoid combination
Carbetocin: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Celiprolol: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Celiprolol. Risk C: Monitor therapy
Chloroquine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Chloroquine. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Citalopram: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Citalopram. Risk X: Avoid combination
Clarithromycin: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Clarithromycin. Risk X: Avoid combination
Clofazimine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Clofazimine. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
ClomiPRAMINE: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
CloZAPine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of CloZAPine. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification
Colchicine: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Colchicine. Colchicine distribution into certain tissues (e.g., brain) may also be increased. Management: This combination is often contraindicated, but combined use may be permitted with dose adjustment and monitoring. Recommendations vary based on brand, indication, use of CYP3A4 inhibitors, and hepatic/renal function. See interaction monograph for details. Risk D: Consider therapy modification
CycloSPORINE (Systemic): P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of CycloSPORINE (Systemic). Risk C: Monitor therapy
CycloSPORINE (Systemic): CYP3A4 Inhibitors (Weak) may increase the serum concentration of CycloSPORINE (Systemic). Risk C: Monitor therapy
CYP3A4 Inducers (Moderate): May decrease the serum concentration of Selpercatinib. Risk X: Avoid combination
CYP3A4 Inducers (Strong): May decrease the serum concentration of Selpercatinib. Risk X: Avoid combination
CYP3A4 Inducers (Weak): May decrease the serum concentration of Selpercatinib. Risk C: Monitor therapy
CYP3A4 Inhibitors (Moderate): May increase the serum concentration of Selpercatinib. Management: Avoid combination if possible. If use is necessary, reduce selpercatinib dose as follows: from 120 mg twice/day to 80 mg twice/day, or from 160 mg twice/day to 120 mg twice/day. Risk D: Consider therapy modification
CYP3A4 Inhibitors (Strong): May increase the serum concentration of Selpercatinib. Management: Avoid combination if possible. If use is necessary, reduce selpercatinib dose as follows: from 120 mg twice/day to 40 mg twice/day, or from 160 mg twice/day to 80 mg twice/day. Risk D: Consider therapy modification
Dabigatran Etexilate: P-glycoprotein/ABCB1 Inhibitors may increase serum concentrations of the active metabolite(s) of Dabigatran Etexilate. Risk C: Monitor therapy
Dabrafenib: May enhance the QTc-prolonging effect of Selpercatinib. Dabrafenib may decrease the serum concentration of Selpercatinib. Risk X: Avoid combination
Daprodustat: CYP2C8 Inhibitors (Moderate) may increase the serum concentration of Daprodustat. Management: Reduce the daprodustat starting dose by half if combined with moderate CYP2C8 inhibitors, unless the dose is 1 mg, then no dose adjustment is required. Monitor hemoglobin and adjust daprodustat dose when starting or stopping moderate CYP2C8 inhibitors. Risk D: Consider therapy modification
Dasabuvir: CYP2C8 Inhibitors (Moderate) may increase the serum concentration of Dasabuvir. Risk C: Monitor therapy
Dasatinib: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Dasatinib. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification
Desloratadine: CYP2C8 Inhibitors (Moderate) may increase the serum concentration of Desloratadine. Risk C: Monitor therapy
Digoxin: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Digoxin. Management: Measure digoxin serum concentrations before initiating treatment with these P-glycoprotein (P-gp) inhibitors. Reduce digoxin concentrations by either reducing the digoxin dose by 15% to 30% or by modifying the dosing frequency. Risk D: Consider therapy modification
Domperidone: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Domperidone. Risk X: Avoid combination
Doxepin-Containing Products: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Doxepin-Containing Products. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification
DOXOrubicin (Conventional): P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of DOXOrubicin (Conventional). Risk X: Avoid combination
DOXOrubicin (Liposomal): P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of DOXOrubicin (Liposomal). Risk C: Monitor therapy
Dronedarone: Selpercatinib may enhance the QTc-prolonging effect of Dronedarone. Dronedarone may increase the serum concentration of Selpercatinib. Management: Avoid combination if possible. If use is necessary, reduce selpercatinib dose as follows: from 120mg twice/day to 80mg twice/day, or from 160mg twice/day to 120mg twice/day. Monitor QT interval more closely for QTc interval prolongation and arrhythmias. Risk D: Consider therapy modification
DroPERidol: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of DroPERidol. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification
Edoxaban: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Edoxaban. Risk C: Monitor therapy
