Posology : מינונים

4.2     Posology and method of administration
Treatment with Cotellic in combination with vemurafenib should only be initiated and supervised by a qualified physician experienced in the use of anticancer medicinal products.
For Treatment of Melanoma
Before starting this treatment, patients must have BRAF V600 mutation-positive melanoma tumour status confirmed by a validated test (see sections 4.4 and 5.1).

Posology

The recommended dose of Cotellic is 60 mg (3 tablets of 20 mg) once daily.
Cotellic is taken on a 28 day cycle. Each dose consists of three 20 mg tablets (60 mg) and should be taken once daily for 21 consecutive days (Days 1 to 21-treatment period); followed by a 7-day break (Days 22 to 28-treatment break). Each subsequent Cotellic treatment cycle should start after the 7-day treatment break has elapsed.
For information on the posology of vemurafenib, please refer to its Prescribing Information.

Duration of treatment

Treatment with Cotellic should continue until the patient no longer derives benefit or until the development of unacceptable toxicity (see Table 1 below).

Missed doses

If a dose is missed, it can be taken up to 12 hours prior to the next dose to maintain the once-daily regimen.

Vomiting

In case of vomiting after administration of Cotellic, the patient should not take an additional dose on that day and treatment should be continued as prescribed the following day.

General dose modifications

The decision on whether to reduce the dose for either or both treatments should be based on the prescriber’s assessment of individual patient safety or tolerability. Dose modification of Cotellic is independent of vemurafenib dose modification.

If doses are omitted for toxicity, these doses should not be replaced. Once the dose has been reduced, it should not be increased at a later time.

Table 1 below gives general Cotellic dose modification guidance.

Table 1 Recommended Cotellic dose modifications
Grade (CTC-AE)*                                 Recommended Cotellic dose Grade 1 or Grade 2 (tolerable)                No dose reduction. Maintain Cotellic at a dose of 60 mg once daily (3 tablets)
Grade 2 (intolerable) or Grade 3/4
1st Appearance                  Interrupt treatment until Grade ≤ 1, restart treatment at 40 mg once daily (2 tablets)
2nd Appearance                  Interrupt treatment until Grade ≤ 1, restart treatment at 20 mg once daily (1 tablet)
3rd Appearance                  Consider permanent discontinuation
*The intensity of clinical adverse events graded by the Common Terminology Criteria for Adverse Events v4.0 (CTC-AE)
Dose modification advice for haemorrhage

Grade 4 events or cerebral haemorrhage: Cotellic treatment should be interrupted. Cotellic treatment should be permanently discontinued for haemorrhage events attributed to Cotellic.

Grade 3 events: Cotellic treatment should be interrupted during evaluation to avoid any potential contribution to the event. There is no data on the effectiveness of Cotellic dose modification for haemorrhage events. Clinical judgment should be applied when considering restarting Cotellic treatment. Vemurafenib dosing can be continued when Cotellic treatment is interrupted, if clinically indicated.


Dose modification advice for left ventricular dysfunction

Permanent discontinuation of Cotellic treatment should be considered if cardiac symptoms are attributed to Cotellic and do not improve after temporary interruption.

Table 2 Recommended dose modifications for Cotellic in patients with left ventricular ejection fraction (LVEF) decrease from baseline

Recommended             LVEF value
LVEF                                                 Recommended Cotellic Patient                     Cotellic dose            following value                                                     daily dose modification         treatment break
≥ 50%
(or 40-49% and < 10%
Continue at absolute                                N/A                      N/A current dose decrease from baseline)
1st occurrence: 40 mg
< 10% absolute
Asymptomatic                                                             2nd occurrence: 20 mg < 40%                             decrease from
(or 40-49%                              baseline        3rd occurrence: and ≥ 10%         Interrupt                             permanent discontinuation absolute     treatment for             < 40% decrease        2 weeks          (or ≥ 10% absolute from                              decrease from baseline)                                              Permanent discontinuation baseline)


Asymptomatic and     1st occurrence: 40 mg
< 10% absolute      2nd occurrence: 20 mg decrease from baseline        3rd occurrence:
Interrupt                             permanent discontinuation
Symptomatic         N/A        treatment for       Asymptomatic and
4 weeks                < 40%
(or ≥ 10% absolute   Permanent discontinuation decrease from baseline)
Symptomatic
Permanent discontinuation regardless of LVEF
N/A = Not Applicable


Vemurafenib treatment can be continued when Cotellic treatment is modified, if clinically indicated.
Dose modification advice for rhabdomyolysis and creatine phosphokinase (CPK) elevations 
Rhabdomyolysis or symptomatic CPK elevations

Cotellic treatment should be interrupted. If rhabdomyolysis or symptomatic CPK elevations do not improve within 4 weeks, Cotellic treatment should be permanently discontinued.
If severity is improved by at least one grade within 4 weeks, Cotellic could be restarted at a dose reduced by 20 mg, if clinically indicated. Patients should be closely monitored. Vemurafenib dosing can be continued when Cotellic treatment is modified.


