Darolutamide

Since androgen deprivation treatment may prolong the QT interval, the co-administration with medicinal products known to prolong the QT interval or medicinal products able to induce Torsade de pointes should be carefully evaluated. These include medicinal products such as class IA (e.g., quinidine, disopyramide) or class III (e.g., amiodarone, sotalol, dofetilide, ibutilide) antiarrhythmic medicinal products, methadone, moxifloxacin, and antipsychotics (e.g. haloperidol).

Patients should be monitored for adverse reactions of BCRP, OATP1B1 and OATP1B3 substrates as co-administration with darolutamide may increase the plasma concentrations of these substrates.

Darolutamide is an inhibitor of breast cancer resistance protein (BCRP) and Organic Anion Transporting Polypeptides (OATP) 1B1 and 1B3. Co-administration of rosuvastatin should be avoided unless there is no therapeutic alternative. Selection of an alternative concomitant medicinal product with less potential to inhibit BCRP, OATP1B1 and OATP1B3 should be considered.

Administration of darolutamide (600 mg twice daily for 5 days) prior to co-administration of a single dose of rosuvastatin (5 mg) together with food resulted in approximately 5-fold increase in mean exposure (AUC) and C_max of rosuvastatin.

Co-administration of darolutamide with other BCRP substrates should be avoided where possible. Co-administration of darolutamide may increase the plasma concentrations of other concomitant BCRP, OATP1B1 and OATP1B3 substrates (e.g. methotrexate, sulfasalazine, fluvastatin, atorvastatin, pitavastatin). Therefore, it is recommended to monitor patients for adverse reactions of BCRP, OATP1B1 and OATP1B3 substrates. In addition, the related recommendation in the product information of these substrates should be followed when co-administered with darolutamide.

Darolutamide is a substrate of UGT1A9. No clinically relevant drug-drug interaction is expected in case of UGT1A9 inhibitor administration. Darolutamide may be given concomitantly with UGT1A9 inhibitors. A population pharmacokinetic analysis showed that co-administration of UGT1A9 inhibitors with darolutamide resulted in a 1.2-fold increase in exposure (AUC_0-72) of darolutamide.

Darolutamide is a substrate of CYP3A4, P-gp and breast cancer resistance protein (BCRP). No clinically relevant drug-drug interaction is expected in case of CYP3A4, P-gp or BCRP inhibitor administration. Darolutamide may be given concomitantly with CYP3A4, P-gp or BCRP inhibitors.

Concomitant use of darolutamide with a combined P-gp and strong CYP3A4 inhibitor increases darolutamide exposure which may increase the risk of darolutamide adverse reactions. It is recommended to monitor patients more frequently for darolutamide adverse reactions and modify darolutamide dose as needed.

Administration of itraconazole (200 mg twice daily on day 1 and once daily on the following 7 days), a strong CYP3A4, P-gp and BCRP inhibitor, with a single dose of darolutamide (600 mg on day 5 together with food) resulted in a 1.7-fold increase in mean exposure (AUC_0-72) and a 1.4-fold increase of C_max of darolutamide.

Darolutamide is a mild inducer of CYP3A4. No clinically relevant drug-drug interaction is expected in case of CYP substrate administration. Darolutamide may be given concomitantly with CYP substrates (e.g. warfarin, L-thyroxine, omeprazole). Administration of darolutamide (600 mg twice daily for 9 days) prior to co-administration of a single dose of the sensitive CYP3A4 substrate midazolam (1 mg) together with food, decreased the mean exposure (AUC) and C_max of midazolam by 29% and 32%, respectively. Darolutamide did not inhibit the metabolism of selected CYP substrates in vitro at clinically relevant concentrations.

No clinically relevant drug-drug interaction is expected in case of P-gp substrate administration. Darolutamide may be given concomitantly with P-gp substrates (e.g. digoxin, verapamil or nifedipine). Co-administration of darolutamide together with the sensitive P-gp substrate dabigatran etexilate did not reveal any increase in exposure (AUC and C_max) of dabigatran.

Darolutamide is a substrate of CYP3A4 and P-glycoprotein (P-gp). Use of strong and moderate CYP3A4 inducers and P-gp inducers (e.g. carbamazepine, phenobarbital, St. John’s Wort, phenytoin, and rifampicin) during treatment with darolutamide is not recommended, unless there is no therapeutic alternative. Selection of an alternate concomitant medicinal product, with no or weak potential to induce CYP3A4 or P-gp should be considered. Repeated administration of rifampicin (600 mg), a strong CYP3A4 and a P-gp inducer, with a single dose of darolutamide (600 mg) together with food, resulted in a decrease of 72% in mean exposure (AUC_0-72) and a decrease of 52% in C_max of darolutamide.

For patients with severe renal impairment (eGFR 15-29 mL/min/1.73 m²) not receiving haemodialysis, the recommended starting dose is 300 mg twice daily.

The available data on darolutamide pharmacokinetics in moderate hepatic impairment is limited. Darolutamide has not been studied in patients with severe hepatic impairment. For patients with moderate and severe hepatic impairment (Child-Pugh Classes B and C), the recommended starting dose is 300 mg twice daily.

There are no human data on the effect of darolutamide on fertility. Based on animal studies, darolutamide may impair fertility in males of reproductive potential.

Co-administration with rosuvastatin should be avoided unless there is no therapeutic alternative.

Patients with clinically significant cardiovascular disease in the past 6 months including stroke, myocardial infarction, severe/unstable angina pectoris, coronary/peripheral artery bypass graft, and symptomatic congestive heart failure were excluded from the clinical studies. Therefore, the safety of darolutamide in these patients has not been established. If darolutamide is prescribed, patients with clinically significant cardiovascular disease should be treated for these conditions according to established guidelines.