Encorafenib: May enhance the QTc-prolonging effect of Selpercatinib. Encorafenib may decrease the serum concentration of Selpercatinib. Risk X: Avoid combination
Entrectinib: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Risk X: Avoid combination
Escitalopram: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Escitalopram. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification
Etelcalcetide: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Etoposide: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Etoposide. Risk C: Monitor therapy
Etoposide Phosphate: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Etoposide Phosphate. Risk C: Monitor therapy
Everolimus: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Everolimus. Risk C: Monitor therapy
Fexinidazole: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Risk X: Avoid combination
Fexinidazole: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination
Finerenone: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Finerenone. Risk C: Monitor therapy
Fingolimod: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias (including TdP) with a continuous overnight ECG when fingolimod is combined with QT prolonging drugs. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor therapy
Flecainide: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Flecainide. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification
Flibanserin: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Flibanserin. Risk C: Monitor therapy
Fluorouracil Products: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Fluorouracil Products. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Flupentixol: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Flupentixol. Risk X: Avoid combination
Fusidic Acid (Systemic): May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Management: Consider avoiding this combination if possible. If required, monitor patients closely for increased adverse effects of the CYP3A4 substrate. Risk D: Consider therapy modification
Gadobenate Dimeglumine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Gadobenate Dimeglumine. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Gemifloxacin: QT-prolonging Kinase Inhibitors (Highest Risk) may enhance the QTc-prolonging effect of Gemifloxacin. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Gilteritinib: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this combination. If use is necessary, monitor for QTc interval prolongation and arrhythmias. Risk D: Consider therapy modification
Glecaprevir and Pibrentasvir: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Glecaprevir and Pibrentasvir. Risk C: Monitor therapy
Grapefruit Juice: May increase the serum concentration of Selpercatinib. Management: Avoid consumption of grapefruit juice, a moderate CYP3A4 inhibitor, with selpercatinib whenever possible. Because grapefruit juice consumption is highly variable, typical dose adjustments associated with moderate CYP3A4 inhibitors are not likely feasible. Risk D: Consider therapy modification
Halofantrine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Halofantrine. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Haloperidol: QT-prolonging Kinase Inhibitors (Highest Risk) may enhance the QTc-prolonging effect of Haloperidol. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Histamine H2 Receptor Antagonists: May decrease the serum concentration of Selpercatinib. Management: Coadministration of selpercatinib and H2 receptor antagonists should be avoided. If coadministration cannot be avoided, selpercatinib should be administered 2 hours before or 10 hours after H2 receptor antagonists. Risk D: Consider therapy modification
HydrOXYzine: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Risk C: Monitor therapy
Imipramine: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Inhibitors of the Proton Pump (PPIs and PCABs): May decrease the serum concentration of Selpercatinib. Management: Coadministration of selpercatinib and PPIs or PCABs should be avoided. If coadministration cannot be avoided, selpercatinib and PPIs or PCABs should be administered simultaneously with food. Risk D: Consider therapy modification
Inotuzumab Ozogamicin: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Inotuzumab Ozogamicin. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Ixabepilone: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Ixabepilone. Risk C: Monitor therapy
Lapatinib: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Lapatinib. Risk C: Monitor therapy
Larotrectinib: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Larotrectinib. Risk C: Monitor therapy
Lefamulin: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Lefamulin. Management: Avoid concomitant use of lefamulin tablets with P-glycoprotein/ABCB1 inhibitors. If concomitant use is required, monitor for lefamulin adverse effects. Risk D: Consider therapy modification
Lemborexant: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Lemborexant. Management: The maximum recommended dosage of lemborexant is 5 mg, no more than once per night, when coadministered with weak CYP3A4 inhibitors. Risk D: Consider therapy modification