Asymptomatic CPK elevations

Grade 4: Cotellic treatment should be interrupted. If CPK elevations do not improve to Grade ≤3 within 4 weeks following dose interruption, Cotellic treatment should be permanently discontinued.
If CPK improves to Grade ≤3 within 4 weeks, Cotellic could be restarted, if clinically indicated, at a dose reduced by 20 mg and the patient should be closely monitored. Vemurafenib dosing can be continued when Cotellic treatment is modified.

Grade ≤3: After rhabdomyolysis has been ruled out, Cotellic dosing does not need to be modified.

Dose modification advice for Cotellic when used with vemurafenib
Liver laboratory abnormalities

For Grade 1 and 2 liver laboratory abnormalities, Cotellic and vemurafenib should be continued at the prescribed dose.

Grade 3: Cotellic should be continued at the prescribed dose. The dose of vemurafenib may be reduced as clinically appropriate. Please refer to the vemurafenib Prescribing Information.

Grade 4: Cotellic treatment and vemurafenib treatment should be interrupted. If liver laboratory abnormalities improve to Grade ≤1 within 4 weeks, Cotellic should be restarted at a dose reduced by 20 mg and vemurafenib at a clinically appropriate dose, per its Prescribing Information.

Cotellic treatment and vemurafenib treatment should be discontinued if liver laboratory abnormalities do not resolve to Grade ≤1 within 4 weeks or if Grade 4 liver laboratory abnormalities recur after initial improvement.

Photosensitivity

Grade ≤2 (tolerable) photosensitivity should be managed with supportive care.
Grade 2 (intolerable) or Grade ≥3 photosensitivity: Cotellic and vemurafenib should be interrupted until resolution to Grade ≤1. Treatment can be restarted with no change in Cotellic dose. Vemurafenib dosing should be reduced as clinically appropriate, please refer to its Prescribing Information for further information.

Rash

Rash events may occur with either Cotellic or vemurafenib treatment. The dose of Cotellic and/or vemurafenib may be either temporarily interrupted and/or reduced as clinically indicated.
Additionally, for:

Grade ≤2 (tolerable) rash should be managed with supportive care. Cotellic dosing can be continued without modification.
Grade 2 (intolerable) or Grade ≥3 acneiform rash: General dose modification recommendations in Table 1 for Cotellic should be followed. Vemurafenib dosing can be continued when Cotellic treatment is modified (if clinically indicated).

Grade 2 (intolerable) or Grade ≥3 non-acneiform or maculopapular rash: Cotellic dosing can be continued without modification if clinically indicated. Vemurafenib dosing may be either temporarily interrupted and/or reduced, please refer to its Prescribing Information for further information.


QT prolongation

If during treatment the QTc exceeds 500 msec, please refer to the vemurafenib Prescribing Information (section 4.2) for dose modifications for vemurafenib. No dose modification of Cotellic is required when taken in combination with vemurafenib.

Special populations

Elderly patients
No dose adjustment is required in patients aged ≥65 years old.
Renal impairment
No dose adjustment is recommended in patients with mild or moderate renal impairment based on population pharmacokinetic analysis (see section 5.2). There are minimal data for Cotellic in patients with severe renal impairment, therefore an effect cannot be excluded. Cotellic should be used with caution in patients with severe renal impairment.

Hepatic impairment
No dose adjustment is recommended in patients with hepatic impairment. Patients with severe hepatic impairment may have increased plasma concentrations of unbound cobimetinib compared to patients with normal hepatic function (see section 5.2). Liver laboratory abnormalities can occur with Cotellic and caution should be used in patients with any degree of hepatic impairment (see section 4.4).

Non-Caucasian patients
The safety and efficacy of Cotellic in non-Caucasian patients have not been established.

Paediatric population
The safety and efficacy of Cotellic in children and adolescents below 18 years of age have not been established. Currently available data are described in sections 4.8, 5.1 and 5.2, but no recommendation on posology can be made.

Method of administration
Cotellic is for oral use. The tablets should be swallowed whole with water. They can be taken with or without food.