It is not to be used in women who are, or may be, pregnant.

Based on its mechanism of action, darolutamide may cause foetal harm. No non-clinical reproductive toxicity studies have been conducted.

It is not known whether darolutamide or its metabolites are present in semen. If the patient is engaged in sexual activity with a pregnant woman, a condom should be used during and for 1 week after completion of treatment with darolutamide. Exposure of the foetus to an androgen receptor inhibitor through seminal transfer to the pregnant woman has to be avoided, as this could affect development of the foetus.

It is not to be used in women who are breast-feeding.

It is unknown whether darolutamide or its metabolites are excreted in human milk. No studies in animals have been conducted to evaluate the excretion of darolutamide or its metabolites into milk. A risk to the breast-fed child cannot be excluded.

Women of childbearing potential / contraception in males and females

This medicinal product is not indicated in women of childbearing potential.

It is not known whether darolutamide or its metabolites are present in semen. If the patient is engaged in sexual activity with a woman of childbearing potential, a highly effective contraceptive method (<1% failure rate per year) should be used during and for 1 week after completion of treatment with darolutamide to prevent pregnancy.

Fertility

There are no human data on the effect of darolutamide on fertility. Based on animal studies, darolutamide may impair fertility in males of reproductive potential.

Darolutamide has no or negligible influence on the ability to drive and use machines.

Summary of the safety profile

The most frequently observed adverse reaction is fatigue/asthenic conditions (15.8%).

List of adverse reactions

The adverse reactions observed are listed below. They are classified according to System Organ Class.

Adverse reactions are grouped according to their frequencies. Frequency groups are defined by the following convention: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000); not known (cannot be estimated from the available data).

Within each frequency group, adverse reactions are presented in order of decreasing seriousness.

Adverse reactions reported in the ARAMIS study:

Cardiac disorders

Common: Ischaemic heart disease^b, Heart failure^c

Skin and subcutaneous tissue disorders

Common: Rash

Musculoskeletal and connective tissue disorders

Common: Pain in extremity, Musculoskeletal pain, Fractures

General disorders and administration site conditions

Very common: Fatigue/asthenic conditions^a

Investigations^d

Very common: Neutrophil count decreased, Bilirubin increased, AST increased

^a Includes fatigue and asthenia, lethargy and malaise.
^b Includes arteriosclerosis coronary artery, coronary artery disease, coronary artery occlusion, coronary artery stenosis, acute coronary syndrome, acute myocardial infarction, angina pectoris, angina unstable, myocardial infarction, myocardial ischaemia.
^c Includes cardiac failure, cardiac failure acute, cardiac failure chronic, cardiac failure congestive, cardiogenic shock.
^d Common Terminology Criteria for Adverse Events (CTCAE) version 4.03.

Description of selected adverse reactions

Fatigue

Fatigue/asthenic conditions were reported in 15.8% of patients treated with darolutamide and in 11.4% of patients treated with placebo. Events with worst grade of 3 were reported in 0.6% of patients treated with darolutamide and in 1.1% of patients treated with placebo. Fatigue (not including asthenia, lethargy or malaise) occurred in the majority of patients (12.1% of patients treated with darolutamide and 8.7% of patients treated with placebo).

Fractures

Fractures occurred in 4.2% of patients treated with darolutamide and in 3.6% of patients treated with placebo.

Ischaemic heart disease and heart failure

Ischaemic heart disease occurred in 3.2% of patients treated with darolutamide and in 2.5% of patients treated with placebo. Grade 5 events occurred in 0.3% of patients treated with darolutamide and 0.2% of patients treated with placebo. Heart failure occurred in 1.9% of patients treated with darolutamide and in 0.9% of patients treated with placebo.

Neutrophil count decreased

Neutrophil count decreased was reported as a laboratory abnormality in 19.6% of patients treated with darolutamide and in 9.4% of patients treated with placebo. The median time to nadir was 256 days. The laboratory tests abnormalities manifested predominantly as grade 1 or 2 intensity. Neutrophil count decreased of grade 3 and 4 was reported in 3.5% and 0.5% of patients, respectively. Only one patient permanently discontinued darolutamide due to neutropenia. Neutropenia was either transient or reversible (88% of patients) and were not associated with any clinically relevant signs or symptoms.

Bilirubin increased

Bilirubin increased was reported as a laboratory abnormality in 16.4% of patients treated with darolutamide and in 6.9% of patients treated with placebo. The episodes were predominantly of grade 1 or 2 intensity, not associated with any clinically relevant signs or symptoms, and reversible after darolutamide was discontinued. Bilirubin increased of grade 3 was reported in 0.1% of patients treated with darolutamide and in 0% of patients treated with placebo. In the darolutamide arm, the mean time to first onset of increased bilirubin was 153 days, and the mean duration of the first episode was 182 days. No patients were discontinued from treatment due to increase in bilirubin.

AST increased

AST increased was reported as a laboratory abnormality in 22.5% of patients treated with darolutamide and in 13.6% of patients treated with placebo. The episodes were predominantly of grade 1 or 2 intensity, not associated with any clinically relevant signs or symptoms, and reversible after darolutamide was discontinued. AST increased of grade 3 was reported in 0.5% of patients treated with darolutamide and in 0.2% of patients treated with placebo. In the darolutamide arm, the mean time to first onset of increased AST was 258 days, and the mean duration of the first episode was 118 days. No patients were discontinued from treatment due to increase in AST.