Levofloxacin-Containing Products (Systemic): QT-prolonging Kinase Inhibitors (Highest Risk) may enhance the QTc-prolonging effect of Levofloxacin-Containing Products (Systemic). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Levoketoconazole: QT-prolonging Kinase Inhibitors (Highest Risk) may enhance the QTc-prolonging effect of Levoketoconazole. Risk X: Avoid combination
Lofexidine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Lofexidine. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Lomitapide: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Lomitapide. Management: Patients on lomitapide 5 mg/day may continue that dose. Patients taking lomitapide 10 mg/day or more should decrease the lomitapide dose by half. The lomitapide dose may then be titrated up to a max adult dose of 30 mg/day. Risk D: Consider therapy modification
Lonafarnib: May enhance the QTc-prolonging effect of Selpercatinib. Lonafarnib may increase the serum concentration of Selpercatinib. Management: Avoid this combination if possible. If coadministration is required, reduce selpercatinib from 120 mg twice daily to 40 mg twice daily, or from 160 mg to 80 mg twice daily. Monitor for QT prolongation. Risk D: Consider therapy modification
Mavorixafor: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Mavorixafor. Risk C: Monitor therapy
Meglumine Antimoniate: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Methadone: QT-prolonging Kinase Inhibitors (Highest Risk) may enhance the QTc-prolonging effect of Methadone. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Midazolam: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Midazolam. Risk C: Monitor therapy
Midostaurin: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Midostaurin. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Morphine (Systemic): P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Morphine (Systemic). Risk C: Monitor therapy
Moxifloxacin (Systemic): QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Moxifloxacin (Systemic). Risk X: Avoid combination
Nadolol: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Nadolol. Risk C: Monitor therapy
Naldemedine: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Naldemedine. Risk C: Monitor therapy
Naloxegol: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Naloxegol. Risk C: Monitor therapy
Nilotinib: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Nilotinib. Risk X: Avoid combination
NiMODipine: CYP3A4 Inhibitors (Weak) may increase the serum concentration of NiMODipine. Risk C: Monitor therapy
OLANZapine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of OLANZapine. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification
Ondansetron: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Ondansetron. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Osimertinib: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Osimertinib. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification
Oxytocin: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Ozanimod: CYP2C8 Inhibitors (Moderate) may increase serum concentrations of the active metabolite(s) of Ozanimod. Risk C: Monitor therapy
PACLitaxel (Conventional): CYP2C8 Inhibitors (Moderate) may increase the serum concentration of PACLitaxel (Conventional). Risk C: Monitor therapy
PACLitaxel (Protein Bound): CYP2C8 Inhibitors (Moderate) may increase the serum concentration of PACLitaxel (Protein Bound). Risk C: Monitor therapy
Pacritinib: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Pacritinib. Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor therapy
PAZOPanib: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of PAZOPanib. Risk X: Avoid combination
PAZOPanib: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of PAZOPanib. Risk X: Avoid combination
Pentamidine (Systemic): QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Pentamidine (Systemic). Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Pilsicainide: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Pilsicainide. Management: Consider alternatives to this combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Pimozide: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Pimozide. Risk X: Avoid combination
Pimozide: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Pimozide. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk X: Avoid combination
Pioglitazone: CYP2C8 Inhibitors (Moderate) may increase the serum concentration of Pioglitazone. Risk C: Monitor therapy
Piperaquine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Piperaquine. Risk X: Avoid combination
Pralsetinib: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Pralsetinib. Management: If this combo cannot be avoided, decrease pralsetinib dose from 400 mg daily to 300 mg daily; from 300 mg daily to 200 mg daily; and from 200 mg daily to 100 mg daily. Risk D: Consider therapy modification
Probucol: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Probucol. Risk X: Avoid combination
Propafenone: May enhance the QTc-prolonging effect of QT-prolonging Kinase Inhibitors (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
Propofol: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
QT-prolonging Agents (Indeterminate Risk - Avoid): May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor therapy
QT-prolonging Agents (Indeterminate Risk - Caution): May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Monitor for QTc interval prolongation and ventricular arrhythmias when these agents are combined. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk C: Monitor therapy
QT-prolonging Class IA Antiarrhythmics (Highest Risk): QT-prolonging Kinase Inhibitors (Highest Risk) may enhance the QTc-prolonging effect of QT-prolonging Class IA Antiarrhythmics (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
QT-prolonging Class III Antiarrhythmics (Highest Risk): QT-prolonging Kinase Inhibitors (Highest Risk) may enhance the QTc-prolonging effect of QT-prolonging Class III Antiarrhythmics (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
QT-Prolonging Inhalational Anesthetics (Moderate Risk): May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
QT-prolonging Kinase Inhibitors (Highest Risk): May enhance the QTc-prolonging effect of other QT-prolonging Kinase Inhibitors (Highest Risk). Risk X: Avoid combination
QT-prolonging Miscellaneous Agents (Highest Risk): QT-prolonging Kinase Inhibitors (Highest Risk) may enhance the QTc-prolonging effect of QT-prolonging Miscellaneous Agents (Highest Risk). Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk): May enhance the QTc-prolonging effect of Selpercatinib. QT-prolonging Moderate CYP3A4 Inhibitors (Moderate Risk) may increase the serum concentration of Selpercatinib. Management: Avoid combination if possible. If use is necessary, reduce selpercatinib dose as follows: from 120mg twice/day to 80mg twice/day, or from 160mg twice/day to 120mg twice/day. Monitor QT interval more closely for QTc interval prolongation and arrhythmias. Risk D: Consider therapy modification
QT-prolonging Strong CYP3A4 Inhibitors (Highest Risk): May enhance the QTc-prolonging effect of Selpercatinib. QT-prolonging Strong CYP3A4 Inhibitors (Highest Risk) may increase the serum concentration of Selpercatinib. Management: Avoid combination if possible. If use is necessary, reduce selpercatinib dose as follows: from 120mg twice/day to 40mg twice/day, or from 160mg twice/day to 80mg twice/day. Monitor QT interval more closely for QTc interval prolongation and arrhythmias. Risk D: Consider therapy modification
QT-prolonging Strong CYP3A4 Inhibitors (Moderate Risk): May enhance the QTc-prolonging effect of Selpercatinib. QT-prolonging Strong CYP3A4 Inhibitors (Moderate Risk) may increase the serum concentration of Selpercatinib. Management: Avoid combination if possible. If use is necessary, reduce selpercatinib dose as follows: from 120mg twice/day to 40mg twice/day, or from 160mg twice/day to 80mg twice/day. Monitor QT interval more closely for QTc interval prolongation and arrhythmias. Risk D: Consider therapy modification
QUEtiapine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of QUEtiapine. Risk X: Avoid combination
Quizartinib: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification
Ranolazine: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Ranolazine. Risk C: Monitor therapy
Relugolix: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Relugolix. Management: Avoid coadministration of relugolix with oral P-gp inhibitors whenever possible. If combined, take relugolix at least 6 hours prior to the P-gp inhibitor and monitor patients more frequently for adverse reactions. Risk D: Consider therapy modification
Relugolix, Estradiol, and Norethindrone: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Relugolix, Estradiol, and Norethindrone. Management: Avoid use of relugolix/estradiol/norethindrone with P-glycoprotein (P-gp) inhibitors. If concomitant use is unavoidable, relugolix/estradiol/norethindrone should be administered at least 6 hours before the P-gp inhibitor. Risk D: Consider therapy modification
Repaglinide: CYP2C8 Inhibitors (Moderate) may increase the serum concentration of Repaglinide. Risk C: Monitor therapy
Repotrectinib: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Repotrectinib. Risk X: Avoid combination
Resmetirom: CYP2C8 Inhibitors (Moderate) may increase the serum concentration of Resmetirom. Management: During coadministration with moderate CYP2C8 inhibitors reduce the resmetirom dose to 80 mg daily for patients weighing 100 kg or more, or reduce the resmetirom dose to 60 mg daily for patients weighing less than 100 kg. Risk D: Consider therapy modification
Ribociclib: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Ribociclib. Risk X: Avoid combination
RifAXIMin: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of RifAXIMin. Risk C: Monitor therapy
Rimegepant: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Rimegepant. Management: Avoid administration of another dose of rimegepant within 48 hours if given concomitantly with a P-glycoprotein (P-gp) inhibitor. Risk D: Consider therapy modification
RisperiDONE: QT-prolonging Agents (Highest Risk) may enhance the CNS depressant effect of RisperiDONE. QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of RisperiDONE. Management: Consider alternatives to this drug combination. If combined, monitor for QTc interval prolongation and ventricular arrhythmias. Patients with additional risk factors for QTc prolongation may be at even higher risk. Risk D: Consider therapy modification
RomiDEPsin: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of RomiDEPsin. Risk C: Monitor therapy
Selexipag: CYP2C8 Inhibitors (Moderate) may increase serum concentrations of the active metabolite(s) of Selexipag. Management: Reduce the selexipag dose to once daily when combined with moderate CYP2C8 inhibitors. Revert back to twice daily selexipag dosing upon stopping the moderate CYP2C8 inhibitor. Risk D: Consider therapy modification
Sertindole: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Risk X: Avoid combination
Silodosin: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Silodosin. Risk C: Monitor therapy
Simvastatin: CYP3A4 Inhibitors (Weak) may increase serum concentrations of the active metabolite(s) of Simvastatin. CYP3A4 Inhibitors (Weak) may increase the serum concentration of Simvastatin. Risk C: Monitor therapy
Sirolimus (Conventional): P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Sirolimus (Conventional). Management: Avoid concurrent use of sirolimus with P-glycoprotein (P-gp) inhibitors when possible and alternative agents with lesser interaction potential with sirolimus should be considered. Monitor for increased sirolimus concentrations/toxicity if combined. Risk D: Consider therapy modification
Sirolimus (Protein Bound): P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Sirolimus (Protein Bound). Risk X: Avoid combination
Solriamfetol: May enhance the hypertensive effect of Hypertension-Associated Agents. Risk C: Monitor therapy
Sparfloxacin: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Sparfloxacin. Risk X: Avoid combination
SUNItinib: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of SUNItinib. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification
Tacrolimus (Systemic): P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Tacrolimus (Systemic). Risk C: Monitor therapy
Tacrolimus (Systemic): CYP3A4 Inhibitors (Weak) may increase the serum concentration of Tacrolimus (Systemic). Risk C: Monitor therapy
Talazoparib: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Talazoparib. Risk C: Monitor therapy
Tegaserod (Withdrawn from US Market): P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Tegaserod (Withdrawn from US Market). Risk C: Monitor therapy
Teniposide: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Teniposide. Risk C: Monitor therapy
Tenofovir Disoproxil Fumarate: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Tenofovir Disoproxil Fumarate. Risk C: Monitor therapy
Terbutaline: May enhance the QTc-prolonging effect of QT-prolonging Agents (Highest Risk). Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification
Thioridazine: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Thioridazine. Risk X: Avoid combination
Topotecan: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Topotecan. Risk X: Avoid combination
Toremifene: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Toremifene. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification
Tovorafenib: CYP2C8 Inhibitors (Moderate) may increase the serum concentration of Tovorafenib. Risk X: Avoid combination
Treprostinil: CYP2C8 Inhibitors (Moderate) may increase the serum concentration of Treprostinil. Risk C: Monitor therapy
Triazolam: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Triazolam. Risk C: Monitor therapy
Ubrogepant: CYP3A4 Inhibitors (Weak) may increase the serum concentration of Ubrogepant. Management: In patients taking weak CYP3A4 inhibitors, the initial and second dose (given at least 2 hours later if needed) of ubrogepant should be limited to 50 mg. Risk D: Consider therapy modification
Ubrogepant: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Ubrogepant. Management: Use an initial ubrogepant dose of 50 mg and second dose (at least 2 hours later if needed) of 50 mg when used with a P-gp inhibitor. Risk D: Consider therapy modification
Vemurafenib: QT-prolonging Agents (Highest Risk) may enhance the QTc-prolonging effect of Vemurafenib. Management: Consider alternatives to this combination. Patients with other risk factors (eg, older age, female sex, bradycardia, hypokalemia, hypomagnesemia, heart disease, and higher drug concentrations) are likely at greater risk for these toxicities. Risk D: Consider therapy modification
Venetoclax: P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of Venetoclax. Management: Reduce the venetoclax dose by at least 50% in patients requiring concomitant treatment with P-glycoprotein (P-gp) inhibitors. Resume the previous venetoclax dose 2 to 3 days after discontinuation of a P-gp inhibitor. Risk D: Consider therapy modification
VinCRIStine (Liposomal): P-glycoprotein/ABCB1 Inhibitors may increase the serum concentration of VinCRIStine (Liposomal). Risk X: Avoid combination
Evaluate pregnancy status prior to use in patients who could become pregnant.
Patients who could become pregnant should use effective contraception during therapy and for 1 week after the last selpercatinib dose. Patients with partners who could become pregnant should use effective contraception during therapy and for 1 week after the last selpercatinib dose.
Based on the mechanism of action and data from animal reproduction studies, in utero exposure to selpercatinib may cause fetal harm.
Evaluate rearranged during transfection (RET) gene fusion status (thyroid cancer) or specific RET gene mutation (medullary thyroid cancer) in tumor specimens or plasma. Monitor ALT and AST (baseline, every 2 weeks during the first 3 months, then monthly thereafter, and as clinically indicated). Assess QT interval (monitor QT interval more frequently in patients with concomitant strong and moderate CYP3A inhibitors or medications known to prolong QTc interval), electrolytes, and thyroid-stimulating hormone at baseline and periodically during treatment; adjust monitoring frequency based upon risk factors. Evaluate pregnancy status prior to use in patients who could become pregnant. Monitor BP (baseline, after 1 week, at least monthly thereafter, and as clinically indicated). Monitor for signs/symptoms of hypersensitivity, hemorrhage, impaired wound healing, tumor lysis syndrome, and pulmonary toxicity (eg, dyspnea, cough, fever); promptly evaluate for interstitial lung disease for acute or worsening respiratory symptoms. Monitor growth plates in adolescents with open growth plates. Monitor adherence.
The American Society of Clinical Oncology hepatitis B virus (HBV) screening and management provisional clinical opinion (ASCO [Hwang 2020]) recommends HBV screening with hepatitis B surface antigen, hepatitis B core antibody, total Ig or IgG, and antibody to hepatitis B surface antigen prior to beginning (or at the beginning of) systemic anticancer therapy; do not delay treatment for screening/results. Detection of chronic or past HBV infection requires a risk assessment to determine antiviral prophylaxis requirements, monitoring, and follow-up.
Selpercatinib is a highly selective anti-RET (REarranged during Transfection) kinase inhibitor (Solomon 2020). Selpercatinib inhibits wild-type RET, multiple mutated RET isoforms, vascular endothelial growth factor receptors 1 and 3 (VEGFR1 and VEGFR3), and fibroblast growth factor receptor (FGFR) 1, 2, and 3. Certain point mutations in RET or chromosomal rearrangements involving in-frame fusions of RET can result in constitutively activated chimeric RET fusion proteins, which may act as oncogenic drivers, promoting tumor cell line proliferation. Selpercatinib has demonstrated anti-tumor activity in cells harboring constitutive activation of RET proteins resulting from gene fusions and mutations (including CCDC6-RET, KIF5B-RET, RET V804M, and RET M918T).
Distribution: Vss/F: 191 L.
Protein binding: 96%.
Metabolism: Predominantly via CYP3A4.
Bioavailability: 73% (range: 60% to 82%).
Half-life elimination: 32 hours.
Time to peak: 2 hours.
Excretion: Feces: 69% (14% as unchanged drug); urine: 24% (12% as unchanged drug).
Clearance: 6 L/hour.
Hepatic function impairment: Selpercatinib AUC0-∞ increased by 7%, 32%, and 77% in subjects with mild (total bilirubin ≤ ULN with AST > ULN or total bilirubin > 1 to 1.5 times ULN with any AST), moderate (total bilirubin >1.5 to 3 times ULN and any AST), and severe (total bilirubin >3 to 10 times ULN and any AST) hepatic impairment, respectively, compared to subjects with normal hepatic function.
Weight: Selpercatinib apparent volume of distribution and clearance increase with increasing body weight.
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